Board of Directors
Time: 1310-1430 hours Venue Date: Wednesday, 31 October 2018 Room 3, 3rd Floor, Unit 2 (Battersea Studio 2), Battersea, London SW8 3HR1 Presenters are reminded to provide a succinct and focused introduction, highlighting the key questions and only things which have changed since the preparation of the report 1 Administrative and other priority items 1.1 Welcome, introduction and apologies: Angela Greatley Verbal 1310 2 1.2 Patient story Hilder Dewa Verbal 1.3 Written questions from the public3 Angela Greatley Verbal 1.4 Interests relevant to the agenda to declare and any new Angela Greatley Verbal interests 1.5 Minutes of meeting held on 20.09.18 and Angela Greatley Pages 3 - 4 27.09.18 Pages 5 - 9 1.6 Matters arising and action log Angela Greatley Page 10 1.7 Chair’s report Angela Greatley Pages 11 - 13 1.8 Chief Executive’s report Andrew Ridley Pages 14 - 23 1.9 Quality report – Q2 Charlie Sheldon Pages 24 - 79 2 Strategic items 2.1 Operational plan 2019/20 – timescales and planned Mike Fox Pages 80 - 91 1335 approval process / dates 2.2 Clinical strategy – refresh – aligned to organisational Joanne Medhurst Pages 92 - 105 strategy – agreed in March 2017 3 Operational items 3.1 Integrated finance and performance report M6 Mike Fox Pages 106 - 127 1350 Jitesh Chotai To be provided 3.1.1 FRIC report, 29.10.18 separately 4 3.2 Learning from deaths – Q2 report Joanne Medhurst Pages 128 - 131 3.3 Health and safety policy - Q2 report Elizabeth Hale Pages 132 - 151 3.4 STP / Partnerships update – Q2 report James Benson Pages 152 - 157 4 Governance / assurance items 4.1 Patient safety – serious incident and being open report Charlie Sheldon Pages 158 - 166 1410 4.2 Medicines management annual report 2017/18 – Joanne Medhurst Pages 167 - 174 including controlled drugs 4.3 Annual security management report to the Board James Benson Pages 175 - 181 4.4 Annual equality report5 Louella Johnson Pages 182 - 231
1 closest tube is Queenstown Road 2 Community HIV Nurse Specialist 3 Written questions that are relevant to the agenda must be submitted in advance (at least one clear day) before the meeting to the Trust Secretary 4 As the meeting is later than the dispatch date for Board papers 5 For follow-up in March 2019 and annually in March thereafter
4.5 Single oversight framework – Q2 Mike Fox Pages 232 - 259 4.6 Board Committee items / reports: 4.6.1 Audit Committee – report 11.10.18 Clive Sparrow Pages 260 - 263 4.6.2 Quality Committee – report 24.10.18 Carol Cole To be provided separately 6
4.6.3 Quality Committee – terms of reference Carol Cole Pages 264 - 270 4.7 Risks / priority topics identified during meeting Angela Greatley Verbal 4.7 Issues/items for which further assurance is required Angela Greatley Verbal 5 Items to agree / note without discussion / already considered in detail by a Committee7 5.1 Board Committee minutes: 1430 5.1.1 Quality Committee 24.07.18 Carol Cole Pages 271 - 278 5.1.2 Audit Committee 12.07.18 Clive Sparrow Pages 279 - 284 5.3 Date of next meetings in public: Thursday, 29 November 2018 Boardroom, Ground Floor, 15 Marylebone Road, London NW1 5JD
Angela Greatley, OBE – Chair
Attached –list of commonly used abbreviations pages 285 - 291 KPI definitions pages 292 - 293
In the interests of transparency, at the end of the meeting, ten minutes will be allowed for members of staff / public in attendance to have an opportunity to ask questions relevant to the agenda or the work of the Trust. Questions will be accepted at the discretion of the chairman; it will not be possible to answer any questions which refer to named staff or patients.
RESOLUTION “That representatives of the press, and other members of the public, be excluded from part of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”, section 1 (2), Public Bodies (Admission to Meetings) Act 1960.
Circulation: Board members, Trust Secretary, Corporate Governance Manager and attendees, including to named lead to present the patient story
6 As the meeting is later than the dispatch date for Board papers 7 Unless the Chair is notified in advance
Agreed by chair 02.10.18 1 Board of Directors Minutes of the meeting held 20 September 2018 Parker Morris Hall, The Abbey Conference Centre, 34 Great Smith Street, London, SW1P 3BU
Present Angela Greatley Trust Chair Louise Ashley Chief Nurse and Chief Operating Officer James Benson Director of Improvement Jitesh Chotai Non-Executive Director Carol Cole Non-Executive Director Paula Constant Associate Non-Executive Director2 Mike Fox Director of Finance, Contracting and Performance Louella Johnson Director of People and Communications3 Joanne Medhurst Medical Director Andrew Ridley Chief Executive David Sines Non-Executive Director Jane Slatter Non-Executive Director Clive Sparrow Non-Executive Director
In attendance Sulekha Ali End of Life Care Lead Christine Bilsborough Consultant Physiotherapist Claire Browning Health Team Manager, Barnet learning disabilities service Jayne Walbridge Trust Secretary
Some 78 other attendees – including patients, staff and stakeholders
BoD/151/18 Welcome, introduction and apologies4 151.1 A Greatley welcomed attendees, introducing Jane Slatter, NED who had joined the Board in April 2018.
151.2 All Board members were present.
BoD/152/18 Minutes of the Annual General Meeting held on 21.09.17 152.1 The minutes of the annual general meeting held on 21.09.17 were agreed as an accurate record.
BoD/153/18 Annual report and accounts for the year 2017/18 153.1 Resolved The annual report and accounts 2017/18 were received.
BoD/154/18 Annual report highlights and the year ahead 154.1 On behalf of the Board, A Ridley thanked L Ashley, who would be leaving the organisation in October (to take a chief executive post) for her inspirational clinical leadership which had transformed the Trust’s approach to improving quality, education and training.
154.2 The work of staff providing support to families affected by serious incidents across
1 T P Sentences marked include an action for ELT members that does not require report back to the Board, sentences marked are items that have been added to the relevant Board and Committee Programme. 2 Non-voting member 3 Non-voting member 4 Quorum = one third the membership including one officer and one NED member. 1 3
London, including the Grenfell tower tragedy, was commended.
154.3 Over the past year there had been a number of significant changes to the organisation which has more than 300 sites across 10 London boroughs and Hertfordshire. Sadly during the year 2017/18, as a result of competitive tendering processes, a number of valued services had been lost. The Board recorded their thanks to staff who had joined new employers and welcomed new staff providing services in South West London.
154.4 Overall, 2017/18 had been a strong year for operational and financial performance with significant progress made in developing partnerships with GPs and other stakeholders in support of integrated care services for patients. Importantly, following the CQC inspection between September and October 2017, a rating of ‘good’ had been confirmed, showing an improved position to that of 2015.
BoD/155/18 Service presentations – patient involvement at CLCH 155.1 Three presentations were made by clinical staff describing how patients had helped shape the services of the Trust:
Christine Bilsborough Musculoskeletal services Sulekha Ali End of life care
Claire Browning Barnet learning disabilities team
155.2 A copy of the slides has been uploaded to the Trust’s website.
BoD/156/18 Questions from the audience and the Trust’s response 156.1 Questions and the Board’s responses are published on the Board Meetings page of the website.
156.2 The chair closed the meeting and thanked presenters and attendees for their contribution.
BoD/157/18 Date of next meeting in public 157.1 Thursday, 27 September 2018 Boardroom, Ground Floor, 15 Marylebone Road, London, NW1 5JD.
The meeting closed at 1540 hours
Signature …………………………………………………………….. Angela Greatley, OBE - Chair
Date ………………………………………………
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Agreed by Chair 02.10.18
1 Board of Directors Minutes of the meeting held 27 September 2018 Boardroom, Ground Floor, Marylebone Road, London, NW1 5JD Present Angela Greatley Trust Chair Louise Ashley Chief Nurse and Chief Operating Officer – for CEO James Benson Director of Improvement Jitesh Chotai Non-Executive Director Carol Cole Non-Executive Director Paula Constant Associate Non-Executive Director2 Mike Fox Director of Finance, Contracting and Performance Louella Johnson Director of People and Communications3 Joanne Medhurst Medical Director David Sines Non-Executive Director Jane Slatter Non-Executive Director Clive Sparrow Non-Executive Director
In attendance4 Gisele Partaker Operational Manager Cardio-Respiratory – Merton (part) Charlie Sheldon Director of Nursing – for Chief Nurse Jayne Walbridge Trust Secretary
BoD/151/18 Welcome, introduction and apologies5 151.1 Apologies had been received from: Andrew Ridley, Chief Executive.
BoD/152/18 Patient story 152.1 Gisele Partaker from the Merton cardiology and respiratory team provided the story of a patient who had attended the pulmonary rehabilitation service.
152.2 The patient, who had initially been somewhat low in mood, was very complimentary about the occupational therapist and the positive impact on both her physical and psychological health – describing the results as “amazing”.
152.3 In response to questions, G Partaker confirmed that referrals were accepted from any specialist for patients registered with Merton GPs with whom the team work closely.
Resolved 152.4 Members thanked the team for their story, acknowledged the value of the service to patients’ well-being, together with making an important contribution to avoidable admissions.
BoD/153/18 Written questions to the Board 153.1 No written questions had been received.
BoD/154/18 Interests relevant to the agenda to declare and any new interests 154.1 J Medhurst declared her interest – as Medical Director for the Hammersmith and Fulham GP Federation (a role to be undertaken alongside her CLCH duties) in relation to agenda
1 T P Sentences marked include an action for ELT members that does not require report back to the Board, sentences marked are items that have been added to the relevant Board and Committee Programme. 2 Non-voting member 3 Non-voting member 4 Two members of the public, including a representative from the CQC 5 Quorum = one third the membership including one officer and one NED member. 1 5
item, 2.1 (minute 159/18) – to be recorded in the register of interests declared at meetingsT.
BoD/155/18 Minutes of the Board of Directors meetings held on 28.06.18 155.1 The minutes of the Board of Directors meeting held on 26.07.18 were agreed as an accurate record, subject to correction of rephrasing to read re-phasing.
BoD/156/18 Matters arising and action log 156.1 It was agreed that completed actions could be closed.
ABoD/28/18 Learning from deaths – register of approved 156.2 J Medhurst confirmed that, in discussion with NHS England, it had been agreed that while the guidance was appropriate for deaths involving in-patients, a different approach was needed for some community patients, for example podiatry.
156.3 An update on the position and the register of approved reviewers, which had been discussed at the resuscitation group, would be included with the quarterly update to the Board in October 2018.
BoD/157/18 Chair’s report 157.1 South West London and St Georges J Benson reported that he would be chairing the Wandsworth Transformation Board as Chief Operating Officer for the Trust – and would seek to strengthen the relationship between all providers.
Resolved 157.2 The Chair’s report was noted.
157.3 The Board recorded their thanks to L Ashley, who would be leaving to take on a new role as a Chief Executive in Kent, for her excellent leadership and determination.
BoD/158/18 Chief Executive’s report 158.1 Board appointments Following a competitive selection process, James Benson had been appointed as Chief Operating Officer and Charlie Sheldon as Chief Nurse to focus on strategy and quality respectively. A full handover had been undertaken – providing continuity and stability to the teams.
158.2 It was confirmed that the external advertisement for the permanent Director of Nursing vacancy and internal advertisement (initial 6 month contract) for the Director of Improvement posts had been published. The interview panel for the Director of Nursing post would include the Chair of the Remuneration Committee (D Sines) and a patient representative.
158.3 There had been a very positive response to the Divisional Director of Operations (South) vacancy for which shortlisting had commenced.
158.4 Health visiting conference The Trust had hosted an event at the Royal College of Nursing with guest speakers from NHS England. The event had been well attended and received, providing an opportunity to discuss the new health visiting model.
158.5 Falcon Road lease Members were pleased to learn that the Falcon Road site lease agreement – in support of the South West London sexual health service had been agreed.
Resolved 158.6 The Chief Executive’s report was noted.
BoD/159/18 Hammersmith and Fulham alliance agreement 159.1 The updated alliance agreement, which had been discussed in detail in July, was
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considered. It was reiterated that the agreement was not legally binding but represented a commitment to work together as a system for the benefit of patients.
159.2 In response to questions from J Slatter regarding inclusion of the GP federation in the risk and reward scheme, J Medhurst explained that Hammersmith and Fulham GP federation were in a difficult financial position and that funding was only confirmed until 31.03.19; thus as independent contractors individual practices felt unable to commit to financial accountability.
159.3 D Sines sought assurance that the revised agreement did not present any additional risks and that the confidentiality arrangements were robust. J Benson confirmed that there were no additional risks and that information governance arrangements had been discussed in detail to ensure parties to the agreement controlled what would be shared.
Resolved 159.4 The Hammersmith and Fulham Alliance agreement was approved for signature by the Chief Executive.
Action ABoD/31/18 (M Fox for A Ridley)
BoD/160/18 Integrated finance and performance M5 report (IFPR) and Finance, Resources and Investment Committee (FRIC) report 160.1 M Fox provided an overview of the month 5 (August) position including the key performance indicators rated red (4). Of the remaining monthly indicators, cyber security had moved to green (due to completion of the system patch); the other two related to an increase in the vacancy rate and the financial position. Quality indicators continued to show strong performance with only 4 of the 35 indicators rated red.
160.2 In response to C Sparrow’s questions regarding the importance of cyber security, J Benson confirmed that a risk based approach to system patches was taken – those which had to be applied immediately and those which could wait for a ‘patch window’ in order to minimise disruption to services.
160.3 L Johnson confirmed that the vacancy rate, particularly retention of staff was being monitored closely and that a deep dive had been undertaken to assess plans in place, for example the early identification of staff considering leaving the Trust and the role of line managers in supporting career development – for which guidance was being prepared. L Ashley added that the Trust’s vacancy target had been based on the Quality Strategy agreed in December 2016, but may be challenging due to: the impact of Brexit, withdrawal of bursaries. L Johnson also reported a significant vacancy increase in London specifically. However, the Trust had already established an Academy (with funding) and was currently recruiting 60 trainee nurse associates.
160.4 Members discussed the falls and pressure ulcer indicators (both red), noting that there was a zero tolerance for each of these indicators. C Sheldon explained that the Trust continued to report all pressure ulcers and had already implemented the new NHS Improvement guidance (deadline 31.03.19). The challenging internal target - a 5% reduction in community acquired pressure ulcers had not been met – an analysis would be undertaken for inclusion in the Q2 quality report.
160.5 Financial performance had improved slightly, however there remained a gap to achieve the year-end control total (£1.3m) inclusive of the shortfall in funding for the national pay award (£400k). The executive team continued to monitor the position closely in order to deliver the financial plan.
160.6 J Chotai reported that the Finance, Resources and Investment Committee (FRIC) had welcomed the improvement from Q1, but remained concerned that the plan was reliant on the recovery of the North and South Divisions and, furthermore, that savings were phased to Q4 – representing an additional risk.
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160.7 Following the positive annual self-assessment review, FRIC had concluded that it would be useful to arrange an external review in 2019.
Resolved 160.8 The integrated finance and performance report and FRIC report 24.09.18 was noted.
BoD/161/18 Workforce race equality standard (WRES) 161.1 Following the Board seminar in July, the final WRES and action plan - comparing the Trust’s position against the 9 indicators for the current and previous 2 financial years was considered.
161.2 The WRES taskforce, chaired by the Chief Executive, had prepared the action plan informed by best practice, supported through staff engagement. While a slight improvement from 2016/17 had been made in 2017/18, the results showed that a significant amount of work was required. Members accepted that, while disappointing, there was a firm commitment to improvement over time.
161.3 In response to C Sparrow’s questions regarding the absence of targets, L Johnson confirmed that this had been discussed – however it had been concluded that it would be more useful to learn from best practice before introducing measures, which might include targets.
161.4 In response to J Chotai’s challenge about using comparisons (ie to prior year performance did not equate to best-practice), L Johnson confirmed that the Trust would use NHS England WRES team benchmarking information to compare the position against other community trusts. The Chair reported that both Chairs and CEOs in London were to work together in order to see if further measures might be taken.
161.5 L Ashley cautioned that benchmarks would not be useful in all areas, for example the number of BAME senior nurses – which was shamefully low nationally - suggesting that it would be useful to look at other sectors outside of the NHS which the WRES taskforce would considerT.
Resolved 161.6 The WRES and action plan was approved for publication the following day.
161.7 Members thanked the WRES taskforce for their work in support of the Trust.
Action ABoD/32/18 (L Johnson) BoD/162/18 Winter planning 162.1 J Benson, as Chief Operating Officer, would be leading the Trust’s winter planning arrangements in liaison with the operational resilience group. A collaborative system wide approach to winter planning would be taken, informed by priorities identified from the review of winter 2017/18.
162.2 L Ashley reported that, unfortunately, delays to the transfer of care (DTOC) had been poor in August, due to staff annual leave across the wider system.
Resolved 162.3 The Board noted the update on the principles of the winter planning approach, including NHS Improvement recommended actions to reduce long stay patients.
BoD/163/18 Patient safety – serious incident and being open report 163.1 The serious incident report covering both July and August was considered together with the being open report.
163.2 Safeguarding resources had been reviewed and a specialist in the Mental Capacity Act had been identified to support teams further.
163.3 In response to D Sines’ questions regarding the investigation of deaths of people with
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learning disabilities, J Medhurst confirmed that learning disabilities mortality review (LeDeR) and preventable incidents, survival and mortality (PRISM) reviews were undertaken for this group of patients.
Resolved 163.4 The serious incident and being open report was received.
163.5 It was suggested that it would be important to include freedom to speak up (FTSU) concerns in relation to patient safety within the whistleblowing section of the report.
Action ABoD/33/18 (L Johnson and C Sheldon)
BoD/164/18 Risks / priority topics identified during meeting 164.1 C Sheldon to review risk in relation to nurse vacancies, given the increasing rate in London (see 160.3 above). Action ABoD/34/18 (C Sheldon)
BoD/165/18 Issues / items for which further assurance is required 165.1 No issues identified.
BoD/166/18 Board Committee minutes 166.1 The Quality Committee minutes of 18.04.18 were received.
BoD/167/18 Date of next meeting in public 167.1 Wednesday, 31 October 2018 Room 3, 3rd Floor, Unit 2 (Battersea Studio 2), Battersea, London SW8 3HR
The meeting closed at 1525 hours
RESOLUTION “That representatives of the press, and other members of the public, be excluded from part of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”, section 1 (2), Public Bodies (Admission to Meetings) Act 1960.
Signature …………………………………………………………….. Angela Greatley, OBE - Chair
Date ………………………………………………
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Board of Directors Public Action Log
Action number Date of meeting Subject Action Responsible officer Due date Comments Last reviewed / to be reviewed Status - completed is defined as confirmation received from ELT responsible lead that the proposed action is complete as described in the comments column. Completed actions will not be closed until the committee has confirmed that action taken is satisfactory.
ABoD/31/18 27.09.18 H&F Alliance Agreement V2 The Hammersmith and Fulham Alliance M Fox for A Ridley 10.10.18 T Wright team are preparing document for Andrew to sign. 31.10.18 complete agreement was approved for signature by CEO has signed the alliance. the Chief Executive.
ABoD/32/18 27.09.8 WRES and action plan The WRES and action plan was approved for L Johnson 30.09.18 Sent to Y Mahmood for publication on 30.09.18 31.10.18 open publication the following day
ABoD/33/18 27.09.18 Serious incident report It was suggested that it would be useful to C Sheldon with L 10.10.18 Included in SI report for October. 31.10.18 complete include freedom to speak up (FTSU) Johnson concerns in relation to patient safety within the whistleblowing section of the report
ABoD/34/18 27.09.18 New risks and issues C Sheldon to review risk in relation to nurse C Sheldon - now L 10.10.18 To be reviewed at the workforce committee in November. 31.10.18 complete vacancies, given the increasing rate in Johnson London
ABoD/35/18 31.10.18 Nov-18 open
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Board of Directors 31 October 2018
Report title: Chair’s report to Board of Directors
Agenda item number: 1.7
Lead director responsible Angela Greatley, Trust Chair for approval of this paper Report author Trust Secretary Relevant CLCH strategic Trust objective 2018/19 priorities Strategy implementation Implement strategic priorities of integration and place Quality Maintain and improve the quality of services delivered by CLCH Finance Deliver the 2018/19 financial plan Operations Deliver all NHS constitutional and contractual standards Workforce Make CLCH a great place to work for everyone Freedom of Information Can be published status Executive summary:
An update on external and internal events and membership.
Assurance provided: Not applicable
Report provenance: Not applicable
Report for: Decision Discussion Information X
Recommendation: To note the report.
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1 External events
1.1 CEO and Chair’s NHS Providers event The CEO and I attended this regular quarterly event. The most interesting contribution was from the new Head of the CQC, Ian Trenholm. He discussed the approach being taken by the CQC to its own continuous improvement. We were unable to attend for the whole day because of the clash with CLCH AGM (see below), but the regular update by Chris Hopson is circulated separately.
1.2 WRES and London – regional meeting Yvonne Coghill and the WRES Action Team addressed a group of London NHS Trust / FT CEOs and Chairs, about London performance. The WRES national returns show that the capital’s performance is poorer than many other parts of the country, despite its being the most diverse. The meeting participants agreed that they would take personal leadership roles and contribute collectively to address this deficit. The CEOs are forming an action group and the Chairs are using an existing mechanism, through NHSI, to do so. Best practice and benchmarking are to be the key tools. CLCH is an active participant.
1.3 Festival of governance 2018 I attended this annual event organised by the Good Governance Institute. The GGI is a consultancy dealing with the public sector broadly, including higher education, health and local government. The AGM heard contributions from Dame Julie Moore, on her retirement from NHS executive leadership and from the RT Hon Jacqui Smith, Chair of University Hospitals Birmingham NHS FT. Both were looking forward to the new NHS national plan and reflecting on the nature of change in the NHS.
1.4 Involvement in appointment process for the Chair of Imperial College Healthcare NHS Trust I was a member of a stakeholder group set up for this appointment. The outcome is not yet known although it is thought that a recommendation has been made. The group I attended was with five other trust Chairs from NW London, together with CCG leaders and local government health and social care leaders.
1.5 NHS Providers Confed, Manchester This two-day conference provided excellent quality speakers and networking opportunities. Simon Stevens and Ian Dalton made their contributions about the NHS Plan and about the planning round for 2019/20. The planning arrangements and changes to finance for the coming year are dealt with elsewhere in this agenda. The Secretary of State provided a recorded interview with Chris Hopson, which set out the political priorities. Integration and change were the key themes of the conference and I attended some well- run workshops on the progress of place-based integration in different parts of the country, including a well-received plenary contribution from Andy Burnham, Mayor of Greater Manchester.
1.6 Effective challenge – participation in development tutorial aimed at women and BAME NHSI provided a novel development opportunity for associate directors who are on the NeXt Director programme. With one other Trust Chair and two existing NEDs I contributed to a webinar run by Dean Spencer from NHSI. Innovative technology for the ‘chats’ was somewhat testing but it did provide a forum for discussion and debate about NED
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effective challenge. Both technology and content are being evaluated.
2 Internal events
2.1 Annual General Meeting, 20 September 2018 I want to record my thanks to all who contributed to the AGM and I am delighted that so many of our patients, carers and ‘shadow members’ came along to participate. The speakers were excellent and the questioning certainly ‘kept us on our toes’. It was an excellent afternoon. Thanks to all my colleague Board members too.
2.2 CLCH safeguarding adult and children’s conference 2018 Once again, the CLCH safeguarding conference was a well-planned and very well attended event. Dealing as it did with all aspects of safeguarding, this year’s event had a special emphasis on adult safeguarding. I was pleased to be able to close the day and to add to the thanks already offered to an array of excellent speakers and to the participants.
2.3 Board development day This development day offered an excellent opportunity for the Board to work on a range of development issues, very intensively. More of the output will be seen throughout our papers in the coming few months. However, at this stage, I do want to thank Carnall Farrer for again taking us though the work so effectively.
3 Membership update
3.1 Membership numbers As at 23 October 2018 there are 7,646 public members.
Angela Greatley Trust Chair October, 2018
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Board of Directors st 31 October 2018
Report title: Chief Executive’s report
Agenda item number: 1.8
Andrew Ridley, Chief Executive Lead director responsible for approval of this paper
Report author Business Manager Relevant CLCH strategic Trust objective 2018/19 priorities Please delete those which do not apply to this paper Strategy implementation Implement strategic priorities of integration and place Quality Maintain and improve the quality of services delivered by CLCH Finance Deliver the 2018/19 financial plan Operations Deliver all NHS constitutional and contractual standards Workforce Make CLCH a great place to work for everyone Executive summary: Not applicable
Assurance provided: Not applicable
Report provenance: Chief Executive
Report for: Decision Discussion Information X
Recommendation: To note the report.
14 1 CLCH DEVELOPMENTS 1.1 Pembridge Bedded Unit As discussed at last month’s Board meeting, consultant cover for the impatient beds is proving problematic and attempts to resolve these issues have so far been unsuccessful. Regrettably therefore the unit remains closed to inpatient referrals, whilst the community team and day hospice continue to operate normally. Recruitment activity for a new consultant for the inpatient beds is ongoing.
1.2 Annual General Meeting (AGM) on 20th September 2018 On Thursday 20th September our annual general meeting (AGM) took place at the Abbey Centre. The theme of the afternoon was patient experience, with almost 100 guests attending the informative event, many joining in the lively discussions. As part of the event, our annual report (2017/18) was received and it can now be accessed it via the Trust’s website.
1.3 New service The Ealing children’s services successfully transferred to CLCH on 1st October 2018. The service model is an integrated model with a number of the Local Authority services including early help and will be the first time CLCH has entered into a joint management approach with a local authority for children’s services. The health visitors, school nurses, family nurse practitioners and support staff have moved along with the early help staff to be based in children’s centres to further facilitate a joined up approach. The benefits to children and families are improved speed of access to support, only having to tell their story once as well as robust safeguarding processes.
1.4 Hounslow Diabetes Service Following our decision not to bid for the service at a new and significantly reduced price point, on 1 October 2018 staff from our Hounslow community diabetes service switched providers and moved over to Hounslow and Richmond Community Healthcare NHS Trust. I’d like to place on record my thanks to our staff and wish them well in their new organisation.
1.5 Annual staff survey 2018 The annual NHS staff survey went live in the first week of October 2018 and staff are being encouraged to fill in this anonymous and essential survey.
1.6 CLCH BAME network staff annual conference The conference is scheduled to be held on 14 November 2018 and is open to all employees.
At this year’s conference I am very pleased we have Javed Khan, CEO of leading children’s charity, Barnardo’s as the keynote speaker and an interactive workshop on ‘Unconscious Bias’ facilitated by Karen Fonseka, from Vercida Consulting.
1.7 Flu campaign The flu vaccine campaign started in earnest with Flu clinics available almost every day in October in various parts of the organisation. A significant campaign to encourage high uptake is being led by the Medical Director and Trust leaders.
15 1.8 World’s biggest coffee morning Friday 28 September Pembridge Hospice has showed support for MacMillan cancer care by taking part in the world’s biggest coffee morning on Friday 28 September. All the money raised from the fundraiser has gone straight to MacMillan.
2 REGULATION AND REGULATORS 2.1 Joint planning update On 16th October, Ian Dalton and Simon Stevens wrote to Trust CEO’s setting out the new approach to strategic and operational planning in the NHS in light of the governments five years funding settlement for the NHS.
This contains an initial timetable for one year operational planning for 2019/20 including significant changes to payment and incentive systems and a timetable for 5 year plans (and CCG Allocations) to be undertaken at STP level by summer 2019 in response to the new NHS Long Term Plan, expected to be published in December. The letter and timetable is attached.
3 REGIONAL AND NATIONAL DEVELOPMENTS AND REPORTS 3.1 Government announces £10,000 “golden hello” for NHS district nurses MP Caroline Dinenage, minister of state for care at the Department of Health and Social Care, announced during a speech at the Queens Nursing Institute that the government will offer “golden hellos” worth up to £10,000 to postgraduate nurses who want to train as a district nurse.
The minister also revealed the government has begun work on apprenticeship standards for District Nursing. The consultation for this is underway and the Education team are coordinating our Trust response. https://haso.skillsforhealth.org.uk/news/apprenticeship-standard-for-district-nurse-consultation- open/
3.2 Care job vacancies in England rise to 110,000 About 110,000 jobs in adult care in England are left vacant, a rise of 22,000 in a year, according to workforce data from Skills for Care. The training charity said the vacancy rate had risen from an estimated 6.6% in 2017 to 8% in 2018. It said employers found it a "challenge" to get people with the "right values" for care work. The Department of Health and Social Care said it is going to run a recruitment campaign.
3.3 Combined NHS Improvement and NHS England to deliver 20per cent efficiency savings Both organisations have committed to an overarching set of financial principles, within a 20 per cent shared efficiency envelope, to ensure the new corporate, regional and local ‘end to end’ design work delivers the efficiencies required.
The bodies currently have a combined annual budget of approximately of £686m - £508m for NHS England and £178m for NHS Improvement. Appointments to new National and regional Director posts are underway.
3.4 Trainee nursing associates to be counted in staffing levels The Nursing and Midwifery Council has given employers the option of not awarding nursing associate trainees ‘supernumerary’ status according to its final standards
16 published. Our Chief Nurse Charlie Sheldon worked with HEE and Chief Nurses nationally for this change to occur.
The standards give employers two options: the supernumerary model where students are additional to the minimum number of staff required for safety and the new option where nursing associate students are included in workforce numbers. Under both options, students would be supervised and must receive the same amount of protected learning time.
Under the new option Nursing Associate students will still be ‘off the job’ for academic study and placements that broaden their experience beyond their normal place of work. But when learning in their own workplace, they will be able to count time protected for learning towards their programme hours. Importantly, students will still need to be appropriately supervised when they’re working towards meeting the NMC standards
3.5 Health and Social Care Secretary pledges £240m to social care to avert NHS winter crisis Matt Hancock, the health and social care secretary, has announced an additional £240m funding for social care ahead of winter. Mr Hancock will distribute the funds to local councils in an effort to stop elderly people going into hospital unnecessarily and then staying there longer than needed.
3.6 Health Secretary promises to crackdown on NHS agency staff The health and social care secretary Matt Hancock has vowed to clamp down on agency spending in the NHS, saying the use of such staff can be 'demoralising' for workers. In a pre-recorded interview streamed at the NHS Providers conference in Manchester, Mr Hancock said he was 'shocked' by how the use of agency staff varies across the health service. He said a lot of work has been done to cut the use of agency staff, but added he would crack down even further. Mr Hancock said the NHS' own bank system – in which workers are kept on the payroll and do casual shifts – works well and is better value for money.
3.7 Government says 'unacceptable' pay gaps must be eliminated by 2028 An announcement by health and social care minister Stephen Barclay who said the NHS has 10 years to boost the diversity of its senior leadership. Currently, 17% of the NHS non- medical workforce is from a black, Asian or minority ethnic background, but this drops to 6.4% at very senior management levels and 11% at senior management levels. The health minister has said this "unacceptable" gap must be closed by 2028. NHS bodies, including NHS England, Public Health England and Health Education England, have also agreed to a new Race at Work charter.
4 CONFIDENTIAL BOARD MEETINGS 4.1 At the confidential meeting in September, we discussed future commissioning arrangements in inner London and some significant issues in relation to patient services.
5 CLCH STAFF CHANGES 5.1 I would like to welcome the following staff who have recently joined CLCH operations divisions across the organisation in October; Rachel Copp, Highly Specialist Musculoskeletal Team Lead; Craig Wooding, Nurse Practitioner Urgent Care Services, Claudia Dobson, Specialist School Health Practitioner; Aminah Yeung, Deputy Principal Pharmacist; Julian Schulte-Bahrenberg, Community Health Services Pharmacist; James
17 Fitzpatrick, Assistant Director -Contracts and Delivery Assurance;
5.2 On behalf of the Board, I would like to thank and wish farewell to the following staff for their loyalty, contribution and commitment to the work of our Trust. We wish them every success in the future: Helen Cassidy, Service Lead; Nicholas Collett, Diabetes Podiatrist; Charlotte Thompson, Diabetes Podiatrist; Rupindar Sahota, Diabetes Dietitian; Debra Lake, Diabetes Specialist Nurse; Laura Mackay, Diabetes Specialist Nurse; Beatrice Jeranyama, Diabetes Specialist Nurse; Francoise Kupa, District Nurse Team Leader; Shona Turvill, Case Manager; Debra Howells, Specialist Occupational Therapist; Catherine Bruce, Tissue Viability Advance Nurse; Donna Ingram, Nurse Practitioner Urgent Care Services; Linda Street, Nurse Practitioner Urgent Care Services; Radoslaw Jarzabek, Highly Specialist Physiotherapist; Elaine Dunne, MERIT Community Liaison Link; Victoria Adebola, Health Visitor; Catherine Thomas, SLT Locality Lead Early Years; Carmen Pagor, FNP Specialist Health Visitor; Nkatha Gitonga, Complex Care Ward Pharmacist; Zakaria Ahmed, Enterprise Architect;
6 USE OF THE TRUST SEAL 6.1 The Trust seal was used since the last report on the following occasion:
Seal No 131, to sign a Heads of Terms agreement for six months with London Borough of Hammersmith & Fulham relating to the provision of 0-19 Public Health Services.
Seal No 132, to sign a Counterpart under lease for Emperor’s Gate, of the ground and gallery second floors for the provision of the same with Dr Hilary King and Dr Caroline Stott.
Seal No 133, to sign a contract with London Borough of Hammersmith & Fulham relating to the provision of 0-19 Healthy Child Programme Services (Health Visiting, Family Nurse Partnership and School Nursing).
Seals No 134 -137 (inclusive), to sign a lease for 15 year term with Lilyville Surgery for the provision of Parsons Green Health Centre.
Seal No 138, on 12th October 2018 to sign a license to alter parts of the ground and first floor of Patrick Doody Health Centre with NHS Property Service Ltd.
Seal No 139, on 12th October 2018 to sign a lease of the ground and first floor of Patrick Doody Health Centre with NHS Property Service Ltd.
Andrew Ridley, CEO October, 2018
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NHS Improvement To: and NHS England CCG AO Wellington House Trust CE 133-155 Waterloo Road London SE1 8UG
CC: 020 3747 0000 NHS Improvement and England Regional Directors NHS Improvement and England Regional Finance Directors www.england.nhs.uk
www.improvement.nhs.uk
Publications Gateway Reference 08559 16 October 2018
Approach to planning
The Government has announced a five-year revenue budget settlement for the NHS from 2019/20 to 2023/24 - an annual real-term growth rate over five years of 3.4% - and so we now have enough certainty to develop credible long term plans. In return for this commitment, the Government has asked the NHS to develop a Long Term Plan which will be published in late November or early December 2018.
To secure the best outcomes from this investment, we are overhauling the policy framework for the service. For example, we are conducting a clinically-led review of standards, developing a new financial architecture and a more effective approach to workforce and physical capacity planning. This will equip us to develop plans that also:
improve productivity and efficiency; eliminate provider deficits; reduce unwarranted variation in quality of care; incentivise systems to work together to redesign patient care; improve how we manage demand effectively; and make better use of capital investment.
This letter outlines the approach we will take to operational and strategic planning to ensure organisations can make the necessary preparations for implementing the NHS Long Term Plan.
Collectively, we must also deliver safe, high quality care and sector wide financial balance this year. Pre-planning work for 2019/20 is vitally important, but cannot distract from operational and financial delivery in 2018/19.
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Planning timetable
We have attached an outline timetable for operational and strategic planning; at a high-level. During the first half of 2019-20 we will expect all Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) to develop and agree their strategic plan for improving quality, achieving sustainable balance and delivering the Long Term Plan. This will give you and your teams sufficient time to consider the outputs of the NHS Long Term Plan in late autumn and the Spending Review 2019 capital settlement; and to engage with patients, the public and local stakeholders before finalising your strategic plans.
Nonetheless, it is a challenging task. We are asking you to tell us, within a set of parameters that we will outline with your help, how you will run your local NHS system using the resources available to you. It will be extremely important that you develop your plans with the proper engagement of all parts of your local systems and that they provide robust and credible solutions for the challenges you will face in caring for your local populations over the next five years. Individual organisations will submit one-year operational plans for 2019/20, which will also be aggregated by STPs and accompanied by a local system operational plan narrative. Organisations, and their boards / governing bodies, will need to ensure that plans are stretching but deliverable and will need to collaborate with local partners to develop well-thought- out risk mitigation strategies. These will also create the year 1 baseline for the system strategic plans, helping forge a strong link between strategic and operational planning. We will also be publishing 5-year commissioner allocations in December 2018, giving systems a high degree of financial certainty on which to plan.
We are currently developing the tools and materials that organisations will need to respond to this, and the timetable sets out when these will be available.
Payment reform
A revised financial framework for the NHS will be set out in the Long Term Plan, with detail in the planning guidance which we will publish in early December 2018. A number of principles underpinning the financial architecture have been agreed to date, and we wanted to take this opportunity to share these with you.
Last week we published a document on ‘NHS payment system reform proposals’ which sets out the options we are considering for the 2019/20 National Tariff.
In particular, we are seeking your engagement on proposals to move to a blended payment approach for urgent and emergency care from 2019/20. The revised approach will remove, on a cost neutral basis, two national variations to the tariff: the marginal rate for emergency tariff and the emergency readmissions rule, which will not form part of the new payment model. The document will also ask for your views on other areas, including price relativities, proposed changes to the Market Forces Factor and a proposed approach to resourcing of centralised procurement. As in
20 previous years, these proposals would change the natural ’default’ payment models; local systems can of course continue to evolve their own payment systems faster, by local agreement.
We believe that individual control totals are no longer the best way to manage provider finances. Our medium-term aim is to return to a position where breaking even is the norm for all organisations. This will negate the need for individual control totals and, in turn, will allow us to phase out the provider and commissioner sustainability funds; instead, these funds will be rolled into baseline resources. We intend to begin this process in 2019/20.
However, we will not be able to move completely away from current mechanisms until we can be confident that local systems will deliver financial balance. Therefore, 2019/20 will form a transitional year, in which we will set one year, rebased, control totals. These will be communicated alongside the planning guidance and will take into account the impact of distributional effects from any policy changes agreed post engagement in areas such as price relativities, the Market Forces Factor and national variations to the tariff.
In addition to this, we will start the process of transferring significant resources from the provider sustainability fund into urgent and emergency care prices. The planning guidance will include further details on the provider and commissioner sustainability funds for 2019/20.
Incentives and Sanctions
From 1 April 2019, the current CQUIN scheme will be significantly reduced in value with an offsetting increase in core prices. It will also be simplified, focussing on a small number of indicators aligned to key policy objectives drawn from the emerging Long Term Plan.
The approach to quality premium for 2019/20 is also under review to ensure that it aligns to our strategic priorities; further details will be available in the December 2018 planning guidance.
Alignment of commissioner and provider plans
You have made significant progress this year in improving alignment between commissioner and provider plans in terms of both finance and activity. This has reduced the level of misalignment risk across the NHS. We will need you to do even more in 2019/20 to ensure that plans and contracts within their local systems are both realistic and fully aligned between commissioner and provider; and our new combined regional teams will help you with this. We would urge you to begin thinking through how best to achieve this, particularly in the context of the proposed move to blended payment model for urgent and emergency care.
Good governance
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We are asking all local systems and organisations to respond to the information set out in this letter with a shared, open-book approach to planning. We expect boards and governing bodies to oversee the development of financial and operational plans, against which they will hold themselves to account for delivery, and which will be a key element of NHS England’s and NHS Improvement’s performance oversight. Early engagement with board and governing bodies is critical, and we would ask you to ensure that board / governing body timetables allow adequate time for review and sign-off to meet the overall timetable.
The planning guidance, with confirmation of the detailed expectations, will follow in December 2018. In the meantime, commissioners and providers should work together during the autumn on aligned, profiled demand and capacity planning. Please focus, with your local partners, on making rapid progress on detailed, quality impact-assessed efficiency plans. These early actions are essential building blocks for robust planning, and to gauge progress we will be asking for an initial plan submission in mid-January that will be focussed on activity and efficiency (CIP / QIPP) planning with headlines collected for other areas.
Thank you in advance for your work on this.
Yours sincerely
Simon Stevens Ian Dalton Chief Executive Chief Executive NHS England NHS Improvement
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Annex
Outline timetable for planning Date
Late November / early NHS Long Term Plan published December 2018
Publication of 2019/20 operational planning guidance including the revised Early December 2018 financial framework
Operational planning
Publication of CCG allocations for 5 years Near final 2019/20 prices Technical guidance and templates Mid December 2018 2019/20 standard contract consultation and dispute resolution guidance 2019/20 CQUIN guidance Control totals for 2019/20 2019/20 Initial plan submission – activity and efficiency focussed with 14 January 2019 headlines in other areas 2019/20 National Tariff section 118 consultation starts 17 January 2019 Draft 2019/20 organisation operating plans 12 February 2019 Aggregate system 2019/20 operating plan submissions and system 19 February 2019 operational plan narrative 2019/20 NHS standard contract published 22 February 2019
2019/20 contract / plan alignment submission 5 March 2019 2019/20 national tariff published 11 March 2019 Deadline for 2019/20 contract signature 21 March 2019 Organisation Board / Governing body approval of 2019/20 budgets By 29 March Final 2019/20 organisation operating plan submission 4 April 2019 Aggregated 2019/20 system operating plan submissions and system 11 April 2019 operational plan narrative Strategic planning
Capital funding announcements Spending Review 2019
Systems to submit 5-year plans signed off by all organisations Summer 2019
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Board of Directors 31 October 2018
Report title: Quality Report - Quarter 2 2018/19
Agenda item number: 1.9
Lead director responsible for Chief Nurse approval of this paper Report author Director of Nursing & Therapies (Patient Experience) Head of Quality Improvement Relevant CLCH strategic Trust objective 2018/19 priorities Strategy implementation Implement strategic priorities of integration and place Quality Maintain and improve the quality of services delivered by CLCH Workforce Make CLCH a great place to work for everyone Freedom of Information status Available on request. Executive summary: Our quality strategy, Simply the Best, Every Time, builds on the highly successful 2013 - 2016 strategy which raised the profile of the quality agenda at CLCH and laid down the building blocks for quality improvement. The 2013-16 strategy supported the development of robust systems, processes and objectives to improve care and provided assurance that high quality care was being delivered and poor practice identified and rectified at an early stage.
Simply the Best, Every Time aims to build on the success of the first quality strategy and focuses particularly on reducing some of the unwarranted variations in care which exist across the trust and moving the trust from providing ‘good’ to ‘outstanding’ care.
Each campaign is led by a director who is responsible for its overall coordination and delivery. The Associate Directors of Quality are responsible for divisional delivery.
This report outlines our progress against the strategy for quarter two of the financial year 2018/19. As well as providing commentary on the quality dashboard KPIs. Each campaign section includes an update against the key outcomes for year two of the strategy.
The final sections of the report contain updates on the trust’s quality action teams and shared governance.
The report appendices provide details of the complaints and pressure ulcer incidence for the quarter.
Assurance provided: Patient Safety Group, Patient Experience Coordinating Committee, Clinical Effectiveness Group
Report provenance: The report was discussed at the Executive Leadership Team meeting held on XXX prior to being presented at the Quality Committee meeting on 24 October 2018.
Report for: Decision Discussion Information X Recommendation: To note the report
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Contents
1.0 Trust Quality Score Card – Q2 2018/19 ...... 5
1.1 Introduction ...... 7
2.0 Positive Patient Experience ...... 7
2.1 Dignity & Respect ...... 7
2.2 Friends & Family Test (FFT) ...... 7
2.3 Explaining Care...... 8
2.4 Involvement in care ...... 8
2.5 Overall Experience ...... 9
2.6 Complaints ...... 9
2.7 Complaints Audit: ...... 10
2.8 Complaints training: ...... 10
2.9 PALS Overview: ...... 11
2.7 Key Outcomes ...... 11
2.8 Assurance Issues from the Patient Experience Coordinating Committee (PECC) ..... 16
3.0 Preventing Harm ...... 17
3.1 Proportion of clinical incidents that did not cause harm ...... 17
3.2 Zero tolerance to falls in bedded units with harm (moderate or above) ...... 18
3.3 5% reduction in pressure ulcers (grade 3 and 4) ...... 18
3.4 Zero tolerance of grade 3 and 4 pressure ulcers in bedded units ...... 19
3.5 NHS Safety Thermometer ...... 19
3.6 Harm Free Care ...... 19
3.7 Key Outcomes ...... 20
3.8 Assurance Issues from the Patient Safety and Risk Group ...... 22
4.0 Smart, effective care ...... 22
4.1 Proportion of patients who did not have CAUTI ...... 22
4.2 Proportion of patients who did not have a VTE ...... 23
4.3 Percentage of deaths in community hospitals ...... 23
4.4 Proportion of safety alerts due, and responded to, within deadline ...... 23
25 4.5 Hand hygiene ...... 23
4.7 NICE baseline assessment ...... 24
4.8 Key Outcomes ...... 24
4.9 Assurance Issues from Clinical Effectiveness Group (CEG) ...... 25
5.0 Modelling the way ...... 25
5.1 Statutory & Mandatory Training ...... 27
5.2 Key Outcomes ...... 27
6.0 Here, Happy, Healthy & Heard ...... 30
6.1 Clinical Vacancies ...... 30
6.3 Staff Engagement Score ...... 34
6.4 Bank Staff Recruitment ...... 35
6.5 Staff Appraisals ...... 36
6.6 Clinical Staff Sickness ...... 37
6.7 Key Outcomes ...... 40
7.0 Value Added Care ...... 42
7.1 Improvement skills training ...... 42
7.3 Key Outcomes ...... 43
8.0 Quality Action Teams (QATs) ...... 44
8.1 Services with a QAT in place during Q2: ...... 44
8.3 South Division QATs ...... 45
8.4 Woodlands ...... 45
8.5 Merton Community Nursing ...... 45
8.6 Podiatry ...... 45
8.7 Wandsworth ...... 45
8.8 Child Health Division ...... 45
8.9 Inner CYPOT ...... 45
8.10 Health Visiting South Team in Hammersmith & Fulham...... 46
8.11 Inner Division ...... 46
8.12 Harrow Cardiology ...... 46
9.0 Shared Governance ...... 46
26 Appendix One: Complaint Themes ...... 49
1.0 Number of complaints ...... 49
2.0 Complaints by division, theme and service ...... 50
3.0 Local Resolution Meetings and outcomes ...... 51
4.0 Closed Complaints ...... 51
27 1.0 Trust Quality Score Card – Q2 2018/19
Quality Campaign Key Performance Indicator Target Performance Sep-18 YTD Proportion of patients who were treated with respect and dignity 95.0 % 98.5 % 98.6 % Friends and family test - percentage of people that would recommend the service 95.0 % 93.5 % 94.0 %
A Positive Patient Proportion of patients whose care was explained in an understandable way 92.0 % 95.8 % 95.5 % Experience Proportion of patients who were involved in planning their care 90.0 % 92.4 % 92.3 % Changing behaviours and Proportion of patients rating their overall experience as good or excellent 92.0 % 94.4 % 93.6 % care to enhance the experience of our Proportion of patients' concerns (PALS) responded to within 5 working days 95.0 % 100.0 % 100.0 % patients and service users Proportion of complaints responded to within 25 days 100.0 % 100.0 % 100.0 % Proportion of complaints responded to within agreed deadline 100.0 % 100.0 % 100.0 % Proportion of complaints acknowledged within 3 working days 100.0 % 100.0 % 100.0 % Proportion of clinical incidents that did not cause harm (moderate to catastrophic categories) 96.0 % 96.1 % 97.2 % Zero tolerance to falls in bedded units with harm (moderate or above) 0 0 5 Preventing Harm 5% reduction in pressure ulcers grade 3 / 4 (on 2017/18 baseline) 8 9 63 Incidents & Risk Zero tolerance of new (CLCH acquired) category 3 & 4 pressure ulcers in bedded units 0 0 4 Proportion of external SIs with reports completed within deadline 100.0 % 100.0 % 100.0 % Proportion of patients who did not have any NEW harms 98.5 % 98.6 % 98.0 % Preventing Harm Prevalence (NHS Safety Proportion of patients who did not have a NEW (CLCH acquired) pressure ulcer 98.5 % 99.4 % 98.8 % Thermometer) Proportion of patients who did not have a fall 98.5 % 99.3 % 99.2 %
28 Proportion of patients who did not have a catheter associated urinary tract infection 99.0 % 99.5 % 99.5 % Proportion of patients who did not have a venous thromboembolism 100.0 % 100.0 % 99.7 % Percentage of deaths in community hospitals (expected and unexpected) compared to all discharges (excluding palliative Smart, Effective Care 3.8 % n/a 0.0 % and end of life care) Ensuring patients and service users receive the Percentage of Central Alerting System (CAS) alerts including Patient Safety Alerts (PSAs) due, and responded to, within 90.0 % 100.0 % 100.0 % best evidence based care, deadline every time Percentage of hand hygiene episodes observed across CLCH services (excluding bedded areas) that are compliant with Effective Services 97.0 % 9,700.0 % 9,700.0 % policy Percentage of local clinical audits, service evaluations and quality improvement projects undertaken by services. 40.0 % 60.7 % 64.5 % Percentage of services completing NICE Baseline Assessment Form within agreed timeframe 80.0 % 90.2 % 99.0 % Modelling the Way Providing world class models of care, Statutory and mandatory training compliance 95.00 % 93.48 % 93.50 % education and professional practice Staff Vacancy rate (Clinical) 10.00 % 13.23 % 13.20 % Here, Happy, Healthy & Heard Staff Turnover rate (Clinical) 10.00 % 15.53 % 15.53 % Recruiting and retaining Staff engagement index score 3.88 % n/a n/a outstanding clinical workforce Sickness absence rate - 12 month rolling (Clinical) 3.50 % 3.79 % 3.79 % September - Trust Level New Bank staff recruited 164.00 12.00 57.00 Only Percentage of staff who have an appraisal 90.00 % 87.72 % 87.70 % Staff to have been trained to basic level in improvement skills including Lean 7.5 % 9.6 % 9.6 % Value Added Care Services have used improvement tools 1.0 % 5.5 % 5.5 %
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1.1 Introduction The quarter 2 quality report for 2018/19 provides updates against each of the 6 campaigns with performance data which is linked to the quality scorecard KPIs. Each section also provides insight into some of the ongoing work and actions as well as progress made with the year two key quality strategy outcomes. The appendices provide more detailed informatics on the incidence of pressure ulcers and complaints.
2.0 Positive Patient Experience • Responsible Director, Holly Ashforth, Director of Nursing & Therapies (Experience & Learning) • Supporting strategy: PPE • Co-ordinating council: Patient Experience Co-ordinating Committee
2.1 Dignity & Respect The Trust has achieved the 95% target in quarter 2 with an average of 98.7% of patients responding positively. The Patient Experience team continue to work with divisions to support training for staff on effective communication and this will now be integrated into the Band 1 to 3 staff development programme currently being designed. In addition, a customer care apprenticeship is being discussed at the Trust Apprenticeship forum with the aim that this would be targeted at all front line administrative staff.
Graph 1: Proportion of patients who reported that they felt were treated with dignity and respect 100% 95% 90% Percentage Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2017/18 Percentage Threshold
2.2 Friends & Family Test (FFT) In the FFT we ask patients how likely they would be to recommend our services to their friends and family. This is calculated by subtracting the number of people who would not recommend the service from those who would. In line with the national target for the number of patients who would recommend the service to their families and friends, the Trust has a target of 95%.
In Quarter 2, the Trust has achieved an average of 94% against the target of 95%. However, there was a slight decrease in September which correlated with a reduction in the number of PREMs received in that month. The monthly FFT meetings, chaired by the Director of Nursing and Therapies, continue with a focus on key actions to increase the awareness of our FFT score Trust wide, increasing the number of PREM responses and improving the overall FFT positive response percentage. As a result, a new FFT Hub page has been developed which breaks down the monthly scores across each division, highlights some top tips for increasing the response rates, and outlines the process map for the collection and return of the comment cards and the PREM surveys.
‘Talk back Tuesdays’ have been implemented in the North division enabling dedicated time for all staff to gain patient feedback. This initiative has been extremely positive and has supported an increase of PREMs responses and therefore, the aim is to now roll this out
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across other divisions. There is also some targeted work being delivered alongside Healthcare Communications to look at ways to encourage patients to leave positive or negative feedback, rather than the neither/nor responses which have a detrimental impact on the overall FFT percentage and also mean that services are not given valuable feedback to support continued improvement.
Graph 2: Friends and Family test - percentage of people that would recommend the service 96% 94% 92% 90% Percentage 88% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2017/18 Percentage Threshold
2.3 Explaining Care We ask patients if their care was explained to them in a way they could understand and graph 3 shows those patients who said that it was. In quarter 2, the Trust continues to achieve over the target of 92% averaging 95.5%.
In order to continue to support this improvement, a number of initiatives have been implemented as outlined in the key outcomes table below.
Graph 3: Proportion of patients whose care was explained in an understandable way 100% 95% 90% Percentage 85% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2017/18
Percentage Threshold
2.4 Involvement in care We ask our patients how involved they have been in planning their own care. Graph 4 represents those patients who said that they were as involved as they wanted to be. In quarter 2, the Trust continues to achieve the target of 90% with an average of 92.1%.
The Patient Experience Team continue to support services with the Always Events project and are in the process of developing two further projects across End of Life services and the Learning Disability Services as outlined in the key outcomes table below.
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Graph 4: Proportion of patients who were involved in planning their care
95% 90% 85% 80% Percentage Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2017/18
Percentage Threshold
2.5 Overall Experience The Trust continues to achieve the 92% target for patients rating their overall experience as good or excellent with an average of 94.1% achieved in Q2. In order to continue to improve this and enable greater service level understanding of the patient feedback received each month, each division has now received Envoy (Patient Experience software) training. This allows staff to analyse their individual feedback and receive timely notices if there are any negative comments, ensuring that real time improvements can be made. Each of the ADQs also now receives alerts when one of their services receives negative feedback enabling them to support positive changes being made.
Graph 5: Proportion of patients rating their overall experience as good or excellent 96% 94% 92% 90% Percentage 88% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2017/18
Percentage Threshold
2.6 Complaints The Trust continues to ensure that all complaints are responded to within 25 working days with 100% achieved against the target of 95%. In quarter 2, 21 complaints were received and all of them were acknowledged within the statutory timeframe of 3 working days.
• In July 2018, 8 formal complaints were received and all were resolved in writing subsequent to a formal investigation • In August 2018, 7 formal complaints were received and all the complaints have been resolved in writing subsequent to a formal investigation • In September 2018, 6 formal complaints were received and all have or are being resolved in writing subsequent to a formal investigation
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Appendix 1 provides an overview of the 21 complaints received in Quarter 2 including the top themes, locations and learning.
2.7 Complaints Audit: The Patient Experience team have been visiting services to speak with staff and patients about their awareness of how to raise a concern or make a complaint. At each visit 5 staff members and five patients were spoken to about the PALS and complaints process.
Of the 12 services that were visited, all bar 1 had both the complaints posters and leaflets on display and staff were aware of the complaints process and were able to direct patients on how to do so. 11 of the 12 (92%) services had patients who stated that they were aware of how to raise a concern or make a complaint, 1 was not sure. The 1 service (Health Visiting and School Nurses at Edgware) where no poster was available do not have a reception area to display this. Therefore, leaflets will be provided so that staff can leave these on display when carrying out the baby clinic.
The audit found that although many patients spoken to at each of the 12 locations were happy to raise a concern or complaint when needed, they preferred to talk to the nurse/coordinator first to discuss their issues with a view to them being addressed and resolved at the time. Each of these services will now have a PALS and complaints surgery delivered on location to further engage patients on the PALS and Complaints processes and how concerns and complaints can be raised.
In September 2018, there was a PALS & Complaints surgery held at Edgware Walk-in Centre with great feedback provided. All the patients spoken to had used the services previously and were very happy with the service provided and would be likely / extremely likely to recommend them to their friends & family.
2.8 Complaints training: Complaint training is now available for colleagues to book on to, with a face to face session being delivered by the complaints team each month.
Graph 6: Number of Complaints received per month 20
15 10 5 Number of of Number Complaints 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2017/18
Graph 7: Number of PALS received per month
100 50 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Number of of Number PALS 2017/18
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2.9 PALS Overview: Resolving 90% of concerns within 5 working days remains a continued focus and in quarter 2, 100% was achieved. 164 Issues for resolution were received in quarter 2 which included:
• CHD=10 • Corporate Services = 3 • Inner=29 • North=76 • South=46
The analysis of PALs concerns received in quarter 2 has helped shape the Patient Experience quarterly projects, which are highlighted in the key outcomes update below.
2.7 Key Outcomes
Key Outcomes Measures of success Update 2018/19 Service 92% or above of In quarter 2, the Trust continues to achieve over 92% developments and proportion of patients having maintained an average of 95.5% of our plans of care co- whose care was patients responding positively. Patients have designed with explained in an reported that they feel that their care plans have patients and service understandable way been explained to them in an understandable way users and they continue to feel involved in the decision making process about their care.
90% of proportion of In quarter 2, the Trust continues to achieve over 90% patients who were with an average of 92.1% of our patients responding involved in planning positively. Through each of the new quarterly Patient their care Experience projects being delivered across each of the four Divisions, the Patient Experience team will ensure that patients are asked how they wish to be involved in their care. Where patients state that they don’t feel like they have been appropriately involved, then we will seek to understand what it is we could have done better. This feedback will then help shape the service level improvements which are then implemented and monitored by the Patient Experience team. The use of co-design Each Patient Experience Facilitator is now managing will be evaluated across quarterly co-design projects focusing on one service the organisation in particular which has been identified through staff and patient engagement and feedback.
South/Inner Division: The podiatry service is the focus for this quarter’s co-design project due to feedback from patients about their experiences specifically around appointment issues. A bespoke survey with the focus on appointment concerns has been used at clinic site visits to support discussions with patients waiting to be seen. The feedback has highlighted the key issue for patients as being long
34 12 waiting times between appointments. Discussion with service leads identified high level of DNAs (patients not attending their appointment) in the service and a failure to discharge all low risk patients as being the main contributing factors to this. Patients also advised that when waiting for an appointment, they are being asked to call the SPA daily to see if any cancellation slots are available which they find time consuming and frustrating.
Through engagement with staff and patients, the agreed improvement targets for the quarterly project are: • Reduce DNA appointments by 20% across Inner boroughs over the next quarter (Q3). • Achieve 90% positive FFT recommendations during Quarter 3 (current avg. 83%) / Reduce PALS concerns related to appointment issues by 25%.
The actions that have been agreed to support targets are as follows: • SPA will change system for allocating cancellation slots and create a waiting list for patients so cancellation slots can be offered proactively with no need for patients to call SPA daily • Drop-in appointments to be considered for pilot podiatry site aiming to reduce DNA’s by offering multiple patients morning or afternoon times with first come, first served time allocation of appointments • The service is considering the introduction of automatic reminder text messages to service users to help drive the reduction of DNAs.
Patients will be updated on the actions being taken with information displayed in clinic waiting areas.
Inner Division: The Patient Experience Facilitator is working closely with the District Nursing teams in Harrow, Hammersmith and Fulham, West London and Central London to look at the end of life care offered to patients and the bereavement processes for their relatives. Through this project we are trying to find out what we do well and what we can do better, supporting CLCH’s aim to provide the best possible end of life care now and in the future. The aim is to contact approximately 20 patients from Harrow and 6 or 7 patients from each of the tri- boroughs.
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The project started at the beginning of August when the PEF met with the locality leads to identify relatives who are appropriate to contact before making contact via telephone or sending out a postal survey. The survey covers questions such as whether the District Nurses explain the patient’s condition in a way that was easy to understand, whether relatives were involved in the care, whether the patient was treated with dignity and respect, whether the patient was made to feel comfortable and peaceful, whether relatives knew how to contact the District Nursing team if additional support was needed, whether care was coordinated, if sufficient bereavement support was given/offered and the level of emotional support given by those caring for patient.
The Patient Experience Facilitator is currently gathering data and the next stage of the project will be to analyse this and compile any key themes. The final stage will be to hold a co-design event with relatives, staff and stakeholders to co-produce the actions identified for end of life care and bereavement.
North Division: The North Division quarterly co- design project is focusing on the Phlebotomy service due to the number of PALS concerns each month and variable patient experience feedback. Many of the concerns are around the patient’s ability to contact the service to book or change an appointment.
The Patient Experience Facilitator has been working alongside the Patient Safety Manager and has started to engage both patients and staff about their experiences when trying to contact the service. Much of the feedback that has been gathered to date has been hugely positive, however, there have been concerns raised about the online booking platform and its complexity and the inability to change/move appointments online. Patients have also noted that when they call the service directly to cancel/move or change an appointment, it is difficult to get another appointment in an appropriate time frame.
The Patient Experience Facilitator will now be working with the Service leads and the Associate Director of Quality to identify areas of improvement and will be working closely with the SPA team to action these. Updates of each of the quarterly projects will be brought to the monthly PECC meeting.
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Evaluation from patient The Patient Experience team will be working feedback of their alongside the Shared Governance Programme Lead involvement in the to design and facilitate a follow up patient feedback Quality Councils event in Q3.
Following the 2018 AGM, the newly appointed programme lead for Shared Governance has identified an additional 10 patient representatives that wish to play an active role in the Shared Governance Councils.
The Head of Patient Experience has met with the Shared Governance Programme Lead to discuss the need for a Quality Council to develop and implement a plan around the recruitment and retention of patient and staff representatives on each of the Councils. This piece of work will align with the aim to review payment and recognition for patient involvement following feedback from patient representatives that they would benefit from accreditation, training and reimbursement in recognition for the time they give to CLCH. This is going to be discussed at the October PECC meeting. Patient stories and Evaluation of Always The Patient Experience team have now started to diaries used across Events and their impact audit and evaluate the success of the very first pathways to identify on patient experience Always Event project delivered across each of the touch points and District Nursing teams. A patient survey will be used `Always events’ to ensure that the scripts, training and leaflets continue to have a positive impact on the patient experience and are being used. Once the results have been collected, they will be analysed and recommendations made as required.
The Head of Patient Experience was chosen by NHSE alongside 5 other Trusts nationwide to be trained as a mentor to help support other Trusts with their Patient Experience initiatives as well as offering expert knowledge on the implementation of an Always Event.
The End of Life Always Event is now well underway which will be co-designed with staff and bereaved family members. The relatives have now been identified and telephone surveys are being undertaken to help shape the vision and next steps for the project. Quality Councils to start In order to take the development of Always Events leading on the forward through the Quality Councils there needs to development of Always be an increased level of engagement with our patient Events with local representatives. This will be discussed as part of the implementation new council being implemented to address the issues
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the Shared Governance Councils have been having with the recruitment and retention of both staff and patients to the councils. In addition, the Patient Experience team continue to engage patients and staff in the Always Events Journey and involve local Quality Councils where possible. Thematic analysis of The annual Patient Stories report has been previous year’s stories developed and was shared with the PECC on the 19th with shared learning July before being presented to the Quality Committee on the 24th July. The thematic analysis from this report alongside the many other avenues used to collect patient feedback has helped shape the new 2018-2020 PPE strategy.
Patient Stories will feed into the Patient Experience Facilitators quarterly projects and through the new 15 steps challenge framework, the Patient Experience team are now able to identify housebound patients that are happy to share their stories. Continued use of The Patient Experience Team continues to deliver patient stories by all patient stories training across each of the divisions to services and shared at support staff continuing to collect and learn from Divisional and Trust them. In addition, patients have been engaged with forums the development of patient videos to support the training.
The Head of Patient Experience continues to note the importance of the collection of patient stories through the induction days for new staff.
The Patient Experience team are focusing on increasing the number of Dynamic stories (films/pictures/drawings) being collected across the Trust. Once completed, these stories will be shared at all Divisional boards, and a number of Trust forums (PECC, Quality Committee, and the Trust Board). Patient feedback Patient feedback will be To ensure that the patient voice is heard, any used to inform staff integral to the review incidents or complaints where staff training needs training and development of may have been identified are bought to the education and training Modelling the Way forum. In addition, incidents and patient feedback continue to be discussed at the Trust End of Life Care Operational Group and Learning Disability forum in order to identify any specific training requirements.
In addition, patients are being involved in training, for example, the Always Event training for staff and the Dementia Care Champions programme.
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Evaluate how patient The new District Nursing Always Events training feedback has influenced which has been designed by staff and patients as training and education equal partners continues to be used in the Compassion in care training programme. Feedback from patients and staff has been extremely positive and all have highlighted the benefit of patient involvement.
Following the June Co-Design event, patients fed back that they would benefit from some level of training or accreditation to ensure they felt comfortable in being equal partners in the decision making process across CLCH. The Head of Patient Experience is working with the QI programme lead to explore QI training for patients and service user representatives. The Q Network has recently allocated funding for nationwide training for patient reps in QI methodology which CLCH will look to be involved in whilst also looking to design in house training around the wants and needs of our patient representatives. Evaluate the use of The Patient Experience team are now being invited patient stories as part of to 48 hour meetings for patients who have learning from serious developed a Pressure Ulcer with the aim of incident reviews identifying patients who can be interviewed. To date, no patients have agreed to give their story and therefore, the Head of Patient Experience has been working with the Head of Patient Safety to reword the ‘Being Open’ letter. This will now ensure that the request for a Patient Story is incorporated with the reasons for this clearly explained to the patient before any future contact is then made by the Patient Experience team.
2.8 Assurance Issues from the Patient Experience Coordinating Committee (PECC) There are no specific areas of concern to bring to the attention of the Quality Committee. The Patient Experience Coordinating Committee continues to meet each month. Standing agenda items include an overview of patient experience outcome measures and engagement activities and a monthly report on complaints including themes and vignettes of learning. Specific actions being taken to address performance have been outlined in the quality report. A patient story has been shared at each meeting and a new standing agenda item includes discussion on a particular area of focus or interest for the Trust in relation to patient experience. In quarter 2, this has included loneliness and the Trust strategy for volunteers. In October, the committee will be holding a workshop to review the percentage of staff recommending CLCH to their family and friends with the aim of identifying actions that can be taken to improve this. An update will be provided in the quarter 3 quality report.
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3.0 Preventing Harm • Responsible Director: Director of Nursing & Therapies (Quality & Safety) • Supporting strategy: Risk Management • Co-ordinating council: Patient Safety & Risk Group
As a learning organisation we use root cause analysis (RCA) methodologies to investigate every serious incident and enable lessons to be learnt and disseminated across the trust. Following the RCAs, actions plans are created, monitored and key messages are widely shared. Discussion of incidents and the associated lessons learnt are important and help us to reduce the risk of reoccurrence. Incidents are regularly discussed within team meetings to ensure lessons are learnt. Discussions also take place at specific meetings such as the Pressure Ulcer Working Group, the Falls Steering Group, Information Governance Group and the Patient Safety and Risk Group. Summaries and highlights are then presented to the Quality Committee.
Our red flag process is progressing well. We developed it to improve our responsiveness in supporting teams to maintain and improve the standards of quality. A monthly list is produced that highlights services which either do not meet two of the following key criteria in a single month or who have not met one criteria for two consecutive months. The current criteria are: • Team Leader absence > 1 month • Clinical Vacancy Rate > 10% • Sickness Rate >3.5% • New external SI reported • New internal (clinical) SI reported • 10% increase in incidents causing harm • Increase in complaints
This is now reported quarterly to the trust Quality Committee. However, the red flag dashboards are presented by each division and discussed at the monthly trust performance meetings.
3.1 Proportion of clinical incidents that did not cause harm In September 2018, 96.1% of clinical incidents reported did not cause harm (moderate or above) achieving the trust target of 96%. This contributes to a year to date figure of 97.2% exceeding the trust target. Most harms in Q2 (89%) were pressure ulcers in community patients, which is similar to the reporting pattern in 2017/18 and Q1 (83%). The other reported harms in Q2 were falls, delay/failure to diagnose, problems with appointments and information incident. A breakdown of harms by severity and location is shown in table one.
Table 1: Harm by severity & location CBU Moderate Severe Total Harm Harm 24 Hour Services 1 0 1 Barnet Community Nursing 7 0 7 Barnet Inpatient Units 4 0 4 Community Nursing: Tri Borough 12 3 15 Corporate Services 1 0 1 East Merton Locality 2 0 2 Harrow Integrated Care and Podiatry 2 1 3 Specialist Nursing & Podiatry 0 1 1
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Wandsworth East, West and South Localities 8 1 9 Wandsworth North Locality 9 0 9 West Merton Locality 4 0 4 Total 50 6 56
The 6 incidents categorised as severe relate to category 4 pressure ulcers (5) and an incident in the podiatry service currently being investigated related to a potential delay / failure to diagnose.
Every six months the National Reporting and Learning System (NRLS) publishes a Patient Safety Incident Report detailing the patient safety incidents for the organisation in a preceding six month period, and comparing the organisation to other similar trusts. All of this can be accessed through the NHS Improvement website: https://report.nrls.nhs.uk/explorerTool/default.aspx
There has not been a further data release since May 2018 which was reported in the Q1 Quality Committee report. It is therefore anticipated that the next data release will be included in the Q3 report.
3.2 Zero tolerance to falls in bedded units with harm (moderate or above) This was a new KPI for 2018/19. During Q2, two incidents causing moderate harm have been reported from the bedded units: one on Marjory Warren Ward and one on Adams Ward. Both are now subject to root cause analysis investigation (one internal and one external serious incident) which are due to be completed in November 2018. This is the same figure as reported in Q1 from Marjory Warren Ward and Jade Ward.
3.3 5% reduction in pressure ulcers (grade 3 and 4)
Graph 8: Incidence of grade 3 & 4 pressure ulcers against 5% reduction target (calendar month, taken from Datix) 20 15
10 5
Ulcers 0 Number of of Number
and 4 Pressure 4 Pressure and Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Community Grade 3 3 Grade Community 2017/18
The Q2 target was for fewer than 24 grade 3 and 4 pressure ulcers to be reported. 38 were reported on the monthly trust scorecards.
The classification of incidents changes when they are investigated. This means that the data in Datix does not become fixed for approximately two months. When Datix was reviewed on 04/10/2018, 24 grade 3 and 4 pressure ulcers were identified within the reporting period, not 38, although it should be noted that a number of these are still going through the weekly review process with the Patient Safety Team, Director of Nursing and Therapies and Associate Directors of Quality.
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The Datix data extracted on 04/10/2018 shows that the Q2 target was achieved.
From May 2017, the Patient Safety Team has provided monthly feedback to divisions on the numbers of pressure ulcers reported as well as the top three learning points from the investigations completed during the preceding month. Each quarter, information is collated into a report which is shared within the divisions for discussion about how the lessons learnt locally and trust wide can be implemented to prevent reoccurrence.
3.4 Zero tolerance of grade 3 and 4 pressure ulcers in bedded units
Graph 9 Incidence of PU (grade 3 and 4) in bedded units
2
1
0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2017/18 Number of of Number incidents Number Threshold
The trust has a zero tolerance of grade 3 and 4 pressure ulcers in the bedded units however; two Category 3 pressure ulcers were reported during Q2. One was on Jade and one was on the Pembridge Unit. Both incidents are being investigated as serious incidents and are therefore subject to root cause analysis. These are due to be completed in October and November 2018.
3.5 NHS Safety Thermometer The NHS safety thermometer is a national prevalence survey. It is conducted on one day each month when our nurses review all relevant patients to determine if they have suffered any harm as a result of their healthcare. The categories they review include pressure ulcers, falls, catheter associated urinary tract infections (CAUTIs) and venous thromboembolism (VTE). Their data is fed back to a national data base, which is used for comparison and benchmarking. All data can be reviewed at www.safetythermometer.nhs.uk. The national target is that 96% of patients are harm free; this applies to the overall score as well as each individual category. The Board has set a stretch target that 98.5% of patients are harm free.
3.6 Harm Free Care We calculate the percentage of patients on the safety thermometer survey day that did not have any of the harms being monitored. This includes harms which occurred within CLCH (new harm) and those that occurred with other providers (old harm). The majority of patients suffer no harm at all with more than 91% of patients free from any harm in the last 12 months. In Q2, the trust target for new harm free care was achieved in August and September 2018 but was missed by 0.4% in July (there were 27 new pressure ulcers, 11 falls and 2 UTIs reported in July).
N.B: It is important to differentiate between all harms and new harms. New harms are those which occurred whilst the patient was under CLCH care and exclude harms that the patient had already sustained when they arrived in our care, for example a patient discharged from an acute hospital to the district nursing service with a pressure ulcer.
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Graph 10: The proportion of patients whose care was harm free (new harms)
100% 98% 96% 94% 92% 90% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Percentage Percentage harm free 2017/18
All Harm Free CLCH Harm Free (New Harms) Other Harm Free Threshold
Graph 11: The proportion of patients that did not have a pressure ulcer
100%
95%
90% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep free PU Percentage 2017/18
All PU Free CLCH PU Free Other PU Free Target
Graph 12: The proportion of patients that did not have a fall
100%
98%
from falls Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Percentage free free Percentage 2017/18 Percentage Threshold
On the safety thermometer survey day, we count the number of patients who fell in the previous 3 days. Both the national target and the trust target of 98.5% were achieved in all of the last 12 months.
3.7 Key Outcomes
Key Outcomes Measures of success 2018-19 Update Systems in place to Maintenance of 98% or > harm free The trust target (98.5%) for new provide early warning care (Safety Thermometer) harm free care was achieved in to illness, service August and September 2018 but failure or a reduction was missed by 0.4% in July (see in the quality of care section 3.6 above).
Incidence of PU and falls will Please see sections 3.2 and 3.3 continue to fall above – both are flagging red YTD
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on the scorecard although Q2 performance was improved for pressure ulcer reporting. Red flag evaluation will take An academic review of process is place to be commissioned. This is pending the completion and outcome of the Academy tender process as the successful academic institute will be approached to undertake this piece of work. Reporting of incidents increases The number of incidents affecting whilst levels of harm reduce patients in Q2 was 2147 which is a 7% decrease from those reported in Q1 although still higher than the number reported in Q4 of 2017/18. The level of harm being reported remains static between Q1 and Q2 with 97% of incidents leading to no/low harm in both quarters and 3% leading to moderate harm and above. Zero tolerance of grade 3 and 4 PU Not achieved; two inpatient acquired in bedded areas pressure ulcers (both category 3) were reported in Q2. Please see section 3.4 above. 100% RCA completed on time Achieved. All 19 external SI RCAs due in Q2 were submitted on or ahead of schedule (excluding those de-escalated (2)). Proportion of clinical incidents that A year-to-date figure of 97.2% has did not cause harm (moderate to been achieved, exceeding the catastrophic categories) target. Please see section 3.1 above. Safety culture and Safety culture and activities During Q2, the Patient Safety Team activities signed up to signed up to in all services dedicated July 2018 to being in ALL services Patient Safety Awareness Month and visited a number of sites and teams to discuss all patient safety and risk matters including: • How to report an incident • What should be reported • Using Datix • Being Open and the statutory Duty of Candour • Learning from incidents which have been investigated • NHS safety thermometer Variations in practice Quality Action Teams to develop During Q2, three teams have been identified and acted areas to exemplars awarded Quality Development Unit
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upon status: Paediatric SLT team (Inner London), Barnet MSK Team and HARI Service (Merton). Develop a learning repository to During 2017/18, the key learning enable teams and services to share from pressure ulcer investigations issues identified from incidents has been shared on a dedicated 2017-18 and evaluate the use of the pressure ulcer learning page of the repository and its effectiveness Hub. Quarterly reports are also 2018-19. produced and circulated to the divisions. This has been continued into Q1 and Q2 of 2018/19 and during Q3 will be further developed with an additional page dedicated to learning from falls incidents. Furthermore, during the second half of the year the process will be evaluated.
3.8 Assurance Issues from the Patient Safety and Risk Group There are no specific areas of concern to bring to the attention of the Quality Committee. The Patient Safety and Risk Group met twice during Q2 in July and September. Being Open data is reported within the Clinical Divisions’ reports to the Patient Safety and Risk Group and performance during Q2 has been as expected. Risk registers continue to be scrutinised during the meeting with all risks rated 12 and above being presented for approval and all risks of all levels presented for approval for closure. There are two areas for which further information/assurance is being sought for the next meeting of the PSRG – Patient Safety Alerts and completion of works by Sanctuary at Athlone.
4.0 Smart, effective care • Responsible Director: Jo Medhurst, Medical Director • Supporting strategy: Continuous Improvement / Clinical Strategy • Co-ordinating council: Clinical Effectiveness
The Clinical Effectiveness Group (CEG) meets bimonthly and reviews the following; • Pressure Ulcer Working Group • Clinical Outcomes Project • NICE Working Group • Audit • The Catheter Associated Urinary Tract Infection (CAUTI) Steering Group • Falls Steering Group • Venous Thromboembolism • Medicines Management Group • Research
4.1 Proportion of patients who did not have CAUTI This category of harm counts the number of patients on the day of the survey who have a CAUTI. The target of 99% has been met during quarter 2.
Graph 13: Proportion of patients who did not have a CAUTI
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100% 99% 98% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep from CAUTI
Percentage free free Percentage 2017/18 Percentage Threshold
4.2 Proportion of patients who did not have a VTE We count the number of patients on the day of the patient safety thermometer survey who have a VTE, such as a deep vein thrombosis (DVT). In July and September this target was met. However, in August 99.9% of patients were free from VTE. This was due to the identification of a patient with a new VTE in the Alexandra Rehabilitation Unit. This is under investigation by the ADQ and the unit.
Graph 14: Patients free from VTE 100% 99%
98% 97% free Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Percentage VTE VTE Percentage 2017/18 Percentage Threshold
4.3 Percentage of deaths in community hospitals This KPI measures the percentage of deaths in community hospitals (expected and unexpected) compared to all discharges (excluding palliative and end of life care). The death rate remains within the expected limits this quarter.
Graph 15: Percentage of deaths in community hospitals 4.0% 2.0% 0.0%
Percentage Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2017/18 Percentage Threshold
4.4 Proportion of safety alerts due, and responded to, within deadline In quarter 2, 100% of Central Alerting System (CAS) alerts including Patient Safety Alerts (PSAs) were responded to within the deadline.
4.5 Hand hygiene This KPI is now reported quarterly. It measures the percentage of hand hygiene episodes observed across CLCH services (excluding bedded areas) that are compliant with policy. The compliance target is 97%. Following the Trust-wide computer outage and loss of access to the Keypoint data entry and extract system during the first quarter, there has been a delay in extracting the data however, this should be available at the end of October 2018.
4.6 Local clinical audits, service evaluations and QI projects undertaken by services.
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The year-end target is 40% and in quarter 2, this has been achieved as outlined in graph 16 below.
Graph 16: Percentage of local clinical audits, service evaluations and quality improvement projects 100% 80% 60% 40% Percentage 20% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2017/18
Percentage Threshold
4.7 NICE baseline assessment As shown in graph 17, in quarter 2, this target was met with over 80% of NICE baseline assessment forms completed within the 6 month deadline.
Graph 17: Percentage of services completing an NBAF within agreed timeframe
100% 80% 60% 40% Percentage Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2017/18
Percentage Threshold
4.8 Key Outcomes
Key Outcomes Measures of success Update 2018/19 Clinical staff use the CAS alerts (Inc. PSAs) – The Infection Prevention/Medical Devices most up to date clinical Monthly Board KPI target Team continues to achieve full compliance practices for timely alert closure relating to this measure as noted in section ≥90% 4.4. NICE – 80% of services We met the KPI target for this quarter as complete a Baseline shown in section 4.7 and continue to monitor Assessment Form for it. NICE Guidance within the agreed timeframe There will be a 78% staff able to This metric is measured annually and is not demonstrable culture contribute to yet due. It will be measured through the of clinical enquiry and improvements at work Trust staff survey which begun on 5th October continuous (staff survey) 2018. improvement across Central resource Staff have access to the Continuous the trust dedicated to Improvement page on the Hub which
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improvement analytics contains analytical tools, support materials and training information. Support and training can also be accessed from peers or the Improvement Team via the analytics and improvement networks using a web based forum on the hub CLCH will be a leader in Each Division to identify The West Herts West Herts Respiratory innovative community within business planning Service in the North Division is setting up practice process an innovation for innovative work to improve patient care and 2018/19 outcomes as well as antibiotic stewardship and preventing hospital admissions. We have been liaising with the remaining divisions to encourage them to identify innovation processes in their business planning. Specifically, we have organised and will be inviting participants from all divisions to a CLCH Research and Audit conference organised for December 14, 2018 where we intend to engage in conversations on viable examples of innovative items. Research activity CLCH have met this target by recruiting over increased by 5% 163 participants into studies by the end of the quarter 2. 148 of these were recruited for the PreP impact study.
4.9 Assurance Issues from Clinical Effectiveness Group (CEG) There are no specific areas of concern to bring to the attention of the Quality Committee. The CEG met in July and September. Standing agenda items included an overview from CEG working groups. Of note, the CEG agreed that future meetings would change from bi- monthly to quarterly. Overall the working groups reported satisfactory updates across all areas. Also discussed and agreed were steps for working more closely with the shared governance councils focusing on Clinical Effectiveness. The group commended the work of the Merton Falls Team following their presentation on the visual screening tool designed for older adults in collaboration with Health Innovation Network’s Healthy Aging Team.
5.0 Modelling the way • Responsible Director: Holly Ashforth, Director of Nursing and Therapies (Experience & Learning) • Supporting strategy: Education & Training • Co-ordinating council: Modelling the Way
The Trust continues to implement initiatives that have been developed to support the development and retention of our workforce, which include further cohorts of the Band 5 Fast Track programmes and 18 month Band 5 community nursing programme. The Band 6 Community Nurse development programme, which includes the Team leader level 3 apprenticeships also continues to be delivered and the Trust is now able to offer the Team leader level 3 apprenticeships as a standalone apprenticeship to other staff groups including Health Visitors, School Nurses and AHPs. The first cohort for is planned for November 2018.
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Work continues on the review of the HCA band 1 -3 development programme which will include the care certificate which has previously been delivered as a standalone course. The aim is to start this in November 2018. In addition, we plan to be able to offer the Health and Social Care level 2 apprenticeships for band 2 HCAs across the Trust.
As part of the bedded rehabilitation transformation project, the development programmes for bands 1- 4 and 5 -7 have been reviewed and will be offered from November 2018.
The Trust has recruited 6 pre-registration nursing students who have undertaken their training as part of the community nursing pathway in the Trust with Kings College London.
The Trust continues to engage with the 4 Trainee Nursing Associate (TNA) pilot sites. The first 2 TNAs, supported by the Trust, are due to qualify in January 2019 and a further 6 in April 2019. Work is underway to ensure processes are in place to support these staff, supporting them through their transition from TNA to Nursing Associate. It is anticipated that this will follow the Trust’s Preceptorship policy for newly qualified healthcare practitioners. Work has commenced on the development portfolio for the Nursing Associates and will be implemented for the first group qualifying in January 2019.
Following a robust procurement process, the Trust has awarded London Southbank University (LSBU) the contract to deliver the training for our future Nursing Associate apprenticeship. Following this, the Trust has since been successful in its application to HEE, to become a 3rd wave Nursing Associate test site. Recruitment is currently underway to appoint to 58 TNAs and it is expected that they will commence their training in October, with 2 further cohorts planned for November and December 2018. In order to support the TNAs, the Trust has appointed 1 Practice Educator and will be recruiting a further 3 to ensure there is support for this new role within each division.
The Trust formally launched the CLCH Community and Primary Care Nursing Academy (CPCNA) on 20th September 2018 with a short brochure outlining the purpose and aims of the academy including an overview of the opportunities available for primary care nursing. Alongside this, a twitter account has been developed and specific email address – [email protected]. We are currently meeting with Community Education Provider Networks (CEPNs), GP’s, commissioners and other stakeholders to talk to them about the Academy and the feedback has been extremely positive. Work remains on going to develop the website and full brochure outlining all opportunities for staff and the first Academy Board meeting will be held in November 2018. The Trust is currently in the final stages of the procurement process for awarding the University partner for the Academy and interviews have taken place to appoint the Implementation programme lead.
As part of the aim to develop ‘Towards 2023’, the Trust Clinical Workforce strategy, the Trust held a final event for Health Visitors on 2 August 2018. A meeting has also been held with Pharmacy, dental and psychology staff to ensure they are engaged and inform the key priorities and objectives. The aim is to have completed the strategy by 31st October 2018.
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5.1 Statutory & Mandatory Training
Table 2: Trust and divisional compliance with statutory and mandatory training Q2 18/19 Statutory and Mandatory July 2018 August 2018 September 2018 * training Compliance (Target is 95%) Overall Trust Compliance 93.48% 93.02% South Division 87.74% 88.89% 89.74% Inner Division 94.80% 95.18% 94.18% North Division 93.53% 94.32% 93.82% Children’s Division 93.01% 93.52% 92.71%
* includes services recently mobilised
Compliance has improved during quarter 2 however, in September the overall compliance has dropped very slightly as a result of newly mobilised and demobilised services. The third Statutory and Mandatory Training Booklet has now been launched across the Trust and the new Welcome Booklet (including the six month induction and probation period) will be launched at the end of October 2018.
The Head of Learning and Development continues to meet with CBU managers to monitor and manage compliance and address any bottlenecks or challenges they may have with training. The ‘at a glance’ non-compliance reports have supported a greater ability to identify areas for focus and action.
The new face to face training day continues to provide staff with greater options to complete their training and has enabled staff to attend training when it is easier to be released for a day’s training rather than separate hours across a number of days.
The Statutory and Mandatory Training Policy has been updated and is now available on the Hub. The policy sets out the revised process for managing compliance with statutory and mandatory training. Information has been sent out to staff including communicating how managers and staff can work together to stay up to date with training and how staff can make use of Allocate to request study leave. In addition, the ‘MyESR’ App is now available for all staff using ESR to download. This provides staff with the option of undertaking on line training no their mobile devices.
5.2 Key Outcomes
Key Outcomes Measures of success Update 2018/19
New roles and Reduction of vacancy rates In September 2018, the Trust vacancy rate career pathways are across the Trust (10%) was 12.62%. The Trust continues to engage in place which with our partner HEIs attending job fairs and supports the needs placement forums to actively promote the of patients/service recruitment of newly qualified staff into band users. 5 posts. The Trust continues to work with Kings College London on the community pathway and 12 students have been recruited onto this from the September 2018
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cohort. The University of Hertfordshire has also agreed to support students on a community pathway and 5 students have been identified from their September 2018 cohort. LSBU are also working with the Trust to implement a child community hosted pathway. Improved staff turnover In September 2018, the Trust’s turnover rate across the Trust (10%) is 15.53%. As noted in the campaign update, a number of training and development programmes have been developed in order to support staffs career development. In addition, the Nursing and AHP career pathway have also been developed and are available for staff. The continued The Trust Apprenticeship Forum (TAF) meets implementation of monthly to review the implementation of the Apprenticeship roles apprenticeship strategy and policy. They also review and update the Trust’s self- assessment report (SAR) which informs the development of the apprenticeship quality improvement plan (AQIP). Both of these documents are required as ongoing preparation for an Ofsted inspection.
The Trust has completed the procurement for the level 5 Nursing Associate Apprenticeship, with London Southbank University (LSBU) being awarded the contract. The first cohort is planned for October 2018, with 2 further cohorts in November and December 2018.
The Trust continues to deliver the Team Leader level 3 apprenticeships with the 3rd cohort commencing in June 2018.Currently there are 21 staff enrolled across the 3 cohorts. The Team Leader Level Three Apprenticeship is now being offered to other staff groups including Health Visitors, School Nurses and AHPs. The first cohort for is planned for November 2018.
The Trust is now also able to offer the ‘Work the Healthcare Support Worker’ Level 2 apprenticeship with the aim that this will be offered to band 2 HCAs across the Trust. Existing staff within band 2 roles already have the qualification or equivalent so this will now be offered to new starters in band 2 roles.
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The evaluation of the Nurse The Trust remains involved in 4 pilot sites Associate pilots in Adults and across London. 3 TNAs have withdrawn from Children services the programme for personal reasons and one for academic failure. The remaining 7 adult TNA are progressing well and feedback from them has been very positive. The first 2 TNAs are due to qualify in January 2019 and the remaining 5 in April 2018.
HEE continues to monitor all pilot sites through regular monitoring visits and ongoing evaluations. To date evaluations remain positive and feedback from the TNAs across all pilot sites is that they are all enjoying and benefiting from the programme.
The NMC have agreed to the regulation of the Nursing Associate role on 26th September 2018. The Nursing Associates will not be supernumerary. Nursing Associate students will still be ‘off the job’ for academic study and placements that broaden their experience beyond their normal place of work. But when learning in their own workplace, they will be able to count time protected for learning towards their programme hours. Importantly, students will still need to be appropriately supervised when they’re working towards meeting our standards. (NMC, 2018)
The Trust, in partnership with LSBU has been successful in their application to be a 3rd wave Nursing Associate test site. The panel were impressed with the quality of the application in general and the thought which had gone into determining how this role fits within our workforce. The evaluation of the Capital The Trust continues to recruit staff onto the Nurse Foundation rotation Capital Nurse Foundation rotation programme pilots programme. The programme has been very positively received by staff in the divisions who feel that it will help attract staff into the Trust who wish to gain experience in a community setting and progress their careers within community nursing. A further 12 newly qualified staff, across the Trust, have been offered capital nurse rotation posts and will commence their programme in October 2018.
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The evaluation of the Work is currently taking place across all staffing models in all clinical divisions to review staffing models to support services new ways of integrated working. Staff survey results The 2018 staff survey is currently in progress and we await the outcome. Evaluation of fast track The Learning team will be developing a band programmes 7 development programme with aim of having this completed by autumn 2018. Each clinical Implement and evaluate a Following the workforce events, staff have profession has a model of professional proposed a number of models of professional clear and successful practice for clinical staff practice. These will be shared with staff model of across the Trust across the Trust using survey monkey. The professional practice feedback from this will be collated and which includes their developed in to a draft model of professional role in improving practice by November 2018. population health as health champions. Clinical staff are well Increase the number of HEE recently invited applications from staff to led, educated, research projects involving / apply for a shared internship programme trained and involved led by clinical staff within the with the view to promote clinical academic in research to Trust careers. The internship programme is evidence the impact designed to assist successful applicants to of what they do. provide a starting point on a clinical academic career pathway and to acquire pre-Master’s level experience in research methods, service improvement and innovation. 2 Trust staff submitted applications with one applicant, from dietetics, being successful. The programme commences in October 2018.
6.0 Here, Happy, Healthy & Heard • Responsible Director: Louella Johnson, Director of People & Communications • Supporting strategy: People & Wellbeing • Co-ordinating council: Recruitment and Retention forum
6.1 Clinical Vacancies The trust recognises that reducing and maintaining a low clinical vacancy rate is key to ensure safe effective care. We have moved to Statistical Process Control (SPC) which is a method of accounting for natural variations in data to understand whether the Trust clinical vacancies rates are both within targeted ranges and sustainable.
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Graph 18: SPC graph, Clinical Vacancy Rates % (Trust) 2017-18 25.00 20.00 15.00 10.00 5.00 0.00 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
Trust Vacancy Rate Trust Mean UCL Trust LCL Trust
At the close of the quarter, there was a single point rise to the mean rate as shown in graph 18 above. At this stage, the single point raise is not a significant cause for concern (a run of 7 data points indicates a stepped change).
Graph 19: SPC graph, Clinical Vacancy Rates % (Divisional) 2017-18 25.00 20.00 15.00 10.00 5.00 0.00 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
Trust Mean UCL Trust LCL Trust CHD Rate Inner Rate South Rate North Rate Target Rate
As can be seen from the graph above, over the last 12 months, no divisional vacancy rate has breached the upper control limit. In terms of run rate analysis, none of the divisional rates shows a reduction or increase of 7 consecutive data points. Therefore, it should be noted that there is a level of overall stability in the clinical vacancy rate although three divisions are not within the stretch target range (Inner London, South Division and the North Division).
The recruitment and retention group has reviewed current retention plans across operational divisions and has identified four areas of focus. These include: Strengthening career pathways; early intervention where staff resign; facilitating movements between localities; and the development of rotations.
6.2 Clinical Staff Turnover (Voluntary 12 month rolling)
The Trust has maintained the stretch target of 12% for 2018/19. At the close of quarter one, applying statistical process control, we had identified an issue that we have set the 2018/19 target rate at the very lower control target which means it is extremely unlikely that the target rate can be achieved. This remains the case in quarter two. The rate has levelled out to the mean turnover rate for the first time in 9 months but there is yet to be evidence of a stepped change.
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Graph 20: SPC graph, Clinical Turnover Rate % Vol 12 month rolling (Trust) 2017-18 20 18 16 14 12 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
Trust Vacancy Rate Trust Mean UCL Trust LCL Trust Target Rate
At the last recruitment and retention group, the operational divisions’ deep dive retention plans were reviewed. The recruitment and retention group agreed centralised initiatives to support local plans. These include: Strengthening career pathways; early intervention where staff resign; facilitating movements between localities; and the development of rotations.
In reviewing the divisional turnover rates as shown in graph 21, we can see that there has been a stepped change in the Children’s Division (9 consecutive reducing data points) indicating that the impact of the commissioning led increase in leavers in quarter three 2017/18 has now passed. None of the other Divisions have shown a significant upwards or downwards trend.
Graph 21: SPC graph, Clinical Turnover Rate % Vol 12 month rolling (Divisional)
24%
22%
20%
18%
16%
14%
12%
Rate Turnover Staff Clinical 10%
8%
Trust CHD Inner South North Target Rate Amber Rate
The charts below show the main reasons sighted for leaving in the 12 months at the close of the quarter and the comparative position the previous year.
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Graph 22: Clinical Staff Leavers HC, reasons for leaving (12 month data to Aug 18)
12 month leaver reasons (vol clinical) to Close of Q2 2018/19
8 3 Voluntary Resignation - Work Life Balance 5 3 2 1 10 13 Voluntary Resignation - Promotion 14 Retirement Age 18 Voluntary Resignation - To undertake 129 further education or training Voluntary Resignation - Lack of 23 Opportunities Voluntary Resignation - Child Dependants
Voluntary Resignation - Other/Not Known 34 Voluntary Resignation - Better Reward Package Midcode 43 63 Voluntary Resignation - Health
46 Voluntary Resignation - Adult Dependants
Voluntary Resignation - Incompatible Working Relationships
Graph 23: Clinical Staff Leavers HC, reasons for leaving (12 month data to Aug 17)
12 month leaver reasons (vol clinical) to Close of Q2 2017/18 Voluntary Resignation - Work Life Balance 6 3 1 4 4 1 Voluntary Resignation - Promotion 8 9 Voluntary Resignation - Lack of 9 Opportunities 12 Retirement Age 96 Voluntary Resignation - To undertake further education or training 15 Voluntary Resignation - Child Dependants
Voluntary Resignation - Better Reward 26 Package Voluntary Resignation - Other/Not Known
Voluntary Early Retirement - no Actuarial Reduction 31 Voluntary Resignation - Health 51 Voluntary Resignation - Incompatible Working Relationships 41 Midcode 49 Flexi Retirement
Voluntary Resignation - Adult Dependants
The main reason for leaving remains work-life balance. The recruitment and retention group have discussed and identified that this wide category, collected on the National Electronic Staff Record, lacks sufficient clarity to aid in effective planning and targeting an effective and lasting reduction in the leaver rate. Divisions are working on collecting more detailed information on leavers and leaving intentions at a team level to present back to the October Recruitment & Retention group.
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6.3 Staff Engagement Score The Quarter 1 Pulse Check was conducted in the first 2 weeks of June 2018. The results are shown below.
Table 3: Pulse Check Results Quarter 1 2018/19 3 1 5 - nor unlikely 4 Neither likely likely Neither - - 2 unlikely - Extremely Extremely Extremely Likely - Unlikely Likely
Area
North 16.36% 47.27% 21.82% 11.82% 2.73%
Inner London 19.38% 39.53% 20.93% 13.18% 6.98%
South 18.95% 34.74% 25.26% 12.63% 8.42%
Children’s Health & Development (CHD) 9.09% 30.30% 21.21% 15.15% 24.24%
Finance, Performance and Contracting 0.00% 25.00% 12.50% 25.00% 37.50%
Trust Management and Chief Executive's Office 0.00% 100.00% 0.00% 0.00% 0.00%
Medical Directorate 30.00% 40.00% 10.00% 20.00% 0.00%
Quality and Learning (QL), Operations 15.38% 50.00% 19.23% 11.54% 3.85%
Improvement 14.29% 85.71% 0.00% 0.00% 0.00%
People & Communications 37.50% 50.00% 6.25% 6.25% 0.00%
Table 4: Percentage of staff recommending the trust as a place to work
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Graph 24: Radar Chart Divisional Results Q2 18/19
North 100.00%
90.00% People & Communications Inner London 80.00%
70.00%
60.00%
50.00%
40.00%
Improvement 30.00% South
20.00%
10.00%
0.00%
Quality and Learning (QL), Operations Children’s Health & Development (CHD)
Medical Directorate Finance, Performance and Contracting
Trust Management and Chief Executive's Office
1 - Extremely Likely 2 - Likely 3 - Neither likely nor unlikely 4 - Unlikely 5 - Extremely unlikely
The position in the South was materially affected by the acquisition of Wandsworth adult services with the first pulse point in Q4 17/18 showing a marked decrease in performance from an otherwise stable position. The Q1 18/19 posting, although outside the amber tolerances, does represent a significant improvement. Given the level of improvement, the current actions within the Division to improve on experience and engagement should be monitored into the quarter 3 position where it is anticipated that the Division will be within acceptable tolerances.
The CHD position was materially affected during the commissioner led changes to SLT services and turbulence the 0-19 services experienced in Q4 2016/17. The Division has shown improvement over the 5 preceding quarters but remains under the set target. Reviewing the Qualitative data for those within CHD that responded negatively to recommending the Trust as a place to work is a priority for the Division.
6.4 Bank Staff Recruitment Recruitment to the bank was identified as a key marker to support both the reduction in agency spend as well as supporting services to provide safe, effective temporary staffing cover.
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Graph 25: Bank Staff Recruitment 350 25 300 20 250 200 15 150 10 100 5 50 0 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar In Month Bank Starters YTD Bank Starters YTD Target Bank Starters YTD Amber Bank Starters
At the end of 2017/18, the Trust had set a target for new bank recruitment of 285. This was exceeded with 321 staff recruited to the bank. However, this recruitment level has unfortunately not been maintained in 2018/19 although the lower vacancy rates and agency usage have reduced the pressure on the need for bank staff. Throughout the period, a fill rate of shifts allocated to bank of circa 90% has been achieved.
The recruitment and retention group has prioritised the need to target bank recruitment alongside substantive recruitment and will be taking a more holistic approach to identifying and resourcing this accordingly.
6.5 Staff Appraisals Staff appraisal rates have remained in the amber range or above for the last 10 months.
Graph 26: SPC graph, Appraisal Rate % (Trust) 2017-18 100
95
90
85
80 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
Trust Appraisal Rate Trust Mean UCL Trust LCL Trust Target Rate
We have applied statistical process control to review the variations and trends in the data. Although all the posted values are within the anticipated variations over time (as shown in graph 27), there was a material and significant drop in the data in October 2017 which was identified as being driven by the acquisition of the South Division’s new services. The event was the transfer of a significant number of staff from St Georges NHS to CLCH (Wandsworth Adults service). The inherited position was not within the Trusts acceptable parameters but the division have successfully applied a remedial plan which can be seen through a run of 7 increasing data points. Divisions have plans in place to improve the appraisal rate and these are discussed at both divisional boards and the monthly trust performance meetings.
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Graph 27: SPC graph, Appraisal Rate % (Divisional)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18
Trust Corp SS Clinical SS CHD Inner South North Target Rate Amber Rate
6.6 Clinical Staff Sickness The Trust has ensured that our sickness levels are maintained at a low level and has been continually targeting a stretch target of 3.50% sickness on a rolling rate.
Graph 28: SPC graph, Monthly Sickness Absence Rates % (Trust) 2017-18 5 5 4 4 3 3 2 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Trust Clinical Sickness Rate Trust Mean UCL Trust LCL Trust Target Rate
As can be seen in the tables above and below, the sickness rates are above the mean rate. Although there are only three increased sickness points since May, this is part of a wider pattern of 10 out of 11 data points above the Trust mean rate. The HR transformation team are supporting managers to proactively manage sickness.
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Graph 29: SPC graph, Monthly Sickness Absence Rates % (Divisional) 2017-18 6
5
4
3
2
1
0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Trust Mean UCL Trust LCL Trust CHD Rate
Inner Rate South Rate North Rate Target Rate
Particular focus will be on the areas that breach the upper control limit of 4.54% (listed below).
CBU staff G Absence FTE Days Available FTE days Rate UCL
0-19 Richmond and Wandsworth Clinical Support 95.62744 1718.47756 5.56% 4.54% Nursing & Midwifery 469.71965 7851.6027 5.98% 4.54% Barnet Integrated Care Nursing & Midwifery 190.8 3072.64 6.21% 4.54% Barnet, Brent and Harrow 0-19 Services Nursing & Midwifery 552.332 10104.8338 5.47% 4.54% Case Management CBU Allied Health Professionals 33 356.5 9.26% 4.54% Clinical Support 50 747.04 6.69% 4.54% Nursing & Midwifery 358 5732.85336 6.24% 4.54% Community Nursing Barnet Clinical Support 309.07333 2894.8393 10.68% 4.54% Nursing & Midwifery 332.42667 6436.63993 5.16% 4.54% Community Specialist Rehabilitation Services Allied Health Professionals 142.9 3413.81364 4.19% 4.54% Clinical Support 53.14666 1271.16 4.18% 4.54% Dental Services Professional Scientific & Technical 267.872 2822.632 9.49% 4.54%
Harrow Core Community Services Nursing & Midwifery 208.8 3529.37364 5.92% 4.54% Inner CBU Management Nursing & Midwifery 29 276 10.51% 4.54% Inner London LTC Clinical Support 53.8 475 11.33% 4.54% Inner Specialist Nursing & Sexual Health Clinical Support 103 368 27.99% 4.54% Inner Specialist services Clinical Support 65.22666 558.85272 11.67% 4.54% Integrated Complex Children’s Clinical Support 71.86656 1029.3655 6.98% 4.54% Nursing & Midwifery 144.4 2111.6496 6.84% 4.54% Merton Children’s Services Clinical Support 122.59414 1455.24724 8.42% 4.54% Nursing & Midwifery 177.70816 4322.82819 4.11% 4.54% Merton Continuing Care Nursing & Midwifery 61 215 28.37% 4.54% Merton Integrated care services Nursing & Midwifery 86.95333 1197.52 7.26% 4.54%
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Sexual Health Herts Clinical Support 54.62667 985.94636 5.54% 4.54% Nursing & Midwifery 262.22614 3014.43749 8.70% 4.54% Wandsworth East and West Localities Clinical Support 284.73338 1600.36 17.79% 4.54% Nursing & Midwifery 203.54665 3644.37363 5.59% 4.54% Wandsworth Intermediate Care Clinical Support 131.3 2553.8 5.14% 4.54% Wandsworth North and South Localities Clinical Support 111.6 1035.36 10.78% 4.54% Nursing & Midwifery 218.4 3798.4 5.75% 4.54% Wandsworth Specialist Nursing Nursing & Midwifery 159.6 2054.4 7.77% 4.54% West locality Merton Clinical Support 33.14685 689.72 4.81% 4.54% WIC/UCC, GPs and GPwSI Clinical Support 13 276 4.71% 4.54% Nursing & Midwifery 432.58973 7208.65123 6.00% 4.54%
Reviewing the reasons for sickness for the breach areas we can see that there is no specific pattern to the core absence reasons however, it is notable that anxiety/stress/depression was the main reason for sickness in the quarter for the breach areas. All cases that trigger via the Trust’s sickness absence policy are proactively managed by the operational line manager with support from the transformation team.
CBU Staff G Absence Reason
0-19 Richmond and Wandsworth Clinical Support S28 Injury, fracture 0-19 Richmond and Wandsworth Nursing & Midwifery S10 Anxiety/stress/depression/other psychiatric illnesses Barnet Integrated Care Nursing & Midwifery S17 Benign and malignant tumours, cancers Barnet, Brent and Harrow 0-19 Services Nursing & Midwifery S98 Other known causes - not elsewhere classified Case Management CBU Allied Health Professionals S99 Unknown causes / Not specified Case Management CBU Nursing & Midwifery S10 Anxiety/stress/depression/other psychiatric illnesses Community Nursing Barnet Clinical Support S25 Gastrointestinal problems Community Nursing Barnet Nursing & Midwifery S98 Other known causes - not elsewhere classified Community Specialist Rehabilitation Allied Health Professionals S98 Other known causes - not elsewhere classified Services Community Specialist Rehabilitation Clinical Support S12 Other musculoskeletal problems Services Dental Services Professional Scientific & S10 Anxiety/stress/depression/other psychiatric Technical illnesses Harrow Core Community Services Nursing & Midwifery S11 Back Problems
Inner CBU Management Nursing & Midwifery S12 Other musculoskeletal problems Inner London LTC Clinical Support S26 Genitourinary & gynaecological disorders Inner Specialist Nursing & Sexual Health Clinical Support S19 Heart, cardiac & circulatory problems
Inner Specialist services Clinical Support S17 Benign and malignant tumours, cancers Integrated Complex Children’s Clinical Support S26 Genitourinary & gynaecological disorders Integrated Complex Children’s Nursing & Midwifery S10 Anxiety/stress/depression/other psychiatric illnesses Merton Children’s Services Clinical Support S10 Anxiety/stress/depression/other psychiatric illnesses Merton Children’s Services Nursing & Midwifery S10 Anxiety/stress/depression/other psychiatric illnesses Merton Integrated care services Nursing & Midwifery S28 Injury, fracture Sexual Health Herts Clinical Support S10 Anxiety/stress/depression/other psychiatric illnesses
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Sexual Health Herts Nursing & Midwifery S25 Gastrointestinal problems Wandsworth East and West Localities Clinical Support S12 Other musculoskeletal problems Wandsworth East and West Localities Nursing & Midwifery S19 Heart, cardiac & circulatory problems Wandsworth Intermediate Care Clinical Support S27 Infectious diseases Wandsworth North and South Localities Clinical Support S25 Gastrointestinal problems Wandsworth North and South Localities Nursing & Midwifery S10 Anxiety/stress/depression/other psychiatric illnesses Wandsworth Specialist Nursing Nursing & Midwifery S98 Other known causes - not elsewhere classified West locality Merton Clinical Support S24 Endocrine / glandular problems
WIC/UCC, GPs and GPwSI Clinical Support S12 Other musculoskeletal problems WIC/UCC, GPs and GPwSI Nursing & Midwifery S11 Back Problems
6.7 Key Outcomes
Key Outcomes Measures of success Update 2018/19 Staff are fully engaged and Four to five Quality There is at present three to four involved in the model of shared Councils are established Quality Councils per division and governance per division and well the aim is to increase this over the attended. next quarter. A staff recruitment drive, protected time for members, training and raising the profile of shared governance and the Quality Councils will continue to be carried out in 2018/19. Shared governance forums There has been an increase in the are effective at resolving engagement of staff and patients issues and concerns within the shared governance forums. Issues have been identified for change and improvement and related data collected. By Quarter 3 2018/2019, the information gathered will be taken forward to resolve issues and the outcomes will be shared across all Divisions. Voluntary staff turnover below Voluntary staff turnover at This has not been achieved and is 10% by 2020 12% currently at 15.53%. At the close of Quarter 1, applying statistical process control, we had identified an issue that we have set the 2018/19 target rate at the very lower control target which means it is extremely unlikely that the target rate can be achieved. Updating the position for quarter 2s data we can see that this remains the case. The rate has levelled out to the mean turnover rate for the first time in 9 months but there is yet to be
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evidence of a stepped change. Staff vacancies to 10% by 2020 Staff vacancy rate to 10% This has not yet been achieved and by March 2018 is currently at 13.57%. Section 6.1 provides an overview of the quarter 2 results. Staff surveys are undertaken 0.5+ on staff engagement The position in the South was which demonstrate improving index compared to the materially affected by the levels of staff engagement average for other acquisition of Wandsworth adult community Trusts services as discussed in section 6.3. nationally The Q1 18/19 posting, although outside the amber tolerances does represent a significant improvement. Given the level of improvement, the current actions within the Division to improve on experience and engagement should be monitored into the Quarter 3 position where it is anticipated that the Division will be within acceptable tolerances.
The CHD position was materially affected during the commissioner led changes to SLT services and turbulence in 0-19 services experienced in Q4 2016/17. The Division has shown improvement over the 5 preceding quarters but remains resolutely under the set target. Reviewing the Qualitative data for those within CHD that responded negatively to recommending the Trust as a place to work is a key priority for the Division Wellbeing strategy to support A 3% reduction in the The 2018 Staff Survey will be staff health and well-being and number of staff who report conducted in Quarter 3 2018/19 reduce staff absence feeling unwell as a result of with results released in Quarter 4 work related stress in the 2018/19 2018 Staff Survey Sickness absence remains This is currently at 3.91% and below target of 3.5% section 6.6 provides an overview of the quarter 2 position.
The Trust is committed to and Agency spend is Achieved. At the close of Month 5 makes demonstrable proportionally reduced as (August 2018) the Trust posted a reductions to agency spend sickness, turnover and year to date agency spend of vacancy rates reduce £1,725,658.15 against the stretch target of £2,190,019.65
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The number of staff This has not been achieved in recruited to staff bank quarter 2 although throughout the increases by 15% period a fill rate of circa 90% has been achieved.
7.0 Value Added Care • Responsible Director: Jo Medhurst, Medical Director. Director of Improvement • Supporting strategy: IM&T / QIPP / Continuous Improvement Strategy • Co-ordinating council: Strategic Improvement
7.1 Improvement skills training The need for embedding systematic continuous improvement (CI) across the Trust is identified within the NHSI leadership framework, Developing People – Improving Care, as well as within the CQC Well led framework. The CI strategy sets out a clear vision for developing a systematic approach to CI and identifies that a key enabler of this to be widespread knowledge and understanding of improvement methods at all levels of the organisation.
The CLCH improvement knowledge and skills framework sets out differing levels of skill and knowledge required for different roles. The basic level requirement is for all staff to have an awareness of improvement methods and the CLCH approach. As of 21st September 2018, 315 staff have achieved the basic level. This represents 9.6% of staff in post and is ahead of trajectory (7.5%). Good progress has been made in all operational divisions and plans are in place to deliver further training for corporate teams in quarter 3. A significant contribution to the progress made in this quarter has been achieved by 40% of the Trust senior management team completing the 1 day improvement leadership training. Managers who have completed this training are counted towards the basic level understanding of improvement metric.
7.2 Innovation and improvement tools Having selected the Model for Improvement as our core methodology for improvement and invested in training our staff in its usage, there is a continued need to ensure that this is being effectively applied across the trust. This requires that services can demonstrate they have run an improvement project with:
1. A SMART goal; 2. An outcome measure; 3. Baseline data; 4. Tests of change using PDSA.
As of 21st September 2018, seven services and two quality councils have demonstrated all the requirements for this KPI (Merton SWMS, Inner Inpatient rehabilitation, Inner Community Nursing, Harrow Community Nursing, ITO service, Partnerships, South SEC council and CHD HHHH council). This represents a Trust position of 5.5% against a Q1 target of 1.0%. Whilst there has been no progress against this metric in the quarter 2, there are currently 37 improvement projects registered on the LIFEQI system which are at various stages of development. Several projects have made good progress but are not yet able to meet all the criteria for this metric.
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LIFEQI is an online system, designed specifically for NHS Trusts who are seeking to support teams that are running QI projects using the model for improvement. All services are being encouraged to utilise this platform to support their QI projects as this enables widespread sharing of progress and learning, not just across the organisation, but also across the entire NHS which also have access to the same platform.
The CLCH Way transformation programme will provide a vehicle for divisions and services to explore potential technology innovations, through the ‘Improving our digital competence’ work stream. This will explore technologies to support improved data and intelligence, self- care and to improve our productivity/efficiency.
7.3 Key Outcomes
Key Outcomes Measures of success 2018 -19 Update
The user experience across Implement actions from LIFEQI projects CLCH, primary care, assessment Following the development and specialist services and delivery of the 2018-2020 PPE social care is as seamless Strategy, the Patient Experience as possible Facilitators are now managing quarterly service improvement projects within their divisions. The first of these projects are focusing on improving the patient experience across; Podiatry, End of Life and Phlebotomy. These projects will be uploaded, developed and monitored on LIFEQi.
Patient QI training: The Patient Experience Facilitators are proactively seeking patients/service users who wish to be QI trained in order to play an influential role on the CLCH Way programme. As part of this work the PE team and the CI team are working together to establish an appropriate platform for our patients and service users to be trained on the QI. Clinical staff use the latest Each Division to identify within The 18/19 business planning technology to improve business planning process an round has now completed and care delivery innovation for 2018/19 numerous technology innovations have been identified across divisions (e.g. Mobile technology, scheduling technologies, telehealth/telecare, etc.). The CLCH Way programme work
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stream ‘Improving our digital competence’ will support divisions to further explore the opportunity for technology enabled innovation. Each division has used Seven services and two quality improvement tools to improve councils have demonstrated all 1% of services the requirements for this KPI. This represents a Trust position of 5.5% which is ahead of trajectory (1.0%). Front line staff lead new 10% staff to have been trained 315 staff have achieved basic level lean ways of working to basic level in improvement improvement knowledge. This skills, including lean represents 9.6% of staff in post which is ahead of trajectory (7.5%).
8.0 Quality Action Teams (QATs) QATs are established when there is concern about an area of quality for a particular team. The QATs are led by the Quality Division who pull together an appropriate group of professionals from across the trust to undertake a time limited piece of work to analyse the problem, recommend evidence based intervention and support the divisions in implementing and evaluating the plan. The QAT’s are reported in detail as part of the quarterly red flag report presented to the Quality Committee.
8.1 Services with a QAT in place during Q2:
Division No. of QAT Services with QAT Children’s 2 • Inner CYPOT • Health Visiting South Team in Hammersmith & Fulham Inner 1 Harrow Cardiology
South 3 • Merton Community Nursing • Podiatry • Wandsworth Adult Community Nursing • Woodlands (on hold) North 1 Bedded Areas (Marjory Warren, Jade & Adams Wards)
Total: 8
8.2 North Division QATs A QAT was introduced for the bedded rehabilitation units in August 2018 following an increase in falls and a pressure ulcer on Marjory Warren Ward and a pressure ulcer on Jade Ward. Although there were no other red flags, complaints or concerns it was felt that the early introduction of a QAT across all three bedded areas of the North Division would ensure the wards take early action to improve outcomes. Staff of all disciplines from bands six to eight were involved and attend six weekly workshops led by the Associate Director of Quality, with the Clinical Business Unit Manager. The QAT focuses on strengthening leadership and ownership and actions include ensuring the highest level of patient independence, socialisation and the introduction of dignity standards.
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8.3 South Division QATs
8.4 Woodlands The Woodlands QAT was suspended in March 2018 due to the majority of actions being completed and the implementation of weekly visits by the Associate Director of Quality. Notice has now been served on CLCH by Central and Cecil Housing Trust and the service is subject to a transformation, demobilization and mobilization plan.
8.5 Merton Community Nursing A QAT was established in November 2017 following concerns, that due to staff nurse vacancies in the team, staff were unable to complete all the allocated visits, some of which had to be re-scheduled. Team members were also finding it difficult to complete statutory and mandatory training and appraisals. Staff are now receiving appraisals and training and successful recruitment is underway. The QAT will continue until the workforce issues are resolved.
8.6 Podiatry A QAT was established in May 2018 following concerns relating to vacancies and sickness in the Inner Podiatry services. This led to longer waiting times and patient dissatisfaction. In addition, caseloads had not been cleansed and presented an inflated patient waiting list. A short term solution of recruiting agency podiatrists was agreed and case load cleansing including clinical triage, prioritisation and discharge has been undertaken. Recruitment to band 5 podiatrists has been successful with progressive recruitment to band 6 podiatrists and staff will be inducted into the team in October and November 2018. There has been one SI which is currently subject to RCA investigation. The workforce issues are on the Risk Register. A shared learning event across the speciality within CLCH has been planned for November 2018. The QAT will continue until the workforce issues are resolved.
8.7 Wandsworth A QAT was established in April 2018 relating to workforce vacancies and sickness. This led to a reduced capacity within the community nursing teams, and consequently, not enough capacity to meet the workload, difficulty completing statutory and mandatory training and appraisals. Additional temporary staff were approved to increase capacity. The safe staffing model has now been agreed and active recruitment is in place. A standard operating procedure is in place to ensure processes are being followed for rescheduling and recording when visits are cancelled across teams which is currently being audited. A daily report of capacity and demand is produced and shared with commissioners. The practice development nurses are working with all nurses to ensure the standard use of documentation and recording practices and training is being delivered locally to enable staff to attend. The QAT will continue until the workforce issues are resolved.
8.8 Child Health Division
8.9 Inner CYPOT This QAT was established in November 2017 because of an increase in waiting times, and forthcoming vacancies in Occupational Therapy (OT) and Physiotherapy (PT). As there were also forthcoming resignations in the Barnet OT and PT teams, a joint QAT was established. However in May 2018, the QAT was reviewed and a decision taken to focus on the Inner OT team, due to the de-mobilisation of the Barnet OT service. Concerns relate to vacancies, maternity leave and waiting lists.
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A review of waiting list management was undertaken by the CBU Managers (job share) and the local systems and processes improved. Recruitment is monitored and temporary staff agreed as necessary using the Capacity Management Tool. Two new agency staff members joined the team on 30 August 2018, which will help to address the waiting list. Quality indicators have been monitored and there have been no significant increases in complaints or PALS concerns noted. A risk was added to the risk register in August 2018. Regular updates have been provided to the commissioners.
8.10 Health Visiting South Team in Hammersmith & Fulham. A QAT was started in April 2018 following concerns about an increase in sickness absence, PALS concerns, and incidents related to staffing and capacity to deliver key activities. This QAT was closed in September 2018.
8.11 Inner Division
8.12 Harrow Cardiology
This QAT was established in August 2018 following a 48hour meeting held on the 20.8.2018 having identified that there were a number of patients awaiting review by the Harrow Cardiology Service. The QAT is being co-chaired by the Medical Director & Chief Nurse. As a result, a number of actions are being undertaken related to recruitment and demand and capacity in the service.
9.0 Shared Governance Shared governance (as defined by the shared governance taskforce USA 2014) is a dynamic staff-leader partnership that promotes collaboration, shared decision making and accountability for improving quality of care, safety, and enhancing work life. Models of shared governance first started in the USA over 30 years ago but it is now a methodology for creating and sustaining well led, engaged organisations across the world. It is clear from a plethora of evidence that empowering front line staff to make patient focused change has visible benefits to patient and staff outcomes and feedback. The Trust has developed a model of shared governance to support continued quality improvement and to support the implementation of the Trust Quality Strategy.
To date we have successfully implemented 15 Shared Governance Quality Councils across the Trust as shown below.
• North (4) • Inner (5) • South (3) • Children’s (3)
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All Quality Councils are chaired by a Band 6 member of staff and nine of the councils have one or two patient representatives as active council members. At the recent Trust AGM, the Shared Governance Programme Lead was able to gain interest from 9 members of the public to join councils across the organisation.
Each quality council has been asked to focus on one project aligned with one of the quality campaigns in the Quality Strategy with the aim of making an improvement. The areas that each of the councils have decided to focus on are outlined in table 3.
Table 3: Shared Governance Projects Division Quality Campaign Project North Modelling the Way Increasing compliance against mandatory training. This council began in February 2018 and has been focusing on staff attitudes towards statutory and mandatory training. They have focused on why staff don’t always attend training and also the reasons why staff become non-compliant with training. Their aim is to improve compliance across the division and to make recommendations that could be taken across the organisation. Positive Patient All about me. This council began in June 2017 and has been Experience focusing on how we can better tailor care to patients’ individual needs with particular focus on patients with cognitive challenges. A booklet has been designed by the team for the patient and family to complete and then share with the clinical teams. Preventing Harm Monitoring and maintaining healthy pressure areas in care homes. This council began in August 2017 and has been considering how we can support residential home staff in keeping residents pressure areas healthy and free from pressure damage. The council have reviewed the information we give to residential care staff and have pulled this into a pack which they hope to launch in the autumn. Smart Effective Care Increasing Mandatory training uptake to 95%. This is a new council to address the challenge of staff attending mandatory training. Inner Smart Effective Care Staff preference for communication across the Trust. This council are looking at how changes in the trust and NHS are communicated to staff and patients. They are reviewing the current information flow. A specific staff survey was developed and distributed and the results are now collated and themes will be presented to the Divisional Quality Council. Modelling the Way Adherence with the Accessible Information Standards Policy across the Trust. The project has conducted an initial baseline survey and an audit of SystmOne template completion in patient records across 3 DN teams in Westminster. This will enable the council to understand if there are any gaps and understand what actions need to be taken to improve adherence with the Accessible Information Standard. Here, Happy Heard To address staff happiness and increase staff morale. The and Healthy project aim is to gain a better understanding of what effects staff morale in the workplace and to make recommendations to the trust on potential areas for improvement where staff morale can be increased. The council have undertaken a specific staff survey
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which had a good response rate and the council is reviewing themes from the survey. Here, Happy, Heard Improving staff morale across Harrow Community Services and Healthy This council is looking at staff morale in Harrow. They are looking to improve communication between management and team members. They are also creating a local information directory to share local services, locations and contact details of the health professionals working in the Honey Pot Lane area. South Smart Effective Care Communication and care plan leaflet for complex patients in Merton. The council is aiming to improve communication and the sharing of information between the staff and our patients with complex care needs. The council have developed a power point presentation. This will be sent to the district nursing team leads to request permission to put leaflets in district nursing folders. Preventing Harm Reducing the risk of cross infection in dentistry. This is a new council for the south which will hold its first meeting in October. Positive Patient Reduction in numbers of patients on podiatry waiting lists Experience The project aim was to agree a systematic approach to reducing the numbers of new and follow up patients waiting on the podiatry waiting lists to improve patient experience. The project has made some great improvements to patient experience by reducing the waiting lists. However, due to some staffing challenges, there is now a Quality Action Team in place to provide further support and oversea the waiting times for each area. Therefore, the council is now looking to close this project and to identify a new issue at the next council. Children’s Positive Patient Development of bespoke PREMS for children/families. The Experience project aim is to make PREMS more user-friendly for clients, families and staff. Smart Effective Care Review of ASQ process. The project aim is to review the process from the admin hub to the health visiting service to ensure that the ASQ element of the 1 and 2 year developmental reviews is working as efficiently as possible. Here, Happy, Heard Improving staff morale. The project aims are to improve staff and Healthy morale by initially improving communication between senior management and front line staff. The objective of the council is to improve staff satisfaction and for 40% of staff to feel that there is effective communication from senior managers
All Quality Councils are enrolled onto the LIFE QI platform to enable them record and plan their council activities and progress. The Continuous Improvement Team is supporting the councils to use the LIFE QI platform to ensure that the system is up to date.
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Appendix One: Complaint Themes
1.0 Number of complaints In quarter 2, 21 formal complaints were received. This has slightly decreased by 27% in comparison to quarter 1, with an average of 8 complaints received per month during this financial year as shown in graph 1 below.
Graph 1: Complaints received per month
10 Number of of Number Complaints 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2017-18
All of the 21 formal complaints have been or are being resolved in writing which includes a formal investigation. 1 complaint has been withdrawn at the time of writing this report as concerns were responded to by the Clinical Commissioning Group. The complaints received were categorised as low or moderate harm. Of the 21 complaints, 10 were received across the North Division, 5 in the South, 4 for Inner and 2 for Children’s Division. Graph 2 shows the complaints received by division across quarter 2.
Graph 2: Q2 Complaints by division 6
5
4
3 Jul 2 Aug
Number of Complaints 1 Sep 0 Children's Division Inner Division North Division South Division Jul 1 2 2 3 Aug 1 5 1 Sep 1 1 3 1
Table 1: Complaints by Theme Number of Complaints received All aspects of Clinical Treatment 10 Appointments, Delay / Cancellation (Out Patient) 2 Attitude of Staff 7 Infection Control 1 Patient's Privacy and Dignity 1 Total 21
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Of the 21 complaints, 10 (48%) were logged under the theme ‘all aspects of clinical treatment’. However, no obvious patterns or trends emerged.
2.0 Complaints by division, theme and service The graphs below provide a breakdown of the complaints received during quarter 2 by division, theme and service.
Graph 3: July Complaints by division, theme and service 1
0 Special Continuing Bedded Inpatient Post Acute Gold Team Purple Team Respiratory Schools Care Rehabilitation Rehabilitation Care (Athlone) (Marjory Enablement Warren) Attitude of All aspects of Attitude of All aspects of Attitude of All aspects of Clinical Treatment Staff Clinical Staff Clinical Staff Treatment Treatment Children's Inner Division North Division South Division Division
Graph 4: August Complaints by division, theme and service 1
0 Peer Group 3-4 – Evening District Inpatient Edgware Walk in North Locality - End of Life Care Community Nursing North and Rehabilitation Centre Torrington Park Nursing South (Jade Ward) Appointments, All aspects of Clinical Treatment Attitude of Staff Infection Control All aspects of Delay / Clinical Treatment Cancellation (Out Patient)
Inner Division North Division South Division
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Graph 5: September Complaints by division, theme and service 1
0 Education Violet Melchett North Locality - St Charles Urgent St Charles Urgent Single Point of Speech and (DN K&C) Torrington Park Care Centre Care Centre Access (SPA) Language Therapy Patients's Privacy Attitude of Staff All aspects of Clinical Treatment Attitude of Staff Appointments, and Dignity Delay / Cancellation (Out-patient) Children's Inner Division North Division South Division Di i i
3.0 Local Resolution Meetings and outcomes There continues to be a much greater emphasis on local resolution meetings with complainants, to resolve concerns in a more personal manner. During quarter 2, each complainant was offered the opportunity for a local resolution meeting. There were no meetings held as complainants chose a comprehensive investigation followed by a written response.
4.0 Closed Complaints For each complaint, the completion and closure of actions is monitored by the Complaints Team and division. As part of the aim to share learning, vignettes are shared at the Trust Patient Experience Co-ordinating Committee and divisional boards. Several vignettes are detailed below providing a summary of some of the complaints closed in quarter 2.
Table 2: Vignettes South Division Complaint 1 Complaint Subject All aspects of care & treatment CBU/Speciality Wandsworth East, West and South Localities, East 2 Details of Patient is upset by her treatment from the District Nurse Wandsworth Service. Complaint Patient feels they don't care and have hurt her on two occasions during visit. Outcome Service UPHELD - Apology given to patient as had been injured when Nurse was assisting with bowel irrigation. Nurse will be attending Sage & Thyme training to improve her communication. North Division Complaint 2 Complaint Subject All aspects of care & treatment CBU/Speciality Barnet Inpatient Units, Adams Ward Details of Son raised concerns about two incidents on the ward, one when mother left the ward Complaint unsupervised (absconded) and second when mother was discharged home with a bag with pants smeared with faeces. Outcome / UPHELD - Apology given to family for the failure to ensure that mother was being Learning closely supervised.
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It was evident from the investigation that family were not informed that there was dirty linen in the bag. This is unacceptable & sincere apologies were given for the distress caused. Service Wide • A review has been undertaken of the current signage on the ward with regards to Improvements 'tailgating', the ward will be implementing a protocol to safely manage patients with confusion and at risk of absconding. This will be clearly communicated to all staff along with the need for all staff to complete risk assessments for all patients on their 1:1 care needs. This will be monitored closely by the ward manager who will audit the use of both the protocol and the risk assessments in three months’ time. In addition all nurses will be trained to use cognitive screening assessment for patients with any signs of confusion or disorientation. • The process has been reviewed and the unit now has access to laundry facilities and following discussions with family members and patients, any dirty or soiled clothing will be washed and not sent home with family members for washing. North Division Complaint 3 Complaint Subject Admissions, Discharge and Transfer CBU/Speciality Barnet Inpatient Units, Marjory Warren Ward Details of Family raised concerns about the process followed for CHC Assessment. They also Complaint feel the staffs on the ward were rude and uncaring in relation to father’s discharge. Learning & UPHELD - It is evident from the investigation that there were a number of shortfalls in Outcome the discharge planning process for the patient and as a result a number of actions have been taken. Service Wide • CBU Manager will ensure that in future family members or the Power of Attorney Improvements is correctly engaged during the completion of CHC. • The Ward Manager will be organising training from the Barnet Continuing Healthcare Team for all staff on the effective completion of Continuing Healthcare Assessments. CBU manager will be auditing practice to ensure that staff are compliant with this. • The staff are looking at developing an information sheet for patients and their families clarifying the discharge process. • All staff have been reminded of the importance of informing families immediately if an incident occurs and also reminded that all patients with complex needs must have a family meeting arranged to ensure we make discharge planning as safe as possible and aid good communication between the ward staff and families. North Division Complaint 4 Complaint Subject All aspects of care & treatment CBU/Speciality Walk in Centres & Urgent Care Centres, St Charles Details of Concerns raised by mother who is upset at the treatment her daughter received at Complaint the WiC. Outcome & UPHELD - Apology given. Member of staff asked to reflect on their communication Learning and consultation with your daughter. Service Wide All staff reminded that they are expected to follow the Trust Customer Service Improvements Standards which set out expectations around staff communication with patients and member of staff has been reminded of this.
South Division Complaint 5
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Complaint Subject Appointments, Delay / Cancellation (Out-patient) CBU/Speciality Wandsworth Intermediate Care, Wandsworth Intermediate Care Details of Patient is very unhappy about the MI service she was informed that she is on waiting Complaint list for physiotherapy and it would take 2-3 weeks instead she had to wait 6 weeks. She went to her GP for a check-up and the GP was surprised that she hadn't even started rehab yet. Outcome & UPHELD - Apology given to patient as she has had to wait over 8 weeks for an Learning appointment with a Physiotherapist. Administrator apologised that she did not escalate patient concerns to Clinical Team. Service Wide The service has now successfully recruited a number of new Physiotherapists to Improvements improve waiting times for patients. South Division Complaint 6 Complaint Subject Appointments, Delay / Cancellation (Out-patient) CBU/Specialty West Merton Locality, Purple Team Details of Patient unhappy that district nurses have not been keeping their appointments to Complaint change his dressings and not notifying him. He has had to ring the D/N offices and has been told he on more than one occasion that he was not on the list. Outcome / UPHELD - The investigation established that the visit following the bank holiday Learning weekend was unfortunately cancelled due to staff shortages. A daily meeting takes place within the service to review the scheduled patient visits in order to plan which staff will be visiting. During this meeting, the staffing is reviewed in order to identify and address any staffing shortfalls and cross cover or temporary staffing will be arranged if possible before making any decisions that patient visits need to be rescheduled. This meeting did take place however the outcome was not shared with the patient. It is evident that there were a number of shortfalls regarding your visits and a failure to effectively communicate with the patient. As a result, a number of actions have been taken. Service Wide The service have now changed the process used for patient visits and are now using Improvement an electronic system to record and plan patient visits which will reduce the risk of this error being made in future. Children’s Division Complaint 7 Complaint Subject All aspects of Clinical Treatment CBU/Specialty Speech and Language Therapy Services, Speech and Language Therapy Services Details of Mother has raised concerns about her sons SLT therapy which has come to an end Complaint and there is now nothing in place for when he starts school. The services have advised that there is nothing they can do. Outcome / PARTIALLY UPHELD - Local resolution meeting held and a number of actions Learning agreed/taken. - Provision of SLT reports from December 2015, May 2016 and December 2016. This action was completed at the meeting. - Referral to the Autistic Spectrum Disorder Outreach Service to enable support around son's requirements in his reception class. Since the meeting the services have contacted the Outreach team to complete this referral and the outreach team have
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confirmed that a referral made by the son's school has already been received by the - - Transfer of your son to the Westminster Mainstream Schools Speech and Language Therapy Service. Support from this service in the autumn term will consist of observation of son in his reception class and advice and support to those working with him on a regular basis to ensure a supportive communication environment for him. Upon receipt of request for SLT advice for an Education, Health and Care Plan the service will complete this and submit to the local authority. North Division Complaint 8 Complaint Subject Attitude of Staff CBU/Specialty Walk-in Centres and Urgent Care Centres, Parsons Green Details of Mother is complaining about the way her son was treated when she took him to Complaint PGHC. She claims the nurse had a poor attitude and was unsympathetic. Outcome / PARTIALLY UPHELD - Expectations of both staff and patients was explained when Learning using the service and a plan for future attendances was agreed. North Division Complaint 9 Complaint Subject All aspects of Clinical Treatment CBU/Specialty Walk-in Centres and Urgent Care Centres, Finchley Details of Mother has raised concerns about her 1 year old son who was seen FMH walk in Complaint centre, presented with a febrile illness & rash. Was triaged and the recorded observations suggest a 'red' high risk of sepsis risk category but the child was sent home. Outcome / UPHELD - Apology given. As a result of the investigation, a number of Learning recommendations have been made including the training of all staff on sepsis and the use of the NICE guidelines for sepsis. Service Wide A new process has also been implemented where clinicians who are seeing unwell Improvements children are expected to re-check and record any observations that may indicate potential signs of sepsis in unwell children. In addition, the medical staff are now ensuring that repeat clinical observations are undertaken for all unwell children. ln order to ensure clinicians are complying with this policy, an audit will be undertaken by a senior clinician, in 3 months' time. South Division Complaint 10 Complaint Subject All aspects of Clinical Treatment CBU/Specialty East Merton Locality, Yellow Team Details of Daughter is very upset as she feels her mother is not receiving the correct care from Complaint the District Nurses. She feels they are ill-equipped to dress her bedsores. She was also called at work and asked by a District Nurse to go home and put a patch on her mother as she had forgotten to do it. Outcome / UPHELD - Apology given that when Pressure Ulcer on right calf was seen for first time Learning no photographs were taken and no Doppler assessment completed. Actions were taken by the district nurses to prevent further pressure ulcers and that the care plan put in place was followed. Service Wide CBU manager has spoken to all of the staff concerned outlining her expectations of Improvements clear and accurate record keeping (including timely photographs of any wounds identified) and effective communication. ln addition, she has reminded staff of the criteria for Doppler assessments and when they should be undertaken and has
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assured me that she will be monitoring this in future. South Division Complaint 11 Complaint Subject All aspects of Clinical Treatment CBU/Specialty Sexual Health: South West London, Sexual Health Services Details of Patient is unhappy at the treatment she received from the SH nurse at the Centre. Complaint Outcome / UPHELD – Apology given as communication could have been clearer so that the Learning process was explained to the patient. Nurse has apologised. Service Wide Clinical Team Leader has confirmed that all clinician's skills and practices are Improvements reviewed and monitored, and that the issues raised in your feedback will be anonymised and discussed at a team review meeting in order to share and discuss any further learning that can be taken to improve the service. South Division Complaint 12 Complaint Subject Communication CBU/Specialty Specialist Nursing & Podiatry, Podiatry Details of Patient raised concerns about why no one has contacted him to explain why there Complaint was such a delay for his insoles, it took 11 months to receive them and it was only because he was chasing that anything got done. He spoke with a number of staff who all said that the reason for the delay was due to a supplier not being paid. Outcome / UPHELD – Apology given as the length of delay was unacceptable. Learning Service Wide Service to review the process for patients who requiring orthotic insoles in order to Improvements ensure that patients are contacted regularly with an update on their delivery. The Trust has now implemented clear procurement processes that services are required to follow to ensure that orders are processed smoothly and that patients are not affected by any delays.
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79
Board of Directors 31 October 2018
Report title: 2019-20 Planning Process
Agenda item number: 2.1 Lead director responsible for Director of Finance, Performance and Contracting approval of this paper
Report author Tom Wright, Commercial Director William Liew, Business Planning Manager Relevant CLCH strategic priorities Trust objective 2018/19 Please delete those which do not apply to this paper Strategy implementation Implement strategic priorities of integration and place Quality Maintain and improve the quality of services delivered by CLCH Finance Deliver the 2018/19 financial plan Operations Deliver all NHS constitutional and contractual standards Workforce Make CLCH a great place to work for everyone Freedom of Information Public status
Executive summary:
This paper outlines CLCH’s proposals for the 2019-20 business planning process with an overview of our approach, governance, planning inputs and outputs, and draft timescales.
Context
The NHSI planning requirements and timetable for this year are unknown at this stage as they may decide to set a deadline for the end of December 2018 or for the 31st March 2019.
Proposed Approach
Our proposed approach is to work towards an internal deadline for end of December 2018 for the elements of planning that are under CLCH internal control whilst we await further NHSI guidance.
As with 2018/19 planning we will focus on preparation of Corporate and Divisional annual plans first before moving forward with CBU annual plans in the January – March period.
The format of the divisional plan template has been refreshed to provide a holistic assessment of each contract. ELT review dates are set as follows:
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• Divisional plans – 12th November • Corporate plans – 27th November.
Timescale for some elements of the planning process, such as contract signature dates will clearly be determined by the NHSI planning timetable.
Governance Governance of the process will include a bi-weekly planning steering group chaired by the Commercial Director, reporting the meeting minutes to the Director of Finance, Performance and Contracts and also to provide planning updates to ELT and Board where relevant.
A special Board meeting date has been scheduled for 20th December 2018 to approve the Operational plan and budget. This will be cancelled if not required.
The terms of reference (TOR) of the steering group are attached as an appendix.
This paper includes the following appendices:
Appendix 1 – 2019-20 Planning process Appendix 2 – 2019-20 Planning group TOR
Assurance provided:
Report provenance: Paper prepared for Board on the 31st October after review at ELT on the 9th October.
Report for: Decision Discussion X Information X
Recommendation:
Board are asked to review and comment.
81 2019-20 Planning Process
Your healthcare closer to home 82 Proposed Approach 2019-20
• The Trust will work towards the 31st of December 2018 as the planning deadline unless indicated otherwise by NHSI
• A special Board meeting date has been scheduled for 20th December 2018 to approve the Operational plan and budget. This will be cancelled if not required.
• For 2019/20, we will keep the planning process order of working on major Transformation schemes and Divisional strategic annual plans first before moving forward with more detailed CBU plans
• The Trust will produce a draft budget for review in December 2018 and have the final budget sign off by Board in March 2019
83 2 2019-20 Planning Governance • Business Planning falls under the Executive responsibility of the Director of Finance, Performance and Contracting • The planning process will be managed by a Planning Steering Group, chaired by the Commercial Director meeting bi-weekly commencing in September 2018 and finishing in March/April 2019 • The Planning Steering Group minutes will be sent to the Director of Finance, Performance and Contracts • Relevant and updated planning
Trust Board
ELT
Planning Steering Group 84 3 19/20 Planning Timescales
Jul Aug Sep Oct Nov Dec Jan Feb Mar
Trust ELT/FRIC update on Business Planning Mtg Board sign off Process Operational Plan
Divisional & Corporate planning
CBU planning
High level QIPP planning QIPP Implementation
Submission of Board sign off draft budget – final budget
85 4 Milestones (for end of December 2018) Item Start End Trust Business meeting workshop (kick off) 20 July Planning timetable ELT sign off 9th Oct Divisional and corporate plans 26th Sep Dec 2018 - ELT review of Divisional Plans 12th Feb - ELT review of Corporate plans 27th Feb High level QIPP planning Oct 31st Dec Budget setting Oct 31st Dec Activity plans, cost pressures, workforce Oct 31st Dec Contract based budgeting Oct 31st Dec Contract (variation) signatures 8th Oct 31st Dec Board sign off on Operational Plan 20th Dec Operational Plan submission TBC CBU plans Dec Feb 2019 Final Board sign off for budget Mar Board 2019 Board KPIs 10th Dec Mar Board 2019 86 5 ELT Final Sign off divisional, corporate & CBU plans Apr 2019 Planning Inputs
External Inputs Owner Timing NHSI planning guidance NHSI TBC~ Oct/Nov Commissioning intentions Commissioners 1st Oct STP Plans STPs Ongoing Market opportunities/bids Various Various Budget assumptions (external) NHSI TBC Internal Inputs Owner Timing Budget assumptions (internal) Director of Finance Nov Activity baseline BIPA Oct Operational priorities Divisions Ongoing Trust strategies (organisational, Various In place Commercial, Quality) Quality priorities Quality Oct
Contract based budgeting Director of Finance Oct 87 6 Planning Outputs
Outputs Owner CBU plans CBU Managers/ DDOs Divisional plans DDOs Corporate/Medical/Quality plans Director Leads Board KPIs Commercial Director Operational Plan (NHSI & Internal) Commercial Director Contract adjustments Commercial Director SOF monitoring Commercial Director Cost pressures Director of Finance, Contracting and Performance QIPPs Director of Transformation Activity plans DDOs Workforce plans Director of Communications and People 2019/20 Budget Director of Finance, Contracting and Performance STP input DDOs Contract based budgeting Director of Finance, Contracting and Performance Learning Needs Analysis Deputy Chief Nurse & Dir. Patient Experience
88 7 Planning Steering Group Membership
• Commercial Director (Chair) • Business Planning Manager (Administrator) • Head of Contracts • Head of Financial Planning and Special Projects • Projects and Programme Management Lead / Director of Transformation • Divisional Director of Operations (x1) • Business Manager (x1) • Head of Patient Experience • Business and Programme Manager, Medical Directorate • Assistant Director of Partnership and Procurement • Head of Workforce Information and HR Systems • BIPA Director • Estates and Facilities Strategic Partnership Director
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2019-20 Planning Group Terms of Reference
1. Purpose
The purpose of the Planning Group is to coordinate the planning process and ensure communication and alignment between the different elements (for example between contracts, business cases, finance, and STP developments).
2. Membership & Quorum
The membership of the Planning Group is:
Commercial Director (Chair) Business Planning Manager (Administrator) Head of Contracts Head of Financial Planning and Special Projects Projects and Programme Management Lead / Director of Transformation Divisional Director of Operations (x1) Business Manager (x1) Head of Patient Experience Business and Programme Manager, Medical Directorate Assistant Director of Partnership and Procurement Head of Workforce Information and HR Systems BIPA Director Estates and Facilities Strategic Partnership Director
In addition to the core membership, the group may co-opt additional members as appropriate to enable it to undertake its role.
Quorum: at least a third of members (delegates permitted); one of whom must be the Commercial Director (or delegate) or the Head of Financial Planning and Special Projects (or delegate).
3. Frequency of meetings
The Planning Group will meet bi-weekly on Thursdays at 10:00am (unless otherwise stated); although additional meetings may be convened as necessary in order to deal with urgent business.
The Planning Group will continue to meet until the end of March 2019 by which time the planning submissions should be complete.
2019-20 Planning Group - Terms of Reference 1 of 2
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4. Reporting arrangements
Minutes of the Planning Group meeting will be submitted to the Director of Finance, Performance and Contracts. ELT will be provided with relevant planning progress and timescales.
5. Key responsibilities
The key responsibilities of the Planning Group can be categorised as follows:
To coordinate the 2019-20 planning process to ensure alignment between the different elements including:
o NHSI required submissions . Operational plan . Activity plan . Financial plan o Contracts o STP o Divisional/Corporate Business Plans o Finance . QIPP . Overall budget . Capital . Cash o Quality and Medical o Workforce o Communications o Single Oversight Framework (SOF) o Activity and reporting o The CLCH Way
To coordinate the preparation of the 2019-20 Operational Plan To ensure alignment between planning and the new Single Oversight Framework Assessment Criteria To maintain and review an action log and risk register for 2019-20 planning To escalate any planning issues to ELT
2019-20 Planning Group - Terms of Reference 2 of 2
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Board of Directors 31 October 2018
Report title: Draft Clinical Strategy Update 2018-2021 Agenda item number: 2.2
Lead director responsible Joanne Medhurst, Medical Director for approval of this paper
Report authors Joanne Medhurst, Medical Director
Relevant CLCH strategic Trust objective 2018/19 priorities
Quality Maintain and improve the quality of services delivered by CLCH Freedom of Information status Executive summary: The medical Director has developed the new CLCH clinical strategy using a co-design process with clinical staff, through a series of 6 workshops across the Trust, shared feedback and videos across the divisions which have led to the draft document set out below.
The document represents what staff have reported is important to them to be enabled to practice ‘at the top of their licence’, set within a changing cultural environment where collaboration and integration have become increasingly important and where prevention and wellbeing are prioritised alongside the management of illness.
Comments from the Quality Committee 24.10.18. Overall the committee was supportive of the draft strategy and were complimentary about the style, content, in particular the accessibility of the language.
Recommendations for change were made as set out below; 1. To have a case study that show cased integration with an acute partner and to consider the podiatric case study that had come to the quality committee that day. 2. To change the core model to ‘wrap’ ‘active support for self-management around all the domains. 3. To explicitly describe links to other key strategies e.g. quality strategy and quality improvement 4. To strengthen the section on workforce and set out and link to the learning culture of the Trust - in particular the iterative reflective style that is emerging. 5. Review ‘To enable the clinical professionals to function effectively CLCH will need to support these communities to access certain technical skills which presently are held corporately ‘
Assurance provided: Paper reviewed by ELT 16/10/18- advised to move co-design description within strategy as a forward, to add some visual images both graphic and real.
Paper reviewed by Quality Committee prior to board review and will become finalised after those
92 CLCH Clinical Strategy 2018-2021 steps and after a round of patient engagement.
Report provenance: The Clinical Strategy slides were presented at the Trust Business meeting on 21st September, and the Quality Committee meeting on October 24th.
Report for: Decision Discussion Information x x Recommendation: To review draft clinical strategy
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CLCH Clinical Strategy 2018-2021
CLCH Clinical Strategy 2018-2021
INTRODUCTION AND SUMMARY
The Trust’s 2015-18 Clinical Strategy set out a core clinical model provides a way of thinking about the purpose of our services, be that prevention or care through the various life stages (birth to death) with a focus on:
• Self- management • Primary Prevention • Secondary prevention • End of life care • Effective use of medicines • Managing ambulatory conditions • Care coordination
This description remains accurate but is high level and can be difficult to relate to the day-to-day care CHCH provides.
CLCH is a geographically dispersed working with multiple cohorts of people with a range of health conditions and needs with a variety of different partners. This strategy acknowledges this diversity of service provision whilst at the same time finding common ground that might be amplified and innovations that could improve community services.
The Clinical Strategy refresh provides an opportunity to move from the very high level definition to something that will work for clinical leaders, both within and outside the Trust. The resulting strategy will make clear our offer to external stakeholders as well as providing direction internally to inform supporting strategies and shorter term operational plans.
However the context for clinical services is changing dramatically as influenced by the move to integration of health and social care services for specific populations. This is being made possible by primary care beginning to work at scale to provide a platform for Integrated Care Systems. Other key policy developments include an emphasis on prevention and patient self-management.
For these reasons we have refreshed the strategy and looked again at the model. This has led us to conclude that a shift is required in the mental model that is used to conceptualise the Trust. This shift is about giving attention to prevention as well as care, integrating our services internally and externally and developing a keen sense of the population to be served. All of this is enabled by the best workforce and technology support.
This strategy refresh engaged senior clinicians across the Divisions. We ran two rounds of workshops bridged by the use of our internal HUB to disseminate discussion and to enable further reflection.
This document sets out the analysis and the solutions in more detail. It begins with the changing context and the influences on thinking about our developing clinical services. We make comment on the current way of operating before describing a vision of our clinical services for the future. This comes together in a number of key change areas that constitute our strategy for clinical services for the next 3 years.
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CLCH Clinical Strategy 2018-2021
THE PROCESS OF THE CLINICAL SERVICES STRATEGY REFRESH
It was important to involve senior professionals in the review of services and in shaping the changes therefore two rounds of geographically based workshops were organised bringing children’s and adult services together. The purpose of the first round in July was to generate an improved understanding of services and to prompt an exchange of good practice. The external policy influences were explained and the clinical leaders began to examine their aspirations for development within this changing context. There was then a period of reflection back in their service teams supported by web based access to output and short videos. The page shown below is available on the CLCH Hub site by following the ‘Our Team’ link to find the medical directorate page.
The page has within it the summarised outputs from the co-design events, the key strategic documents and links to 3 videos of the CEO and medical director where they discuss the key strategic drivers that they have noticed and the impact they believe these changes will have.
The second round of workshops in September moved the discussion forward into a simulation of the implications of having a Place based population health and integrated care approach. These processes provided a series of products to support the strategy refresh; an identification of best practice currently, an identification of current blockages and constraints and finally a vision for how services might work in future.
There is a forum page on the site to enable on-going dialogue between clinicians which can be accessed by clicking on this link: http://thehub/ourteams/medical/Pages/Clinical-Strategy-Refresh- 2018.aspx
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CLCH Clinical Strategy 2018-2021
DEFINITIONS
Communities In the specific context of health and care services, the term ‘community’ can be used in different ways: to describe a group of people with similar health needs (for example, a group of people with diabetes), or a group receiving similar health services (for example, a group of patients receiving the same diabetes intervention), or a group of people who shape or provide services. The local voluntary and community sector often both supports and represents such communities, and also provides services to them.
Community Trusts NHS community health services provide support across a range of needs and age groups, but are most often used by children, older people, those living with frailty or chronic conditions and people who are near the end of their life. Numerous sources point to both the number and acuity of patients being cared for in their own homes increasing over recent years . Increasing numbers of people living with complex long-term conditions means that more people are likely to need support from community health services in the future.
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THE CONTEXT FOR THE REVISION OF OUR CLINICAL STRATEGY
Our review of current clinical services is influenced heavily by the strategy laid out in the Five Year Forward View and subsequent up-dates and the strategic plans published by the four Sustainability and Transformation Partnerships in the areas that we work in, NWL, NCL, SWL and Hertfordshire. In particular we have been mindful of the emphasis on:
. The need to develop and strengthen community care provision . The need to improve services and outcomes for cancer, mental health and obesity . The management of a population’s health and the prevention of illness . Place based care around specific populations . Integrated physical, mental and social care . Being much more aware of and linked to community based resources and assets . Supporting primary care so that they operate more at scale
Our own Trust’s Strategic Direction (2018-20) has set out a desire to develop a place based integrated strategy enabled by strong leadership, workforce and technology strategies.
The other key strategies include Lord Carter’s work on efficiency for community services prompting us to reducing back office time and maximise the value of patient focussed There is also the Kings’ Fund work on integration of services providing us with a benchmark for our levels of service integration.
PRIMARY CARE DEVELOPMENT
The national picture The NHS General Practice service delivery model, developed in 1948, has remained relatively unchanged for 70 years. The patient and population needs however, have changed and the delivery of the care system has not kept pace.
There is an exciting opportunity to improve patient care and population health through providing system leadership and integrating our community services and general practice. This will improve patient care and address the pressures facing general practice, community services and the wider system. Evidence shows that system leadership and integration can improve patient care and reduces costs.
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Case for Change and Vision of CLCH entering into the general practice market Our approach has been informed by the current challenges facing general practice and community services, together with a realisation that different models of service delivery can significantly improve the experiences and outcomes for patients.
Patient journey National surveys tell us that patients experience challenges along their pathway, from understanding who delivers what service to being able to get an appointment with the GP. There are a range of benefits for patients and the population that could be achieved through integrating community services and general practice.
We have a growing aging population as a percentage of the population; people are living longer, are frailer and have increasingly complex health needs that require a new approach to better manage their care. Today there are 0.5 million more people over 75 than were in 2010, and there will be 2 million more in ten years. (Source: Diagnosis critical Launching an inquiry into health and social care in England June 2018)
To respond to the needs of the population the NHS and social care are moving towards integrated care for patients and population based systems as described in the Five Year Forward View (Oct 2014).
COMMUNITY CARE AND GENERAL PRACTICE
General practice provides the majority of NHS patient care activity and is core to the integration of services. There needs to be enough general practitioners, backed up by the resources, support and other professionals to enable them to deliver quality care.
General practice however faces considerable challenges. The General Practice Forward View (2016, p6) highlights “There has been a steady rise in patient expectations, a target driven culture and a growing requirement for GPs to accommodate work previously undertaken in hospitals, or in social care. This has resulted in unprecedented pressure on practices, which impacts on staff and patients. Small changes in general practice capacities have a big impact on demand for hospital care, so the need to support general practice in underpinning the whole NHS has never been greater.”
To address this, practices are forming large scale general practices and federations with some seeking support from larger acute and non-acute providers. Although federations are forming they do not have the scale, experience or the infrastructure of provider organisations required to transform care.
The viability of out of hospital services, including general practice, matters to CLCH, and to our patients and the system. The Trust needs to respond to the opportunity to transform patient pathways and integrate care to improve quality and develop a sustainable healthcare system for the population and our patients.
Our vision is to improve services for patients, the population and the system by integrating community services and General Practice potentially through a number of ways.
WORKFORCE
The CLCH Community and Primary Care Nursing Academy plays a vital role in the integration and preparing the workforce for changes in ways of working to support the contribution to the
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integrated primary healthcare team agenda. The Academy will align skills and career pathways, specifically in nursing. [DN more detail required from HA.]
INFORMATION TECHNOLOGY AND INFORMATICS
Informatics – use of data for changing practice Population health analytics, delivering change through information, is an important driver for improving the health of a population.
Information technology Digital provision is a core component of a comprehensive offer of care for patients and key for integration e.g. shared patient records, video appointments, digital patient monitoring, and single point of access.
HOW WE SEE OUR SERVICES CURRENTLY
The current core clinical model provides a way of thinking about the purpose of our services, be they prevention or care through the various life stages (birth to death).
The workshops confirmed the predominant focus of our services is around the 0-12 and over 65 age groups. For children there are a range of prevention and care services; for older age groups the emphasis is on continuing care for longer term conditions and episodic care for rehabilitation.
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Each of our 77 service areas would differ in the degree to which they:
• Provide prevention and health promotion, Patient Group • Integrate with other services Any adult with a confirmed diagnosis of • Deploy technology Parkinson’s disease whose GP belongs to the NHS Central London (Westminster) CCG They also differ in terms of their mix of professional skills; some are predominantly nursing, some are uni-professional teams of therapists, Lead Clinician whilst many have a strong multi-professional approach including Pete Smith Parkinson’s Disease Nurse Specialist doctors, pharmacist and psychologists. Other Parkinson’s related partner services include. Community Neuro-Rehab Team In general, our services do not currently take a population view that is (CNRT), Secondary Care Neuro and Elderly proactive and planned and that impact on mortality, morbidity, health services and Parkinson’s UK (PUK). and wellbeing for a given population. Our services are much more Referrals are made between services, joint visits and collaborative working helps geared to the transaction of care according to an agreed contract. improve care.
It is clear that we have some very good examples of practice within Patients are given verbal and written the Trust. Each of the first round workshops highlighted examples and information including a Parkinson’s guide, drug treatment and an anticipatory care they came together within some key themes; for example: plan which helps patients identify potential causes of sudden deterioration and actions • Outcome measurement and goal setting (SALT, MSK,) to take. • MDT and team working (Learning-Disabilities, Barnet Bedded Service, End of Life team) Patients and carers are given info and • Integration with primary care ( COPD in Merton) encouraged to join local Parkinson’s support groups and activities. The monthly • Sharing of case notes (Harrow Integrated Service) Westminster meeting is free and includes a • Patient enablement (Diabetes care, Parkinson’s) Yoga session plus an educational activity • Links with Hospital specialists (COPD) i.e. a talk from a member of the CNRT or • Applying research to practice (Heart Failure Team) other health related organisations. Patients are also directed to other groups run by • Access to services (COPD 8/8/7 and one stop Sexual Health, patients or PUK which are listed below. Duty Advice Line Richmond 0-19 Out of Hours Care Merton Night Nursing) Provision of information in this way has • The three services showcased in this document [awaiting best helped patients understand and self- practice example from the Dental Service] manage their condition better and the simple introduction of the anticipatory care One of the critical conclusions from the workshops was the degree of plan has helped reduce unnecessary variation of practice within services across geographies and the lack of hospital admissions. Patients and carers understanding of what does and does not work well. Given the history report feeling better supported and group of the Trust, it is perhaps not so surprising that incremental activities improve social interaction. enlargement has led to certain silos of working and practice. Further Development In partnership with PUK we plan to start A number of key constraints were identified by participants. The another Parkinson’s exercise group around inability to access common patient information was a feature of many the St Johns Wood area. discussions although there are areas of the Trust where there is this kind of integration (e.g. Wandsworth). Other constraints had to do with current levels of staffing and the ability to work swiftly to address issues of recruitment and retention. A final area was access to technology to enable mobile working.
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A vision of Services looking ahead Looking to the future we wish to see our clinical services: • Geared to impacting on a defined population’s health and well being • Proactively planning preventive and reactive services to impact on agreed general outcomes for health and value • Using this planning to inform and modify demand and capacity • Integrated internally much better for learning and for supporting patients • Integrated externally with our partners in primary and acute care as well as social care and mental health to plan and deliver for patients daily and weekly • Aware and connected to the range of other community resources that could improve responses to social issues
OUR VISION OF PLACE
This strategy organises services using geography as the organising principle acknowledging that services have different geographic identities. Some will be organised and have a close identity around populations of 30k to 70k. Other services will be organised at Borough and cross Borough level but will have connections to local services.
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This identity around Place has two purposes; the proactive planning and management of a given populations’ health wellbeing; and to more actively plan interventions for a specific caseload, to achieve individual outcomes and to be productive.
There are two implications for this orientation.
The first is a requirement to systematically source, analyse and present up to date and accurate data including information on public health and wellbeing presented at the level of care delivery. This information is matched with much better data on service usage both over time and compared to other like services. This maybe internal or external, in other words the organisation continuously uses benchmarking to inform conversations about improvement.
The second is the development of local knowledge regarding the local statutory, non-statutory and community assets that is presented in an easily available format and is kept up to date.
The levels and type of data that are required are set out in the table below:
OUR VISION FOR INTEGRATION
At the proactive planning level, we need to ensure the right professionals are brought together face to face or virtually to share information, to agree priorities and outcomes and then later to review progress. This requires a deep understanding of care delivery within the identified area and a relentless focus on building and sustaining strong relationships within that clinical community. To enable the clinical professionals to function effectively CLCH will need to support these communities to access certain technical skills which presently are Held corporately as well as develop
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professionals in skills such as health education and coaching, East Merton Primary Care Home (EMPCH) and social prescribing and the critical analysis of data. CLCH Merton Cardio-Respiratory Service
At the level of individual patient service delivery, integration Lead clinicians will be achieved through multi-disciplinary team meetings Gisele Partaker. Clinical Operations Lead, CLCH Merton Cardio-Respiratory Service (real or virtual), access to shared patient information and Sayanthan Ganesaratnam supported by common processes of assessment and Clinical Director - South Division planning. Integration might be enhanced through co-location The EMPCH is a provider-led project that aims to of services and supported by case management and care improve the quality and delivery of care through navigation. We already have some very good practice around working with other providers including education this level of integration but we need consistency across our and working at scale (up to a 50,000 patient population). As part of this, our CLCH Merton services. Cardio-Respiratory Service was invited to a network meeting with two EMPCH GPs. To date Integration will be enabled through leadership development, the CLCH service and the EMPCH GPs have had good organisation development (training and facilitation of three meetings discussing ideas for joined up teams) and through technology. The latter is critical in work such as: 1. Networking with GPs and PNs: to promote enabling improved connectivity for information transfer and open communication between EMPCH and meetings. CLCH, including the ability to attend GP practice meetings and discuss cases as well as take complex cases to be discussed at OUR STRATEGY FOR CLINICAL SERVICES existing consultant clinical supervision sessions attended by CLCH 2. Data: to analyse prevalence for COPD, We have identified 5 areas for action. asthma and heart failure to guide service provision. 1. A focus on getting the basics right. This means having 3. Case finding: to reduce the gap between plans in place for appropriate staffing and skill mix with expected and registered prevalence for COPD, asthma and heart failure and identify technology support to enable mobile working and to suitable cohorts of patients for interventions support the planning and delivery of care for individual such as admission avoidance care plans, patients. There is a need to fast track the integration of cardiac or pulmonary rehabilitation and medication review. information systems or at least have an effective work 4. CLCH Respiratory and Heart Failure clinics around. based in primary care: to improve access and 2. Developing our sense of Place-based on access to good offer opportunities to build professional relationships between CLCH and EMPCH and public health information and improved data on sitting in training for PNs. Two CLCH clinics resources working with our primary care providers to (Respiratory and Heart Failure) have already agree priorities and general outcomes- see appendix A been set up in East Merton as part of this. 5. Cardio-Respiratory Primary care Education: for an example of an outcome framework. (There are to establish a regular workshop session for some areas in the Trust that are more developed in this primary care/community teams on the regard than others. The recommendation is to focus on diagnosis and management of respiratory and cardiac conditions. these as early pilots). 3. Understand our community assets, mapping and Further development publishing them to support clinical teams to access The CLCH and EMPCH relationship is work-in- progress and CLCH is hoping to soon meet up them in the delivery of holistic care. again with the EMPCH GPs to continue on the 4. Increasing the Trust’s focus on public health - work. strengthening links with public health schools, appointing a public health champion and each year agreeing a campaign on an important disease area. 5. Strengthening connectivity - building shared knowledge, research, learning and development using improved IT infrastructure to mitigate the wide geographical spread of the Trust. Considering the interoperability of clinical IT systems that allow connection across CLCH, GP and
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acute with some visibility of social care. We need to make sure that best practice is known about and is transferred into practice. We should be optimising the use of our Hub to do this alongside planned face to face exchange.
This clinical services strategy needs to integrate with the strategies being developed for workforce, ICT and primary care.
SUMMARY
We are talking about a cultural shift for the Trust in thinking and acting both locally and across services with the same strength of drive. The emphasis is on active collaboration and teamwork at a local level and across services, enabled by improved information and leadership and organisation development. This strategy and the process used to develop it, have opened up the discussion but implementation of the general policy needs team endorsement through the planning and performance review process.
NEXT STEPS -PLAN ON A PAGE
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Appendix 1
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Board of Directors 31 October 2018
Report title: Integrated Finance and Performance Report
Agenda item number: 3.1
Lead director responsible for Mike Fox, Director of Finance, Contracting and Performance approval of this paper
Report author Ruta Jamantiene, Deputy Director of Finance
Relevant CLCH priority Trust objective 2018/19 (delete as appropriate) Quality Implement strategic priorities of integration and place Finance Maintain and improve the quality of services delivered by CLCH Operations Deliver the 2018/19 financial plan Workforce Deliver all NHS constitutional and contractual standards Freedom of Information status Executive summary: Key points to note from the report are:
Performance: During September the Trust had 6 KPIs rated Red, 4 rated Amber and 9 rated Green. The 6 Red rated KPIs are: 3.1 Recurrent value of QIPP delivered against target, 4.3 Percentage of Bed Days lost to DTOC, 4.4 Contract performance notices, 5.1 Staff Recommending the Trust as a place to work, 5.3 Vacancy Rate and 5.4 BAME appointed at Band 7+
Quality: During September 3 out of 33 indicators were rated as red on the Trust quality scorecard with 5 rated as amber.
I&E Performance: The Trust has agreed a revised target surplus of £7.2m for 2018/19 with NHS Improvement (NHSI), the target surplus comprises the following:
£ m Original planned Surplus 2.2m NHSI Target reduction -0.6m General PTF Funding 2.6m Additional PTF Funding 2.0m Stretch Target 1.0m
Surplus 7.2m
106
The Trust has reported YTD surplus of £1,608k, this represents a £17k favourable variance against plan. The key driver of the improvement in month is the release of centrally held reserves to support the position.
The Trust is forecasting a surplus of £7.2m (which reflects additional £2m PTF funding and £1m additional stretch target). The forecast assumes an under spend of £4.7m on reserves, £4.1m of which is identified. The main driver of the £0.6m remaining gap is unidentified and unachieved QIPP and a shortfall in funding of the national pay award; these are the key risks to the Trust achieving its financial plan.
The Trust at Month 6 is trading at £1.1m annualised run rate variance. The difference of £0.5m between forecast variance and run rate variance against annual budget primarily relates to forecasted improvement later in the year (linked to recovery plans) in North and South divisions being partially offset by impact of vacancies in Children’s. If this recovery does not happen there will be a further shortfall to the Trust’s reserves gap.
Capital: The Trust submitted an updated capital plan of £5.3m to DofH for 2018/19 and has received £0.2m PDC funding for WiFi which constitutes its requested statutory capital resource limit (CRL) in 2018-19. The investment will have a positive impact on the quality of clinical services. The Trust has invested £259k capital in Month 6 (£830k YTD) and plans to invest £5.5m capital which constitutes its requested statutory capital resource limit (CRL) in 2018-19.
Cash: As at the end of Month 6 CLCH had a cash balance of £32.9m (£32.1m Mth5). This was £21.3m above target. The cash was above target due to outstanding capital accruals along with partial non-payment to NHS Property Services relating to prior years as the Trust is waiting for correct invoices to be issued.
Debt management is subject to weekly management and reporting to ensure the trust has sufficient funds on hand to fund investment and operational costs and ensure that cash is collected in a timely manner and is not impacted by wider NHS liquidity issues. We have applied for revolving working capital facility loan.
SOF: In month 6 the Trust’s risk rating has improved to 1 against single oversight framework, as a result of improved I&E performance. The Trust is forecasting achievement of 1 against single oversight framework at the end of 18/19.
Assurance provided: The report represents the aggregate results of the Trust performance.
Report provenance: This report has been produced by Finance, BI, Quality, Workforce and Operational teams and also reflects Divisional Management Boards and Monthly Performance Improvement Meetings.
Report for: Decision Discussion Information Recommendation: To review and note Trust performance.
107 Central London Community Healthcare NHS Trust
Contents Page
• Overview 2 • Trust KPIs 3 • Finance 16
• Key Financial Issues 17
INTEGRATED FINANCE & • QIPP Overview 18
PERFORMANCE REPORT • Appendices 19 TO 30th September 2018
108 1 Overview – The Must Knows
Finance Quality
I&E Performance (3.2): Trust surplus of £1,607k YTD; a favourable variance of £17k against plan. The Trust has a £0.6m gap in the amended forecast £7.2m surplus.
QIPP recurrent (3.1): The recurrent value of 18/19 QIPP in year is £6.2m No inpatient category 3 / 4 pressure ulcers this monththe other 2 r (£8.2m FYE) against a recurrent target of £9.5m.
Cash (3.3): Cash balances of £32.9m are above plan by £21.3m as a result of 5 delayed payments to NHSPS and capital payments relating to 17/18. There were no falls with harm in the bedded units
Working Capital: Receivables >90 days 14% (16% Mth5), Payables >90 days
57% (64% Mth5). We currently are amber for clinical vacancies
The highest rate is in inner London with a 16% vacancy rate Capital: The Trust has invested £259k in month 6 (£830k YTD). The requested capital resource limit (CRL) for 18/19 is £5.5m.
Workforce
Operations
Constitutional Metrics (4.1 and 4.2): the Trust achieved the targets for 18 week RTT and 4 hour A&E waits for Quarter 1 to date.
109 Note: = Trust KPI = Other Must Know 2 Central London Community Healthcare NHS Trust
Trust KPIs
110 3 Awaiting Sept Data 2018– Strategic KPIs Strategic
111 4 September 2018 – Strategic KPIs
Quality
112 5 September 2018– Strategic KPIs
Finance
113 6 September 2018 – Strategic KPIs 4.1 -5 Awaiting Commentary Operations
Thids should be red?!?!?!?!
James Benson
Elizabeth Hale
114 7 September 2018 – Strategic KPIs Workforce
115 8 Quality Scorecard (1) –September 2018
116 9 Quality Scorecard (2) – September 2018
117 10 TDA Access and Outcomes Framework
As part of Monitor’s Risk Assessment Framework, the Trust is monitored on a set of Access and Outcomes Metrics. Our compliance with those measures relevant to the Trust is as follows: This metric is reported Quarterly.
Access and Outcomes Metrics 2018/19 per Risk Assessment Framework (updated to September 2018)
2015/16 2016/17 2017/18 2018/19 Trust expectation of Threshold or # Measure Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 target (per self target YTD certification) Maximum time of 18 weeks from point of referral to treatment 1 92% 99.8% 99.8% 99.1% 98.8% 99.4% 99.1% 99.4% 99.4% 99.0% 99.6% 98.0% 95.9% 96.8% 96.8% Achieved in aggregate – patients on an incomplete pathway A&E: maximum waiting time of four hours from arrival to 2 95% 100% 100% 100% 100% 100% 100% 99.1% 99.7% 99.1% 99.2% 98.8% 98.9% 99.4% 99.2% Achieved admission/ transfer/discharge Certification against compliance with requirements regarding 18 N/A Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Achieved access to health care for people with a learning disability
Outcomes Data completeness: community services, comprising: Referral 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Achieved to treatment information Data completeness: community services, comprising: Referral 19 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Achieved information Data completeness: community services, comprising: 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Achieved Treatment activity information
118 Source: BIPA Team 11 Inpatient Mortality DATA PROVIDER: BIPA
The table below gives the number deaths by month in the CLCH inpatient units. The information contained in the table is currently reviewed on a monthly basis by the Medical Director, and is presented to both the Quality Committee and the Resuscitation & Mortality Review Group. In line with the recommendations of NHS England this report is now included in the Integrated Finance & Performance Report.
Athlone Rehabilitation Unit Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Deaths 0 0 0 0 0 0 Discharges for resuscitation 0 0 0 0 0 0 Deaths & Discharges (inc resuscitation) 12 23 18 13 12 12 % Deaths (inc resuscitation) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Alexandra Rehabilitation Unit Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Deaths 0 0 0 0 0 0 Discharges for resuscitation 0 0 0 0 0 0 Deaths & Discharges (inc resuscitation) 12 6 9 8 8 4 % Deaths (inc resuscitation) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Edgware Hospital - Jade Ward Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Deaths 0 0 0 0 0 0 Discharges for resuscitation 0 0 0 0 0 0 Deaths & Discharges (inc resuscitation) 29 28 24 22 19 19 % Deaths (inc resuscitation) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Adams Ward Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Deaths 0 0 0 0 0 0 Discharges for resuscitation 0 0 0 0 0 0 Deaths & Discharges (inc resuscitation) 15 14 19 13 19 12 % Deaths (inc resuscitation) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Finchley Hospital - Warren Ward Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Deaths 0 0 0 0 0 0 Discharges for resuscitation 0 0 0 0 0 0 Deaths & Discharges (inc resuscitation) 50 51 42 37 31 46 % Deaths (inc resuscitation) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Pembridge Palliative Care Unit Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Deaths 13 12 16 13 9 8 Discharges for resuscitation 0 0 0 0 0 0 Deaths & Discharges (inc resuscitation) 13 12 16 13 9 8 % Deaths (inc resuscitation) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
CLCH - Total (including Pembridge) Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Deaths 13 12 16 13 9 8 Discharges for resuscitation 0 0 0 0 0 0 Deaths & Discharges (inc resuscitation) 131 134 128 106 98 101 % Deaths (inc resuscitation) 9.9% 9.0% 12.5% 12.3% 9.2% 7.9%
CLCH - Total (excluding Pembridge) Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Deaths 0 0 0 0 0 0 Discharges for resuscitation 0 0 0 0 0 0 Deaths & Discharges (inc resuscitation) 118 122 112 93 89 93 % Deaths (inc resuscitation) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
119 Source: BIPA Team 12 FRIC Report: Exemptions- Vacancy Rate
The Trust vacancy rate has risen to 12.74% which is in the red range against the stretch trajectories. Applying statistical process control (the graph on the top right) we can observe that the data points remain under the mean level for the last 21 months. At the 5th increased data point it is also short of the 7 data point run to be considered a stepped statistical change. It is notable that the rate is lower than the same point in 2017.
In order to understand the overall rates, we need to review the 4 Clinical Divisions individually. A CHD is within tolerances the graphics focus on the 3 other Divisions.
Division Turnover Vol (last 3 Starters (3 Leavers (3 Net Hours Net Establishment Movement Commentary months) months) months) Change (last 3 Change (last 3 months) months)
Inner 3.30% (22.24FTE) 27.84 FTE 39.15 FTE 5.11 FTE 7.05 FTE Net in post change of 6.02 (-) and increase in posts of 7.05 both act to exacerbate vacancy rate
South 5.45% (30.36FTE) 12.46 FTE 33.56 FTE 5.69 FTE 10.70 FTE Net in post change of 15.41 (-) and increase in posts of 10.70 both act to exacerbate vacancy rate
North 3.03% (21.37FTE) 23.60 FTE 24.37 FTE 9.72 FTE 10.73 FTE Net in post positive, (8.95 FTE), detrition due to increased establishment (10.73 FTE) North Vacancies 1500 15.00% 955.09 14.00% Budgeted Establishment FTE 1000 818.52802.5 801.47 801.97 798.97 812.7 704.56 698.6 700.62 694.11 706.57 13.00% Frozen FTE 500 12.00% In Post FTE Vacancy Rate 0 11.00% Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Inner Vacancies South Vacancies
1000 20.00% 800 15.00% Budgeted Establishment Budgeted Establishment 628.8 629.46 629.36 621.06 631.56 631.76 FTE 574.34 575.16 570.34 565.06 554.9 549.57 FTE 800 15.00% 600 10.00% 600 Frozen FTE Frozen FTE 10.00% 400 400 5.00% In Post FTE 200 In Post FTE 200 5.00% 120 0 0.00% 0 0.00% Vacancy Rate Vacancy Rate Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 FRIC Report: Exemptions- BME % recruited at Band 7+
The Rationale for the KPI metric measuring appointments at band 7+ is designed to ensure the Trust is moving towards increasing the overall population of BME staff. As can be seen in the graphic below, the actuals recruited internally and externally varies each month and Sept was the lowest intake so far. The low levels recruited in month makes the marker more volatile therefore we need to assess the Year to Date position to understand the general trend. At the close of September, from the turn of the financial year 32.69% of staff recruited at band 7+ are from a BME background which would be in the amber range (0.31% outside of the target).
45.00% 30
40.00% 25 35.00%
30.00% 20
25.00% Total Recruited to Band 7+ 15 20.00% In month %
15.00% 10 YTD total %
10.00% 5 5.00%
0.00% 0 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18
121 FRIC Report: Exemptions- Quarter 2 Pulse Check – Staff recommending the Trust as a place to work There is a varied picture across the trust with regard staff positively agreeing with CLCH no of responses recommending the Trust as a place to work. It is also worth noting that the response rate is the lowest in the last 6 iterations of the pulse. 1400 1250 1215 1200 CHD – following the significant downturn in agreement in Q4 2016/17 (dropping from 50.87% to 20.42%) the scores have been increasing with 46.55% posted last month. 1000 Inner – Inner rate dropped in Q4 16/17 and Q1 17/18 to circa 45% but since has 800 posted circa 60-70% agreement with Q2 18/19posting 68.33% 568 584 CLCH South – The South position was materially affected by the acquisition of Wandsworth 600 507 537 services in Q4 2017/18 with the rates of 70%+ falling to a low of 40.82%. The Q2 421 398 426 posting was 43.48% and known staffing issues are likely reflected in the limited 400 308 qualitative data 200 North – The north position has been consistently strong up to the quarter 2 posting of 51.43%. The limited qualitative data indicates increasing pressure on staffing as a 0 cause. Q1 2016.17Q4 2016.17Q3 2017.18Q2 2018.19
100.00%
90.00%
80.00% CHD Inner 70.00% North
60.00% South QL&O 50.00% Med
40.00% Imp TMH 30.00% P&C
20.00% FPC CLCH 10.00% 122 0.00% Q1 2016.17 Q2 2016.17 Q3 2016.17 Q4 2016.17 Q1 2017.18 Q2 2017.18 Q3 2017.18 Q4 2017.18 Q1 2018.19 Q2 2018.19 Central London Community Healthcare NHS Trust
Finance
123 16 Key Financial Issues Income and Expenditure Summary
Income At Month 6 CLCH has achieved a £1,608k YTD surplus; this represents a Income & Expenditure FY Budget YTD Plan YTD Actual YTD Forecast Run Rate Expenditure £17k favourable variance against plan. The key driver of the improvement Variance Variance Variance Year to Date in month is the release of centrally held reserves and improvements in £000 £000 £000 £000 £000 £000 operational forecasts. Income -230,261 -115,704 -116,225 521 2,453 5,057 The Trust achieved an EBITDA margin of 3.8% as at the end of Month 6 compared to the plan of 3.9%. Pay Expenditure 150,752 75,592 76,975 -1,383 -1,597 -6,060 Non-Pay Expenditure 70,214 35,578 34,803 775 2,138 -137 I&E Forecast The Trust is forecasting a surplus of £7.2m (which reflects additional £2m EBITDA -9,296 -4,534 -4,447 -87 2,993 -1,140 PTF funding and £1m additional stretch target). The forecast assumes an Depreciation 3,639 1,820 1,820 0 0 underspend of £4.7m on reserves, £4.1m of which is identified. The main Amortisation 2,461 1,230 1,230 0 0 driver of the £0.6m remaining gap (£1.3m at Month 5) is unidentified and Dividend 1,600 800 703 97 0 unachieved QIPP and this is the key risk to the Trust achieving its financial Interest Received 0 0 -7 7 7 plan. (Planned Surplus)/Deficit -1,596 -684 -701 17 3,000 -1,140
The Trust at Month 6 is trading at £1.1m annualised run rate adverse Technical adjustments -2,590 -907 -907 0 0 variance (£3.4m Month 5). The difference of £0.5m between forecast (Total Surplus)/Deficit -4,186 -1,591 -1,608 17 3,000 -1,140 variance and run rate variance against annual budget primarily relates to EBITDA Margin 4.0% 3.9% 3.8% forecasted improvement later in the year (linked to recovery plans) in North Statement of Financial Position and South divisions being partially offset by impact of vacancies in Children’s. If this recovery does not happen there will be a further shortfall to Opening Month 6 Forecast the Trust’s reserves gap. as at Year end 01/04/18 Quality, The QIPP target for 2018/19 is £9.5m, at present £7.4m of schemes have £'000 £'000 £'000 Innovation, been identified. As at Month 6 the Trust is reporting under-achievement of Property, Plant and Equipment 53,039 50,818 51,393 Productivity £0.7m against a year to date plan of £2.9m. Non-current Trade and Other Receivables 0 0 0 and Cas h 22,709 32,896 11,346 The Trust is currently forecasting achievement of £6.2m QIPP by the end of Prevention Debtors 27,232 28,167 24,721 the financial year resulting in a £3.3m forecast adverse variance against (QIPP) Total Assets 102,980 111,881 87,460 plan before factoring in contingency.
Total Liabilities -39,531 -46,620 -16,621 The recurrent value of 18/19 QIPP is £8.2m. Net Assets 63,449 65,261 70,839 Surplus(Deficit) 6,883 1,608 7,186 As at the end of Month 6 CLCH had a cash balance of £32.9m (£32.1m Balance General Fund b/f 42,422 49,304 49,304 Mth5). This was £21.3m above target. The cash was above target due to Sheet, Capital Revaluation Reserve 13,148 13,148 13,148 outstanding capital accruals along with partial non payment to NHS Property and Cash Public Dividend Capital 996 1,201 1,201 Services relating to prior years as the Trust is waiting for correct invoices to be issued. Total Reserves 63,449 65,261 70,839 QIPP Plan Summary The Trust has invested £259k capital in month six (£830k YTD) and plans to 2018/19 2018/19 YTD YTD Actual YTD Actual 2018/19 Full Recurrent invest £5.5m capital which constitutes its requested statutory capital Target Identified Identified Variance to Year Forecast Value of resource limit (CRL) in 2018-19. The %age of Trust payables over 90 days Identified 2018/19 QIPPs was 57% (64% Mth5) and receivables 14% (16% Mth5) compared to a £'000 £'000 £'000 £'000 £'000 £000 £000 target of 5%. Total QIPPs 9,474 7,445 2,852 2,159 -693 1246,192 8,169 SOF The Trust was evaluated as Segment 1 out of 4 under the Single Oversight Framework (SOF). 17 QIPP Programme Overview
Segment Scheme Category 2018/19 2018/19 Recurrent YTD YTD Actual YTD Actual 2018/19 Full FY Forecast FY Forecast Target Identified Value of Identified Variance to Year Variance to Variance to 2018/19 Identified Forecast 2018/19 2018/19 QIPPs Target Identified £000 £000 £000 £000 £000 £000 £000 £000 £000 Clinical Children's Local Schemes £1,348 £1,209 £1,134 £347 £278 (£69) £1,038 (£310) (£171) Inner Local Schemes £2,127 £1,651 £1,695 £765 £504 (£261) £1,179 (£948) (£472) North Local Schemes £1,695 £1,312 £1,453 £561 £485 (£76) £1,123 (£572) (£188) South Local Schemes £2,405 £1,783 £1,786 £558 £280 (£279) £1,208 (£1,197) (£575) Clinical Total £7,574 £5,954 £6,067 £2,231 £1,547 (£685) £4,547 (£3,027) (£1,407) Corporate Estates £1,000 £413 £500 £175 £170 (£5) £415 (£585) £3 Procurement £500 £409 £720 £234 £232 (£2) £561 £62 £152 IT £7 £7 £0 £4 £2 (£1) £6 (£1) (£1) Finance £100 £100 £100 £50 £50 (£0) £100 (£0) (£0) Transformation £12 £12 £12 £6 £6 £0 £12 £0 £0 Chief Executive £10 £10 £10 £4 £4 £0 £10 £0 £0 Trust-Wide £271 £525 £760 £145 £145 £0 £525 £254 £0 Partnership & Procurement £0 £15 £0 £2 £2 £0 £15 £15 £0 Corporate Total £1,900 £1,491 £2,102 £620 £612 (£8) £1,645 (£255) £153 Grand Total £9,474 £7,445 £8,169 £2,852 £2,159 (£693) £6,192 (£3,283) (£1,254)
The QIPP requirement for 2018/19 is £9.5m (excluding identified contingency) and as at Month 6 £7.4m of schemes have been identified (£7.2m at Month 5). The increase in identified schemes is linked to Children’s where there is a new scheme for Wandsworth Transformational funding. Overall, as at Month 6 the Trust is reporting QIPP under-achievement of £0.7m against a year to date plan of £2.9m. The Trust is currently forecasting achievement of £6.2m (risk adjusted) of QIPP by the end of the financial year (£6.4m at Month 5) resulting in a £3.3m forecast adverse variance against plan (£1.9m adverse variance once £1.4m contingency factored in). The deterioration in forecast is predominantly due to impact of reduction in South recovery plan delivery (schemes impacted are management economies of scale and holding of vacancies). The recurrent value of 18/19 QIPP is £8.2m (£8.9m at Month 5). Deterioration to recurrent value linked to impact of reduction in South recovery plan delivery plus removal of Inner scheme re. Hounslow Diabetes re. timing of lease termination.
Recovery of the QIPP position: The Estates team has just brought in an additional resource to manage trust-wide estates schemes, so the uncertainty around the level of deliverable QIPP should be resolved in the coming months. The forecasted estates QIPP delivery in year is £0.4m with recurrent value of £0.5m. Divisions are meeting regularly to monitor the progress on existing QIPP schemes, as well as coming up with additional schemes for both this year and the pipeline. Clinical teams across the Trust continue to work with the Transformation team and Finance to come up with additional schemes to improve the position further. The Transformation team are co-ordinate weekly updates to schemes and reporting this to ELT. 125 18 Central London Community Healthcare NHS Trust
Appendices
126 19 Workforce KPIs –September2018 DATA PROVIDER: HR
127 Source: HR Workforce Team
Board of Directors 31 October 2018
Report title: Update on the Learning from Death (LfD) policy Q2 Agenda item number: 3.2
Lead director responsible for Dr Joanne Medhurst approval of this paper
Report author Dr Joanne Medhurst
Relevant CLCH strategic Trust objective 2018/19 priorities Quality Maintain and improve the quality of services delivered by CLCH Freedom of Information status Executive summary This paper sets out guidance from a recent meeting with NHSI that enables and supports a change on the approach the trust is taking with the ‘Learning from Death’, policy. The paper suggest stratifying care delivery into 3 levels and asks the members of the committee to agree which services are at what level. This will mean that services classed as low risk will be excluded from following the processes set out in the policy.
Assurance provided:
Report provenance: This report was presented to the ELT meeting on 9th November 2018 where it was agreed without change. We have subsequently updated the report for the Quality Committee with our plan to ensure that we continue to meet the Trust’s KPI compliance. This is due to the Trust achieving 92% (amber) compliance during September 2018.
Report for: Decision Discussion Information x x Recommendation: To adopt new stratification approach.
1 Purpose
128 1.1 The purpose of this paper is to update the committee on a meeting with NHSI that concluded with recommendations to change the LfD policy. 2 Introduction 2.1 CLCH published a ‘Learning from Death’ policy in October 2017 based on The National Quality Board at NHSI ‘National Guidance on Learning from Deaths’. The adult divisional teams are making good progress in embedding this policy however divisions have been feeding back that there was a considerable burden on teams to adhere to the guidance within the LfD policy which seemed disproportionate to the learning generated. 3 Progress to date 3.1 Eligible adult services are currently reviewing all deaths known about within 30days of being on a CLCH caseload. The medical director has raised this issue through NHSI and this culminated in a meeting on the 10.8.18 with the deputy MD of NHSI and a selection of MDs from community and combined community/ mental health trust MDs from around London.
The meeting agreed the following approach;
. Everyone to continue focussing on inpatient deaths, with variable ways of (and amount of ) looking at community deaths . To focus on the community elements of your Trusts, we agreed that the patients fell into two groups: those where your staff provided significant levels of care (e.g. EOLC, inpatient care) and those where they provided a small element of care (e.g. podiatry). . Each trust would therefore stratify their services to determine high and low impact services . LeDeR reviews: as is the picture nationally, investigations have been slow in coming back to Trusts. Recommended that a local review is done for any Trust specific learning and fed into the LeDeR process
The meeting agreed that the following groups of patients need an automatic review: . Significant concerns raised by family, carers or staff . Patients with learning disabilities . Patients with significant MH problems . Homeless patients . Inpatients (plus within 30 days of discharge where data available) . EOLC patients: patients with an EOLC plan being delivered by the community team . Any high impact services as determined by stratification . Other patient cohorts should be selected based on improvement initiatives in the Trust or other concerns. These cohorts may change over time. E.g. pressure ulcers, diabetic patients
3.2 Next steps The members of the resuscitation committee will be tasked with reviewing the service portfolios within each of the adults divisions and ranking services at 3 levels based on the complexity and dependency of the care being delivered based on the dependency heat map used in CLCH nursing services.
The group will rank services as ; • Service providing care with intensively dependent / high levels acuity- Level 1 service • Services providing care with medium to high dependency/ moderate acuity but that is linked to an organisational priority – Level 2 service • Service providing care with low dependency/low acuity – Level 3 service
This paper is proposing that we then exclude all level 3 services from the policy processes but include levels 1 and 2. For these services the divisions will be asked to nominate a named reviewer and give assurance to the quality committee that the person named has suitable skills and competencies. Once
129 this approach has been agreed via Board the LfD policy will be amended.
4 Update on inpatient and trust deaths CLCH publishes the numbers of deaths within the inpatient units of the trust as part of regular reporting (there are five in-patient units and an inpatient hospice), and any deaths in these units are all reviewed using an accredited review tool, the CLCH Mortality Review Form, based on a accredited case review methodology.
During the period under review, 3 PRISM Reviews from the inner Division with no discrepancies were discussed. All were signed off and agreed with no further comments.
Across the second quarter of the year 2018/19 there were no unexpected deaths in the Trust’s inpatient units. See table A below.
Table A From January 2018 divisional leaders have been working with teams to implement the new processes described in the policy that set out how to record all deaths within a broader scope across adult community services. In parallel, the clinical effectiveness team has developed a reporting template which is produced at divisional level and then collated up to Trust level.
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For the month of September-18, 122 deaths were reported in 3 adult divisions, and 112 deaths were reviewed using the screening tool. Trust KPI achieved was 92% in that month. For August-18, Trust KPI achieved was 100% with 130 deaths reported and reviewed using the screening tool.
We are currently investigating the reason behind the drop in compliance in the North and South Divisions in September to ensure that an action plan is in place to guarantee the KPI target is continually met. Additionally, this issue will be discussed at the next Resuscitation and Mortality Group meeting.
See table B below
Table B This data is then used to judge achievement against the board KPI. This is the percentage of eligible deaths in CLCH that are reviewed using the CLCH screening tool in line with policy. The Trust target is 100% and the Amber Threshold is 75%.
We are working with the lead psychologist for Learning Disabilities to develop a report for the deaths of CLCH patients with known learning disabilities and will begin to case review deaths in this group. 5 Quality implications and clinical input 5.1 To be reviewed through the MDT resuscitation committee 6 Equality implications 6.1 Nil 7 Comments of the Director of Finance, Performance and Contracting 7.1 N/a
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Board of Directors 31 October 2018
Report title: Quarterly report on Fire, Health & Safety, and Progress against the 5 Year Plan
Agenda item number: 3.3 Elizabeth Hale, Director of Improvement Lead director responsible for Mike Fox, Director of Finance, Contracting and Performance approval of this paper
Report author Ian Daccus, Capita CLCH Partnership Estates and Facilities Management Director Relevant CLCH strategic Trust objective 2018/19 priorities Quality Maintain and improve the quality of services delivered by CLCH Workforce Make CLCH a great place to work for everyone Freedom of Information Open status Executive summary: This report is the Quarter 2 update to the Trust Board on activities and progress of actions in respect of the Trust’s Fire, Health and Safety (FHS) general activities, FHS risks, compliance, update on the Health & Safety 5 Year Plan, training standards and compliance with the Health and Safety Policy.
The report covers the following areas:
• Fire safety • Governance • Mobile Working Display Screen Assessments • Moving and Handling • Employee Health Service • Policies
The following are being brought to the attention of the Trust Board
Fire Safety The agreed target for e-learning fire training is 95%. Compliance at the end of September 2018 is currently 92.0% - an improvement on the last quarter which was 89.5%. Learning and Development are sharing the compliance training data more frequently with the divisions, to help managers ensure staff complete their on-line training.
Fire evacuation training across the bedded units is at 91.3%, with thirteen members of staff requiring training. Fire evacuation training is a continual process with training being delivered on a monthly basis. Assurance is provided by the bedded units that each shift is covered by staff who have received fire evacuation training.
Governance The quarterly health and safety checklist, introduced in April 2018 for all services, continues to be embedded. The checklist covers a variety of environmental, procedural and policy areas and has been developed so that specialist knowledge is not required for completion. The checklist is being monitored 132 through the monthly performance report and provides a level of assurance that health and safety requirements are being met or, where they are not, actions are put in place to address the gaps in compliance.
RIDDOR There have been two Health and Safety RIDDOR reportable incidents involving members of staff this quarter. Both incidents were discussed at the Health and Safety Committee (HSC) and actions were agreed to ensure •RIDDOR reportable incidents are reported to ELT. •The RIDDOR policy is revised with this additional escalation procedure. •The Health and Safety Sub Group (HSSG) review the incidents and determine if a specific risk should be added to the risk register.
Moving and Handling The compliance rate for Level 1 at the end of September 2018 is 96.84%. The compliance for Level 2 at the end of September 2018 is 89.36%.
Employee Health Service The Trust compliance for measles and varicella immunity is set at 95%. The overall compliance has improved since the last quarter, with most of the divisions reaching compliance. The South remains non-compliant, and this is due to the TUPEd services of Wandsworth Community and SWLSHS and some existing staff in the division. This is being monitored by the HSSG and the HSC. Employee Health is working with DDOs to address non-compliance by providing a monthly non-compliance list to be actioned. They are also providing screening sessions at the Trust’s Welcome sessions to capture new starters – this has helped improve the compliance rate across the Trust.
Turnaround times for sickness absence appointment targets are set at 7-10 days for a doctor and 5-7 days for a nurse. These are not currently being met and a review of the turn-around times will need to take place.
Risk Register Significant progress has been made in reviewing and moving forward actions across the fire, health and safety risks, which has seen a reduction in the number and level of risks. Currently the highest risk score is 12 and this applies to one risk.
Health and Safety 5 Year Action Plan The 5 Year Health and Safety Action Plan is monitored through the HSC and HSSG and of the 35 actions 27 are green and 8 are amber, of which three relate to stress. Significant areas of improvement continue to be seen in all areas and there are no major issues for board attention.
Assurance provided: Progress against the 5 year Plan is subject to review through the Health and Safety Committee (HSC) and the Strategic Estates Group (SEG).
Report provenance: This paper has been presented to the Executive Leadership Team and the Health and Safety Committee. Report for: Decision Discussion Information x Recommendation: The Board are asked to note the continued progress with Health and Safety compliance.
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Quarter 2 Report on Fire, Health & Safety
1 Fire Safety 1.1 The agreed target for e-learning fire training is 95%. Compliance at the end of September 2018 is currently 92.0%. This is an improvement on the last quarter which was 89.5%. Learning and Development (L&D), as part of a strategy to reach and maintain the 95% target, continue to share more frequently the compliance training data with the divisions. This is in order that managers can encourage staff to complete their on-line training.
1.2 Fire evacuation training across the bedded units is at 91.3%, with thirteen members of staff requiring training. Fire evacuation training across the bedded units is a continual process with training being delivered on a monthly basis. Compliance with fire training is monitored through the Health and Safety Sub Group and the Health and Safety Committee. Assurance has been provided by CBU managers and recorded on the monthly performance report that all shifts within the bedded units are covered by a minimum of one member of staff who has been trained in fire evacuation procedures.
1.3 The following classroom based training was delivered during this quarter (to September 2018): • Fire Awareness Training o Trust Induction o Edgeware Community Hospital x3 o Merton Civic Centre x4 o Parsons Green x5 o Wandsworth School Nurses • Fire Warden Training . Parsons Green x2– Not service specific . Edgeware Community Hospital – Not service specific • Fire Evacuation Training o Alexandra Ward x2 – Bedded Unit o Woodlands – Bedded Unit o Jade Ward – Bedded Unit o Parkview – Dental o South Westminster – Dental o Health at the Stowe - Podiatry
The details of fire evacuation training are below in the Fire Evacuation Training section.
2 Governance 2.1 Health and Safety Checklists The quarterly health and safety checklist introduced in April 2018 for all services, continues to be embedded. The checklist covers a variety of environmental, procedural and policy areas and has been developed so that specialist knowledge is not required in order to complete the checklist. The checklist is being monitored through the monthly performance report and provides a level of assurance that health and safety requirements are being met and where they are not, actions are put in place to address the gaps in compliance.
2.2 Policies The program of updating Health and Safety related policies is reviewed monthly at the HSC. The following policies were approved during this quarter:
• Young Persons at Work Policy • Safe Use of Medical Gases Policy
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2.3 Site Compliance Assurance 2.3.1 Tier 1 Sites: Where the Trust is a freehold occupier or majority leaseholder and the hard FM services are provided by Capita Partners – Compliance with all aspects of Fire, Health and Safety remains 100% for Tier 1 sites.
2.3.2 Tier 2a Sites: Where the landlord is mainly NHS Property Services (NHS PS) or Community Health Partnerships (CHP). Progress has further improved over the last quarter with these landlords and assurances in particular for Fire, Water Safety and general compliance. Performance Indicators are being provided increasingly and assurance through this is much higher than the preceding period. Monthly meetings are held with NHS PS to review performance.
2.3.3 Tier 2b Sites: These are Bedded Units owned by third parties, e.g. Central & Cecil, where the Trust has staff delivering services but the control of Fire, Evacuations and Safety Compliance rests with the owners.
2.3.4 Tier 3 Sites: Are those where the Trust occupies on a low use, sessional basis – e.g. one clinic a week. Compliance assurance from these landlords is a long standing area of concern. All Tier 3 sites now have been written to and emailed, formally asking for compliance assurance.
2.4 Fire Safety 2.4.1 Fire Risk Assessments There is currently 100% compliance. There is a scheduled programme in place throughout 2018 to ensure compliance is maintained.
2.4.2 Fire Drills: Drills continue to be undertaken on a rolling schedule in line with the Trust policy and are monitored through the monthly performance report. The Trust is liaising with NHS PS to co-ordinate fire drills in locations that come under their control.
2.4.3 Fire Evacuation Training: in the bedded units is at 91.3%. Fire evacuation training is a continual bespoke rolling program on the bedded units, delivered by the FHSM.
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Fire Evacuation League Table for Bedded Units – September 2018
Note: These statistics relate to Staff in Inpatient Areas ONLY. Staff numbers verified by the matron from the inpatient area.
Non- Total Compliant Organisation Compliant Division Compliant Required %
Inner Directorate Alexandra Ward 15 15 100.00% Inner Directorate Athlone Rehabilitation 1 29 30 96.67% Inner Directorate Continuing Care Therapies 1 1 100.00% Inner Directorate Pembridge In-Patient Unit 5 15 20 75.00% Inner Directorate Total 6 60 66 90.91% North Directorate Barnet Adams Ward 6 15 21 71.43% North Directorate Barnet Jade Ward 20 20 100.00% North Directorate FMH - Marjorie Warren Ward 39 39 100.00% North Directorate Total 6 74 80 92.50% South Directorate Merton Inpatient beds 1 2 3 66.67% South Directorate Total 1 2 3 66.67% Grand Total 13 136 149 91.28%
2.5 Fire Wardens
2.5.1 Zone Plans: All sites have Fire Zone Plans which have been created and placed on the Hub for the Trust Tier 1 and 2 sites. All services are required to have a nominated fire warden.
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2.5.2 Training: All sites occupied by CLCH have fire wardens on each floor. This is monitored through the monthly PI report to the HSC.
Inner Division North Division Wardens required for 59 Wardens required for individual 76 individual zones zones Total no: of wardens trained 104 Total no: of wardens trained 94 and appointed within and appointed within individual individual zones zones Shortfall 0 Shortfall 0 % of sites occupied by CLCH 100% % of sites occupied by CLCH 100% with fire wardens per floor with fire wardens per floor
South Division Children’s Division Wardens required for 52 Wardens required for individual 39 individual zones zones Total no: of wardens trained 57 Total no: of wardens trained 73 and appointed within and appointed within individual individual zones zones Shortfall 0 Shortfall 0 % of sites occupied by CLCH 100% % of sites occupied by CLCH 100% with fire wardens per floor with fire wardens per floor
Corporate Wardens required for 5 individual zones Total no: of wardens trained 27 and appointed within individual zones Shortfall 0 % of sites occupied by CLCH 100% with fire wardens per floor
2.5.3 Display Screen Equipment Display Screen Equipment (DSE) on-line training and assessments are very well embedded. However, there is still a need for line managers to be more proactive when staff raise concerns. Also the number of high risk users clearing their status to low risk when issues have been resolved is not happening in the majority of cases. Monthly performance and compliance data is shared with the divisions in order that the staff can be followed up. This is monitored through the monthly PI report, which is reviewed at the HSC.
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2.6 Moving and Handling Moving and Handling Level 1 is delivered using the Statutory and Mandatory Training Booklet that is reissued in the autumn. The compliance rate for level 1 for the end of September 2018 was 96.84%.
The Quality, Learning and Development and Moving and Handling leads have been reviewing delivery of Level 2 training with a view to delivering more generic training sessions so that staff can book themselves onto the course. Workshops have been run and Learning and Development are in the process of kitting out three training rooms, one in the North, one in the South and one in Inner.
We continue to follow up the staffing groups that require training resulting in an improvement in the compliance rate. At the end of September 2018, compliance for Level 2 was reported at 89.36%.
Support to front line staff in the form of joint visits and support in risk assessing has been provided by the Moving and Handling team to support them looking after some complex cases in the community.
2.7 RIDDOR (July – September 2018) There have been two Health and Safety RIDDOR reportable incidents involving members of staff this quarter. • First incident - staff member’s vehicle was hit from behind, whilst stationary. This resulted in the staff member being off work for more than seven days. • Second incident - staff member was hit by a vehicle whilst crossing a road to visit a patient during the evening. The incident was categorised as a specified injury as it resulted in a bone fracture, to both wrists.
Both incidents were discussed at the HSC and the following actions were agreed:
• Briefing note to be distributed to CBU managers stating that RIDDOR reportable incidents should be reported to ELT. • RIDDOR policy to be revised with the additional escalation procedure. • HSSG to review and debate if there is a risk to staff using their cars when carrying out their everyday duties and whether a specific risk should be added to the risk register.
3 Employee Health Service (EHS) 3.1 Measles and Varicella Compliance (1st July – 30th September 2018) The Trust compliance for measles and varicella immunity is set at 95% and is currently below this target. The measles and varicella immunisation reports now reflect the directorate/divisions of the Trust. There are still issues with the new report as there are discrepancies between ESR and the EHS database around some dates of birth and names (first and surnames) and leavers. This is an ongoing issue which involves working with recruitment and workforce analysis.
Table 1a Varicella and Measles Immunity Varicella Measles CLCH (Trust position) 96.23% 94.96% CHD 97.13% 95.22% Inner 96.27% 94.32% South 93.78% 92.40% North 96.93% 96.59% Improvement 100.00% 100.00% Medical 97.67% 97.67% Operations, Quality & 95.59% 95.59% Learning Trust Management 100.00% 100.00%
3.2 TUPEd Services
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The measles and varicella compliance for the TUPEd service of Wandsworth School Nursing service on 3rd September was good at 79% (based on the review and manual update of immunisation data). The Employee Health Service attended the induction of the Wandsworth School Nursing service on 5th September to screen the non-compliant staff in attendance.
For the rest of the Trust, a non-compliant staff list is sent to the DDOs and Deputy DDOs for action, the last list was sent on 22nd August, and the next list is due on 5th of October.
The Trust Welcome sessions commenced in February 2018 and takes place twice per month. Initially alternating between Edgware Community Hospital and Parsons Green but since July this has been at Parsons Green. The EHS nurse has a slot at each session to screen new staff and this has assisted with the overall immunisation compliance.
3.3 Flu Campaign 2018/19 Influenza Working Group meetings commenced on 27th March to look at a programme for the forthcoming campaign and will continue monthly throughout.
Changes for the forthcoming campaign It was agreed by the group that an e-learning educational package would be the best way forward, which would then be added to the flu e-learning booklet. The aim of the e-learning package would be:
To understand the characteristics of influenza viruses including: • pathology • transmission • impact • signs and symptoms • to understand global influenza activity • to dispel myths and misconceptions • to be aware of how to get vaccinated
Campaign to date • Flu vaccines arrived in the Trust week beginning 10th September • 83 site visits confirmed across the Trust for walk in flu vaccination. All advertised on the HUB • Influenza PGD signed off on 17th September • E-learning package available on the HUB • Fairview pharmacy commenced flu deliveries to peer vaccinator sites week beginning 17th September • As of 2nd October, there are 22 peer vaccinators recruited across the Trust • Two weekly reporting to the DOH on campaign progress , vaccine uptake, any issues, successes etc • Weekly reports to ELT, DDOs and CBU managers to commence the week commencing 15th October • ImmForm reporting will commence on the first week in November. There will be a moving baseline to accommodate starters and leavers
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Flu uptake to date Progress Rates Static Baseline figure for reporting Category Numerator (numerator) Denominator % GP 0 0 10 0.00% Medic 3 3 49 6.12% Other Qualified Professional Clinical Staff 29 29 544 5.33% Qualified Nurse 62 62 1499 4.14% Student 1 1 16 6.25% support to clinical staff 61 61 1044 5.84% Total 156 156 3162 4.93% not on immform 24 24 179 13.41%
Formal vaccine declines
only protects never vaccine heard it not from Formal Declines results had the makes lowers convinced certain recorded (all dataset) Deferred flu me ill immunity of value strains Other GP 0 0 0 0 0 0 0 Medic 0 0 0 0 0 0 1 Other Qualified Professional Clinical Staff 2 0 0 0 0 0 0 Qualified Nurse 0 1 3 0 3 0 3 Student 0 0 0 0 0 0 0 support to clinical staff 0 0 2 0 2 1 3 not on immform 1 0 0 0 0 0 0 Total Declines = 22 3 1 5 0 5 1 7
3.4 Management of Sickness Absence (up to 30th September 2018) The response time for an appointment within 7-10 days is improving slowly.
Sickness absence referral July August September
Initial short term sickness absence 44 44 19 Initial long term sickness absence appointments 32 17 35 Reviews 39 35 29
% of appointments offered as per PI (nurse and physiotherapist 5-7 days and doctor 7-10 days)- 89% % of appointments offered as per PI nurse 5-7 days - 85% % of appointments offered as per PI doctor 7-10 days - 100% Standard 95% for all
Management referral responses Response time for issuing of reports following assessment: % of reports out in 3 days or less for nurse is 98% % of reports out in 3 days or less for doctor 81% Standard 95% for all
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Staff have the right to see the report (GMC guidance) before it is sent out to the referring manager and this may mean the response does not go out within the timeframe of 3 days or less.
3.5 Staff Trips and Falls up to 30th September The total number for the quarter was 7.
3.6 Physiotherapy Physiotherapy sessions twice per month continue at South Westminster Centre and the Civic Centre at Morden, which makes the service more accessible to staff in the South of the Trust.
3.7 Mental Health The Mental Health Services provided by the EHS includes 1:1 therapy for individuals which can be accessed by self-referral and management/HR referral as well as individual team training. The Mental Health service access is one day per week at Edgware and five days per week on site at St Charles as well as telephone counselling for those staff where these sites are not accessible. From December 2016 the team has included a part-time mental health nurse.
As well as the above therapy, the team is involved in supervision and training for mediators and street homeless team, time to change volunteers and group sessions for teams requiring support. In addition, Mental Health Awareness training sessions are provided for managers and staff as part of the CQUIN.
4 Health and Safety 5 Year Action Plan
The 5 Year Health and Safety Action Plan is monitored through the HSC and HSSG and of the 35 actions 27 are green and 8 are amber, of which three relate to stress. Significant areas of improvement continue to be seen in all areas and no major issues require board attention at this report.
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FIVE YEAR HEALTH AND SAFETY ACTION PLAN (February 2016 – February 2021) UPDATE September 2018
Evidence Item Strategic Aim Description Overall Delivery Programme Board Report Update HSSG/HSC Updates Action by Date
a c d e f g h 1 Commence a review of all existing Policies prioritised as per PRG log. December 2017 - All Health and safety policies are currently up All Health and safety policies are currently up Minutes from Health and policies procedures and guidance to date. The schedule is monitored through the HSSG and HSC to date. The schedule is monitored through the FHS/HSC Safety Sub group (HSSG) and notes that are due to expire in the HSSG and HSC Health and Safety Committee calendar year. 04/01/17: The policies below are being progressed via the HSSG (HSC). and HSC to ensure they are reviewed and agreed in accordance with the Trust Policy on Policies. Drafts of each policy are progressing New H&S policy now completed. 6 other policies due for renewal/revision by the end of 2016: • Control of Substances Hazardous to Health – Oct ’16. • Asbestos Policy – Dec ’16. • Control of Contractors – Dec 16 • Environmental Cleaning Policy – Dec ’16 • Transport Policy – Dec’16. • Water Safety and Water Quality Policy – Dec’ 16.
2 Review content of FHS pages on the Being reviewed, redeveloped and December 2017: The FHSM and FSO left the trust in June 01.02.2018 (HSSG) This is on-going. The HUB is HUB and update information revised in year. and the team administrator left in January. FHS/HSC updated as and when This is ongoing for the FHSM. The new FHSM displayed as necessary. 04/01/17: The FHSM and FSO have been updating the Hub required. received training from the communication team pages and have attended Hub Update and training meetings th on 8 January 2018. with the Trust Communications Director.
3 Bi-annual reviews in February and FHSM and advisors are maintaining 06/11/17: Ionising Radiations Regulations 2017 - new 01.02.2018 (HSSG) This is a continual process. September. an overview of all professional regulations due to come into effect on 1st January 2018 (Ionising FHMS monitors the HSE website and receive FHS/HSC Minutes from HSSG and HSC publications and the HSE Web site for Radiations Regulations 2017 (IRR17)), and Ionising Radiation alerts for changes to or updates to legislation FHSM and possible changes to legislation. (Medical Exposure) Regulations 2018 (IRMER2018), are due to and/or guidance. FSO come into effect on 6th February 2018. New system of providing the Health and Safety Executive (HSE) with information on 04/01/17: The next update in legislation is in April 2017. work with ionising radiation. The registration There is currently a ‘live’ review of the Gas Safety (installation will be completed by the deadline of 5th and Use) Regulations 1998 being carried out. The closing date February 2018. for responses is 27th January 2017. It is thus unlikely any changes to these Regulations will be introduced in April ’17, more than likely it the amended Regulations will come into force in October ’17, Q3 of Fin Yr 2017/18.
4 Produce the Annual Health & Safety The Annual H&S report forms part of The Annual H&S Report was produced, presented and accepted 01.02.2018 (HSSG) Minutes from HSSG, HSC, Report for the Trust Board the quarterly updates to the Board. by the Board in May 2016. There is a process in place. FHS/HSC Executive Leadership Team All updates now include the complete The cycle of reporting from the Board for and Trust Board. report so an annual update is 2017/18 has the reports now quarterly. delivered through the year.
5 Undertake reviews of Fire, Health & 04/01/17: Details of the independent H&S review conducted by 01.02.2018 (HSSG) Minutes of HSSG, HSC and Safety performance against KPIs and Robert Caldeira Associates Limited are subject to agreement to This is now green. The monthly PI report is Trust and Trust performance the Service Level Agreement with the action plan at February HSC. updated and uploaded to the Hub. Capita management. Capita. FHSM, Work is underway within the Trust and Capita to develop KPIs . FSO, Establish key performance indicators for the FHS services, DDO/CBU for, incident reduction; improved To be addressed in conjunction with Action Plan arising from s reporting both in time and by volume. independent &S Review??? 6 Establish Divisional Health & Safety This task will require joint working December: This risk 1387 was reviewed by HSSG and the HSC 24.09.2018: It was agreed at HSSG and HSC Datix risk register risk assessment and risk register with the Divisional Management and it was agreed that there was sufficient evidence and work that the risk rating should be reduced due to: Trust review programmes. To be assessed Teams (DMT) and FHS Team being undertaken to reduce the risk score from 16 to 12. Divisions one division per quarter, in members. Attendance at DMT The bedded units are completing their and HSC conjunction with each of the divisional meetings and support from DDOs will 04/01/17: Divisional CBU Safety Leads and FHSM are monthly and quarterly Health and Safety health and safety leads. ensure facilitation of this activity. progressing this matter. checks. There has also been a marked increase in the number of quarterly Activity based risk assessments by the Trust remain a concern assessments being submitted by the and work is underway to improve the level of assessment. divisions. Sessional checklists are also being completed by the divisions. All issues and 142 This matter is being addressed by the HSC through the Chair of actions are captured on a spreadsheet by the the committee and at Divisional Director level. Estates and Facilities Team. This has been
shared with the divisions, in order that issues Risk assessment week 17-21 October 2016 and actions identified would inform new or existing risks on their risk register. This is notwithstanding their own governance arrangements in place to monitor actions and issues identified from their checklists. The Estates and Facilities team are also undertaking their annual health and safety checks. Issues identified are being reported to the ISS service desk for monitoring purposes and progress is being monitored at the E&F weekly team meeting. NB The health and safety checklists were developed to capture as appropriate, requirements set out in the CLCH policies that come under health and safety.
14.06.2018 – Risk registers are discussed at the divisional meetings as well as PSRG and the Trust monthly performance meetings. Checklist compliance is being monitored by HSSG and HSC.
01.02.2018 (HSSG) The H&S checklists have been circulated and they contain a section on risk and risk assessment requirements. The checklists are to be reviewed by the divisions when completed and risk assessments where identified will be undertaken.
There is a task and finish group in place, with representation from the divisions. The group have reviewed the H&S policies that require a risk assessment to be undertaken. The risks are being reviewed by the divisions and the group is meeting on 24th January to review the progress. The completion of risk assessments also forms part of the H&S quarterly checklist.
7 Continue to monitor and deliver This activity requires close liaison with 18/07/16: On-going liaison through normal working activities; the The Fire, Health and Safety Manager is H&S progress is monitored by improvements in health & safety Estates & Facilities Operations Strategic Estates Group and Operational Estates & Facilities continuing to concentrate on the strategic FHSM, HSSG, HSC with a quarterly throughout the financial year. Managers, in addition both parties meetings. overview of the delivery of the role, reviewing E&F Ops report going to the Trust Board shall share how the functions of the role can be embedded Managers Work continues to be in the form of ‘Business as Usual’, with within the current systems and processes to regular joint working and liaison between the Ops Managers, avoid a single point of failure, whilst continuing FHSM and attendance at SEG and H&S sub groups and to provide daily operational support. committee meetings. 8 Site Risk Assessments The programme for site inspections October 2017: A review of site risk assessment process as 24.09.2018: The bedded units are completing Compliance with the and reporting is in progress, it will recommended by the independent H&S review was undertaken their monthly and quarterly Health and Safety FHSM and completion of the H&S concentrate on Tier 1 and 2 sites, and a number of localised checklists were developed. checks. There has also been a marked FSO checklists is monitored by whilst externally checking and 04/01/17: The FHST and E&F managers have completed circa increase in the number of quarterly HSSG and HSC monitoring with the respective 30 Site Assurance Assessments and a programme for the assessments being submitted by the divisions. Borough Councils Safety compliance remaining assessments is underway. Sessional checklists are also being completed at schools where CLCH personal by the divisions. All issues and actions are deliver services. Tier 3 site There have been Circa 80 new premises requiring assessments captured on a spreadsheet by the Estates and assurances are in discussion with the which were completed in Q1 Facilities Team. This has been shared with the Trust for a solution. divisions, in order that issues and actions Tier 1 and 2 sites reviews are underway in Q3. identified would inform new or existing risks on their risk register. This is notwithstanding their own governance arrangements in place to monitor actions and issues identified from their checklists. The Estates and Facilities team are also undertaking their annual health and safety checks. Issues identified are being reported to the ISS service desk for monitoring purposes and progress is being monitored at the E&F weekly team meeting.
NB The health and safety checklists were developed to capture as appropriate, 143
requirements set out in the CLCH policies that come under health and safety.
14.06.2018. The bedded unit monthly checklist is embedded. The quarterly checklist and sessional checklist for services was rolled out in April 2018 and divisions have been asked to present their process for monitoring compliance to the HSC in June 2018
01.02.2018 (HSSG) It was agreed to remain amber, but it is expected to progress to green when the new system to provide assurance is embedded.
Site risk assessments are being undertaken as part of the mobilisation process and localised health and safety checklists have been developed. There are two for the bedded units – monthly and quarterly and quarterly for all other tier 1 and 2 sites. The documents are being circulated in January. The divisions will be leading on the inspections within their services, supported by Estates and Facilities. 9 01.02.2018 (HSSG) Amendment. All Tier 1 and 2 sites to be surveyed Tier 1 sites: Registers in place 24.09.2018: There is an Asbestos policy in Asbestos policy in the reporting year. The last set of Tier 2 sites: verbal assurance from NHSPS that all sites are place and a control of contractor’s policy FHSM and Control of Contractor’s policy. The Trust must maintain a current surveys were conducted In late 2014 compliant, documents are being received on ad-hoc basis at E&FOM asbestos register for its locations and and early 2015 by Oakleaf Limited present Risk assessments and method statements are Risk assessments and method have assurance from Landlords that requested as appropriate from contractors for statements. they have and are maintaining an work undertaken in Trust owned premises asbestos register. Assurance on this matter is 14.06.2018 The Trust does have current provided by ISS, the Capita Ensure all premises are subject to asbestos registers for their locations. These Healthcare contract holder. annual Asbestos Management are updated as work is progressed and shared NHS PS has confirmed that Survey; that all actions are added to with third parties before work commences. their sites have asbestos the Trust Annual Maintenance and registers in place, and a Backlog Maintenance Programmes. 01.02.2018 (HSSG) program of updating exists. It was agreed that the wording should be amended to reflect a change in legislation – i.e. annual inspections are no longer required by law.
- Assurance on this matter is provided by ISS, the Capita Healthcare contract holder. NHS PS has confirmed that their sites have asbestos registers in place, and a program of updating exists. 10 Ensure all premises are subjected to Capita/CLCH/NHSPS to agree a November2017: It was agreed by the HSSG that the Water 24.09.2018: This continues to be monitored by Copies of water safety regular Water Safety Inspections as programme of water sampling and Safety Group should be scheduled to meet after the HSSG for the Water Safety Group and Infection WSG, ISS, inspections are provided my per L8 and Infection Prevention regular reporting to the Water Safety better continuity Prevention and Control NHS PS ISS for Trust owned buildings Guidelines. Group; Health & Safety Sub Group 04/01/17: ISS and NHS PS are progressing sites on a Tier and sourced from third parties and Health& Safety Committee. responsibility basis, that is to say ISS T1 and NHSPS T2. 14.06.2018 This is monitored monthly by the Water Safety Tier 1 sites: ISS are in process of annual updates for Water Group with a quarterly report to the Infection Risk Assessments and Prevention Group Tier 2 sites: verbal assurance from NHSPS that all sites are compliant, documents are being received on ad-hoc basis at 01.02.2018 (HSSG) present This is monitored monthly by the Water Safety Tier 3 sites: 1 of 8 legionella samples at one site has proved Group with a quarterly report to the Infection positive: Authorising Engineer actions are underway and the site and Prevention Group remains in operation with management action and monitoring in place Nov 2017 For better continuity the meetings as from January will follow on from the HSSG.
11 Conduct Fire Risk Assessments The work-plan for FRAs will be linked 04/01/17: On Target to achieve assessments for all sites as 24.09.2018: There is a rolling programme of Estates and Facilities tracker. (FRAs) of all Trust owned and to the review dates for assessments alluded to above FRA being undertaken. Third party FRAs and FSO Compliance by third parties is occupied premises. Action plans for conducted in 2015. Additionally new evacuation procedures are requested. capture on the E&F tracker. remedial works and emergency plans assessments will be carried out as Tier 1 sites; all FRAs completed shall be included in each report along and when the Trust acquires new Tier 2 sites: NHSPS confirm FRAs in place for common areas All FRAs are complete which means for the with all Red Line Drawings. accommodation/ service delivery and escape routes. FSO has undertaken FRAs for demised HTM 0005 guidance the Trust has two years to locations through the process of areas. re assess. 144
competitive tendering and contract Additional sites 9 of circa 80 assessed, the remainder are awards. planned to be completed before the Q4 of the FY.
12 Ligature risks, and falls from height, This action has been included in the November 2017: Discussed as part of the risk review process 24.09/2018: The H&S checklist , which has a H&S Checklists - HSSG, including from windows, roofs, stairs ‘Work Plan’ due to the annual issue of by HSSG and it was agreed that ligature risks should be added question referencing ligature points has been FHSM, HSC, Patient Safety Risk and other high location risk a Ligature Safety Alert by the Central to the H&S checklist. rolled out. Checklists are being completed. E&FOM Group (PSRG) assessments to be carried out Alert Service (CAS). Monitoring of compliance is through HSSG and and E&F CAS Alerts – HSSG, HSC annually. 04/01/17: This work is being progressed by Ingleton Wood HSC. CAS alert EFA/2015/001 – Window Managers and PSRG Limited on behalf of the Trust and all WIC and sites where the blinds has been closed by the Trust. risk category patient may present themselves will have an anti- CAS Alert EFA/2018/005 – Assessment of ligature design installed. Part of 2017 capital programme. Ligature points. Strategy in place. CAS alerts are facilitated through the Infection Prevention The Site Safety Checklist includes questions on Ligature Safety and Medical Devices team and will be reported to services, the SEG, HSSG and HSC as necessary on completion of the ongoing program of inspections. 14.06.2018 The trust is compliant with the CAS alert. This also forms part of the checklists. The divisions have been asked to specifically present a report on window blind cords and chains to the HSC in June.
01.02.2018 (HSSG) It was agreed by HSSG to keep as amber until assurance is received through the H&S checklists, which are being rolled out during January.
Patients presenting at WiCs are assessed and supervised at all times if they are thought to be at risk. They are not left alone and this is the only thing that can be done. Each WiC has this procedure in place.
13 Electrical Safety inspections, The requirement to check electrical October 2017: ISS have advised this work is on-going and 24.09.2018: - There are policies in place for Copies of fixed wiring reports including PAT and Fixed wire safety compliance and PAT testing is provide the Trust with a programme of works. fixed wiring testing and PAT testing. ISS EFM H&S checklists assessments to be carried out as per done so on a rolling basis by an NHSPS will be providing evidence of the same, supported by undertake fixed wire testing at Trust owned Managers Visible evidence that PAT the contract established with Capita. Electrical Testing Contractor, inspection report for the sites it owns buildings and third parties undertake fixed wire testing has taken place additionally the FHS Team will check 04/01/17: ISS will commence the undertaking Portable testing as part of their responsibilities. compliance as part of annual site Appliance Testing in February 2017 safety audits. 14.06.2018. The bedded unit monthly checklist FIXED WIRING is embedded. The quarterly checklist and Tier 1 sites: 5-yearly fixed wiring checks are on program. New sessional checklist for services was rolled out requirement for Annual tests in clinical spaces is under review in April 2018 and divisions have been asked to Tier 2 sites: NHSPS have given verbal assurance that 5-yearly present their process for monitoring fixed wiring testing in place. New requirement for Annual tests in compliance to the HSC in June 2018 clinical spaces is under review H&S checklists references PAT testing and the ELECTRICAL APPLIANCES Estates and Facilities checklist references the Work commenced in mid-February 2016 to review Portable fixed wire testing. Fixed wire testing and PAT Appliance safety compliance, this is an on-going, year round testing is also reviewed when fire risk issue due to the size and geographical spread of the Trust. assessments are undertaken. Where necessary, issues are addressed at source and reported beck to the Trust via E&F Ops managers and the FHSM. 01.02.2018 (HSSG)
This has been added to the annual site checklist and the local monthly and quarterly checklist.
14 Monitor the third party contract for all Planned, Routine and Ad-hoc 04/01/17: ISS conduct all inspections of lifts and Boilers as the The evidence previously provide by ISS is still lifts and boiler/heating systems to maintenance of lifts, boilers and service partner of Capita, the Trust partner for Tier 1 sites. All valid, ISS do also conduct Ad hoc checks and EFM ensure there are no breaches of heating systems will be carried out by other sites these are landlord responsibility – NHS PS provide attend call-outs on an as needed basis. Managers legislation and industry standards either ISS, NHSPS or third party assurances. across Trust premises. contractors on some sites. Checks of Routine meetings are scheduled with NHS PS site maintenance record books will be NHS PS has been asked to confirm how they manage and in to discuss and address issues around planned made during E&F/FHS site audits. future report planned, routine and Ad-hoc maintenance of lifts, preventative maintenance. boilers and heating systems.
Tier 1 sites: Full compliance. 145
Tier 2 sites: NHSPS have given verbal assurance of compliance A series of spot audits are planned for the Q3 of the FY
15 Conduct a review of Disability Access OakLeaf Limited last conducted a 04/01/17: Awaiting statements from NHSPS. Disability Access statement required from NHS arrangements in line with the Equality review of DDA Compliance between PS. FHSM, Act 2010. Nov’14 and Jan’15 Tier 1 sites: All tier 1 sites have be assessed with targeted E&FOM, reviews in Q3 & 4 of this FY E&F Tier 2 sites: NHSPS have been asked to provide statements on Director compliance. All capital development works bring DDA compliance standards within the projects. 16 Manage an inspection programme These are Tier 2 sites and a 04/01/17: Progress is now good with updating Trust site based 01.02.2018 (HSSG) that will assess safety concerns that programme of visits will commence in risk assessments for all Tier 1 and 2 sites with compliance It was agreed to change to green as It has E&FOM, are pertinent to a specific role or the 3rd 2016. expected to be 100% by the end of the financial year been superseded by the monthly Checklist NHS PS service, in premises NOT owned by which is being rolled out. and CHP the Trust (e.g. owned by NHS PS) Tier 2 sites: Building user group meetings are re-established where it is the Head Lessee. with NHSPS Localised health and safety checklists have been developed and will be circulated in Progress is on plan with a report due on improvements in Q3 of January for local completion on a monthly and the FY. quarterly frequency
17 Continue to manage assessments This is an out of Trust responsibility 04/01/17: This is an on-going piece of work currently being 01.02.2018 (HSSG) and inspections carried out in schools being managed by the appropriate carried out by a contracted administrator on behalf of Capita It was agreed that this can go green, as the FHSM and and GP practices throughout the Borough Council FH&S managers and the Trust. Trust has done as much as it can and written FSO Trust domain, as per the previous Fire assurances were received by the Trust in 2015 from to everyone, with very few responses. where CLCH occupy. Westminster, Kensington &Chelsea and Hammersmith & Fulham. Requests were made to the remaining Boroughs but The E&F Director of Capita has written to nothing has been received. Schools and Boroughs on behalf of the Trust and new letters to those non responders are CLCH FHSM is seeking assurance from the Borough Council being issued in the name of the Chief FH&S managers that fire and safety inspections at schools are Executive Officer - with a further request that being conducted and that where there are issues these are they complete and return to CLCH within reported to CLCH as a matter of priority. specified time frames.
CCN funding approved for additional support to undertake reviews. 18 Ensure, where Trust personnel are This is a known area of under 04/01/17: This is allied to the work being carried out at 17 This is linked to the work being carried out at based, if not working in, or from Trust compliance with assurance for non- above. 17 above. FHSM, owned premises that all statutory and Trust premises compliance with FSO, mandatory assessments and standards and H&S CLHC will be seeking assurance from all landlords including CBUs inspections are being carried out by NHS PS, CHP and Borough Councils that all statutory and the Third Party contractors. These legislative inspections and assessments are being carried out in are to include Asbestos, Legionella, premises where its staff deliver services from which those Ligature, Falls from Height, Fire Risk organisations have primary responsibility. Assessments, lift and boiler assessments and maintenance are carried out. 19 Review with the Trust Datix There are mixed incident figures 04/01/17: The task is approximately 50% 01.02.2018 (HSSG) Administrator, all Fire, Health, Safety coming out of Datix and so it is completed and will be finalised in Q4. The FHSM was meeting with the Datix FHSM and and Welfare codes on the database. essential to have the codes properly Administrator to review the Fire, health and FSO reviewed and a new list will enable The extant coding on Datix needs to be revised to facilitate safety codes. trend analysis. meaningful management of risks and production of management information. FHS Team are liaising with the Trust Datix A new administrator is in post and Coordinator to accomplish this. arrangements are in place for the FHSM to meet with the new incumbent 20 Improve Trust managers and staffs There is no overall delivery Guidance uploaded to the HUB (FHST only to contact HSE on 01.02.2018 (HSSG) understanding of the RIDDOR programme as the responsibility for RIDDOR issues). RIDDOR policy updated and being presented FHSM, The Trust RIDDOR reporting reporting requirements. RIDDOR reporting is vested in the to HSC on 15th February 2018. FSO, L&D. procedure is uploaded on the Fire Health & Safety manager The FH&S sector of the HUB will be used to provide advice Hub and can be found using (FHSM) and the Employee Health and support for accident and incident reporting. The policy is still in date, but is being reviewed the following link: Manager (EHM). The FH&S pages of as part of the scheduled policy review http://thehub/library/Policies/RI the HUB will be used to provide The FHST will be conducting a 12 month audit of Datix Reports programme. DDOR%20procedure.pdf advice and support for accident and to determine whether there have been further breaches in the incident reporting. reporting year. The Trust RIDDOR reporting procedure is uploaded on the Hub and can be found using the following link: http://thehub/library/Policies/RIDDOR%20procedu re.pdf
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21 Monitor all aspects of RIDDOR The requirement to monitor RIDDOR There has been communications between the FHSM and 24.09.2018: The H&S team receive and review The monthly performance reporting, including 3 day (but NOT and analyse incidents is an internal Patient Safety Managers where they have identified potential all Datix incidents as does the patient safety FHSM report records reported reportable to the HSE); 7 day and Trust matter. 3 days events are not RIDDOR issues in their divisional areas of responsibility. This team. Incidents, that may be RIDDOR RIDDOR incidents . over ‘reduced activity’ reporting and reportable to the HSE but are being serves to confirm there are sufficient checks and balances in reportable are followed with the handler of the major injury reporting. used to determine whether there are the A&I process to prevent reportable incidents being missed. incident. any hangover or recurring types of incidents that need to be monitored 04/01/17: In view of a recent reporting breach the FHST will and managed more effectively. continue to monitor over 3 and 7 day reportable incidents and shall advise the Trust in due course of the actions to be taken going forward. 22 Ensure ALL RIDDOR reports are This is a legal requirement and to- 04/01/17: Whilst the Trust was late in reporting one incident in 24.09.2018: The H&S team receive and review Datrix and HSE RIDDOR submitted to the HSE within 15 days date the Trust has met all of its Q3, this has identified the need for the FHST to establish a all Datix incidents as does the patient safety FHSM acknowledgement. of the reportable event arising. obligations. regular audit process to ensure no further breaches occur. team. Incidents, that may be RIDDOR FHSM to arrange for ‘Reminder’ communication to be uploaded reportable are followed with the handler of the on the Hub Carousel. incident. The FHSM receives emails of health and 8/07/16: To date all incidents have been reported to the HSE safety and fire reported DATIX incidents. The within the required timeframes. FH&S reviews the reports and follows up with the reporters and managers for further information where statements or additional information are needed, so as to enable him to determine correctly whether and incident is reportable or not. 23 Training Deliver IOSH Managing Safely CLCH needs to have more staff than 04/01/17: No change at present, although in Q4 the Trust 01/10/2018 Training to at least 24 managers, just the FHST members and Safety will be pursing IOSH managing Safely training as per a JB recommended that two CBUs per Division FHSM courses to be for a minimum of 8 Representatives to maintain its recommendation made in the Robert Caldeira Associates (one to be the Divisional H&S rep) and the delegates. safety profile. To this end funding for Limited report. This matter will be addressed at the Director of Improvement should attend the recognised H&S courses needs to February HSC and reported on in the Q4 and Annual H&S course. be identified and staff nominated as Report to the Board. 01.02.2018 (HSSG) ‘Local Safety Support Officers’ Take to HSC how the Trust should proceed. The FHSM is developing a series of online training sessions Can a shortened, half day IOSH course for that CBUs and Line managers can access to improve their around 30 CBU Managers with a focus on Risk H&S knowledge and skills. Assessments and process be arranged. Estimated cost around £8k.
Agreement to deliver mangers with IOSH level training still remains outstanding.
The cost of delivering IOSH training is being reviewed for options as follows: • Delivery by a Third party organisation. • Delivery from within the Capita/CLCH Team (the FHSM). • Online training. • Development and delivery of a Trust approved bespoke risk assessment training package. 24 Monitor DSE assessment and All staff using DSE must complete 04/01/17: Compliance % figure fell by 15% points in the 01.02.2018 (HSSG) training compliance and review the DSE training package reporting quarter, this is primarily due to staff departing and It was agreed that item 24 and 25 be FHSM as necessary any staff with on- new staff joining the Trust. The figure has sat in the mid 80s for combined. a going or exceptional responses more than a year now. There is a process in place which is updated n following completion of the risk on the monthly PI report. The Cardinus d assessment programme. Of the 3086 staff on the DSE database, 2693 (87%) active system is being reviewed and updated to avoid Cardin users have completed the Cardinus Online DSE training and over-reporting of high risk individual users. us assessment package. The specific training modules for Mobile and Agile working are provided within the existing Cardinus • Cardinus the provider of the on-line DSE DSE training and assessment package. This element of the tool sends monthly statistics to the Trust package is being reviewed by the HSA and will be going live which is included in the monthly PI report. before the end of October 2016. • Mobile module on Cardinus live - The FHSM and Cardinus have modified and uploaded DSE RAs for PCs, Laptops, Tablets and Smart Devices. 700 plus trained in laptop use, 70 in tablet and 60 on smartphone since initiating. • FHSM has conducted 41 face to face personal DSE assessment reviews of the 149 staff that have a DSE action plan that shows the User has reported ‘High’ risk ‘regular pain related issues when working with a computer’ • CBUs have been advised that their managers are to review Users with ‘High’ 147
risk ratings, and if they are unable to resolve concerns raised, to escalate the matter(s) to the FHSM. • At the end of April 2017, 85% of Trust staff had completed their online DSE, risk assessment programme. • Mobile workers have started to submit assessments relating to not having peripheral DSE equipment available to them to make working in the various locations they visit, safe. The FHSM has contacted Cardinus, Posturite and Osmond Ergonomics with details of mobile working kits with a view to obtaining ‘bulk-buy’ prices for equipment. A detailed review of costs and equipment will be presented to the HSSG and HSC once suppliers’ information has been received. 25 Review as necessary any staff HSA to review all assessments December: The number of High Risk Pain conditions has 01.02.2018 (HSSG) with on-going or exceptional where staff are unable to resolve reduced from 222 to 41, the FHSM continues to work with It was agreed to combine item 24 and 25 F responses following completion RA issues without support either Cardinus, the individuals concerned and line managers to H of the risk assessment from FHS or from Cardinus. address these issues. Capita and Cardinus are working together to S programme. identify how the system can be further M 04/01/17: The number of High Risk Pain conditions has risen developed to better capture high risk users from 119 to 144 in Q3, the H&SA is working with Cardinus, the and resolve their issues in a timely manner. individuals concerned and line managers to address these issues.
119 High Risk incidents specifically relating some degree of pain due to working with DSE have been recorded in assessments. These are being addressed by the HAS, progress and resolutions is good in this matter, it should be noted this is an on-going matter as new issues regularly arise.
26 Support the Trust Moving and The MHL delivers and manages The Moving and handling lead continues to support staff Level two Moving & Handling training sessions Handling Lead where possible with moving and handling training for where appropriate by providing specialist information with have been delivered to 1,211 staff members in Moving Moving and Handling Assessments, staff across the Trust. Moving and Handling Risk Assessments. Level 1 training the last 2 years (Feb 16 – Sep 18). L&D & Investigations and Training. compliance is steadily improving and on her return to work advises we are well on target to achieve full Handlin Level 1 is now delivered using the from maternity leave the MH assistant will take on the support compliance in the reporting year. g Lead mandatory training booklet. This role for the delivery of Level 2 people moving and handling for is annual training. practical training. deliver • 2,654 staff require Level 1 MH Training, 2,423 (91.3%) staff y of Level 2 is delivered to staff who are compliant with Stat-Man requirement. M&H move and handle people as part • 353 staff require Level 2 MH Training, 323 (91.5%) compliant training of their role. This training is with Stat-Man requirement. delivered twice yearly. L&D do bookin 04/01/17: Level 1 MH training now rests in the mandatory g and training Booklet, issued to all Trust staff in December 2016. admin for training sessio ns 27 Maintain as a minimum, but improve The aim of the Fire Strategy is to 04/01/17: Work to identify shortfalls throughout the Divisions 01.02.2018 (HSSG) wherever possible, Fire Warden identify across the Trust domain has been on-going throughout Q3, the DDO’s PAs and H&S HSSG agreed this was accurate and should DDO/CB training standards achieved in the every possible Fire Warden CBUs have been supporting the FSO with the task which is be green. This is monitored through the PI U, FSO previous reporting year. Zone (FWZ). Then for nearing completion. monthly report. and DDOs/CBUMs to identify and The identification of divisional shortfalls for Fire FHSM nominate persons within the Requested from FSO 14/10/2016 Wardens has been identified by the FHST and for HSC premises their services occupy passed to DDOs, PAs and Divisional CBUs for to be trained as fire wardens. Whilst all of the preparatory work for FWZ has been completed H&S for them to identify zones they have staff by the FSO the Divisions have been slow in allocating staff to in and to nominate persons to attend courses. the zones within their areas of responsibility. Some staff have been identified, nominated as wardens and subsequently trained.
The FSO has engaged the support of DDOs and is currently attending Divisional Management Team meetings to advise DDOs and CBUs what assistance is required from them in order to ensure adequate numbers of wardens courses are arranged and personnel trained as soon as possible. HSC has written to Divisions for improved compliance with fire 148
Wardens.
28 Continue to deliver on Fire, Health Resolved by full 04/01/17: With effect from mid-December 2016, Face to Face Face to Face, Fire awareness training has to & Safety Awareness Training implementation of the ‘Online’ and Online H&S training ceased on the basis the Trust has all intents and purposes ceased, with the FSO Days. Fire Awareness Training introduced a Mandatory Training Booklet that has been issued to exception of the inclusion of awareness Package all staff. training being covered in the first hour of the 3 hour Fire Wardens Training Course. The aim Requested from FSO 14/10/2016 of this first hour is to capture those staff that have a preferred learning style of face to face Online fire awareness training programme and went live on 1st delivery, and those that fail the and online April 2016. This is in line with the completion of the 2015/2016 training packages 3 times. A face to face fire L&D training programme. training session will be introduced as part of the induction programme for all new starters from February 2018 and also as part of the refresher programme from April 2018 so staff can alternate face to face with e-learning. 29 Divisional Continue to support the divisions The aim of this action is to ensure 04/01/17: The FHSM attended 2 Divisional Management Attendance at DMTs is an on-going feature Management throughout the year. the Divisional Management Team Meetings in December and is scheduling further sorties that has proved valuable and effective. FHS Team Teams’ (DMTs) receive to DMTs in 2017. M appropriate FH&S support and throughout the year. 18/07/16: All four of the DMTs have been attended by the FSO FSO and plans are in place to attend them on regular basis for the rest of the reporting year. FHSM and FSO have been holding meetings with CBUs assigned with responsibility for H&S in the Division and plan to continue doing so. 30 Continue to support divisional risk Where required the FHST will 04/01/17: Ad hoc support remains on offer to the risk Ad hoc support remains on offer to the risk managers throughout the year. support risk managers throughout managers. managers. FHSM the year, particularly during FH&S investigations post accidents / 18/07/16: This is an Ad hoc requirement for this support which incidents and where there are in this quarter has only been accessed by the Trusts claims and perceived risks that require FH&S complaints department in respect of the supply of support. documentation for policies, reports, assessments and other claim related information.
31 Stress Management Work with Employee Health to 04/01/17: Stress management is being monitored by the EH 25/09/18 Group meetings held on: identify the major causes of work- Department with Support from Neal Gething and Steph Griffin March 2018 HR 12.04.18 related stress across the Trust and From HR. The HSE have recently announced they will be Mental Health minders group commenced. Lead, 12.06.18 develop prevention strategies. assessing stress awareness and management of such when Group includes a variety of disciplines across EHM, 07.08.18 conducting planned inspections over the next 5 years. divisions in the Trust. The group meets on a FHSM two monthly basis and is led by the Mental and all The Wellbeing Working Group has met and will meet again in Health Nurse/Occupational Health Practice Manage Blog is on the on the HUB July to discuss liaison has commenced with the Trusts Stress Nurse. rs Advisor. Team visits took place on: The FHST will be liaising with the Stress Advisor and assisting in Mental Health BLOG commenced in February 01.03.18, 15.03.18, the development of a strategy to overcome the rising perception 2018 with different themes and topics on a 29.06.18, 04.07.18, and reporting of stress, as well as supporting personnel, whether fortnightly basis. Feedback is good. 06.07.18, 26.07.18, 31.07.18, 02.08.18, from the general staff structure, from middle or senior 10.08.18, 17.08.18, management through difficult and distressing periods of their Wellbeing workshops for stress hot spot teams 07.09.18 work. commenced February 2018, carrying out two
A stress assessment tool is to be developed which will be to three sessions per month. To date 12 available for staff and managers to complete, have analysed teams have been visited. October 9th Edgware and then appropriate actions introduced. Community Hospital Two mental health awareness /wellbeing days th th October 19th – Merton have been arranged for 9 and 19 October , Edgware and Merton respectively
Neal Gething, the Practitioner Psychologist working in the Employee Health Service is working through the mental health programme for managers.
Mental Health Workshops for managers run by Neal Gething and Caroline Clarke have been well received. As at 28th February 2017, 185 Managers have received training. CQUIN target has been achieved for 2016-17.
CLCH signed the Time To Change pledge 149
(25.09.2017). Time To Change is an organisation focussed on ending discrimination against Mental Health. (https://www.time-to-change.org.uk/get- involved/get-your-workplace-involved). This initiative involves training staff about the essentials of mental well-being as well as raising awareness about how to help colleagues who are displaying signs of stress and distress. These programmes have been well received. Thus far 8 groups (98 staff) have been trained. EH has also been recruiting Wellbeing Champions. They will be trained to signpost and enable colleagues to seek psychological support when necessary. Thus far 9 champions have been recruited. EH will train and supervise the Champions. The EH mental health nurse writes regular blogs about mental health and these are posted on the hub.
EH continues to run compassion focussed groups (2016- to date). These groups are run over 6-8 sessions and are designed to promote psychological resilience using the principles of Mindfulness and Compassion Focussed Therapy. They will continue into the foreseeable future.
EH provided training and support for staff who are either personally or professionally involved in the Grenfell fire. The training is an introduction to theories around PTSD. They have been well received. The demand for this training has diminished but it can be provided if necessary. EH continues to provide psychological support for individuals and groups affected by the fire.
EH has provided, and will continue to provide, bespoke training or lectures for teams in CLCH; e.g. the Safeguarding Conference.
The Trust reached achievement level in June 2017 for the ‘Healthy London Charter’. This package has a considerable volume of Stress related information, which will prove the Trust has the mental health and wellbeing of its staff firmly in its sights and is under good management. The Trust is considering applying for the excellence level. 32 Monitor the effectiveness of current 04/01/17: Update to be requested by the FHSM from Neal This information is contained in the Trusts stress prevention and management Gething. submission to be awarded the ‘Healthy HR interventions. London Charter’. Lead, 18/07/16: FHSM Liaison with the Stress Advisor under way. EHM, Managers training being delivered in September and October Manag 2016. ers
33 Review stress indicator and 04/01/17: As above in 32. As above. management tools for use by staff EHM and managers if necessary. 18/07/16: FHSM Liaison with the Stress Advisor under way. Managers training to be delivered in September and October 2016. 34 Lone Working A full review of Lone Working is 04/01/17: The LSMS is currently reviewing the Lone Working 19.09.18: 19.09.18 required across the Trust, the aim of Policy with a view to substantially overhauling it previous to the • Lone Worker Policy renewed June, 2018 CBUs Lone Worker Policy the review will be to identify whether 2018 review date. • Delay due to long- term absence of LSMS. and On Hub there is an actual or perceived ‘Lone • Lone Working Risk Assessments are currently being • CBU and local managers encouraged to LSMS Working’ Problem in the progressed through team meetings and were a large part of the regularly complete and/or review their lone Skyguard Database : organisation. Post the review and Personal Safety Week held between 17 and 21 October 2016. worker risk assessments. Accessed via Resilience & depending on its findings, a new • Skyguard Personal Safety devices: 2000 Compliance Team strategy for Lone Working may need The review of lone working should be carried out by CBUs at 150
to be developed or the existing Divisional level and assistance sought from the LSMS where devices now procured and 1200 have package endorsed and enforced appropriate been rolled out through a cohesive system throughout the Trust including appropriate lone worker safety training. 35 Violence and Aggression CBUs and the LSMS should 04/01/17: All DATIX reports concerning incidents of violence 19.09.18: Violence and Aggressions conduct a full review of V&A and abuse of staff are appropriately investigated by the LSMS, • Violence and Aggressions at Work CBUs at Work Policy : reports recorded on Datix in the with recommendations made to prevent further occurrence Policy renewed and presented to PRG and (with PRG 19.9.18) past 12 months; identify ‘hot reported on each individual report under “Action Taken 19.9.18. LSMS spots’, and develop a strategy (Investigation)” for the information of Managers and for use in • Delay due to long-term absence of LSMS. Investigation of all incidents : for reducing and if possible feedback to staff, particularly the original reporters. All such • Investigation of all incidents involving eliminating the known causes of violence and aggression have been on- Lines of investigation incidents are reported, both statistically and verbally as well as recorded on each DATIX the problems. going, including whilst the LSMS was on discussed at length (as appropriate) with Louise Ashley at our Report under “Action Taken sick leave working from home. LSMS/SMD Monthly Briefings, together with any trends, should – Investigation) • they become visible. Appropriate advice/guidance via. telephone given to managers. Reporting of VAH and • Reporting of statistics is provided monthly Security Stats : via the HSSG by the LSMS Reported monthly on the PI Monthly Stats to H&SSG
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Board of Directors 31 October 2018
Report title: Strategic Transformation Partnership Update
Agenda item number: 3.4
Lead director responsible for James Benson, Chief Operating Officer approval of this paper
Report author James Benson, Chief Operating Officer
Relevant CLCH strategic Trust objective 2018/19 priorities Please delete those which do not apply to this paper Strategy implementation Implement strategic priorities of integration and place Quality Maintain and improve the quality of services delivered by CLCH Finance Deliver the 2018/19 financial plan Operations Deliver all NHS constitutional and contractual standards Workforce Make CLCH a great place to work for everyone Freedom of Information status Executive summary:
The Board last quarter received a detailed update on the specific work being delivered by the Trust in regard to the delivery of place-based integration across the STP. The Trust continues to be actively engaged with this work, with a key driver being that we ensure we maintain strong and effective relationships with GP colleagues, build local teams and with partners to develop pathways.
This report updates on the specific developments of the work streams that the Trust is engaged within. The paper identifies that there have been substantial developments in taking forward an integrated adult model of services in Barnet and continued development in all other areas in the delivery of integrated care.
Assurance provided: Reviewed by ELT
Report provenance: Report of ELT
Report for: Decision Discussion Information x x Recommendation: To note
152 The report describes the work that the Trust has been delivering with partners in our local Sustainability and Transformation Partnerships
1.0 South West London STP
The focus for the Trust in South West London is the delivery of effective and integrated community services wrapped around the eight GP localities in Merton and Wandsworth. Key to this work is the creation of MDTs and effective rapid care and discharge pathways to maintain people in their home environment. The aim of the Trust is to provide where possible the same service offering or model of care to support a co-ordinated approach to care delivery in the sector.
As this is being achieved, local pathways are being reviewed to ensure that the Trust maximises the potential of scale. Work continues with partners to refine specialist pathways, particularly around diabetes, care home input and Facilitated Supported Discharge (FSD). Collaborative partnership working between CLCH’s CAHS service, Wandsworth CCG, Battersea CHIC and St George’s Hospital is driving this work forward.
1.1 Merton
In Merton there continues to be a focus on the delivery of integrated care pathways with the Local Authority to maximise the relationships and working between intermediate care and reablement services. The Merton services are specifically reviewing the community rehabilitation pathways including the bedded services provided by the Trust. During the next quarter the Trust, plans to re- provide new inpatient beds in Merton, and at the same time improve and increase the provision of community rehabilitation. In agreement with the CCG, this enhanced community pathway will increase the number of patient’s access community therapies in their own home.
There continues to be a drive toward the creation of a Multi-Specialty Community Provider (MCP) model of care within Merton, now known as “ Merton Health & Care Together programme,” co- chaired by the Director of Community - London Borough of Merton, and the Managing Director of Merton and Wandsworth CCG. The partnership board is in the process of finalising a shared Memorandum of Understanding during the last quarter. This MoU will be shared with the Board for approval in quarter three.
1.2 Wandsworth The focus for the Trust has been the delivery of an integrated digital record with primary care, using EMIS. This has now been successfully achieved and maximises the potential of integrated care with partners. Likewise in delivering a new clinical recording system the Trust has been able to review the recording of activity and KPIs, and will continue to work with the CCG and Battersea Healthcare CIC (GP Federation) to ensure the most appropriate use of resources to meet the needs of the population. Further work has been undertaken to build KPIs in the core operating system for reporting
153 At the same time, the Trust continues to work with Battersea Healthcare Community Interest Company (CIC) to enhance the MCP partnership. Specifically the Trust has agreed with Battersea CIC the next stage of the model of community nursing services, which harmonises the leadership of this service, in line with the other Trust districts nursing services. The recruitment to the new band 7 district nursing posts in Wandsworth is underway and the partnership believes that this will enhance leadership and quality of this valuable service.
The Chief Operating Officer has agreed to lead represent providers in Wandsworth and act as co- chair for the Wandsworth Transformation Board. This presents an exciting opportunity for the Trust to work even more closely with partners and improve care delivery.
2.0 North Central London STP
The Trust aims to support the system with service redesign and pathway development in North Central London to develop integrated care services and co-ordinated specialist pathways in Barnet. The Trust is finalising the proposed local integrated community nursing and intermediate care teams in line with income and will go to consultation with staff in the next quarter. These integrated locality teams will support the delivery of integrated care locally and be aligned to local GP networks (CHINs).
Additionally there is a strong focus on working with Primary Care to support the development of the Care Closer to Home Integrated Networks (CHINs) in Barnet. The Trust has been working with the GP Federation to test individual pathway pilots in each area, as well as considering if a more formalised alliance would be useful in strengthening the working relationships and governance associated with integration.
2.1 Barnet
The Trust has been working to review and re-organise community services within Barnet, to reflect an integrated service offer in each of the localities. This was agreed with commissioners and specifically focused on the relationships with primary care localities. The consultation with staff was completed within quarter two with the implementation of the new structures and integrated teams on track for delivery in quarter three. When completed this integrated service will become the fourth integrated adult locality service within the Trust.
Significant work to re-organise the clinical reporting and recording systems of SystmOne has been delivered as part of the work plan for the new integrated team. It will allow the teams and the Trust the opportunity to review activity and performance at integrated locality level.
At a system level, the Trust has agreed with partners in Barnet the establishment of a provider board in quarter three. It is proposed that this follows the same principles as other provider
154 boards, and specifically focus on key work streams that promote integrated working, improving outcomes for patients and overall system performance.
At a STP-level, the executive team has agreed to the proposal to work in collaboration with partners in shared procurement. This is in line with the work that the Trust engages in North-West London. Partners agree that where a procurement has been quality assured and a robust process has been established for testing of products or services, that partners do not need to repeat these processes and should actively work together to maximise benefit and reduce repeated procurements.
Helen Pettersen, the Accountable Officer for Barnet, Camden, Enfield, Haringey and Islington CCGs, convened a commissioner and provider 2 day event looking at Integration across the NCL STP area on the 3rd and 4th October. The Chief Executive Officer and Medical Director attended for CLCH. This event was well-attended with CEOs, medical directors, chief nurses, local authority colleagues and senior commissioning directors in attendance across the 2 days and used a simulation approach where the group role played how elements of the system would work together. On the following day the implications of this new way of working was analysed. A number of key themes were identified; • Integration required strong relationships across all the senior leaders. • Financial models currently hinder and new models may need to be tried. • There was a strong commitment to this approach. The Chief Executive Officer committed to initiate a Provider Board for Barnet as a gesture of CLCH’s commitment to the local system.
3.0 Herts and West Essex STP
As previously noted there Trust has reduced engagement in this STP given the size of our operational services. However, there continues to be dialogue and relationship building with Herts and Valley Federation about models of care for the services we provide.
Clinically the Trust continued to contribute to a review of the breathlessness pathway and the clinical and management team is leading implementation. During quarter three, the benefits the new pathways will begin to be evidenced, with monitoring and reporting of performance over the winter period.
4.0 North West London STP
Consistent with the other STP areas, the focus for the Trust in this area is the delivery of integrated teams. The development of these is focused specifically within each CCG area, and recognises the different stages of progress of each GP Federation and partners in the system.
155 4.1 Central London
Central London continues to progress their work to deliver an MCP for their population. The Board has been updated on this work previously, and noted that the CCG was looking to engage with providers to test the market and potential commissioning. The Trust has been meeting with partners to progress this work.
4.2 West London
The Trust is taking an active leadership role in mobilising phase 1 of the ICT development in West London through integration of the district nursing service with the My Care My May service.
Community nursing services have agreed a plan to practically integrate with other providers of services; wrapping around localities and reducing duplication of services in order to maximise input for patient care. This will be monitored in quarter 3 and 4, to ensure that the new service model is in place for the new financial year.
With partners, the Trust has completed the mapping current IT platforms across all providers to understand “as- is” current configurations and process. Workshops held with clinical teams to understand “to- be”.
A comprehensive case management review has been undertaken that reviews the development of the integrated Care Team with a skill-mix that delivers clinical quality ongoing with a number of workshops held across (DN, My Care My Way) and the wider system. The ICT structure has been drafted and being implemented with a specific focus on the clinical governance framework.
Additionally a refresh of the governance and the leadership of the West London Integration Board has been agreed by the CEO and COO. The aim will be to increase oversight from all providers at a strategic level, ensuring that projects remain on track and benefits can be monitored and realised.
4.3 Hammersmith and Fulham
The Board will remember that the Trust’s Medical Director has been appointed as the H&F GP Federation Medical Director as part of her Trust role. Dr Medhurst continues to forge strong links with the two organisations and support continued effective integration of services.
The Divisional Director is working jointly with GP Fed DDO and CCG lead to develop a MDT workforce wrapped around the newly formed geographically based primary care networks. Delivery of these during quarter four will result in an integrated MDT approach for our services with primary care.
The London Borough of Hammersmith and Fulham (LBHF) have agreed a new contract with the Trust for the delivery of Health Visiting, School Nursing and Family Nurse Partnership. The contract will run until the 31st March 2019. The Trust is pleased to continue to provide these services to the
156 children and families of Hammersmith and Fulham, and continues to actively work with the Local Authority to agree next steps in terms of service for the new financial year.
The H&F children’s forum continues to meet and is working on a family charter that will outline the cross organisational priorities and approach families can expect of children’s services within the alliance.
4.4 Harrow
The Trust has maintained an effective working relationship with Harrow and is finalising the outcomes framework to be presented to the Transformation Sponsorship Group.
The Divisional Director is one of the programme sponsors, sponsoring the frailty work-stream with the Deputy Divisional Director leading on provider development with the programme team.
The Director of the Children’s Division continues to work on scoping the work plan for integrated services following the strategic leadership development sessions in quarter two. The workshops identified three key areas for future work, weight management and prevention of obesity, long- term conditions (asthma in particular) and supporting children with complex needs.
5.0 Summary
The Trust continues to work with partners in all areas to deliver the work of the STPs. There is a clear focus in the delivery of place based integration, which supports the Trust’s strategy to integrate services locally to improve pathways for our populations. It is anticipated that the Trust will continue to engage and support these developments.
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Board of Directors 31 October 2018
Report title: Patient Safety – Serious Incident & Being Open Report (September 2018 data)
Agenda item number: 4.1
Lead director responsible for Chief Nurse approval of this paper
Report author Head of Patient Safety
Relevant CLCH priority 1. Quality
Freedom of Information For distribution on request status Executive summary: The attached report contains information on Serious Incidents which have occurred within CLCH in September 2018. The incidents have been anonymised in order to protect the identity of patients and staff. The report also includes Trust ‘Being Open’ performance.
The report also has a section added this month on FTSU activity.
Assurance provided: The minutes of the Quality Committee and Patient Safety and Risk Group meetings provide evidence of the review of serious incidents.
Report provenance: Patient Safety and Risk Group and Trust Quality Committee
Report for: Decision Discussion Information X
Recommendation: To note the report
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1.0 Newly Reported Serious Incidents
1.1 Six new externally declared Serious Incidents were reported in September 2018:
Status Datix ID Steis ID Steis Classification CCG Incident Date Date of Date Date RCA Date RCA Date reported on Knowledge reported on Report due Report due Datix Steis to PST to CWHHE Open W56888 2018/21519 Pressure Ulcer NHS West 22/08/2018 22/08/2018 04/09/2018 04/09/2018 16/10/2018 27/11/2018 Category 3 London CCG Open W57026 2018/21583 Unstageable NHS West 29/06/2018 28/08/2018 05/09/2018 05/09/2018 17/10/2018 28/11/2018 Pressure Ulcer London CCG Open W56876 2018/21590 Pressure Ulcer Battersea 21/08/2018 21/08/2018 05/09/2018 05/09/2018 17/10/2018 28/11/2018 Category 3 Healthcare CIC Open W57287 2018/22154 Pressure Ulcer NHS 05/09/2018 06/09/2018 12/09/2018 12/09/2018 24/10/2018 05/12/2018 Category 4 Hammersmith and Fulham CCG Open W57290 2018/22700 Pressure Ulcer Battersea 06/09/2018 06/09/2018 19/09/2018 19/09/2018 31/10/2018 12/12/2018 Category 4 Healthcare CIC Open W57263 2018/23294 Unstageable NHS 07/08/2018 06/09/2018 26/09/2018 26/09/2018 07/11/2018 19/12/2018 Pressure Ulcer Hammersmith and Fulham CCG
1.2 There were also six internally declared serious incidents for the month of September 2018:
Datix Reference Borough/CCG/Commissioner Date of Incident Type of Incident CLCH Status W56563 Battersea Healthcare CIC 09/08/2018 Pressure Ulcer Category 3 Open W57284 NHS West London CCG 31/08/2018 Pressure Ulcer Category 3 Open W56966 NHS West London CCG 22/08/2018 Pressure Ulcer Category 3 Open W57662 Battersea Healthcare CIC 17/09/2018 Unstageable Pressure Ulcer Open W57792 NHS Barnet CCG 21/09/2018 Pressure Ulcer Category 4 Open C1243 / W57345 NHS Barnet CCG 08/09/2018 Pressure Ulcer Category 4 Open
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1.3 The number of external Serious Incidents reported each month for the last 12 months, excluding those de-escalated:
12
10
8
6
4
2
0 No. of External Serious Incidents Incidents Serious External of No.
2017/18
2. Submission of SI Reports
2.1 Six external RCA reports were due for submission in September 2018, all of which (100%) were submitted on or ahead of schedule.
3. De-escalation Requests
3.1 No de-escalation requests were sent to the Commissioners during September 2018.
4.0 Being Open
4.1 The following Being Open Part 1 requirements were met for each of the four divisions in August/September (25/08/2018 – 24/09/2018):
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Division 25/08/2018 – 24/09/2018 Children’s N/A South 100% Inner 83% North N/A
5.0 Lessons Learnt / Recommendations – September 2018
All Root Cause Analysis (RCA) reports are reviewed for the identification of key themes which form action plans for the relevant teams, and appropriate actions are included in the Trust wide pressure ulcer action plan (updated in September 2018) and shared with the Pressure Ulcer Working Group from where they are disseminated to Divisional meetings.
Four RCAs (excluding de-escalated cases) were submitted in September 2018, two of which related to pressure ulcer incidents. The remaining two incidents related to IG Breaches (see 5.2).
5.1 Pressure Ulcers Issues and themes identified from the analysis of the lessons learnt / recommendations are included in the trust wide pressure ulcer action plan. It should be noted that these are themes in practice and are not the cause of the pressure ulcer, in that the ulcer may well have occurred even if these were in place. The main issues identified in RCA investigations continue to be around the completion of training, documentation (care planning and risk assessments), taking and uploading photographs of wounds, ensuring that patients have appropriate equipment in place and ensuring the timely reporting of pressure ulcers on Datix.
5.2 Information Governance Breaches . Ensuring that client records are up to date. . Ensuring that staff follow the correct procedures for the transferring out of vulnerable clients. . The education of staff in the importance of synchronising records on the spine within SystmOne. . The importance of following each step within detailed processes which are robust, clear and are there to reduce the risk of breaching confidentiality. . Ensuring that processes are maintained.
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. The requirement and importance that any team member must as a matter of course double check any correspondence containing records or confidential information to ensure it is addressed appropriately.
6.0 Freedom to Speak Up and Whistleblowing
6.1 The table below details the Freedom to Speak Up data submission for September 2018. The data indicates the main themes at the point of recording by the reporter rather than what might be identified during or following investigation.
Month: SEPTEMBER 2018
Children Corporate Inner North South TOTAL
New FTSUG contacts 3 3 6 Primary category of concern raised Patient safety/quality 1 1 Staff safety 2 1 Behavioural / relationship 2 Bullying / harassment 2 System /process 1 1 Infrastructure / environmental Culture Leadership Categories as defined by National Guardian’s Office
6.2 At the point of writing the report, no new whistleblowing concerns raised in September 2018 have been reported.
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7.0 Ongoing Safeguarding Cases
7.1 Children:
Brent: Case 1: Chronology requested by the designated doctor in relation to child at risk of neglect who was not presented for medical appointments despite having ongoing needs. CLCH chronology submitted and awaiting feedback re: learning from the case.
Case 2: Chronology requested by Brent LSCB concerning family where home was taken over by a gang (cuckooing) and the children in the home were sexually exploited. The case is being considered by the LSCB serious case review panel. Chronology submitted – some areas for learning for CLCH school nursing staff including timeliness of response when parent identifies concerns.
Ealing: Following the mobilisation of 0-19 services in Ealing a number of cases were highlighted by the previous provider. CLCH will review the action plans provided and work with the local authority and CCG to ensure actions are completed and learning embedded.
Case 1 Child J.: DHR DI: This Domestic Homicide Review (DHR) included the death of a 13 month old child who was found by London Ambulance Service to have multiple and severe injuries and who subsequently died. The previous provider has shared an action plan which requires action in relation to the development of a no access policy, consideration of mental health and domestic abuse at the new birth visit and robust safeguarding supervision policy and practice in place. CLCH Head of Safeguarding Overview: CLCH has in place the required policies, systems and processes and will ensure that Ealing 0-19 service are complaint with these through training, supervision, monthly monitoring and audit.
Case 2 DHR SR: This DHR was undertaken following the murder of a male partner (SR) by his partner (EHB). EHB was found not guilty of murder as the abuse she was suffering within the relationship was taken into account. There were two children in this family. The previous provider has shared an audit that was undertaken following a recommendation by the DHR panel. The audit has apparently not been shared with practitioners within the 0-19 Ealing service. CLCH Head of Safeguarding Overview: The audit undertaken in response to the findings of the DHR considered continuity of service and recording of vulnerability. Good practice was identified in 90% of cases reviewed (44/49) but 10% (5/49) recording keeping and discussion at safeguarding supervision was not recorded. CLCH will cascade the findings of the audit to Ealing 0-19 practitioners and review and monitor the action plan via monthly named nurse meetings and quarterly safeguarding committee.
Richmond: CLCH staff escalated concerns relating to interfamilial sexual abuse involving a significant number of children. The case is being considered by the Richmond LSCB serious case review group and CLCH will share information to ensure the children involved are safe and protected from further abuse.
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Wandsworth: Case 1: Concerns raised by social care regarding a 7 week old baby who appears to be failing to thrive and historical safeguarding concerns in relation to parenting capacity as siblings previously removed. .Chronology of health visitor involvement being collated but it would seem there has not been any input from the service or engagement by the parent since the new birth contact. CBU manager and named nurse/head of safeguarding overseeing practice and caseload management where children at risk of neglect or harm.
Case 2: On 10th October 18 the Wandsworth safeguarding team were advised that a 17 day old baby (AT) was admitted to Great Ormond St Hospital on 9th October 18 with fixed and dilated pupils and a police investigation is in progress. The baby’s mother was a looked after child, had previous mental health concerns, substance misuse and had moved from Wandsworth to get away from gang involvement. A new birth visit was undertaken on 3.10.2018. The Head of Safeguarding has requested a chronology of input with AT and her mother and extended family.
7.2 Adults:
Inner: 1. Community nurses have raised concerns about a bedbound patient in her 50s who has capacity but continues to smoke in bed and is now refusing care. London Fire Brigade have risk assessed and implemented what they can with patient’s consent (fire retardant bedding) to reduce risk of harm or injury to the patient from fire. Community nurses are very concerned that patient will become seriously unwell as has happened before. Case being escalated to high risk panel and for consideration to the Bi-borough safeguarding case review group. CLCH will also seek legal advice in relation to the need to go to the Court of Protection (social care provide care package).
Inner 2. There are a number of cases being scoped to go to the Court of protection (Continuing Healthcare Cases) and CLCH will support the CCG with evidence and reports until the service transfers from CLCH in November 2018.
Completed and Ongoing Cases (Excludes confidential and embargoed cases)
Ongoing Statutory Reviews September/October 2018 Barnet SCR Child E Update October 18: This is a case from 2016: re: 16yr old LAC –unexpected death – due to cocaine mis-use. SCR Child E Published 09.05.2018 Themes: multiple placements, domestic abuse, self-harm, use of escalation. Action plan published on 9.05.2018 Outstanding actions: School nursing service to undertake mental health first aid toolkit training on 12.10.2018. Action plan to be updated accordingly and this should close as CLCH actions completed. Barnet Child Update October 18: Case involves an 8 month old child who suffered a significant non-accidental brain injury while in his parent’s care. CLCH awaiting date for learning review to be facilitated by CCG health lead
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Barnet SAR Update October 18: This is a 2017 case (MS) Death of patient in fire in a residential setting: CLCH continue to await (MS) publication of review and findings by Barnet Safeguarding Adult Board (BSAB) SAR panel. Barnet DHR Update October 18: Re: death of a mother and daughter killed by a family member. DHR on hold due to criminal (1) proceedings. DHR panel meeting to be convened late October 18. Barnet DHR Update October 18: Death of a man allegedly stabbed by his partner. Criminal investigation in place .Head of (2) safeguarding to attend DHR Panel meeting July 18 CLCH chronology submitted. Brent Learning Case relates to health staff not linking families so not identifying risk and/or escalating concern. July 2018: CLCH review audit of 20 cases has not been completed –head of safeguarding to prompt Named Nurse for Brent. Update October (IO) 18: CLCH Head of Safeguarding requested cases to be shared from local authority director. Apparently cases have been shared with designated doctor but not forwarded to CLCH so request to designated Dr has been made so action from review can be closed. Potential SCR Update October 18: SCR group awaiting outcome of post-mortem and coroner’s inquest into the unexpected death of 23 month girl in April 2018. CLCH chronologies completed which identified family had not engaged with health or social care and parent exercising choice regarding non-immunisation and home schooling for siblings. Merton SCR Child Update October 18: Awaiting SCR panel meeting date re: 7 year old girl murdered by her father. SCR terms of reference have been circulated –CLCH to be panel members. Richmond Mother and Update October 18: CLCH Named nurse on DHR panel –case relates to the murder of a mother and her two child deaths children by the children’s father who subsequently killed himself – CLCH named nurse for safeguarding is a DHR panel member. Child P Update October 18: Learning and improvement review into the exploitation of a vulnerable 15 year old girl missing from home who subsequently self-harmed. Richmond named nurse for safeguarding children is on the review panel. Tri-Borough: SAR Case LS Update October 18: This SAR relates to an adult with complex health needs and a learning disability and younger siblings in the household. External reviewers have met with frontline practitioners involved in the case (2 CLCH staff and a CLCH safeguarding children advisor) over a number of years and also a local strategic group (includes CLCH Head of Safeguarding). Draft report due November 2018 and findings learning will be shared with Board and frontline staff and managers. . Complex case Update October 18: Ongoing safeguarding concerns in relation to a patient open to the continuing health care (HR) team. CLCH submitted chronology and report to inform the case going to the Court of Protection and staff may be required to give evidence.
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Section 44 Update October 18: Triborough SAR WH: Complex case presented at the SAB case review group. CLCH staff to Enquiry (WH) attend a multiagency learning workshop in October18 as an action from the review. Wandsworth
Adult Updated October 18: Following SAR action CLCH has completed an audit of discharges/transfer of care during bank SAR (Mrs K) holiday period. 20 cases reviewed in line with the SAR action plan and findings presented to commissioners in September 2018. The audit identified community nurses responded appropriately to discharges/transfers of care. However it highlighted the need for acute trusts to advise community nurses in a more planned way. Work continues to support safe and effective discharge pathways with all acute providers. Adult Updated October 18: Death of patient known to community nursing service. Staff statements submitted to Coroner S42 (including a safeguarding statement) and awaiting information re: inquest and if CLCH practitioners will be called as Complex case witnesses. (MB) Adult S42 Updated October 18: Commissioner completed RCA report into death of patient known to community nursing service Complex case and CLCH Had of Safeguarding has challenged some of the findings around community nurses documenting if mental (MN) capacity assessment undertaken. Planned record keeping training sessions by legal firm for staff in Q3 /4. SCR 1. Child Updated October 18:CLCHIndependent Management Report (IMR) submitted to the LSCB in relation to a 10 month old child who was admitted to hospital with severe chicken pox and during a routine x-ray it was identified the child had a fractured rib. Child and Sibling previously on a CP plan category of physical abuse, but the case was stepped down less than a month before the incident. Both children are currently Children now looked after by a neighbouring borough. SCR 2. Child Updated October 18: SCR terms of reference being agreed re: 6 month old admitted with severe malnutrition and infected abscess to the back of throat. Concerns parents have learning needs that were identified and a history of both being known to Children Services as were on CP plans category of physical abuse and neglect and father previous LAC child out of borough. CLCH chronology being undertaken and will be reviewed by Head of Safeguarding, ADQ and Chief Nurse prior to submission. SCR 3. Child Updated October18: SCR to be undertaken re: unexpected death as a 2yr old child as a result of parent’s non- compliance with prescribed steroidal treatment for chronic asthma. No previous children services involvement. CLCH will submit chronology and report and engage in the SCR process and learning. SCR 4. Child Updated October 18: Currently a police investigation and court hearing on week beginning 15th October re: 9 week old admitted to hospital and intubated as a result of catastrophic injuries with no obvious pathological cause and so considered to be as a result of non-accidental injury Police investigation in progress and CLCH health visitor has submitted court statement and has been called to court. CLCH safeguarding service supporting.
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Board of Directors 31 October 2018
Report title: Medicines Management Annual Report 2017/18
Agenda item number: 4.2
Lead director responsible for Dr Joanne Medhurst, Medical Director approval of this paper Report author Arfana Butt, Head of Medicines Management Relevant CLCH strategic Trust objective 2018/19 priorities Strategy implementation Implement strategic priorities of integration and place Quality Maintain and improve the quality of services delivered by CLCH Operations Deliver all NHS constitutional and contractual standards Freedom of Information Available on request status Executive summary: This report highlights the medicines management activities undertaken in CLCH during 2017/18 and provides assurance that systems are in place for medicines management in line with legislation, CQC Regulation 12 and Controlled Drugs Regulations 2013. It also supports the CLCH Clinical Framework 2015 – 18 and aligns with the Patient Led Assessment of the Care Environment (PLACE) as part of the Trust strategy.
In 2017/18 the Medicines Management Team has focused on the following major areas:
• Advising and supporting community health services staff on medicines related issues. • Providing a high quality clinical pharmacy service to bedded units • Ensuring all policies, protocol and procedures are current and up to date. • Reviewing the process for updating, approving and ratifying patient group directions and ensuring they are current and up to date. • Delivering the antimicrobial stewardship programme. • Undertaking clinical audit in key areas and highlighted areas for further work, e.g. omitted doses, cold chain and safe and secure handling of medicines. • Ensuring safer management and use of controlled drugs. • Ensuring all medicine incidents are reviewed as they are reported and at MMG, Quality Committee and Regional Medicines Optimisation groups on a quarterly basis • Assessing and responding to medicines alerts. • Providing information under the Freedom of Information Act. • Providing education, training and health promotion to healthcare professionals • Ensuring systems are in place to promote patient safety in relation to medicines, including bedded services. • Delivering a high quality medicines optimisation service in patients’ homes. • Providing MM input into the mobilisation and de-mobilisation of services e.g. dental, sexual health, children’s. • Working with new services including Wandsworth Adult Community Services and South West London Sexual Health Services to get to ‘business as usual’. • Commenced process to re-tender the pharmacy supply contracts.
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167 Achievements in 2017/18 • Reduction of drug expenditure in the North Division by £200k. • Successful negotiation with NHSE to agree the reimbursement of drugs used in sexual health services. • Completion of the safe and secure handling of medicines audit programme which involved audits at approximately 200 clinical services across CLCH • More controlled monitoring of medicine incidents by senior pharmacists to review and monitor incidents being reported to enable targeted learning • Appointment of a pharmacist and Consultant Microbiologist to deliver the antimicrobial stewardship programme within CLCH. • Improved monitoring of pharmacy SLAs resulting in regular performance management • Compilation of a comprehensive Medicines Management Training Programme including sessions on controlled drugs, Patient Group Directions, omitted and delayed medicines, self-administration of medicines • The Proactive Care Homes Project was shortlisted for two HSJ awards: Improving Safety in Medicines Management and Care of Older People
Assurance provided: The Medicines Management Annual Report provides assurance that there are robust Medicines Management systems in place in line with legislation, CQC Regulation 12 and Controlled Drugs Regulations 2013.
Report provenance: The Medicines Management Annual Report was discussed and ratified at the Medicines Management Group (MMG) in July 2018. The report was agreed at ELT on 9th October 2018.
Report for: Decision Discussion Information X Recommendation: The Group is asked to note the content of the report and the work being undertaken by the Medicines Management Team, along with CLCH staff and managers to protect patients from medicines related harm.
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168 1 Purpose 1.1 The Medicines Management Annual Report highlights the medicines activities undertaken in CLCH during 2017/18 and provides assurance to the Board that there are robust Medicines Management systems in place in line with legislation, CQC Regulation 12 and Controlled Drugs Regulations 2013.
2 Introduction 2.1 Medicines management encompasses a range of activities that aim to improve the way that medicines are used, both by patients and by the NHS. It includes activities such as ordering, receipt, handling, transporting, prescribing, administering, counselling, recording and disposing of medicines, all of which are fundamental to ensuring safety for patients and staff, with regards to medicines use. Medicines management is an area where access to professional advice is essential, to ensure that services can be delivered and developed to secure health gain for the local population.
2.2 The Care Quality Commission (CQC) Regulation 12 (formerly Outcome 9), has identified the management of medicines as one of its core quality and safety standards. It states that service users must be protected against the risks associated with the unsafe use and management of medicines and that they will have their medicines at the times they need them, in a safe way and have information about their medicines made available to them. In order to meet this standard within CLCH, the Medicines Management Team works hard to ensure medicines are handled safely, securely and appropriately; are prescribed and given by staff members safely; and keeps up to date with published guidance on medicines safety so that best practice can be implemented within the Trust.
2.3 The vision of the medicines management team is to:
“Improve patient’s lives by optimising the safe and effective use of medicines in the community, through innovation and effective partnerships with both internal and external stakeholders.”
3 Underlying Principles 3.1 Incorporate risk management, patient safety and incident management mechanisms into all areas of work.
3.2 To ensure necessary standards of accountability, probity, financial balance and value for money relating to medicines use.
3.3 To support high quality, cost-effective, evidence-based prescribing by doctors and non-medical prescribers within the CLCH.
3.4 To minimise the risk to patients and staff associated with handling/administering/supplying/disposing of medicines, thereby promoting patient safety and reducing harm.
4 Quality implications and clinical input Key areas of work in 2017/18 included: 4.1 Clinical audits, reported to the Clinical Effectiveness Steering Group and the Quality Committee, have been undertaken. These led to improvements in clinical practice and compliance with regulations, where required, in relation to prescribing and safe and secure handling of medicines.
4.2 Omitted Doses audit results showed 99.8% of all doses were signed for on the drug chart or had a 3
169 valid omission code recorded, in line with results from the previous 4 years. This year, 98% of charts audited had the allergy status completed compared to 100% the previous year. There has been significant improvement in reducing omitted doses over the last 4 years and the Clinical pharmacists continue to monitor these on a daily basis.
Antimicrobial audit showed improved results for documentation of allergy status again – 97% 4.3 compliance (compared to 46% in October 2016) and prescribing in line with guidance fell to 79% (compared to 97% in 2016). Areas for further improvement included to record clinical indication in both patient notes and drug charts.
Services holding medicines are audited annually as part of the safe and secure handling of 4.4 medicines audit programme. A total of 188 audits were conducted across Clinics and Bedded services. Each service within the trust achieved a compliance rating between 44 – 97%. The average compliance rating across the trust was 77%, an increase from 73% in 2015/16 and 66% in 2014/15.
Areas of non-compliance included security of medicines and controlled stationary, poor 4.5 temperature control of rooms used for medicine storage, lack of robust audit trails around managing delivery notes and inappropriately stored flammable items.
Controlled Drugs (CDs) audits were carried out quarterly at all bedded units and annually at 4.6 community clinics stocking CDs. The audits at bedded units did not find serious concerns, however, low compliance was found at North Division bedded units and a risk was added to the risk register (1807). Areas that require improvement include better record keeping, up to date signature lists and more timely destruction of CDs.
Findings from the community clinics audit included incomplete standard operating procedures, 4.7 staff not recording date of opening liquid CDs or receipt of CDs and incomplete audit trail of transport of CDs. All staff handling CDs have been offered training accessible via the hub.
There are 353 active non-medical prescribers (NMPs) within CLCH, an increase from 311 the 4.8 previous year. The Medicines Management Team maintains a database of NMPs and monitors their prescribing quarterly.
The total drug expenditure for CLCH this year was approx. £3.3m, a 4% reduction on the previous 4.9 year (FP10 prescribing at CLCH services = £270k, NMP = £1.6m and SLA drugs = £1.4m).
There are 32 medicines related policies, protocols and procedures reviewed and approved by the 4.10 MMG. Nine were reviewed or approved in 2017/18. The MMG contribute to the development of 5 other Trust policies. All policies are up to date.
There are 88 Patient Group Directions (PGDs) managed by the Medicines management Team. 22 4.11 of these were reviewed this year and all are up to date. 3 new PGDs were developed.
The PGD audit is conducted on a rolling basis for all PGDs, six months prior to their expiry. The 4.12 audit looks at whether the PGD is being used appropriately to warrant its renewal and to ensure that the practitioners using the PGDs have the appropriate training and relevant experience to use them.
Overall compliance to all the audit standards specified was over 93%. Areas for improvement 4.13 included: to ensure all PGDs are coded onto electronic systems correctly so that the data collection for the audit can be obtained in an efficient manner; consent and allergy status to be obtained and documented at the time of PGD consultation; staff records to be up to date stating they are authorised to work under the PGD.
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170 4.14 The MMG receives quarterly incident reports. There were 695 medicines related incidents reported in 2017/18 (compared to 630 in 2016/17 and 532 in 2015/16). 31 incidents were categorised as causing low harm, a 39% reduction compared to 2016/17. 664 incidents were categorised as causing ‘no harm’ and this made up 96% of the total reported incidents. No incidents were reported to have caused moderate/severe harm.
4.15 There were 90 Datix incidents involving controlled drugs (compared to 54 in 2016/17 and 61 in 2015/16). Main themes identified were omitted doses, recording errors, medication unaccounted for and error in ordering or delivering medication. Management of CD incidents occurs day to day and is reported quarterly to the MMG and Quality Committee.
4.16 Quarterly occurrence reports sharing any unresolved CD incidents and/or matters of concerns were submitted to the London Area CD Accountable Officer at NHS England.
4.17 A clinical pharmacy service is provided to all bedded services (158 beds). Each service has an agreed level of pharmacy input. This year, service improvements made included: Introduction of a technician at each of the North Division wards, review and rationalisation of wards stock lists to minimise stockpiling and reduce wastage, recording off all pharmacist interventions and KPIs, ongoing monitoring and feedback on the quality of medicines information and medicines supplied on transfer of patients to CLCH bedded services from acute Trusts.
4.18 West London and Merton CCGs commissioned the CLCH medicines optimisation (MOPs) service which involves specialist pharmacists visiting patients in their homes to undertake clinical medication reviews and help patient’s optimise their use of medicines. This year, 426 patients were visited, an average of 5 interventions made per patient and average £80 cost saving per patient.
4.19 A comprehensive training programme was delivered at training events, classroom induction, refresher and e-learning.
4.20 This year saw the start of the Antimicrobial Stewardship (AMS) Programme as the Antimicrobial Pharmacist joined the team. This has been a priority for the Trust since the launch of AMS initiatives by the government.
4.21 AMS work streams have included building working relationships and sharing best practice with fellow antimicrobial pharmacist colleagues; promoting antimicrobial guardian activities during antimicrobial awareness week, and sharing relevant AMS national resources with services to raise public awareness; developing audits to assess the appropriateness of antimicrobial usage within ‘high user’ services e.g. WICs and sexual health and collation of baseline antimicrobial consumption data for the Trust to enable surveillance.
4.22 Trust projects supported by the medicines management team have included working with End of Life working group to develop drug charts to help improve the transfer of care, reduce District Nursing time to obtain a completed chart and improve patient experience; Updating the Community Nursing Drug Authorisation and Administration Record and working on cost saving initiatives with Hertfordshire Sexual Health Service.
4.23 Services new to the Trust requiring additional clinical pharmacists have included Wandsworth Community Adult Services’ (WCAHS) - Complex Care and Care Homes services. The team has supported SWL Sexual Health and Wandsworth & Richmond Health Visiting services to ensure a seamless transition. Post mobilisation work with SWL Sexual Health has continued to ensure services are delivered in line with best practice and national recommendations and that drug expenditure is continuously monitored.
4.24 The re-tendering process to streamline the provision of medicines via SLAs, from 3 agreements
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5 Risks and mitigating actions There were 4 open risks on the medicines management risk register at the end of 2017/18, increasing from 2 at the beginning of the year and 2 medicines-related risks on the North Division’s Risk Register.
5.1 Risk ID & Risk Rating Reason/ Action 2020 Wandsworth Adults 12 Training delivered by MM If CLCH have acquired Medicines Management risks and Prof nurse lead in and substandard clinical practice with the acquisition modules. Dedicated time of new services, this poses a risk to patient safety and for learning and facilitated a clinical and reputational risk to CLCH. learning offered. A business case for There have been ad hoc reports from staff of additional resource is substandard practice in Wandsworth Community awaiting presentation and Adult Health Services e.g. patients not receiving decision at ELT. insulin on time, transcribing not being a part of day to day practice, involvement of HCAs with medicines administration. 2070 SWLSH 9 Meeting with MM and SH If Sexual Health Services in SWL are practicing outside leads took place on 25.7.18. local policy/national recommendations, this poses a Actions agreed going risk to patient safety and a clinical and reputational forward to complete risk risk to CLCH. assessment for dispensing There have been ad hoc reports from audits and practices. This was meetings with staff of practice happening outside presented to MMG in Sept national recommendations and local policy in SWL 2018. Sexual Health Services e.g. doctors involved in the Also agreed to rationalise prescribing and dispensing process for the same stock lists and limit drugs patient; some drugs kept in stock are outside sexual where the prescribing and health remit; 2 cold chain breaks happened at Balham dispensing operations over a two month time (no designated cold chain cannot be separated. lead); no prescription log kept to account for all pages of the prescription pads issued at some of the services; poor record keeping of delivery notes, vaccine stock inventory, return sheets etc. 1915 SWLSEX 9 SWLSH drug expenditure As the annual drug expenditure for the SWL Sexual report covering the period Health service is unknown this poses a financial risk to Oct 2017 – December 2017 CLCH as drug expenditure will have to be absorbed if for all six family planning this is more than what has been budgeted for. and sexual health clinics in south west London sent to CBU manager and DDO. MM to continue monitoring drug expenditure and send analysis on a quarterly basis. Reporting to MMG. Initiatives to date to contain costs e.g. rationalising stock lists, manufacturer agreements for supply at LPP price. 1593 The lack of an antimicrobial stewardship 8 AMS action plan and programme within CLCH(organisational and system- Antimicrobial pharmacist in
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172 wide approach to promoting and monitoring the place. Imperial withdrew judicious use of antimicrobials) presents a clinical risk from SLA and options are to patients due to growing antimicrobial resistance being considered for and a reputational risk to CLCH due to non-compliance Microbiologist input. with regulations and NHS initiatives from the AMS Pharmacist has following: reported ongoing progress to date at Quality 1.CQC requirements Regulation 12 Committee and MMG. 2.Trust Development Authority (NHS Improvement) 3.DH UK 5 year Antimicrobial Resistance Strategy 2013-2018 4.DH Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI). 5. NICE 6.Public Health England/NHS England 7. The Hygiene Code
Benchmarking exercise shows other community trusts have dedicated antimicrobial pharmacists in place to set up and deliver on this work on an ongoing basis. North Division 9 We have moved drugs 2087 Following the medicines audit, the two clean around to store them safely utility rooms at FMH which are used to store stock and have changed the drugs, have been recording high temperatures on and process of receiving TTOs off above 20 degrees C. The temperature guideline so we don’t have to store recommendations are between 15-20 degrees. them for extended times. Therefore there is a risk that medicines stored in the Funding approved for air clean utility room would be compromised for patient conditioning units. Awaiting use. commencement date for works on the wards from Estates. North Division 6 Improvements made at 1807 A recent CD medicines audit has highlighted a Jade and Ruby wards. lack of full compliance with the CD medicines Introduced separate CD management policy, this may result in a reduced cupboards and use of stock quality of patient care. CDs rather than PODs to reduced quantities. Q4 2016-17 & Q1 2017-18 audit reports to be presented at next MMG
6 Consultation with partner organisations 6.1 The full report will be shared with CCG colleagues via Heads of Medicines Management and Clinical Quality Review Group meetings.
7 Challenges in 2017/18 7.1 Recruitment – delays in recruiting to vacancies added pressure to the team during the course of the year with team members having to take on additional duties and locums being required to help deliver front line clinical services to bedded services.
7.2 Despite some progress, bringing Medicines Management practice up to the standard required has continued to prove a challenge in the Wandsworth Adult Community and South West London Sexual Health services.
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7.3 Embedding Safe and Secure Handling of medicines into practice through the audits was a challenge for the technical team, particularly new staff members. Patience and perseverance was required to engage staff that had been used to substandard historical practices. The team have however built many relationships with frontline staff and are frequently contacted for advice on medicine-related issues.
7.4 Mobile and agile working have proven challenging at times from a managerial perspective due to the geography of the Trust.
7.5 The acquisition of new services without pharmacist resource for MM advice, support, training, has continued to impact during 2017/18, and the requirements for reporting and engaging with 11 CCGs has increased the demand on the team.
7.6 Streamlining and ensuring consistency in the sexual health services across the Trust.
8 Priorities identified for 2018/19 8.1 Continue to improve in-house services to deliver a high quality, safe service and optimal patient care.
8.2 Retain existing staff, recruit to vacancies and further build the team to enable a pro-active service, with the growth of the Trust
8.3 Explore more innovative ways of working to enable the team to continue delivering a high quality service
8.4 Secure new business opportunities for the Trust e.g. expansion of the clinical Medicines Optimisation Service (MOpS), provision of MM services in care homes
8.5 Ensure robust and consistent audit of safe & secure handling of medicines across all newly acquired services.
8.6 Develop a medicines management strategy based on NICE guidance on Medicines Optimisation, aligned to Carter 2 recommendations sitting within the Trust’s 3 year Clinical Strategy and with the Patient Led Assessment of the Care Environment (PLACE), Trust priority.
8.7 Deliver the objectives of the Antimicrobial Stewardship action plan across the Trust.
8.8 Build relationships with partner CCGs to manage medicines across the interface.
8.9 Engage with and implement the new re-validation programme from the General Pharmaceutical Council (GPhC).
8.10 Engage with the commercial team to ensure an accurate medicines management model is factored into new business bids.
8.11 Mobilisation of the new pharmacy supply contract.
9 Recommendations 9.1 The Group is asked to note the content of the report and the work being undertaken by the Medicines Management Team, along with CLCH staff and managers to protect patients from medicines related harm.
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BOARD OF DIRECTORS 31 October 2018
Report title: Annual Security Management Report 2017-18 Agenda item number: 4.3 Report of: James Benson, Chief Operating Officer Contact officer: Ronald Faulds, Local Security Management Specialist Relevant CLCH priority 1. Quality 2. Transformation / Integration 3. Value for money 4. Leadership / Governance Freedom of Information Can be made public status Executive summary: This report provides an update on the security management work undertaken 2017-18 in pursuance of the Trust’s compliance with the “Standards for Providers (Security Management)”, required under the NHS Standard Contract.
Assurance provided: This Report details the ongoing development of security improvement and the various internal and external monitoring processes in place through the Trust’s Security Management Director, Associate Director for Resilience & Compliance and Local Security Management Specialist
Report provenance: Health & Safety Sub Group, Health & Safety Committee, Trust Board
Report for: Decision Discussion Information
Recommendation: The Board is asked to note the progress of security management work and approve the Report
175 1 Introduction 1.1 This report details all security management work undertaken during the period 1 August, 2017 – 31 July, 2018.
1.2 The security and safety of staff, patients, visitors and property continues to be the ongoing priority for security management so as to enable our staff to deliver quality care to the communities in which we operate.
1.3 Bearing in mind that priority, there is a need for staff to feel secure whilst at work and for our patients and visitors to feel secure whilst on our premises. The Trust has continued to upgrade its security management capability in line with the NHS Standard Contract, our other stakeholders, e.g., CCGs, CQC, etc., and in response to recognised issues arising out of the Incident Reporting System. This has included :
• The continued rollout of the Skyguard Personal Safety Lone Worker devices to over 1200 of our designated lone worker staff • Acknowledging the fact that there is a need for frontline nursing staff to have an appropriate level of professional guidance when managing individuals who present with clinically challenging behaviours, the Blended Training Project continues the search for providers to deliver the advised additional conflict resolution add-on training.
1.4 For the last two years, 2016-17 and 2017-18 the number of reported incidents for assaults on staff by patients and/or relatives has slightly decreased from 26 (2016-17) to 25. Once again there is no apparent trend towards a particular root cause for the assaults, save for the inevitability brought about by the diverse nature of the clinical conditions our patients suffer from and the human reaction to pain and fear.
1.5 The LSMS continues to investigate and support our staff whenever these incidents are reported and staff have an opportunity to talk through their experiences when the LSMS attends their team meetings from time to time. Staff are continually encouraged and instructed on how to report incidents and to seek advice from their manager or the LSMS in case of doubt.
2 Background 2.1 This Trust’s commitment to ensuring the provision of a secure environment for staff, patients and visitors includes the provision of adequate and appropriate security measures being put in place and properly managed. CLCH aims to achieve this objective through the implementation of nationally agreed security management standards, including those set down by the Department of Health, the Health & Safety Executive, CCTV Surveillance Commissioners, etc. 2.2 Since 2013, the Trust has measured its effectiveness in providing the safe and secure environment by adherence to a number of mandatory and obligatory standards provided by the above mentioned stakeholders. Pre-April 2017, these standards were monitored centrally by NHS Protect’s Security Management Service. This service has now ceased to exist, leaving quality assurance to the Trust itself in the persons of the Security Management Director, Prof. David HINES (Non-Exec Director), the Associate Director for Resilience & Compliance and the LSMS. 2.3 In late 2017, a conscious decision was made by the Security Management Director that we should continue to observe the Security Management Standards (2016-17) and that the LSMS will continue to report locally through the Health & Safety Sub Group, Security Management Director and Trust Board. Should there be any confirmed change of procedure at national level, our proposed use of these Standards may need to be reviewed and amended accordingly.
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176 2.4 The standards were originally designed to support NHS providers in ensuring they have appropriate and consistent security management arrangements in place by identifying areas requiring improvement and providing scope for them to develop their own plans for those improvements. They provide for the following four key sections that comprise NHS Protect’s former strategy :
Strategic Governance – the organisation’s strategic arrangements to ensure anti-crime measures are embedded at all levels Inform and Involve – raising awareness of crime risks against the NHS and working with NHS staff, stakeholders and the public to highlight the risks and consequences of crime against the NHS Prevent and Deter – the discouraging of individuals who may be tempted to commit crime against the NHS and ensuring that opportunities to do so are minimised Hold to Account – the detecting and investigation of crime, prosecuting those who have committed the crime and seeking redress 2.5 The work streams undertaken by the LSMS between 1st August, 2017 until the end of August, 2018 have reflected the needs of the Trust as identified through the incident reporting system in line with the four “Areas of Priority Action”, which were :
• Patients and staff • NHS property and assets • Maternity and paediatric units • Drugs, prescription forms and hazardous materials
These incorporated what is referred to as the seven “Generic Areas of Action” :
Creating a pro-security culture – so as engender a culture in which the responsibility for security is accepted and shared by all Deterrence of security breaches / incidents – through incident reporting, investigation, root cause analysis and risk assessment, Identifying and implementing ways to deter security incidents and breaches Prevention of security breaches / incidents – through investigation, root cause analysis, risk assessment, developing communication links and intelligence gathering from staff, police, etc., so as to enable identification of the most appropriate and effective methods capable of driving home security awareness to all Detection / reporting of incidents – Encouraging the reporting of all security and violence and aggression related incidents. Through security awareness training, enhance the detection rate of breaches, e.g., defective lights, locks, systems, etc. Investigation of incidents – providing a consistent and fair investigation of all reported incidents, applying an appropriate level of investigation to each, identifying root cause (in appropriate cases) and providing adequate feedback to reporters and stakeholders with a view to reducing the likelihood of recurrence, etc. Sanctions following investigation – identifying root cause of incidents and considering appropriate sanctions for criminal activity, including support for criminal court/civil court sanctions, community orders, etc. Redress following investigation - Supporting the Trust in assessing financial losses to the Trust through criminal activity and pushing for recovery of those losses through the Crown Prosecution Service, etc., and to assist and advise individuals to seek redress in all appropriate cases as well as assessing the true cost of security incidents to the NHS.
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177 3 Security Management Work Undertaken – 2017-18 3.1 The following outlines the security management work undertaken during the reporting period and is set out under the four key sections : Strategic Governance The Trust’s Security Management Strategy (2016-19) has been a guide to security work undertaken since its inception in 2016. It is currently now under review to evaluate its effectiveness to date and with a view to identifying how it can be improved upon for the period 2019 – 2022.
3.2 Inform and Involve
Standard 2.1 - (Amber) – relating to the requirement for substantial engagement with the police and other stakeholders was declared as compliant (Amber), with some work having been undertaken to make contact with the policing boroughs covered by CLCH.
Once again, due to the prioritisation of police work throughout London, the aim of regular liaison meetings with police has been impossible to meet, although we are responsive to their requirements when called upon, e.g., terrorist attack at Parsons Green Tube Station. This is likely to be the position for the foreseeable future.
3.3 Prevent and Deter
Standard 3.2 – (Amber) Requires patient facing staff to undertake an additional component in addition to their Conflict Resolution Training. It includes technique in managing difficult and challenging clinical behaviours. Throughout 2016-17 the Blended Training Project team has been attempting to identify an appropriate training provider. This work is still ongoing. Evidence of the Blended Training Project’s involvement rests with the Learning & Development Team. Standard 3.5 – (Amber) Following the site visits carried out in 2016-17 to identify the access control measures in place across the estates, a number of security installations in the form of additional CCTV, etc., have been implemented. CCTV system checks have also been undertaken by Estates throughout Westminster and Barnet Tier 1 and 2 sites and their findings have been reported back to the Health & Safety Sub Group (H&SSG) for evaluation. The CCTV Policy is expected to be implemented later this month and that will necessarily produce regular audits of control management which will be reported regularly to the H&SSG, identifying any risk issues. Standard 3.11 – (Amber) Site surveys and team meetings revealed that staff at the bedded units run by the Trust apparently had insufficient safe storage for staff personal property. This situation has now become less of an issue as staff lockers have been made available as well as other lockable vessels for their personal property of our staff. Further checks are to be made of facilities at newly mobilised staff sites in Wandsworth and Ealing. Standard 3.14 – (Amber) The Trust now has on site security officers at each of the Walk in Centres. ISS provide a contracted service at Parsons Green, Soho Health Centre and Edgware Community Health Centre, whilst Finchley Memorial and St Charles Centre for Health are operated through the PFI provider (Finchley Memorial) and NHS PS (St Charles). Due to the geographical distances between our Trust sites, the availability of increased security in the event of an incident are limited and in such cases where appropriate, the police would be called.
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178 3.4 Hold to Account
Standard 4.4 – (Amber) Liaison between the LSMS and Trust’s contracted Local Counter Fraud Specialist Service should ensure that policy relating to financial losses suffered by the Trust as the result of criminal activity is effective.
4 Violence and Aggression – Reported Incidents 4.1 CLCH has seen a slight reduction in the reported incidence of physical assault on staff by patients and relatives in 2017-18. This is in line with the trend over the past 3 years, with no apparent one particular root cause. The Trust is currently researching the best possible media provision to get across the message that we will not tolerate violence or aggression towards our staff. The LSMS is currently liaising with the Diversity and Inclusion Lead with this initiative.
4.2 The reporting of incidents involving racial abuse continues to be a concern as the majority of those that are on the receiving end of it still show a tendency to not wish to take proceedings further against the perpetrator. Support is provided by the LSMS in any event, should the staff member agree to meet with him.
4.3 The following graph shows the comparative statistics for the last two years, 2016-17 and 2017-18 :
Disruptive or aggressive behaviour to patient by patient
Disruptive or aggressive behaviour to patient by Staff
Disruptive or aggressive behaviour to staff by patients Disruptive or aggressive behaviour to staff by staff Physical abuse by staff or visitor to patient Physical Assault on Staff by Patient Physical assault to patient by patient
Physical assault to staff by staff 2016-17 Racial Abuse to staff by patient or visitors 2017-18 Racial abuse to staff by staff Sexual abuse to staff by patients Verbal abuse by staff to patient Verbal abuse to patient by patient Verbal abuse to staff by patients Verbal abuse to staff by staff Other 0 20 40 60 80 100 120 140 160
5 Lone Working 5.1 Skyguard Personal Safety Lone Worker Devices The Lone Worker Policy was fully reviewed and updated and has been introduced, which includes a Standard Operating Procedure for the use of the Skyguard devices.
Since the last Annual Report, the LSMS, together with the Resilience and Compliance Team, have
rolled out over 1200 Skyguard devices with several other staff members booked onto issue and lone
working awareness training sessions. Improvement has been made to the manner in which staff go about booking this training, commencing with ESR.
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179 6 Conflict Resolution Training (CRT) 6.1 Conflict Resolution Training continues to be delivered to all staff with a very high take up rate and attendance at courses.
7 Security – Reported Incidents 7.1 The following graph shows the comparative statistics and trends for the last two years, 2016-17 and 2017-18 :
Blocked exit / defective lift
Breach of security
Damage to equipment
Damage to property
Damage to vehicle 2017-18 Intruder 2016-17 Loss of mobile phone or blackberry
Theft of equipment
Theft of property
Other
0 10 20 30 40 50 60 70 80
7.2 Due to the long term sick leave of the LSMS, the planned work in clarifying DATIX codes for security related matters has been delayed and will now be prioritised as a work stream for 2018-19.
8 Quality Implications and Clinical Input
8.1 The updates outlined in this report will not have any affect upon the clinical quality of services provided by the Trust.
9 Equality Implications
9.1 There are negligible implications from this report in terms of the equality impact.
10 Risks and Mitigating Actions
10.1 The main residual risks include :
• staff continuing to under-report incidents of racial and other verbal abuse as they feel there is little that can be done about it • frontline community staff being at risk of violence and physical abuse through lack of providing appropriate training and support to them when dealing with individuals presenting with difficult and challenging clinical behaviours, including mental incapacity, etc.
10.2 Underreporting of racial incidents : The Diversity and Inclusion Lead is heading up a project to highlight this issue so as to add to the confidence of staff to report when an incident occurs.
10.3 Management of difficult and challenging clinical behaviours :
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180 To mitigate this risk, the LSMS continues to work with teams day to day and at team meetings, providing appropriate guidance and support, etc. The Blended Training Project team are continuing to identify the best way forward with regards to introducing this additional CRT training.
11 Monitoring Performance
11.1 The Security Management Director, assisted by the LSMS continually monitor compliance with the mandatory standards.
12 Recommendations
12.1 The Board is asked to note the progress of security management work, approve the Report.
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181
Board of Directors 31 October 2018
Report title: Public Sector Equality Duty Report 2018
Agenda item number: 4.4
Lead director responsible for Louella Johnson approval of this paper
Report author Julian St. Clair-Gribble/Yasmin Mahmood/Dominic Mundy
Relevant CLCH strategic Trust objective 2018/19 priorities Strategy implementation Quality Maintain and improve the quality of services delivered by CLCH Finance Deliver the 2018/19 financial plan Operations Deliver all NHS constitutional and contractual standards Workforce Make CLCH a great place to work for everyone Freedom of Information status Executive summary: The Equality Act 2010 requires all public bodies to show due regard to the following 3 aims: • eliminate unlawful discrimination, harassment and victimisation, • advance equality of opportunity, and • foster good relations between those who share a protected characteristic and those do not.
This report delivers against the first specific duty under the Equality Act, which requires public bodies to publish relevant, proportionate information showing how they meet the Equality Duty annually.
The report includes information on the Trust’s patients and employees, analysed by protected characteristics. It incorporates information on:
• An analysis of patient experience and access to services, including targeted services for protected groups and key engagement work undertaken with vulnerable patients, such as older people and people with learning disabilities. • An analysis of the workforce profile, highlighting any disproportionality in terms of representation in a range of areas, such as appointments, disciplinary proceedings and perceptions related to career progression, bullying and harassment and discrimination. The report highlights, for example, underrepresentation of women and BAME staff in senior grades. • Work undertaken to promote good relations among staff through a range of networks and forums, such as the BAME Network and Rainbow networks and the Workforce Race Equality Standard (WRES) taskforce. Events such as the Annual BAME Conference, the London and Hertfordshire Pride and World Mental Health Month have contributed to staff engagement and well-being. • Key performance improvement standards adopted to progress equality and diversity, such as the
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182 WRES, the Disability Confident accreditation and the Accessible Information Standard. • Improving opportunities for career progression among under-represented groups through targeted actions on recruitment and selection, career progression and disciplinary processes as outlined in the WRES Action Plan, and • training and development opportunities offered to all staff on a range of topics such as Unconscious Bias avoidance and Conflict Resolution. Assurance provided:
The datasets have been confirmed via the Head of Patient Experience, Diversity & Inclusion Lead, Head of Workforce Information & HR Systems and Acting Head of HR.
The report highlights gaps in information related to patients and the workforce and these gaps will be addressed in time for the next Equality and Diversity report by March 2019.
Report provenance:
Report for: Decision Discussion Information X X X Recommendation: The Board is asked to note the findings and approve the report..
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Public Sector Equality Duty Report 2018
October 2018
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184 Foreword
We are pleased to present the Public Sector Equality Duty Report for 2018. The report documents the work Central London Community Healthcare (CLCH) NHS Trust has undertaken to proactively address inequality and improve outcomes for patients and employees between April 2017 and August 2018.
The report includes a detailed analysis of take up of services and patient experience by protected characteristics – which we will continually monitor to ensure we are able to meet the needs of people we serve.
Likewise, it includes detailed information on our workforce to help us understand the trends and patterns of inequality that exist within it, so that we are able to mitigate them in a systematic manner.
Some of the key highlights of the past 18 months include:
• Procuring a new 24-hour Translation and Interpretation service for patients with communication and language support needs, which includes face-to-face, telephonic and video interpretation services for patients. • Good patient experience results, which have inspired us to continuously challenge ourselves with patient stories and engagement which help us understand the everyday barriers patients face and how we can work to overcome them. • The establishment of the Workforce Race Equality Standard (WRES) Taskforce and led by the Chief Executive. Involving a cross-section of employees, the Taskforce has embarked on an ambitious plan to improve the experiences and outcomes for Black Asian and Minority Ethnic (BAME) staff in recruitment and selection, employee relations and career progression. • Developing the scope and influence of our staff networks to ensure they continue to advocate for change for the groups they serve. The Trust currently facilitates the BAME and Rainbow networks for Lesbian, Gay, Bisexual and Transgender (LGBT) staff – and is working towards establishing a network for staff with disabilities.
We recognise that change and improvement require time, effort and resources, but we are confident that the commitment of our staff and support of our partners across the geographies we serve will help us see the desired improvements over the next few years.
Angela Greatley Andrew Ridley
Chair Chief Executive
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185 1. Executive Summary
The Equality Act 2010 requires all public bodies to show due regard to the following 3 aims: • Eliminate unlawful discrimination, harassment and victimisation • Advance equality of opportunity • Foster good relations between those who share a protected characteristic and those who do not.
To meet the general duties, they are expected to show due regard to the following specific duties: • To publish annually relevant, proportionate information showing how they meet the equality duty • To develop one or more equality objectives to meet the general duty, which can be refreshed every four years or earlier.
The Trust’s Equality Objectives for 2016/18 are as follows:
• We will deliver more targeted intervention and outreach activities to protected groups in order to promote our health services. • We will improve how we communicate with diverse patients using alternative and accessible formats. • We want to provide reasonable adjustments for patients with Learning Disabilities and Dementia who use our mainstream health services. • We will improve the reporting of discrimination, harassment, bullying or abuse at work and seek to reduce the occurrence of incidents by valuing diversity and difference in our workforce. • We will increase the representation of our Black Asian and Minority Ethnic (BAME) staff at senior manager levels. • We will improve the number of young people the Trust employs and respond to the challenge of a multi-generational workforce.
This report aims to meet the first specific objective, and also reports on progress against its equality objectives for the period through its services and workforce. These objectives are in the process of being refreshed.
The report includes information on the Trust’s patients and employees, analysed by protected characteristics. It shows how the Trust has sought to minimise disadvantage, meet the needs of protected groups and encouraged their participation in decision-making, both in service delivery and employment.
Some of the key work undertaken to support inclusion in the past year includes:
• Engaging elderly housebound patients through phone groups. • Collecting dynamic patient stories (film or picture) from patients with a learning disability, enabling their voice to be heard. • Facilitating listening events across Hammersmith and Fulham and Richmond to understand the experiences of young people accessing the school nursing service.
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186 • Provision of a sexual health service in South West London, which runs a Sexual Health Service Users Forum including representatives from the Lesbian, Gay, Bisexual and Transgender (LGBT) communities. • Provision of sexual health services in Hertfordshire, which run gay specific clinics and a clinic for transgender people. • Providing staff access to a range of networks and support services, including the BAME and LGBT staff networks and Mental Health minders for people with mental health concerns. • Providing staff access to a range of career development opportunities, such as the Ready Now programme, which aims at developing a representative talent pipeline. • Promoting good relations among staff through events such as the annual BAME Conference, the London and Hertfordshire Pride events and World Mental Health Month. • Adoption of performance improvement standards to monitor progress on equality and diversity systematically, such as the Workforce Race Equality Standard (WRES) and the Disability Confident accreditation. The WRES Taskforce has developed a robust action plan to address concerns around recruitment and selection, bullying and harassment, career progression and disciplinaries.
2. Purpose of the report
The purpose of this report is to present the actions taken by Central London Community Healthcare NHS Trust (CLCH) to meet its Public Sector Equality Duty in the period 1 April 2017 to 31 March 2018. The report includes key workforce data for that period and actions that have taken place between March 2017 and August 2018.
The report meets the first specific duty of the Equality Act 2010, which requires public bodies to publish information annually to demonstrate compliance with the general equality duty.
According to guidance from the Equality and Human Rights Commission, the report must include information on:
• Its employees (for authorities with 150 staff or more) • People affected by its policies and practices (for example, service users).
The above information needs to relate to their protected characteristics.
In keeping with the guidance, this report is divided into 2 parts. Part 1 covers patient information and Part 2 covers information related to the workforce. The information covers:
• Patient feedback analysed by protected characteristics • Access to services analysed by protected characteristics • Engagement activity undertaken to improve patient access and experience • Key improvements made based on patient feedback • Gaps in information • An analysis of the workforce by protected characteristic • Steps taken to improve employee engagement and wellbeing • Plans to improve workforce representation at all levels and satisfaction rates.
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187 In addition to demonstrating legal compliance, this report helps to meet regulatory standards. The Care Quality Commission (CQC) inspection framework introduced in 2016 assesses health care providers for their progress on the WRES under the ‘Well-Led’ domain. CQC rated CLCH ‘Good’ overall and for the Well Led domain in its last inspection report published in February 2018.
3. About CLCH
CLCH provides more than 70 different community healthcare services in London and Hertfordshire. We employ approximately 3,468 staff who care for more than two million patients. We help people stay well, manage their own health and avoid unnecessary trips to, or long stay in, hospital.
We provide care and support for people through every stage of their lives from health visiting for new-born babies through to community nursing and palliative care for people towards the end of their lives.
In 2017/18 we provided a broad range of services in eleven different London boroughs plus specialist sexual health and respiratory services in Hertfordshire.
Our range of services includes: • Adult community nursing including district nursing, community matrons and case management.
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188 • Children and family services including health visiting, school nursing, community nursing, speech and language therapy, blood disorders and occupational therapy. • End of life care supporting people to make decisions and receive the care they need at the end of their life. • Long-term condition management supporting people with complex ongoing health needs caused by disability or chronic illness. • Rehabilitation and therapies including physiotherapy, occupational therapy, foot care, speech and language therapy and osteopathy. • Specialist services including delivering care for people living with diabetes, heart failure, Parkinson’s and lung disease, homeless health services, community dental services, sexual health and contraceptive services and psychological therapies. • Walk-in and urgent care centres providing care for 226,000 people with minor illnesses and injuries and providing a range of health advice and information.
Many of our services are open seven-days-a-week and our community nursing and inpatient rehabilitation and palliative care units offer 24 hour care.
Our vision is to deliver: Great care closer to home. Our mission is: Working together to give children a better start and adults greater independence.
We have four core values, providing a reference point for all our staff on how we should conduct ourselves when working with patients, colleagues and partners.
• Quality: We put quality at the heart of everything we do. • Relationships: We value our relationships with others. • Delivery: We deliver services we are proud of. • Community: We make a positive difference in our communities.
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189 Part 1- Patient Information
We are a high performing trust that puts quality of care at the heart of everything we do. Our most recent CQC inspection took place in September 2017. During the visit, we hosted a team of 28 CQC inspectors and specialist advisors, who assessed four of our core services: Children's; Adults; Inpatient and End of life care. The team visited 17 sites, in six boroughs, where they talked to over 150 staff, carers, patients and service users about their experience of CLCH and shadowed staff on their visits to observe the care that our staff provide. They also reviewed our documentation and patient notes, evaluated our systems and processes and assessed the environment in which we provide care. Following the inspection, we were pleased to receive an overall Good rating as outlined in the image below.
At CLCH, we recognise that equality means treating everyone with equal dignity and respect irrespective of any protected personal characteristics. In doing so we acknowledge that people have different needs, situations and goals. The trust provides a number of different services across ten different London boroughs and Hertfordshire. This means that the population we serve is extremely diverse and it is important to ensure that we understand this in order to engage and listen to patients from all different backgrounds and diverse groups to improve and make changes to the care and services we provide.
An example of the populations within the areas that we work in has been provided below in order to highlight their diversity.
Barnet: For 2018, the population of Barnet is estimated to be 394,400, which is the largest of all the London boroughs. The number of people aged 65 and over is predicted to increase by 33% between 2018 and 2030, compared with a 2% decrease in young people (aged 0- 19) and a 4% increase for working age adults (aged 16-64), over the same period. The Barnet population is projected to become increasingly diverse, with the proportion of Black, Asian and Minority Ethnic (BAME) people in the borough population rising from 39.5% in 2018 to 42.3% in 2030. Women in Barnet have a significantly higher life expectancy than men, with the life expectancy of people living in the most deprived areas of the borough
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190 being on average 7.4 years less for men and 7.8 years less for women than those in the least deprived areas.
Wandsworth: The population of Wandsworth is estimated to be 316,096. While the majority of the Wandsworth population is remarkably young and healthy, there are significant areas of deprivation and our older population is more likely to have poor health and live in deprivation than that of other areas of South West London. There are approximately 2,800 deaths in Wandsworth a year and approximately 1,000 of these are of people under the age of 75. The two most frequent underlying causes of death in the under 75’s are cancer and circulatory disease.
Harrow: Around 243,500 people live in Harrow with just over 50% being female. Compared to London, the population of Harrow has a greater proportion of older people (over 60) and a lower proportion of people in their 20s and 30s. In 2011, 43% of the Harrow population were from an Asian / Asian British background, the percentage from a White ethnic background was almost equal at 42% and a further 8% were from Black / African / Caribbean / Black British ethnic background. Over the next 10 years it is predicted that the local Black, Asian and Minority Ethnic (BAME) population will increase from almost 54% to 68%.
Merton: In 2018, Merton has an estimated resident population of 209,400, which is projected to increase by about 3.9% to 217,500 by 2025. The age profile is predicted to shift over this time, with notable growth in the proportions of older people (65 years and older) and a decline in the 0-4 year old population. Currently 77,740 people are from a Black, Asian, or Minority Ethnic (BAME) group and by 2025 this is predicted to increase to 84,250 people (38% of Merton’s population). There is a gap of 6.2 years in life expectancy for men between the 30% most deprived and 30% least deprived areas in Merton, and the gap is 3.4 years for women.
Kensington and Chelsea: In 2017, the population of the Royal Borough of Kensington and Chelsea was estimated to be 155,700. 39.3% of the population are White British, 4.1% Arab and 3.5% Black African.
Hammersmith and Fulham: In 2017 the population of the London Borough of Hammersmith and Fulham was 183,000. 44.9% of the population are White British, 19.6% Other White, 5.8% Black African and 3.5% White Irish.
Hertfordshire: In 2012, the population of Hertfordshire was 1,129,000. It is projected to increase over the next 25 years to 1,400,700 in 2037. There are 168,000 Hertfordshire residents aged over 65. People born overseas make up 13.4% of our population. 19.2% of Hertfordshire residents identified themselves in ethnic groups other than “White British”, which compares to 11.23% in 2001.
Ealing: The 2017 mid-year population estimate for Ealing was 342,700. There are 169,175 males and 169,274 females living in Ealing. There are 67,042 people over the age of 55 and 76,605 people under the age of 18.
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191 1. Patient Experience
The Trust Quality Strategy, ‘Simply the Best, Every Time’ aims to support the delivery of outstanding care to all of our patients. As part of the strategy, there are six campaigns, each with enabling strategies and key objectives. The first campaign is ‘Positive Patient Experience’ and the key objective and outcomes have been reflected in the revised Trust Public and Patient Engagement Strategy: Ensuring patients are at the very heart of the decision making process (2018 – 2020). This aims to put patients at the heart of the decision making process. It ensures that patient feedback helps drive service improvements and that co-design and working in partnership with our patients to transform services and improve care and experience is embedded into the way that we do things.
There are three key objectives which are:
• We will change staff behaviours and care to improve the experience of our patients. We will do this by continuing to focus on strengthening the methods used to gain patient and public feedback, the core communication channels we use to engage with our patients and the public and improve how feedback is used to inform and influence service delivery and patient care. • We will aim to make sure that our patients are involved in all decisions about their care and the service/s they are using: We will do this by continuing to embed the co- design methodology and putting the patient at the forefront of the decision making process. • We will aim to make sure that we engage with all of our patients, with a specific objective of engaging communities who are less frequently heard: In order to do this, we will ensure that we work in partnership with our patients through working closely with Healthwatch and other key stakeholders, engaging with patient experts on proposed service changes, Shared Governance – Quality Councils and focused engagement and listening events.
We administer both national and in-house surveys to large numbers of patients, such as the Friends and Family test, in order to review the experience of all aspects of a patient’s journey. In 2017/18, the Trust collected between 2500-3500 pieces of feedback from patients using our services every month. Some key headlines included:
• Over 92% of our patients said that their care was explained in an understandable way for the whole of 2017/18. • Over 95% of our patients said that they felt that they were treated with both dignity and respect for the whole of 2017/18. • Over 85% of our patients reported that they were involved in planning their care throughout the whole of 2017/18. • Over 90% of our patients rated their overall experience as good or excellent for the whole year.
As part of the 2018-2020 strategy we continue to collect feedback in a variety of different ways, these include the use of the following initiatives:
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192 Patient Stories Patient stories are a valuable way of listening to our patient’s feedback about their experience and for us to learn and continuously improve the services we provide. The Patient Experience Team delivers the patient story training to all staff and helps support teams and the division to set annual targets of numbers of stories to collect.
These stories are then thematically analysed and the findings/actions are shared with staff in order to enable them to identify areas for improvement and share learning. Patient stories are also shared by either the patient themselves or the service lead at all key trust forums, from the Patient Experience Co-ordinating Committee to the Trust Board.
An example of positive change that has come from the analysis of a number of District Nursing specific patient stories is the implementation of service level leaflets. These leaflets aim to ensure that each of our patients is aware of how to contact their District Nursing team. This followed feedback that not all of our patients knew how to contact their nursing team and often struggled to find out when they were due to be visited.
15 Steps Challenge The 15 Steps Challenge is a tool developed by the NHS Institute for Innovation and Improvement following a mother’s visit to an acute setting who stated: “I can tell what kind of care my daughter is going to get within 15 steps of walking on to a ward.” Working together staff, including Non-Executive Directors, patient representatives and carers, ‘walk around’ a site providing structured feedback on how welcoming, safe, caring and well organised they experienced the services. These visits offer staff a way of better understanding a patient, relative or carer’s first impressions of our services. The Patient Experience Team support teams to respond to suggested areas for improvement and the implementation of an action plan to address these.
Following the analysis of 7 completed fifteen step challenges and 6 follow up visits completed revisiting services from the preceding year, much of the feedback centred on the welcome that each of the teams received at a number of the visited sites. As a result, externally facilitated ‘front of house’ training sessions were implemented for all reception staff to attend. The sessions were designed to ensure that the welcome and first impression that our patients receive each time they enter a clinic, walk-in centre or ward is always exceptional.
Shared Governance Shared governance is a dynamic staff-leader partnership that promotes collaboration, shared decision making and accountability for improving quality of care, safety, and enhancing work life. The Trust has developed a model of shared governance to support continued quality improvement and to support the implementation of the Trust Quality Strategy. To date we have successfully implemented 15 Shared Governance Quality Councils across the Trust.
All Quality Councils are chaired by a Band 6 member of staff and nine of the councils have one or two patient representatives as active council members. Each quality council has been asked to focus on one project aligned with one of the quality campaigns in the Quality
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193 Strategy with the aim of making an improvement. An example of this is where one quality council, focusing on the positive patient experience campaign, explored why patients were not attending their appointments. Having spoken to patients, they established that they were unable to find the clinic to attend. As a result, the council have added a map to the existing leaflet providing clear directions for patients.
Always Events Always Events are an Institute for Healthcare Improvement (IHI) initiative. They are aspects of the patient experience that are so important to patients, their relatives and carers, that health care providers must aim to perform them consistently for every individual, every time they have contact with a healthcare service. The Always Events methodology requires genuine partnerships between patients, service users, care partners, and clinicians. This partnership is the foundation for co-designing and implementing reliable care processes that hold promise for transforming care experiences.
The Trust has successfully implemented its first Always Event across all community nursing teams focusing on patients’ involvement in care, with the aim being:
“We will always support patients, relatives and carers to be involved in the planning and delivery of their care”.
As a result of listening and working with patients and staff, a new location specific service leaflet has been developed to provide consistent and clear information about the service to patients. A script was produced for each member of the Single Point of Contact team and the nursing staff to make sure that the initial contact with the patient was concise, clear and ensured that the patient felt involved in the care they would be receiving. This has been supported with a training video developed and including one of our patient representatives and community staff. As a result of these actions, there has been a significant improvement to the proportion of patients that feel that they have been involved in the decision making about their care across the community nursing teams.
The Trust is one of only three in the country who have successfully implemented Always Events and are committed to the continued implementation of these in the future.
Following the success of the Trust’s first Always Event there has now been a plan developed to roll out our next Always Event across the Learning Disability services. Following the initial engagement with staff and patients it has been agreed that the event will focus on the transition between children and adult services and will look to ensure our patients are fully involved in their care planning throughout this transition.
2. Equality and Diversity Analysis from patient feedback
In order to understand if our patient feedback is representative of the populations we serve, we ask our patients a number of equality and diversity questions as part of the Friends and Family test (FFT) survey. These include:
• Age.
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194 • Ethnicity. • Sex (Gender). • Disability. • Sexual Orientation.
The data has been broken down into the four divisions within which we work which are aligned to specific boroughs (with the exception of the Children’s division who work across the Trust).
• South division: Merton, Wandsworth, Richmond. • Inner division: Westminster, Kensington and Chelsea, Hammersmith and Fulham, Harrow, Hounslow. • North division: Barnet, Brent, Hertfordshire (Walk-in Centres across trust).
In addition, to establishing whether the feedback is representative of the populations we serve, the graphs outline how likely or unlikely each group would be to recommend the Trust to family or friends.
Protected Characteristic: Age
In accordance with the Equality Act 2010 in relation to the protected characteristic of age:
• A reference to a person who has a particular protected characteristic is a reference to a person of a particular age group. • A reference to persons who share a protected characteristic is a reference to persons of the same age group.
A reference to an age group is a reference to a group of persons defined by reference to age, whether by reference to a particular age or to a range of ages.
Of the 9788 responses that have been received, 8317 were from people over the age of 55 and 1246 were from those over the age of 85, equating to 85% of the patients who responded to the question being over the age of 55. The number of people over the age of 65 is increasing in the boroughs that we work within. Therefore, this would suggest that the responses received are representative of our population in relation to age.
Graph 1: Children’s Health and Development FFT responses by age range. 300 250 Extremely Likely 200 Likely 150 Neither/Nor 100 Unlikely 50 Exremely Unlikely 0 N/A 0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Graph 2: Inner division FFT responses by age group
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195 600
500 Extremely Likely 400 Likely
300 Neither/Nor Unlikely 200 Exremely Unlikely 100 N/A 0 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Graph 3: North division FFT responses by age Group 1000 Extremely Likely 800 Likely 600 Neither/Nor 400 Unlikely 200 Exremely Unlikely 0 N/A 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Graph 4: South division FFT responses by age Group 500 Extremely Likely 400 Likely 300 Neither/Nor 200 Unlikely 100 Exremely Unlikely 0 N/A 0-15 16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Protected Characteristic: Race
In accordance with the Equality Act 2010 the definition of race includes: • Colour. • Nationality. • Ethnic or national origins.
In relation to the protected characteristic of race: • A reference to a person who has a particular protected characteristic is a reference to a person of a particular racial group. • A reference to persons who share a protected characteristic is a reference to persons of the same racial group.
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196 • A racial group is a group of persons defined by reference to race; and a reference to a person's racial group is a reference to a racial group into which the person falls. • The fact that a racial group comprises two or more distinct racial groups does not prevent it from constituting a particular racial group.
Of the 9305 responses that have been received across the Trust, 3611 patients have reported to be either White or White other, and 3701 responded with ethnicity unknown (equating to 40% of all responses). As a result of the large number of unknown responses, it is difficult to ascertain if the feedback received is representative of the populations in which we work. Therefore, in 2018/19, we will explore how we can reduce the number of unknown responses we receive in conjunction with focused engagement events with BAME patient groups in order to listen to their experience of care.
Graph 5: Children’s division FFT responses by race 200 180 160 140 120 100 Extremely Likely 80 60 Likely 40 20 Neither/Nor 0 White - British - White African Any other Asian… otherAny Black… Any other ethnic group Any other mixed… Any other White… Irish - White Bangladeshi Caribbean Chinese Indian StatedNot Pakistani Unknown White and Asian African Black and White Black… and White Unlikely Exremely Unlikely N/A
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197 Graph 6: Inner division FFT responses by Race 1000 900 800 700 600 500 Extremely Likely 400 300 Likely 200 Neither/Nor 100 0 Unlikely African Any other Asian… otherAny Black… Any other ethnic group Any other mixed… Any other White… Bangladeshi Caribbean Chinese Indian StatedNot Pakistani Unknown British - White Irish - White White and Asian African Black and White Black… and White Exremely Unlikely N/A
Graph 7: North division FFT responses by race 1200
1000
800
600 Extremely Likely 400 Likely 200 Neither/Nor 0 African Any other Asian background otherAny Black background Any other ethnic group Any other mixed background Any other white background Bangladeshi Caribbean Chinese Indian StatedNot Pakistani Unknown British - White Irish - White White and Asian African Black and White White Black and Caribbean Unlikely Exremely Unlikely N/A
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198 Graph 8: South division FFT responses by race 600
500
400
300 Extremely Likely 200 Likely 100 Neither/Nor 0 Unlikely African Any other Asian background otherAny Black background Any other ethnic group Any other mixed background Any other White background Bangladeshi Caribbean Chinese Indian StatedNot Pakistani Unknown British - White Irish - White White and Asian African Black and White White Black and Caribbean Exremely Unlikely N/A
Protected Characteristic: Sex
In relation to the protected characteristic of sex as stated in the Equality Act 2010: • A reference to a person who has a particular protected characteristic is a reference to a man or to a woman. • A reference to persons who share a protected characteristic is a reference to persons of the same sex.
Of the 10156 responses that have been received across all divisions regarding our patient’s sex (gender), 6325 responses have been completed by females, which would suggest that we see more females in the community than males. Or indeed, it simply means if you are a female you are more likely to complete our patient feedback surveys, 62% of responses were completed by females.
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199 Graph 9: Children’s division FFT responses by sex 800 700 600 500 Female 400 300 Male 200 Not Specified 100 0 Extremely Likely Neither/Nor Unlikely Exremely N/A Likely Unlikely
Graph 10: Inner division FFT responses by sex 1200 1000 800 600 Female 400 Male 200 0 Extremely Likely Neither/Nor Unlikely Exremely N/A Likely Unlikely
Graph 11: North division FFT responses by sex 2000
1500
Female 1000 Male 500 Not Specified
0 Extremely Likely Neither/Nor Unlikely Exremely N/A Likely Unlikely
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200 Graph 12: South division FFT responses by sex 1400 1200 1000 800 600 Female 400 Male 200 0 Extremely Likely Neither/Nor Unlikely Exremely N/A Likely Unlikely
Protected Characteristic: Disability
In accordance to the Equality Act 2010 a person has a disability if: • The person has a physical or mental impairment. • The impairment has a substantial and long-term adverse effect on the person’s ability to carry out normal day-to-day activities.
In relation to the protected characteristic of disability: • A reference to a person who has a particular protected characteristic is a reference to a person who has a particular disability. • A reference to persons who share a protected characteristic is a reference to persons who have the same disability.
Of the 3377 responses that have been received across all divisions regarding whether or not our patients identify as having a disability, 2003 responses have been completed by patients that don’t have a disability, or that they would rather not say, equating to 59% of all responses received. Where people have stated that they do have a disability, it is unclear what this is. However, as part of the responsibility for all NHS Trust is to offer reasonable adjustments to help people with disabilities or sensory loss, we will continue to ensure that we provide accessible information and monitor access to our services through 15 step challenge visits and annual PLACE assessments.
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201 Graph 13: Children’s Health and Development FFT responses given by people who have identified themselves as having a disability 300 Memory or ability to concentrate, 250 learn or understand (Learning 200 Disability) 150 No 100 50 No Disability 0
Not Stated
Graph 14: Inner division FFT responses given by people who have identified themselves as having a disability 250
200 Hearing 150 No 100 Not Stated Prefer not to say 50 Yes 0 Extremely Likely Neither/Nor Unlikely Exremely N/A Likely Unlikely
Graph 15: North division FFT responses given by people who have identified themselves as having a disability 700
600
500
400 No Prefer not to say 300 Yes 200 Yes, limited a little 100
0 Extremely Likely Neither/Nor Unlikely Exremely N/A Likely Unlikely
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202 Graph 16: South division FFT responses given by people who have identified themselves as having a disability 450 400 350 300 250 Manual Dexterity No 200 Yes 150 Yes, limited a little 100 50 0 Extremely Likely Neither/Nor Unlikely Exremely N/A Likely Unlikely
Protected Characteristic: Sexual Orientation In accordance to the Equality Act 2010 sexual orientation means a person's sexual orientation towards: • Persons of the same sex. • Persons of the opposite sex. • Persons of either sex.
In relation to the protected characteristic of sexual orientation: • A reference to a person who has a particular protected characteristic is a reference to a person who is of a particular sexual orientation • A reference to persons who share a protected characteristic is a reference to persons who are of the same sexual orientation
Of the 2851 responses that have been received across all divisions regarding the sexual orientation of our patients, 1990 have ticked the ‘rather not say’ box, equating to 70% of our patients who perhaps did not feel comfortable telling the organisation of their sexual orientation.
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203 Graph 17: Children’s FFT responses by sexual orientation 100
80
60 Heterosexual 40 Not Stated 20
0 Extremely Likely Neither/Nor Unlikely Exremely N/A Likely Unlikely
Graph 17: Inner division FFT responses by sexual orientation 300 250 Bi-sexual 200 150 Gay/Lesbian 100 Heterosexual 50 0 Not Stated
Person asked and does not know or is not sure
Graph 19: South division FFT responses by sexual orientation 450 400 350 300 Bi-sexual 250 200 Gay/Lesbian 150 Heterosexual 100 Not Stated 50 0 Extremely Likely Neither/Nor Unlikely Exremely N/A Likely Unlikely
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204 Graph 18: North division FFT responses by sexual orientation 700
600
500
400 Bi-sexual Gay/Lesbian 300 Heterosexual 200 Not Stated 100
0 Extremely Likely Neither/Nor Unlikely Exremely N/A Likely Unlikely
Complaints
When written complaints are received, the individual’s equality and diversity information is not usually provided and an attempt to capture this is made at a later stage by way of a phone call if a contact number is available, or a letter. In addition, an equality monitoring form is sent with all acknowledgement letters. We gather this information and pass it on to the Diversity and Inclusion Lead to help assess whether we are providing equal access and treatment for different groups of people. The data requested is as follows: Ethnicity; Age; Sexual Orientation; Religion or Beliefs. In addition, there will also be retrospective aftercare calls made to the complainants by the complaints team. At this point the equality data will also be requested and captured.
A total of 98 formal complaints were received by the Trust during 2017/2018 and none of these were accompanied by a completed equality monitoring form despite follow up requests from the Complaints team when sending the complaint acknowledgement letter. As a result of this, there is very limited information to report on. Therefore, in 2018/19, the complaints team have started following up each formal complaint response letter with a telephone call to the complainant to establish whether they are satisfied by the outcome of the complaint investigation and response, and to ask the equality monitoring questions. To date, although these calls have been undertaken every quarter, patients have declined to give this information.
The Trust work closely with POWHER advocacy service, there have been two complaints received into the Trust through POWHER one of which was resolved through a local resolution meeting, the second was resolved through a formal complaint response which was provided to the complainant in an easy read version. In 2018/19, we will continue to work with POWHER advocacy service ensuring we are making reasonable adjustments so that patients with a disability have easy access to our Complaints service and receive a response that meets their needs.
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205 3. Engaging with our communities
The Head of Patient Experience has undertaken an analysis of patient engagement activity across the trust against each of the 9 protected characteristics (Age, Disability, sex, Transgender, Race, Sexual Orientation, Pregnancy and Maternity, Civil Partnership/Marriage, Religion and belief). The analysis showed that there are some excellent examples of engagement with patients for certain equity groups relating to age, disability, sex and race. These include:
• The trust is now delivering phone groups to engage elderly housebound patients. • Our patients with a learning disability also have their own feedback form to ensure their feedback is captured and helps inform service improvements. • The trust collects dynamic patient stories (film or picture stories) from our patients with a learning disability enabling their voice to be heard. • There have been a number of listening events across Hammersmith and Fulham and Richmond to help the trust understand our young service user’s experiences of the school nursing service. • The trust has an excellent sexual health service in South West London which runs a Sexual Health Service Users Forum including representatives from the LGBT communities. • Sexual Health Services in Hertfordshire run gay specific clinics and the Clinic U for transgender people. • A number of events were held across the Trust to listen to our patients and help inform our revised Patient and Public Engagement strategy.
However, the results highlighted areas where the trust needs to improve and this is mainly around religion and belief. Therefore, in 2018/19, the Patient Experience team will be working with patients and carers to understand what is important to them in relation to their belief and religion and whether there are any specific initiatives that could be undertaken.
We continue to work with a number of “expert patients” through our Learning Disability Forum, Dementia Steering group, End of Life Care group and Patient Experience Coordinating Committee. We also invite “expert patients” to sit on service reviews and projects to redesign services, through our Service improvement teams.
4. Progress with 2016-2018 Equality objectives
The Trust set objectives in order to meet its obligations under the Equality Act and a brief account of the progress made with the two patient specific objectives is provided as follows:
• We will improve how we communicate with diverse patients using alternative and accessible formats
The Accessible Information Standard means all NHS Trust's must offer reasonable adjustments to help people with disabilities or sensory loss to fully understand the information we give them. Accessible Information requires us as an NHS organisation to record the information and communication support needs of disabled patients, service users
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206 and carers, and take action to ensure that those needs are met. It applies to both communications during an appointment and any information we give people to take away.
The Trust implemented the Accessible Information Standard in 2016 and in order to support staff, an Accessible Information Policy was developed providing guidance on best practice around meeting the information and communication needs of people with a disability. In addition, posters were developed along with related guidance on identifying, recording and sharing information on people’s communication support needs. These are supplemented with guidance on types of accessible information that people many need. All documents are accessible to staff through the Trust’s intranet. To capture patient’s needs, an electronic template has also been developed in the electronic patient records system.
One of the Shared Governance Quality Councils has chosen a project looking at monitoring staff’s adherence with the Accessible Information Standards Policy across the Trust. The project has conducted an initial baseline survey and an audit of the electronic systems template completion in the patient records across three District Nursing teams in Westminster. This will enable the council to understand if there are any gaps and understand what actions need to be taken to improve adherence with the Accessible Information Standard.
The Trust has worked closely with both patient representatives and Mencap to help develop and design an easy read version of our new Trust Learning Disability Strategy. We have also worked alongside a number of patient representatives to help us design a more patient friendly version of our new Trust End of Life Care Strategy.
The North Division have a Quality Stakeholder Reference Group made up of patient representatives which now specialises in the design and review of patient leaflets, posters and other patient information. This group helps the trust to ensure that all of our leaflets, posters and information are now patient friendly in terms of design and language.
• We want to provide reasonable adjustments for patients with Dementia and Learning Disabilities who use our mainstream health services
A number of projects have been undertaken throughout 2017/18 and an example of two has been outlined below:
Learning Disability Buddying project: The objectives of this project were: to provide support for individuals with Learning Disabilities whilst attending appointments within our services; to ensure that our service users feel confident when attending appointments; and to give opportunities to those with Learning Disabilities to gain experience within our Trust in a supported working environment.
The Patient Experience team have worked with service users and staff from the Learning Disability services and have developed picture maps and easy read tools to guide service users to appointments. In addition, we have developed a buddy role for volunteers who then meet service users and accompany them to their appointment. As part of this, the Volunteers Manager has worked with Mencap to enable those with a Learning Disability to join the buddy programme and become volunteers. The feedback received has been mainly positive
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207 throughout as volunteers are well received with service users. Some advice from service users that we are working on is to make picture maps (Parkview) more concise as well as placing our volunteers in a yellow volunteering t-shirt to stand out.
Dementia Engagement Project: The Dementia Engagement project 'Engaging people with Dementia and their carers as partners in training and education' used an experience based co-design methodology to gather information that was meaningful to people with Dementia. A series of open action group meetings took place in order to explore the critical issues as identified by people with Dementia and their carers. From the engagement work undertaken throughout the project, a film has now been developed by our patients. This is being used in training for front line nursing staff to ensure they are always considering what is important for our patients with Dementia.
Furthermore, the Dementia Engagement lead has worked closely with people with Dementia and their carers to design the ‘This is me’ leaflet. This leaflet was initially produced by the Alzheimer’s society but has been adapted for CLCH and is a simple form for anyone receiving professional care that is living with Dementia or is experiencing delirium or other communication difficulties. It is for people living in any setting - at home, in hospital, respite care or a care home and includes space to record information about the person along with detailed guidance to help with its completion. It can help provide background information about the person including likes, dislikes, interests, preferences and routines, enabling staff to tailor care specifically to the person's needs.
Identifying and meeting the need for reasonable adjustments: The GP referral form and District Nurse referral form have been revised to enable the identification of a patients need for reasonable adjustments when they attend one of our services. The Dental, Podiatry and other specialist services have scheduled longer appointments times in order to support patients with a Learning Disability and their families ensuring that any additional support can be identified and provided. In addition, work has been undertaken with the SPA/SPOR staff to enable awareness of making reasonable adjustments including longer appointment times.
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208 Part 2 - Workforce Information
Introduction
The Trust workforce during the financial year ending 31 March 2018 was 3468. Based on information held on the Electronic Staff Record (ESR) systems the breakdown of staff by protected characteristics is:
• By Gender: 86.6% female, 13.4% male. • By Ethnicity: 45.1% White, 41.9% Black, Asian or Minority Ethnic (BAME) and 13% of the workforce not having disclosed their ethnicity. • By Disability: 65% declared ‘No’ disability, 2.6% declared ‘Yes’ to having a disability and 32.5% either chose not to answer at all (‘undefined’) or answered that they do not wish to declare (‘undisclosed). • By Religious Belief: 43.5% Christian; 10.1% of another major world religion (Buddhism, Hinduism, Islam, Jainism, Judaism, and Sikhism), 4.6% of another faith, 6.2% atheists and 35.6% chose either undefined or undisclosed. • By Sexual Orientation: 62.2% Heterosexual, 2.1% Lesbian, Gay or Bisexual and 35.7% chose either undefined or undisclosed. • By Age: 94.7% were between the ages of 25 and 64. This is evenly spread across the age groups 25 to 34 (22.3%); 35 to 44 (24.4%); 45 to 54 (27.8%) and 55 to 64 (20.2%). • By Maternity Leave: The average number of women on maternity leave in any given month during 2017/18 was 89. • Marital status: 42.1% were married, 39.3% were single, 9.1% null, 6.1% divorced or legally separated, 1.1% widowed, 0.9% were in a civil partnership, and the marital status of 1.4% was unknown. • Transgender / gender neutral identity: We record gender on ESR as male or female. We use the classification unknown where no information has been provided. We do not record information about staff who have transitioned from one gender to another. When they declare they have changed their gender, it is changed on ESR based on their guidance. We do not record on ESR the fact that a change has been requested and made. Therefore we cannot report any information on how many transgender staff we have. For those staff who wish to declare a gender neutral identity, they can use the title Mx, which is recorded on ESR at their choice. In the financial year 2017/18, no staff member used the title Mx. For this reason there is no analyses for these characteristics but there is reference to actions and initiatives we have taken in relation to transgender staff. • By hours worked: 65.6% full-time; 34.4% part-time. Anyone working less than 37.5 hours is classified as part-time. 94.6% of part-time workers are female; 5.4% male. Of Full-time workers, 82.5% are female, 17.5% are male.
Of the total workforce, 2746 (79.2%) are clinicians and 722 (20.8%) are non-clinicians. Of the Clinicians, 59 are medical or dental staff, which is 1.7% of the total workforce.
The biggest groups of clinicians are Qualified Nurses, of whom there are 1540 (44.4%). Of the others, Clinical Support (529) comprise 15.3% of our workforce and Allied Health professionals (439) 12.7% of the same.
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209 Contractual arrangements
Staff are employed under three types of contract: Agenda for Change (98%); Medical and Dental (1.7%) or Very Senior Manager (VSM). The 5 Executive Board Directors are on VSM contracts.
Analysis of pay bands / grades by protected characteristics
The following charts show the percentage of staff within pay bands analysed by gender, ethnicity, religious belief, sexual orientation and disability, based on data we currently hold on these protected characteristics. Where the numbers who have disclosed a particular protected characteristic are small or the number of not disclosed / not defined is high or incomplete – that is highlighted as the data should be treated with caution or not reported.
The chart below shows that the proportion of women within an Agenda for Change pay grade decreases with seniority (i.e. as the staff moves from Bands 1 through to 9). This is not an unusual trend in the NHS. As explained in the later sections on recruitment and selection and perceptions of equality of opportunity and discrimination, women are 1.42 times more likely to be appointed than a man. Based on our 2017 national staff survey results, 83% of women versus 81% of men believed there was equality of opportunity in career progression and promotion. Also from the national staff survey, a lower percentage of women than men reported they had experienced discrimination (13% compared to 16%). There are multiple factors which may be contributing to the lower percentage of women in more senior grades. As part of refreshing its equality strategy, the Trust will look at the barriers women face in seeking or being appointed to more senior roles.
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210 The chart below shows the percentage of White and BAME staff by pay grade. The percentage of BAME staff in all grades across the workforce is 41.9%. As the chart shows, the percentage of BAME staff within the grade decreases significantly with seniority, most noticeably from Band 7. Our Workforce Race Equality Standard report for 2018 shows that White staff are 1.73 times more likely to be appointed than BAME staff and a smaller percentage (69%) of BAME than White staff (90%) believe there is equality of opportunity in career progression and promotion. Also, based on the responses in the 2017 national staff survey, 12% of BAME staff reported experiencing discrimination at work from a manager/team leader or work colleague in last 12 months, compared with 6% of White respondents.
The Trust is addressing these issues through its 2018 Workforce Race Equality Standard (WRES) action plan, details of which can be found on our website through the link given, and which are summarised in later sections of this report. See https://www.clch.nhs.uk/application/files/9315/3812/8497/Workforce_Race_Equality_Sta ndard_Report_2018.pdf for more information.
The chart below shows the percentage of staff within a pay grade analysed by religious belief. There does not appear to be any disproportionality, but the high percentage of staff who have not disclosed or defined there religious belief, suggests the data should be treated with caution.
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211
The chart below shows the percentage of staff within pay grade by sexual orientation. There does not appear to be any disproportionality, however the numbers of declared LGBT staff is small and the percentage of staff that have not disclosed or defined their sexual orientation is high.
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212 The chart below shows the percentage of staff within a pay grade that has disclosed they do or do not have a disability. The numbers are small and the levels of non-disclosure / not defined are high and should be treated with caution.
Analysis of employment practices by protected characteristics
The following section provides a workforce analysis by protected characteristics under the following headings:
• Recruitment and selection; based on shortlisting and appointments in the financial year 2017/18 • Employee Relations: based on HR cases relating to grievances, disciplinary cases – including suspensions, complaints of bullying or harassment, and formal management of sickness absence • Career progression and treatment at work: based on staff perceptions of equality of opportunity and their experience of discrimination, bullying or harassment as reported in the 2017 national staff survey results for CLCH • Leavers – staff who leave CLCH’s employment
Recruitment and selection
In analysing our recruitment and selection data by protected characteristics, we have adopted the methodology of the Workforce Race Equality Standard (WRES). In the Table below, we have outlined the relative likelihood of appointment from shortlisting for each protected group for the financial year ending 31 March 2018. The comparison we have made
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213 for each group is against the dominant staff population of that group (e.g. comparing the relative likelihood of White staff being appointed as compared with BAME staff).
In 2017/18, 2,395 staff were shortlisted and 483 were appointed. The table below highlights the following facts in terms of equality and diversity.
Protected Relative likelihood of appointment Percentage of characteristic those appointed who did not disclose or define Ethnicity White candidates were 1.73 times more likely to 15.8% be appointed than BAME candidates. Gender Women were 1.42 times more likely to be Nil appointed than men. Disability Candidates without disabilities were 1.46 times 9.1% more likely to be appointed than people with disabilities Sexual orientation Heterosexual candidates were 0.96 times as likely 16.6%% to be appointed when compared with LGBT candidates. Religion Christians were 0.83 times as likely to be 20.7%% appointed as people of other faiths. Age See note below Nil Pregnancy and No valid analysis possible Nil maternity Marriage and Civil No valid analysis possible 1.4% Partnership Note: this information needs to be treated with caution where there is a high proportion of undisclosed information
Age:
For this protected characteristic we are not using the above methodology as there is no dominant age group to measure against. The data on this characteristic (see table below) shows that there is no significant statistical difference between shortlisting and appointment based on age criteria. The table also shows CLCH’s current workforce is multi-generational. With 49% of staff appointed being below the age of 35, the Trust is reducing the risk of creating an older age profile and a significant proportion of staff retiring at the same time.
% 16- % 25- % 35- % 45- % 55- % not Age 24 34 44 54 64 65+ stated total 10.90 36.90 24.90 20.00 0.30 100.10 Shortlisted 6.90% 0.20% % % % % % % 10.10 38.80 24.80 19.50 1.00 100.00 Appointed 5.80% 0.00% % % % % % % - - - - 0.70 Difference 1.90% -0.20% 0.80% 0.10% 0.50% 1.10% %
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214 Current workforce 100.00 0.00% profile 1.8% 22.3% 24.4% 27.8% 20.2% 3.5% %
Employee Relations
The Table below collates information on suspensions, grievances, sickness absence, bullying and harassment and formal disciplinary proceedings, and analyses it by the protected characteristics of the employee raising the complaint or against whom proceedings are being brought.
Protected Formal Suspensions Formal Disciplinary Bullying and characteristic Grievances sickness proceedings Harassment reviews 17 23 67 52 6 All staff Too small a Ethnicity White: 5 White: 7 White: 28 White: 17 number – BAME: 10 BAME: 14 BAME: 35 BAME: 29 potential risk of Undefined: 2 Undefined: 2 Undefined: 4 Undefined: 6 breaching confidentiality As above Gender Female: 13 Female: 19 Female: 58 Female: 46 Male: 4 Male:4 Male: 9 Male:6
As above Disability Not Disabled: 9 Not Disabled: 17 Not Not Disabled:42 Disabled: 4 Disabled: 0 Disabled:46 Disabled: 0 Undefined: 4 Undefined: 6 Disabled: 3 Undefined:10 Undefined: 18 Heterosexual: Heterosexual: 18 Heterosexual: Heterosexual: As above Sexual 10 Gay/Lesbian: 1 51 38 Orientation Gay/Lesbian:0 Bisexual: 0 Gay/Lesbian:1 Gay/Lesbian:0 Bisexual: 0 Undefined: 4 Bisexual:0 Bisexual:0 Undefined:6 Do not wish to Undefined:11 Undefined:8 Do not wish to disclose: 0 Do not wish to Do not wish to disclose:1 disclose:4 disclose:6
As above Religion Age As above Pregnant Too small a As above number – potential risk of breaching confidentiality Marriage and Too small a civil Partnership number – risk of breach of confidentiality
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215
The table below analyses the findings on employee relations by protected characteristics.
Protected Findings characteristic Age The age profile information is too small on a granular level to provide a robust analysis and maintain anonymity of the individual involved so has not been included in this section.
Ethnicity BAME staff were found to be overrepresented across the range of employee relations areas.
Gender Of the total grievances raised in 2017/18, 23.5% were male and 76.5% female.
Disability 23% of disabled staff had raised a grievance in the past year. This is disproportionately high given the low level representation. It will be further analysed and addressed under the Workforce Disability Equality Standard (WDES) action plan.
Faith The religious affiliation information is too small on a granular level to provide a robust analysis and maintain anonymity of the individual involved so have not be published in these sections.
Sexual Orientation In terms of the employee relations data, in all the areas, there is no statistically significant indicators of disproportionate use of ER procedures.
Pregnancy and As above. Maternity Marriage and Civil As above. Partnership
Note: Owing to the high level of non-disclosure on disability and sexual orientation, the information provided needs to be treated with caution. The employee relations data on age and religion is incomplete and not being published in full due to the small numbers.
Experience and perceptions of staff working in CLCH: Career progression and treatment at work
This section provides information on staff perception of career progression, discrimination and bullying and harassment. The data is drawn from the NHS National survey which was
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216 conducted between October and December 2017. The survey takes place annually and includes all eligible staff (not just a sample), who are able to give their feedback anonymously. Approximately 40% (1100) of CLCH’s staff completed the survey. Their responses are provided in the tables below:
Overall staff survey responses on career progression, discrimination and bullying and harassment Question CLCH 2017 CLCH Community Results 2016 Trust Results Average 2017 Percentage of staff believing the Trust acts fairly with regard to career progression/promotion regardless of ethnic 82% 82% 89% background, gender, disability, sexual orientation age of religious affiliation Percentage of staff experiencing discrimination at work from manger/team leader or work 13% 13% 9% colleague in last 12 months Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the 26% 25% 23% public in the last 12 months
Percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 21% 23% 19% months Percentage of staff/colleagues reporting most recent experience of harassment, bullying or 54% 51% 53% abuse. (higher the score, the better)
The data shows:
• 82% of staff believes the Trust acts fairly with regards to career progression/promotion and 13% feel they have been discriminated by a manager, team leader or work colleague in the past year, which was the same for 2016, but was worse than the Community Trust average (89% and 9% respectively).
• 26% of staff in the Trust stated experiencing harassment, bullying or abuse from patients, relatives or the public in the last 12 months. This is higher (worse) than the national median score for community trusts (23%) and the 2016 score of 25%.
• 21% of staff in the Trust stated experiencing harassment, bullying or abuse from staff in the last 12 months. This is higher (worse) than the national median score for community trusts (19%), but lower than the 2016 score of 23%.
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217 • 54% of staff reported their most recent experiences of harassment, bullying or abuse in 2017. For this finding, the higher the score the better as reporting of this unacceptable behaviour is encouraged. The 2017 score is therefore better than that for 2016 (51%) and higher (better) than the national community trust average of 53%.
The Tables below highlight the disaggregated data for the questions by protected characteristics:
2017 Survey responses on career progression and discrimination disaggregated by– gender, disability and ethnicity
time time
-
Question - CLCH 2017 Women Men Not Disabled Disabled White BAME Full Part Percentage of staff believing the Trust provides equal opportunities for career progression/promotion 82% 83% 81% 82% 81% 90% 69% 81% 87% regardless of ethnic background, gender, disability, sexual orientation age of religious affiliation Percentage of staff experiencing discrimination at work from manger/team 13% 13% 16% 12% 23% 6% 12% 14% 9% leader or work colleague in last 12 months
2017 Staff survey responses on career progression and discrimination disaggregated by protected characteristics – age Question CLCH 16-30 31-40 41-50 51+ results years years 2017 Percentage of staff believing the Trust acts fairly with regard to career progression/promotion regardless of 82% 88% 81% 82% 82% ethnic background, gender, disability, sexual orientation age of religious affiliation Percentage of staff experiencing discrimination at work from 13% 13% 15% 16% 10% manger/team leader or work colleague in last 12 months
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218
The key points from the tables above show:
• A significantly smaller percentage (69%) of BAME staff, compared with 90% of White staff, believes the Trusts provides equal opportunities for career progression. • Twice the percentage of BAME staff (12%) compared with 6% of White staff responded that they had experienced discrimination at work from colleagues in the last 12 months. • Nearly twice the percentage of Disabled staff (23%) compared with 12% of non- disabled staff responded that they had experienced discrimination at work from colleagues in the last 12 months.
The next set of tables disaggregates the staff survey findings for bullying, harassment and abuse by protected characteristics.
Staff survey responses on bullying, harassment and abuse disaggregated by gender, disability, ethnicity, full or part-time
Question Women Men Not Disabled White BAME F/T P/T Disabled Percentage of staff experiencing harassment, bullying or 26% 26% 26% 30% 28% 24% 27% 26% abuse from patients, relatives or the public in the last 12 months Percentage of staff experiencing harassment, bullying or 21% 18% 20% 28% 20% 22% 23% 18% abuse from staff in the last 12 months Percentage of staff/colleagues reporting most recent 55% 57% 56% 48% 56% 53% 57% 40% experience of harassment, bullying or abuse.
2017 Staff survey responses on bullying, harassment and abuse disaggregated by age
Question 16-30 31-40 41-50 51+ years years Percentage of staff experiencing harassment, bullying or abuse from 30% 28% 29% 23% patients, relatives or the public in the
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219 Question 16-30 31-40 41-50 51+ years years last 12 months. Percentage of staff experiencing harassment, bullying or abuse from 13% 25% 24% 19% staff in the last 12 months. Percentage of staff/colleagues reporting most recent experience of 63% 54% 55% 53% harassment, bullying or abuse.
When disaggregated by protected characteristics, the staff survey results on bullying and harassment highlights the following with regards to the public:
• 26% of men and women experienced harassment by the public – demonstrating little significant difference in experience by gender. • 30% of disabled staff stated experiencing harassment by the public, compared with 26% of staff without disabilities. • 28% of White staff stated experiencing harassment from the public, compared with 24% of BAME staff. • 30% of staff in the 16-30 years age group stated experiencing harassment from the public, followed by 29% in the 41-50 age group and 28% in the 31-40 age group. • Full-time staff experienced more harassment from the public than part-time.
With regards bullying harassment and abuse by staff against staff, the key points are:
• 21% of women stated experiencing harassment, bullying or abuse from staff, compared with 18% of male staff. • 28% of disabled staff stated experiencing harassment from staff, compared with 20% of non-disabled staff. • 22% of BAME staff stated experiencing harassment, bullying or abuse from staff, compared with 20% of White staff. • 25% in the 31-40 year age group stated experiencing harassment from staff, followed by 24% in the 41-50 age group and 19% in the 51+ group. • Full-time staff experienced more harassment from staff than part-time.
In terms of reporting most recent experience of harassment, bullying or abuse:
• 57% of men reported abuse, compared with 55% of women. • 56% of staff without disabilities reported abuse, compared with 48% of disabled staff. • 56% of White staff reported abuse compared with 53% of BAME staff. • The majority of staff reporting abuse were in the 16-30 age group (63%), followed by 55% in the 41-50 age group, 54% in the 31-40 age group and 53% in the 51+ age band. • More full-time staff reported harassment than part-time.
To address the perceptions stated above, the Trust has taken the following actions since March 2018:
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220 • A Workforce Race Equality Standard (WRES) Taskforce has been set up to address career progression, discrimination, bullying and harassment and recruitment and selection. • It has developed a new policy called Addressing Bullying and Harassment Policy – A Framework for Managing Unwanted Behaviour. • The data recorded on Datix is reviewed monthly for key trends. • A working group, which includes representatives from the Joint Staff Consultative Committee and the staff networks, has been set up to review guidance and support for staff to deal with and report aggressive or abusive behaviour from the public. This is a sub-group of the WRES Taskforce led by the Chief Executive.
The full 2018 WRES report and action plan can be found on our website through this link:
https://www.clch.nhs.uk/application/files/9315/3812/8497/Workforce_Race_Equality_Standar d_Report_2018.pdf.
Leavers – staff who have left the Trust
This section analyses by protected characteristics the leavers data for the financial year ending 31.3.2018 and compares it with the previous financial year (ending 31.3.2107)
A total of 740 staff left the Trust between April 2016 and March 2017. 163 of the leavers (22%) cited work life balance as their reason for leaving. The next highest reason for leaving was staff leaving for a promotion (97) -13%.
The table below shows the breakdown of leavers by protected characteristics, first comparing the percentage of leavers in 2017 with the percentage that protected characteristic is in the staff population. The difference is then calculated for 2017 (leavers percentage minus staff population percentage). This is repeated for 2018 data and the differences between the two years are compared. The data below shows no clear trend in terms of adverse disproportionality by protected characteristics.
2017 2018 2017 Staff 2018 Staff Group leavers Difference leavers Difference Population Population % % BAME 38.70% 38.90% -0.20% 35.00% 41.90% -6.90% White 51.70% 49.60% 2.10% 52.30% 45.10% 7.20% Not disclosed 9.60% 11.50% -1.90% 12.70% 13.00% -0.30% /defined Female 85.57% 85.23% 0.34% 86.76% 86.58% 0.18% Male 14.43% 14.77% -0.34% 13.24% 13.42% -0.18% Disabled 1.92% 2.73% -0.81% 2.57% 2.56% 0.01% Not Disabled 71.37% 68.85% 2.52% 71.49% 64.99% 6.50%
Not disclosed 26.69% 28.42% -1.73% 25.95% 32.45% -6.50% /defined
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221 2017 2018 2017 Staff 2018 Staff Group leavers Difference leavers Difference Population Population % % Bi-Sexual 0.38% 0.28% 0.10% 0.54% 0.37% 0.17% Gay/Lesbian 1.15% 1.82% -0.67% 1.49% 1.76% -0.27%
Heterosexual 69.60% 67.63% 1.97% 68.24% 61.95% 6.29%
Not disclosed 20.05% 30.27% -10.22% 29.73% 35.92% -6.19% /defined Atheism 9.07% 6.56% 2.51% 10.00% 6.19% 3.81% Buddhism 0.77% 0.78% -0.01% 0.95% 0.65% 0.30%
Christianity 46.62% 47.71% -1.09% 44.32% 43.44% 0.88% Hinduism 3.19% 4.55% -1.36% 3.24% 3.92% -0.68% Islam 3.96% 3.86% 0.10% 4.46% 3.44% 1.02% Jainism 0.26% 0.38% -0.12% 0.00% 0.34% -0.34% Judaism 0.64% 1.10% -0.46% 1.08% 1.11% -0.03% Other 5.11% 4.71% 0.40% 5.81% 4.57% 1.24% Sikhism 0.38% 0.66% -0.28% 0.81% 0.60% 0.21% Not disclosed 30.01% 29.70% 0.31% 29.32% 35.75% -6.43% /defined
16-24 1.92% 1.00% 0.92% 2.84% 1.82% 1.02%
25-34 31.67% 20.17% 11.50% 30.81% 22.26% 8.55%
35-44 22.73% 24.87% -2.14% 26.76% 24.28% 2.48%
45-54 19.28% 28.58% -9.30% 20.68% 27.68% -7.00%
55-64 17.50% 20.77% -3.27% 13.51% 20.39% -6.88%
65-74 6.39% 4.33% 2.06% 5.27% 3.44% 1.83%
75+ 0.51% 0.28% 0.23% 0.14% 0.14% 0.00%
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222 The key points from the leavers analysis are:
Ethnicity: The proportion of BAME leavers has reduced in relation to the overall staffing population, there is no indication of disproportionality.
Gender: Although the proportion of female leavers has increased from 2017 to 2018, it remains in line with the overall population size with a nominal variance.
Disability: There is no statistically significant movement of variance in terms of declared disabled leavers and the wider workforce population.
Sexual Orientation: There is no statistically significant movement of variance in terms of declared sexual orientated categories. The level of non-disclosure presents and issue however.
Religion: There is no statistically significant movement of variance in terms of declared religion. The level of non-disclosure presents and issue however.
Age: There were three groups in the 2017/18 period which show a statistical difference in leavers, 25-34 at 8.55% higher than the staff population (although this is down from 11.50% in 2016/17), 45-54 at -7.00% (a less variance than 2016/17 at -9.30%) and 55-64 at -6.88% (up from 2016/17 at -3.27%).
Pregnancy and maternity: To clarify the number of staff who did not return following completion of their maternity leave, further analysis of multiple data sources would be required. This could be an area of investigation for the Public Sector Equality Duty report for 2018/19.
2016/18 Equality Objectives on workforce were as follows:
• We will improve the reporting of discrimination, harassment, bullying or abuse at work and seek to reduce the occurrence of incidents by valuing diversity and difference in our workforce. • We will increase the representation of our BAME staff at senior manager levels • We will improve the number of young people the Trust employs and respond to the challenge of a multi-generational workforce.
To address the first two objectives the Trust has set up the WRES Taskforce and is working closely with the Joint Staff Consultative Committee.
To address the third objective, the Trust has introduced an apprenticeship programme, within its People Strategy.
The section below provides more detail.
Staff Engagement
CLCH facilitates a range of initiatives to promote employee engagement and good relations between staff. These include the annual structured NHS Staff Survey which provides the Trust some baseline information on equality and diversity (as stated in the previous section).
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223 The staff survey also provides the Trust with an engagement score. For the 2017 survey, the Trust engagement score was 3.89, which was higher than the previous year’s score of 3.86 and the national average for community trusts (3.78).
In addition, the Trust facilitates a range of networks, forums and committees (given below), which provide staff the opportunities to express concerns and support improvement plans in the workplace. In addition to the WRES Taskforce, key engagement activities facilitated annually include:
• An annual BAME Conference. • Black History Month. • LGBT History Month. • London and Hertfordshire Pride events. • World Mental Health Month.
Forums and Networks
There are currently a range of formal and informal mechanisms in place to promote employee engagement within CLCH. These include:
Joint Staff Consultative Committee (JSCC): CLCH has a partnership agreement with recognised trade unions (Staff Side). Managers and HR leads regularly meet workplace representatives (who are part of the JSCC) to discuss and agree issues related to employment terms and conditions, service changes, policies and practices.
All staff are encouraged to join a trade union, which entitles them to local representation and advice from a trade union workplace representative. This ensures they are not disadvantaged unfairly and have expert support on key issues affecting their employment status.
Staff Networks
CLCH currently facilitates a number of networks for protected groups, including a network for Black Asian and Minority Ethnic (BAME) staff and the Rainbow Network for Lesbian, Gay, Bisexual and Transgender (LGBT) staff.
BAME staff network
The BAME network has expanded in the past year and its work programme includes an annual conference, followed by smaller workshops which provide staff an opportunity to develop their skills and advocate for change and improvement within the workplace.
The netwok is currently working towards establishing a new committee, to ensure it is sustainable and offers BAME staff a safe space to voice their concerns and influence policies and practices. The BAME staff network, with the WRES Taskforce, is playing a key role in driving the WRES Action Plan 2018-19, organising activities for Black History Month and planning the annnual staff BAME conference in November 2018.
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224 Rainbow Network
The Trust’s Rainbow Network plays an active role in supporting LGBT staff. It organises monthly meetings to provide LGBT staff and allies an opportunity to meet and discuss concerns. The network participates in a range of events annually to celebrate diversity and promote inclusion, including the London Pride and Hertfordshire Pride events, the LGBT History Month in February and workshops and conferences to raise awareness.
London Pride 2018
The Trust is in the process of setting up a network for staff with disabilities, called Positive about Disability, which will be launched by December 2018.
The above networks have been involved in updating key policies for the Trust, including the Equality, Diversity and Inclusion (Staff) Policy, the Disability Policy and Code of Practice and the Trans Equality Policy. The networks will receive a special focus during the National Freedom To Speak Up Month in October 2018.
Staff Awards
To recognise and reward staff for their contribution and to promote diversity, the Trust has institued an award for Promoting Diversity.
Support services for staff
The Trust offers a range of services to staff to promote their health and well-being. These include:
Time to Change Pledge
CLCH signed the Time to Change Pledge in the summer of 2017. This means that CLCH is actively attempting to break down stigma and discrimination around mental health in the workplace.
The Employee Health Department offer workshops to teams to raise awareness about mental health, how to access support and how to support colleagues.
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225
The Employee Health Department have also recruited a group of staff members who are interested in Mental Health, to be a listening ear and a friendly face in the workplace, called Mental Health Minders.
The Mental Health Minders support their colleagues, signpost them to Employee Health or other services and provide activities to help break down stigma and discrimination, such as coffee and chat mornings, walking groups and workshops. A regular blog is published on the Trust intranet that offers advice on mental well-being, sleep and common mental health issues.
Employee Health Counselling Service
Staff have access to the Employee Health professional counselling service for support with anxiety, stress and depression. In addition, the Trust has a stress management policy, which managers and teams can access for guidance on best ways to manage stress within teams.
Dementia Friends
The Trust has participated in campaigns around raising awareness of Dementia – which includes support and guidance for staff who are carers for people with Dementia and increasing the number of Dementia Friends across the organisation.
Freedom to Speak Up Guardians
All staff have access to confidential support from Freedom to Speak Up (FTSU) guardians. The guardians are staff members who have been given special responsibility and training in dealing with concerns. They act as an independent and impartial source of advice to staff at any stage of raising a concern, with access to anyone in the Trust, including our Chief Executive, or if necessary, outside the Trust. Information on the FTSU guardians is available on the Trust’s intranet and the Freedom to Speak Up: Raising Concerns Policy.
Mediation Service
CLCH staff have access to an informal confidential mediation service, which is supported by independent, accredited mediators who help resolve disagreements, if the concerned parties are agreeable. By encouraging positive communication in a safe and structured environment, the mediators help staff understand each other’s perspectives, enabling them to find solutions, rebuild relationships and work together more effectively. The service helps staff resolve differences early and informally to avoid the emotional and financial costs of formal processes.
Access to Training and Development
To ensure staff are supported with access to training and development, the Trust offers a range of training programmes. These are highlighted below:
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226 Statutory and mandatory training
All staff receive statutory and mandatory training on a range of topics, including equality, diversity and inclusion as part of their induction through a statutory and mandatory training booklet – which they sign to confirm completion. At CLCH, the compliance rate for equality, diversity and inclusion training as of March 2018 was 96.14%. Other mandatory training related to inclusion which our staff receive is listed:
• Adult and Child safeguarding, including Prevent Violent Extremism (PREVENT) training for clinical staff. • Domestic Violence awareness training for health visitors.
Career Development Opportunities
Since March 2018, the Trust has offered a range of development courses aimed at developing a representative talent pipeline, including:
• The Ready Now Programme, a 12-month group coaching programme targetted at developing leadership skills of BAME staff at Bands 8A and 8B. • An Empowerment Programme open to all staff below Band 7, with 12 places available on the upcoming progarmme later in 2018/19. • Mentoring with a senior staff member for any BAME staff member who requests it, although the resource is limited. Coaching and mentoring are available to all staff in other ways. • The WRES action plan has a specific strand on career development, which includes access to acting up and secondment opportunities and a range of interventions to improve effective teams and interpersonal skills. For more details see the summary WRES Action Plan in the section: Equality benchmarking.
This is in addition to the suite of development opportunities available, some to managers and others to all staff, which include short, maximum one-day training events offered several times a year, such as:
• Managing for the First Time. • Coaching Skills for Managers. • Appraisals. • Assertiveness. • Presentation Skills.
The Trust has offered Unconscious Bias training as part of its Recruitment and Selection training package for interview panels in the past. This package is now being refreshed and will be offered to all interview panels as part of the WRES Action Plan 2018-19.
Equality analysis
The Trust has updated its Equality analysis templates – which include screening and full analysis templates - in keeping with Department of Health guidelines. These are now used when reviewing services or developing or updating policies.
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227 Between April 2017 and August 2018, 12 Equality analyses were undertaken, which include:
• Equality analyses on six HR policies. • Equality analyses on three TUPE transfers and three team restructures.
Equality benchmarking
CLCH has been delivering on the following benchmarking and performance improvement initiatives with a view to developing a structured, collaborative approach to improvements in employment and service delivery for all population groups.
Workforce Race Equality Standard (WRES)
The National Workforce Race Equality Standard (WRES) is a benchmarking tool introduced by NHS England to assess annually the progress of race equality within NHS organisations, following an initial evidence baseline gathered in 2015. The WRES is part of the NHS Standard Conditions of Contract and providers employing over 150 staff are expected to report their WRES results annually.
It is designed to improve outcomes for BAME staff when compared with White staff, by analysing quantitative and qualitative data against nine indicators, with a view to closing the gap between the experience of BAME and White staff over time through an action plan.
CLCH has analysed its performance against the WRES annually since 2015 to identify outcomes for BAME staff when compared with White staff.
In May 2018, a WRES Taskforce was set up and led by the Chief Executive to focus the action plan for 2018-19 on key areas where BAME staff were found to experience poorer outcomes when compared to White staff.
The intention was to focus on specific employment practices that were likely to lead to a step change in outcomes for BAME staff over the next 2 years. The taskforce comprises a cross- section of staff from across the Trust and includes representation from the staff side. It is supported by senior management, including functional heads and directors.
Between May and September 2018, the taskforce met fortnightly to discuss key findings and national best practice. Their recommendations have informed the 2018 WRES action plan.
The taskforce has also been involved in raising awareness of their work with different teams across key divisions. Feedback from this engagement exercise is being used by the taskforce to improve the action plan.
The WRES action plan develop by the taskforce is set out in the infographic overleaf. The full report and action plan can be found on: https://www.clch.nhs.uk/application/files/9315/3812/8497/Workforce_Race_Equality_Sta ndard_Report_2018.pdf.
Improvements resulting from the WRES include:
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228 • Development of career progression initiatives for BAME staff through initiatives such as the Ready Now Programme in 2018. • A review of recruitment and selection processes and training to ensure interview panels are trained and receive guidance on unconscious bias avoidance. • Plans to develop a cohort of BAME staff trained to participate as decision-makers on interview panels by January 2019. • A review of the disciplinary processes and introduction of a pre-disciplinary checklist for managers to increase informal resolution of workplace disputes. • A working group to review bullying and harassment of staff by the public and internally, by staff.
The CLCH Workforce Race Equality Standard
ACTION PLAN 2018/19
To address the To provide equal opportunities To address the disproportionate disproportionate ratio of BAME for career progression for all ratio of BAME staff experiencing staff appointed following staff groups disciplinary, grievances, bullying shortlisting and harassment Develop talent management Develop and communicate the pipeline to facilitate Establish pre-investigation Trust's vision for recruitment progression for all staff groups checklist based on best practice Raise awareness of Establish BAME representation professional behaviours and Encourage and support informal in recruitment panels for Band managing/working within resolution of conflict through 7 and above posts multi-cultural teams access to mentors, buddies and networks Train recruiting panels on Create and facilitate unconscious bias avoidance opportunities for progression Develop a training plan to cover and fair selection practices. through mentoring, coaching acceptable behaviour, conduct and secondments and professional boundaries For the detailed version of the plan visit the hub or email:: [email protected]
The WRES action plan will be part of the Trust’s wider equality and diversity plan.
Disability Confident Committed
Disability Confident is a scheme that is designed to help organisations recruit and retain disabled people and people with health conditions for their skills and talent. It is an accredited scheme managed by the Department of Work and Pensions to support organisations develop inclusive practices that enable people with disabilities to be productive members of the workforce.
CLCH was reaccredited as a Disability Confident Committed employer in 2018. It was assessed as being Disability Confident Committed in 2017, with plans of aiming for Level 2 of the scheme (Disability Confident Employer) by September 2019. This is Level 1 of the accreditation process, which means that the organisation has committed to:
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229 • Ensuring that recruitment processes are inclusive and accessible. • Communicating and promoting vacancies. • Offering an interview to disabled people. • Anticipating and providing reasonable adjustments as required. • Supporting any existing employee who acquires a disability or long-term condition to ensure they are able to stay in work. • Undertaking at least one activity that will make a difference for disabled people.
Gender Pay Gap Report
The Trust published its first Gender Pay Gap Report in March 2018. The report can be found in the following link: https://www.clch.nhs.uk/application/files/5115/2233/6699/Gender_Pay_Report_2017.pdf .
The report highlighted that the Trust’s gender pay gap (8.99%) is smaller than the UK average (18%) but this means that the overall average hourly rate is £1.84 per hour more for men than women. More importantly, the median pay gap tells us that the difference in the middle pay between men and women within CLCH is 1%, or £0.18p.
The Trust pays most of its staff via the Agenda for Change pay bands, which means that gender is not a factor in the amount we pay staff.
It is recognised that proportionately, CLCH have more men in the higher quartile which results in a mean pay gap in favour of men.
It is also acknowledged that there is a gap between part time men and women of £3.88 per hour. This can be attributed to the number of women working part time for CLCH (1078) compared to men (76) working in different roles within the Trust. However, women do compare favourably across a range of pay bands within CLCH.
The statistics have provided CLCH data to inform actions, which include:
1. Ongoing review of barriers that prevent women from applying and being selected for senior medical and dental roles as well as senior management roles.
2. Reviewing the pay gap as part of the Quality and People strategies. This will ensure that, not only do we attract women into the most senior management posts, we also encourage men to apply for roles predominantly filled by women and create a more even gender balance.
3. Supporting women who return to work after maternity or adoption leave and continuing to communicate and promote caring initiatives for both men and women such as shared parental leave and other flexible working opportunities.
Incident Reporting
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230 CLCH encourages all staff to report incidents within the workplace or in interactions with the public and patients. This includes reporting incidents related to racist, homophobic or any other verbal abuse aimed at a person’s protected characteristics.
The incidents are reported on an internal system called Datix and monitored monthly for trends. The Trust is in the process of developing corporate messaging for the public and staff to demonstrate its commitment to protect staff against any form of abuse, violence, threat, harassment or other forms of unwanted behaviour from any source. The publicity material will be promoted at all sites by March 2019.
Procurement
As part of procuring services, the Trust stipulates that potential suppliers declare that they do not meet any of the grounds of exclusion, such as corruption and employment of child labour and other forms of human trafficking. The information would need to cover any sub- contractors involved in delivering a service. Examples of grounds of exclusion would include supplier complaints (service or employment), which were investigated and upheld.
All tender applications are evaluated as part of the Trust’s Quality Impact Assessment process, which include a review of responses related to diversity and inclusion.
The NHS Standard Conditions of Contract CLCH signs with a supplier states that the latter would need to:
• Ensure that (a) it does not; engage in any act or omission that would contravene the Equality Act both in employment and service delivery, and (b) it takes reasonable endeavours to ensure that staff do not unlawfully discriminate.
• Co-operate with the Trust in the management of its affairs and the development of its equality and diversity policies.
• Take reasonable and proportionate steps to promote equality and diversity.
• Ensure its subcontractors comply with the conditions of the contract.
• Provide evidence of compliance with the Equality Act.
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231
Board of Directors 31 October 2018
Report title: Single Oversight Framework (SOF) Quarterly Report Q2 – 2018/19 4.5 Agenda item number:
Lead director responsible for Director of Finance approval of this paper
Tom Wright, Commercial Director Report author William Liew, Business Planning Manager Relevant CLCH strategic priorities Trust objective 2018/19 Please delete those which do not apply to this paper Strategy implementation Implement strategic priorities of integration and place Quality Maintain and improve the quality of services delivered by CLCH Finance Deliver the 2018/19 financial plan Operations Deliver all NHS constitutional and contractual standards Workforce Make CLCH a great place to work for everyone Freedom of Information Public status
Executive summary:
This is the quarterly update on compliance with the Single Oversight Framework (SOF) for Q2 – July to September 2018.
The overall CLCH segment rating remains at 1 based on current rating by NHSI (source: https://improvement.nhs.uk/resources/single-oversight-framework-segmentation/)
During Q1 of 18/19, the Trust’s finance metric rating was red with an overall score of “3” due to the score of “4” in both ‘I&E’ and ‘distance from financial plan’. Due to the successful implementation of a recovery plan, the Trust’s finance position now has an overall rating of “1”, which is the top score.
CLCH has continued to monitor itself against internal quality and performance metrics with majority being a RAG rating of green (10/13) with information updated for September 2018 data.
A paper with an update on our internal refresh of the NHSI Well-led Framework will be going to October Board.
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A summary of our internal assessment on SOF compliance is tabled below:
This paper includes the following appendices:
Appendix 1 – Summary of theme indicators and triggers with internal assessment and RAG rating Appendix 2 – SOF Quality and Performance metrics overview Appendix 3 – SOF Finance metrics overview Appendix 4 – SOF Leadership and Improvement capability Appendix 5 – FT Provider license conditions Appendix 6 – SOF Action plan Appendix 7 – SOF UoR assessment
Assurance provided:
233 Report provenance: Paper prepared for Board on 31st October following review at ELT on 16th October 2018.
Report for: Decision Discussion X Information X
Recommendation:
Board are asked to:
• Review the paper and provide comment
234 Single Oversight Framework – Quarterly Compliance Assessment Q2 2018/19
1. Introduction
1.1 This is the quarterly update on compliance with the Single Oversight Framework (SOF) for Q2 – July to September 2018.
1.2 The overall segment rating remains at “1” as recorded by NHSI.
During Q1 of 18/19, the Trust’s finance metric rating was red with an overall score of “3” due to the score of “4” in both ‘I&E’ and ‘distance from financial plan’. Due to the successful implementation of a recovery plan, the Trust’s finance position now has an overall rating of “1”, which is the top score. A paper with an update on our internal refresh of the NHSI Well-led Framework will be going to October Board. CLCH has continued to monitor itself against internal quality and performance metrics with majority being a RAG rating of green (10/13) with information updated for September 2018 data.
2. Compliance with the SOF – Internal Assessment
2.1 The table below provides an overview of our internal assessment of compliance using September 2018 data provided by BIPA and relevant departments:
Currently all our assessment areas are classified as green except:
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• ‘Metrics (finance)’ – in the previous quarter, the Trust had an overall finance score of “3”, however due to a recovery plan, CLCH has now returned to the top score of “1” due to the implementation of a recovery plan • ‘Use of data’ – rated as an improving amber position with a working data warehouse in place. Comments can be found in Appendix 6 – SOF action plan.
3. Use of Resources (UoR)
3.1 Appendix 7 presents a summary of the Use of Resources Metrics (UoR) and has been included in this paper with an initial indication of the metrics that would apply to CLCH and which we can start to monitor in shadow form in 2018/19. After meeting with NHSI in August, there is no foreseeable date to implement UoR assessments for community Trusts as they are still ironing out issues with acute Trusts.
4. SOF Action Plan
4.1 Open actions are listed below:
Assessment Component Action Owner Leads Due Status Notes Area
An internal update of our NHSI Well-led Framework assessment has been carried out and will be submitted to October Board. External Review and Leadership Associate review of this refresh Associate and Effective Director of assessment will be Trust Well- Director of 2018 On Improvement Board and Resilience deferred till 2019 Led Resilience & (Internal) track Capability Governance & (subject to NHSI framework Compliance (Well-led) Compliance agreement). action plan
The NHSI framework uses the same 10 KLOE as the CQC but goes into further depth with sub questions.
236 Following the CQC well led assessment in October 2017 and reported outcome of ‘good’ the external assessment has been considered and the Schedule Board has concluded an external Trust Trust that the external N/A N/A well led Secretary Secretary assessment planned for assessment the summer of 2018 does not need to be undertaken as this would be repetitive.
The external well-led review will take place in May 2019.
The Trust now has an operating data warehouse, with both SystmOne and Emis, pulling data into a conformed layer. The delivery of corporate services data into the conformed layer is now on track. Ensure action The Data Quality forum CIO, BIPA plans to continues to review Director address Director of 31-Oct- data quality issues, with Use of Data and Ongoing data Improvement 18 change control Business concerns managed by the Change Managers are up-to- Authority Board. Data date performance is monitored by the Executive Team and monthly performance review.
Further development work is underway to build and report clinical outcomes directly from the data warehouse.
237 To implement shadow monitoring once metrics are confirmed by NHSI for 2018. Agree on a Use of plan for Director of Director of 31-Dec- Have spoken with NHSI Finance Ongoing Resources shadow Finance Finance 18 on the implementation monitoring date of UoR for community Trusts but they do not have one for the foreseeable future.
5. Log of Changes
5.1 Log of changes of our assessment below:
Log of Changes: SOF Internal/ Date Assessment Ref. Theme/Metric Action External
Leadership and Updated and expanded the theme improvement 28/03/2018 SOF Theme Analysis Internal 1.5 assessment with dedicated appendix to capability paper. (No change to overall rating) Exec. owner: CEO
It was agreed that it would be helpful to Strategic change 31/01/2017 SOF Theme Analysis Internal 1.4 include the CWHHE QIPP target work as Exec. owner: CEO evidence for strategic change.
238 Added 8 key lines of enquiry to internal assessment from NHSI guidance:
1. Is there the leadership capacity and capability to deliver high quality, sustainable care? 2. Is there a clear vision and credible strategy to deliver high quality sustainable care to people who use services, and robust plan to deliver? 3. Is there a culture of high quality, sustainable care? Leadership and 4. Are there clear responsibilities, roles improvement and systems of accountability to support 14/08/2017 SOF Theme Analysis External 1.5 capability good governance and management? Exec. owner: CEO 5. Are there clear and effective processes for managing risks, issues and performance? 6. Is appropriate and accurate information being effectively processed, challenged and acted upon? 7. Are the people who use services, the public, staff and external partners engaged and involved to support high quality sustainable services? 8. Are there robust systems and processes for learning, continuous improvement and innovation?
Aggressive cost reduction plans SOF Performance NHSI guidance to remove this metric 14/08/2017 External 2.6 Exec. owner: Metrics Overview from performance overview Director of Improvement
The majority of the changes and updates were not applicable to the Trust as it focused more on acute and mental health Trusts.
6. Recommendations
6.1 Board are asked to:
• Review the paper and provide comment.
239 Appendix 1: Single Oversight Framework theme analysis The Single Oversight Framework details which information sources will be analysed by NHS Improvement to monitor trusts and decide which segment (and therefore level of autonomy) the trust is positioned in. Currently, not all benchmarks and targets have been published. This document provides an internal assessment against the metrics and our compliance using our own reporting benchmarks, as well as qualitative review where appropriate Appendix 1: Single Oversight Framework assessment theme overview rating 1: Summary of information used and triggers Ref. Theme Information used Triggers Current internal assessment 1.1 Quality of care • CQC information • CQC ‘inadequate’ or ‘requires • Monthly meetings with CQC relationship Exec. Owners: Chief • Other quality information to inform our improvement’ in overall rating manager, ensuring concerns are addresses Nurse and Medical view of a provider (see Appendix 2) • CQC warning notices quickly Director • 7-day services • Any other material concerns • No CQC warning notices identified through, or relevant to, CQC’s • We are green for the majority of the SOF monitoring process, eg. civil or criminal quality metrics cases raised, whistleblower •The four priority 7 day standards (Standard 2: information, etc. Time to Consultant Review, Standard 5: Access to • Concerns arising from trends in our Diagnostics, Standard 6: Access to Consultant- quality indicators (Appendix 2) directed Interventions and Standard 8: On-going • Failure to deliver against an agreed Review) have been reviewed and do not apply to committments regarding the four CLCH priority standards for 7-day hospital • CQC inspection undertaken in services September/October 2017. We have achieved a • Any other material concerns about a current rating of: "Good" provider's quality of care arising from intelligence gathered by or provided to NHSI 1.2 Finance and Use of • Sustainability (capital service cover, • Poor levels of overall financial We have reviewed the financial template that Resources liquidity) performance (average score of 3 or 4) assesses our position against these indicators and Exec. owner: Director of • Efficiency (I&E 14 margin) • A UoR rating of 'inadequate' or currently score 1 across all indicators. Finance • Controls (performance against plan and 'requires improvement' agency spend) • Any other material concerns about a This has come as an improvement from the last •Value for money information provider's finance or use of resources quarter after a recovery plan was put in place. •Reference to new UoR framework, with arising from intelligence gathered by or The Trust has recovered from an overall score of explanation of how UoR assessments will provided to NHSI 3 with a red rating to an overall score of 1 and a be used under the SOF green rating. • NHSI will use UoR report/rating alongside the finance score to inform The overall score is now a 1 (top score) provider support needs 1.3 Operational • NHS Constitution standards • A&E performance: The performance targets which apply to us as a performance • Other national targets and standards - performance below threshold for community provider are A&E 4 hr wait (in Exec. owner: Director of Sustainability and Transformation Fund relation to our walk in centres) and 18 week Finance (STF) quarterly trajectory (quarter to referral to treatment. We have met these targets date) comfortably and consistently over the last few - breach of absolute threshold of 95% years. It is currently monitored in Integrated for two months Performance Reports • Failure to meet any other standard for at least two consecutive months • Other factors (eg a significant deterioration in a single month, or multiple potential support needs across other standards and/or other themes) indicate we need to get involved before two months have elapsed • Any other material concerns about a providers’ operational performance arising from intelligence gathered by or provided to NHS Improvement
1.4 Strategic change • Review of sustainability and • Material concerns with a provider’s CLCH has engaged in the STP process for the four Exec. owner: Director of transformation partnership (STP) plans delivery against the transformation STPs where we provide services. Although we Improvement and other relevant matters agenda, including new care models and cannot currently identify any part of STP plans devolution that directly impact CLCH we expect this to emerge as more detailed planning progresses.
CLCH has signed up to its STP control total for 2018/19.
CLCH has engaged in a signiciant transformation programme with CWHHE commisisoners that continues into 2018/19.
CLCH has a Board KPI that measures STP engagement, which will be reported quarterly.
240 • Findings of governance or well-led review undertaken against the current well-led framework • Third party information, egg Healthwatch, MPs, whistleblowers, coroners’ reports • Organisational health indicators • Operational efficiency metrics • CQC well-led assessments • Data quality • Improvement capability
NHSI and CQC have introduced a new well-led framework focusing on 8 key lines of enquiry around the question: Are services well led?
1. Is there the leadership capacity and capability to deliver high quality, sustainable care? 2017 CQC inspection of 'Good' for well-led (with an outstanding in Adult Community Health 2. Is there a clear vision and credible Services). strategy to deliver high quality sustainable care to people who use The NHSI written assessment against the KLOEs is • Material concerns Leadership and services, and robust plan to deliver? still pending. • CQC ‘inadequate’ or ‘requires 1.5 improvement capability improvement’ assessment against ‘well- Exec. owner: CEO 3. Is there a culture of high quality, There is an ongoing concern over "use of data" led’ sustainable care? which NHSI is aware of.
4. Are there clear responsibilities, roles The internal assessment rates this domain as and systems of accountability to support green overall but with the use of data indicator as good governance and management? Amber.
5. Are there clear and effective processes for managing risks, issues and performance?
6. Is appropriate and accurate information being effectively processed, challenged and acted upon?
7. Are the people who use services, the public, staff and external partners engaged and involved to support high quality sustainable services?
8. Are there robust systems and processes for learning, continuous improvement and innovation?
241 Appendix 2: Single Oversight Framework performance metrics overview 1: Quality of care monitoring metrics Current performance (as of Sep18 unless Ref. NHSI measure Lead Internal KPI / target Where currently monitored/source stated otherwise) 3.5% (Quality 1.1 Staff sickness Dir. of People and Communications 3.83% (12 month rolling) Workforce Committee, FRIC Committee markers)
18.32% (12 month rolling - All staff including Staff turnover (All staff, 12% (Quality involuntary transfers/service demobilisations) 1.2 Trust wide according to Dir. of People and Communications Committee markers - Workforce Committee, FRIC NHSI definition) reducing trajectory) 14.60% (12 month rolling - Voluntary)
Chief Nurse & Operating Officer (1 role) scheduled to leave in October – Post split and 1.3 Executive team turnover Dir. of People and Communications - Qualitative review recruited to with hand over period before post holder leaves Trust
Despite significant changes to our workforce, Two elements form National Staff Survey results have remained Workforce and Quality stable and at or above average for community KPI targets for 2018/19 trusts across most indicators. Initial analysis (staff recommending 1.4 NHS Staff Survey Dir. of People and Communications shows a strong position against the Annual report to Board the trust as a place to Community Trust benchmark in many areas. work and as a place to receive treatment The 2018 survey is due for release Friday respectively) October 5th with results due in Q4 2018/19
CLCH has decreased our reliance on temporary staffing by reducing permanent vacancy rate and strengthening controls on agency spending.
We achieved the 2016/17 and 2017/18 NHSI targeted agency spend (£15,845,773.09 against £16,400,000 and £6,350,404.70 Proportion of temporary 1.5 Dir. of People and Communications N/A against £8,003,000 respectively). We are Workforce Committee, FRIC staff currently on target to achieve our agency spending cap in 2018/19 (£1,725,658.15 vs £2,190,019.65 YTD at the close of 5).
We have been exceeding our target ratio of 60% bank to 40% agency use – with a stable position of circa 70%+ bank usage (close of August 2018 – 74.69% ban to 26.31% agency)
63% - results from 2017 NHS National Staff Annual as part of Staff Survey, in-year as Staff Friends and Family Survey (Q21c) part of Pulse Surveys 1.6 Test % recommended place Dir. of People and Communications 62% to work (Advisory: 52.60% as of Aug18 from CLCH Board KPI as of 18/19 Quarterly Pulse Survey - Q2 18/19)
95% responded within 1.7 Written complaints Dir. of Patient Experience 100 % YTD Quality Committee 25 days
Occurrence of any Never Director of Nursing & Therapies (Quality & 1.8 None Our occurrence of never events is nil As part of the escalation policy Event Safety)
NHS England/NHS 1.9 Improvement Patient Medical Director 90% 100% Quality Committee Safety Alerts outstanding
CQC Inpatient/Mental Associate Director of Resilience & 1.10 Health and Community - N/A N/A Compliance Survey 95% (Proportion of Friends and family test - % patients rating their 1.11 of people that would Dir. of Patient Experience 93.5% Quality Committee overall experience as recommend the services good or excellent) 2: Operational performance monitoring
A&E maximum waiting IFPR reports - Access and Outcomes time of 4 hours from arrival metrics 2.1 Head of Performance Management 95% 99.2% Q2 to admission/transfer/ discharge Board KPI
242 Appendix 3: Single Oversight Framework finance metrics overview (data from September 18) YTD Forecast Score Area Weighting Metric Definition actual year end 1 2 3 4 1
Degree to which the Capital provider’s generated income 1.25- 0.2 service >2.5x 1.75-2.5x < 1.25x 1 1 covers its financial 1.75x capacity obligations Financial Days of operating costs held Sustainability in cash or cash-equivalent Liquidity 0.2 forms, including wholly >0 (7)-0 (14)-(7) <(14) 1 1 (days) committed lines of credit available for drawdown
Financial I&E surplus or deficit / total 0.2 I&E margin >1% 1-0% 0-(1)% ≤(1)% 1 1 efficiency revenue
Distance Ytd actual I&E surplus/deficit from 0.2 in comparison to YTD plan ≥0% (1)-0% (2)-(1)% ≤(2)% 1 1 financial I&E surplus / deficit Financial plan Controls Agency 0.2 Distance from provider’s cap ≤0% 0%-25% 25-50% >50% 1 1 spend2
Overall score 1 1
Notes .The Trust achieved Segment 1 out of 4 under the Single Oversight Framework (SOF). .The Trust's performance would need to decline to '2' across three areas for the Trust's overall metrics to reduce to '2'. .It is important for the Trust to meet its surplus target as three metrics; capital service capacity, I&E margin and distance from plan, are dependent on it.
243 Appendix 4: Theme 1.5 Leadership and Improvement Capability The Single Oversight Framework details which information sources will be analysed by NHS Improvement to monitor trusts and decide which segment (and therefore level of autonomy) the trust is positioned in. Currently, not all benchmarks and targets have been published. This document provides an internal assessment against the metrics and our compliance using our own reporting benchmarks, as well as qualitative review where appropriate
Ref. 1.5 Leadership and Improvement Capability Where Area Information used CLCH Exec Lead Current Assessment Assessed
CQC inspection of 'Good' for well-led (with an CQC Well Led Assessment COO outstanding in Adult Community Health Services) Trust Board for Autumn 2017
An internal update of our NHSI Well-led Framework assessment has been carried out and Well led Reviews will be submitted to October Board. External review of this assessment will be deferred till New NHSI Well Led Framework COO 2019 (subject to NHSI agreement). Trust Board
The NHSI framework uses the same 10 KLOE as the CQC but goes into further depth with sub questions.
SOF Guidance states "We will consider Assessment currently based upon the CQC well assessments of learning, improvement led assessment as described above. Continous Improvement and innovation within the well-led Dir Improvement Capability reviews undertaken by CQC or in Also supported by developmental reviews using the well- 1) Trust continous improvement strategy led framework. 2) CLCH Way
The Trust now has an operating data warehouse, with both SystmOne and Emis, pulling data into a SOF Guidance states" Effective use of conformed layer. The delivery of corporate information is an important element of services data into the conformed layer is now on good governance. Well-led providers track. should collect, use and, where required, submit robust data. The well-led The Data Quality forum continues to review data Use of data framework recommends that providers Dir Improvement quality issues, with change control managed by FRIC should adopt a measurement-for- the Change Authority Board. Data performance is improvement approach, using data to monitored by the Executive Team and monthly identify how improvements can be performance review. implemented and sustained, not just to understand current performance. Further development work is underway to build and report clinical outcomes directly from the data warehouse. Divsional Quality Meetings in place and structure Quality Surveillance Groups (QSGs) Chief Nurse for Quality Campign groups to feed in to the Trust Quality Committee Quarterly meeting with GMC liaison officer , all General Medical Council Medical Dir issues and or concerns raised and discussed , updates shared. 100% attendance NHS Ombudsman COO Nil issues Healthwatch England COO Nil issues NHS Digital CIO (Andrew Chronias leads) Nil issues Auditors Dir Finance Nil issues The Trust has a detailed health and safety scorecard that is reviewed monthly at the Trust performance meeting and at the Health and Health and Safety Executive Dir Improvement Safety Committee. The board takes a twice yearly report on Health and Safety for review and assurance
Third party Information with A patient engagement plan is in place for the trust Governance Implications Patient Groups Chief Nurse Each division has a qulaity stakeholder reference group 100% compliance with complaints answered Complaints Chief Nurse (Holly Ashforth leads) within 25 days
The Trust has a “Freedom to Speak Up: Raising Concerns Policy” which is reviewed annually. ‘Whistleblowing’ information based on protected disclosures criteria is requested from Whistleblowers Dir of People and Comms directors/managers monthly and is held on a central register. Concerns raised with Freedom to Speak Up Guardians are recorded on a separate spreadsheet, based on guidance from the National Guardian’s Office No regular meetings with medical royal colleges. Medical royal colleges Medical Dir We would meet ad hoc if there was a relevant issue.
244 Workforce Staff sickness Dir of People and Comms 3.83% (12 month rolling) Committee, FRIC Workforce Organisational Health Staff turnover Dir of People and Comms 14.60% - 12 month rolling (Voluntary) Committee, Indicators FRIC Chief Nurse & Operating Officer (1 role) scheduled to leave in October – Post split and Qualitative Executive turnover Dir of People and Comms recruited to with hand over period before post review holder leaves Trust
Workforce Race Equality Equality and Diversity Strategy Workforce Workforce Race Equality Standards Dir of People and Comms Standards WRES Action plan Committee
Despite significant changes to our workforce, National Staff Survey results have remained stable and at or above average for community trusts across most indicators. Initial analysis Annual report NHS staff survey Dir of People and Comms shows a strong position against the Community to Board Trust benchmark in many areas.
The 2018 survey is due for release Friday October 5th with results due in Q4 2018/19 Annual as Staff and Patient Surveys 63% - results from 2017 NHS National Staff part of Staff Staff Friends and Family Test % Survey (Q21c) Survey, in- recommended place to work Dir of People and Comms year as part Target: 62% (Advisory: 52.60% as of Aug18 from CLCH of Pulse Quarterly Pulse Survey - Q2 18/19) Surveys. Friends and family test - % of people that would recommend the services Board KPI Target: 95% (Proportion of patients Dir of People and Comms 93.5% rating their overall experience as good or excellent)
245 Appendix 5: FT Provider Licence Compliance - Supporting information The Health and Social Care Act 2012 gives Monitor new powers and duties. It states that our main duty will be to protect and promote the interests of people who use health care services. We must do this by promoting provision of health care services which is effective, efficient and economic, and which maintains or improves the quality of services. The Act requires us to introduce a licence for providers of NHS services. This licence sets out various obligations for providers of NHS services, including obligations relating to the four functions listed above and some specific obligations for NHS foundation trusts.
This document outlines our compliance with each condition in the provider licence. Condition Lead Compliant? Supporting evidence / comment General conditions General Condition 1: Provision of information JW N/A Not currently required as not licensed. We will provide this information when requested by a This condition contains an obligation for all licensees to provide Monitor with any regulator. information we require for our licensing functions. General Condition 2: Publication of information JW N/A Not currently required as not licensed. We will publish this information when requested by a This licence condition obliges licensees to publish such information as Monitor regulator may require. General Condition 3: Payment of fees to Monitor JW N/A Not currently required as not licensed. We will pay fees to when requested by regulator. The Act gives Monitor the ability to charge fees and this condition obliges licence holders to pay fees to Monitor if requested.
General Condition 4: Fit and proper persons JW Yes Individual directors have all provided self-certification as recommended by the People and This licence condition prevents licensees from allowing unfit persons to become or Remuneration Committee to the Trust Board (now Remuneration Committee). continue as governors or directors (or those performing similar or equivalent functions). In exceptional circumstances and at Monitor's discretion we may issue Contracts have been updated to include a clause that gives the Trust the ability to dismiss ‘unfit a licence without the licensee having met this requirement. persons’.
The Trust also takes into account guidance and actions issued by NHSI
The disqualified directors register and insolvency register (Companies House) is checked annually and directors are asked to confirm that they remain compliant with CQC regulation 5 – annually in Sb General Condition 5: Monitor guidance JW Yes This condition relates to the power of the regulator in setting regulations in relation to price, This licence condition requires licensees to have regard to any guidance that configuration and continuation of services. Monitor issues. At authorisation, regulatory guidance will be followed and the board will be provided with assurance of compliance.
General Condition 6: Systems for compliance with licence conditions and related JW Yes The Board has agreed to monitor compliance with the single oversight framework which will obligations include the licence conditions - quarterly. This licence condition requires providers to take all reasonable precautions against the risk of failure to comply with the licence and other important requirements.
General Condition 7: Registration with the Care Quality Commission CS Yes The Trust is registered with the CQC and is rated as 'good'. This licence condition requires providers to be registered with the CQC (if required to do so by law) and to notify us if their registration is cancelled. In December 2016, the Board approved the new Quality Strategy with a vision to move from 'good' to 'outstanding'.
General Condition 8: Patient eligibility and selection criteria TW Yes Eligibility criteria for all services (where this is available) now published on the CLCH web site. This condition requires licence holders to set transparent eligibility and selection criteria for patients and to apply these in a transparent manner. Patient Access Policies can be found here: http://thehub/library/Policies/Access%20to%20Health%20and%20Personnel%20Records%20Polic y.pdf
http://thehub/library/Policies/Accessible%20Information%20Policy.pdf
General Condition 9: Application of Section 5 (Continuity of Services) TW N/A NHS Trusts are exempt from CRS designation, however CLCH works with commissioners on service This condition applies to all licence holders. It sets out the conditions under which transfer where required by either party to ensure continuity of service. a service will be designated as a Commissioner Requested Service. If a licensee provides any Commissioner Requested Services, all the Continuity of Services Conditions apply to the licence holder. Pricing conditions Pricing Condition 1: Recording of information MF Yes The Trust has maintained a system for identifying the cost and activity relating to the services Under this licence condition, Monitor may oblige licensees to record information, provided. particularly information about their costs, in line with guidance to be published by Monitor. Assurance is gained through the completion on internal reports relating to activity and costs such as SLR and the completion of external reporting via monthly commissioner reports, NHSI returns and annual reference costs.
It has been confirmed that in reality most of the Trust’s activity is non-payment by results and reference costing for activity is maintained. Pricing Condition 2: Provision of information MF Yes The management team and Board will take all reasonable steps to ensure that information is Having recorded the information in line with Pricing condition 1 above, licensees accurate, complete and not misleading. can then be required to submit this information to Monitor. The Board of Directors have signed a code of conduct consistent with the Nolan Principles which include the requirement to “be honest, and act with integrity and probity”
Pricing Condition 3: Assurance report on submissions to Monitor AR N/A Not currently applicable, however the trust is committed to meeting regulatory requirements as When collecting information for price setting, it will be important that the an FT, including audit as required. information submitted is accurate. This condition allows Monitor to oblige licensees to submit an assurance report confirming that the information they have provided is accurate Pricing Condition 4: Compliance with the National Tariff MF Yes Majority of Trust services are provided under block contract or locally agreed tariffs due to lack of The Health and Social Care Act 2012 requires commissioners to pay providers a a national tariff. price which complies with, or is determined in accordance with, the National Tariff for NHS health care services. This licence condition imposes a similar obligation on licensees, i.e. the obligation to charge for NHS health care services in line with the National Tariff Pricing Condition 5: Constructive engagement concerning local tariff MF Yes The Trust engages with commissioners regarding local tariff due to the nature of Trust business modifications being local tariff based and block contracts. The Act allows for local modifications to prices. This licence condition requires licence holders to engage constructively with commissioners, and to try to reach agreement locally, before applying to Monitor for a modification.
Choice and Competition Conditions
246 Condition Lead Compliant? Supporting evidence / comment Choice and Competition Condition 1: Patient choice AR Yes Aside from carrying DH leaflets and posters about patient choice, the trust does publish This condition protects patients’ rights to choose between providers by obliging information about patient choice. GPs and commissioners have a primary role in patient choice. providers to make information available and act in a fair way where patients have a choice of provider. This condition applies wherever patients have a choice of CLCH contracts with CCGs are based on the NHS standard contract which mandates that we follow provider under the NHS Constitution, or where a choice has been conferred locally national guidance on patient choice. by commissioners. The Trust has a policy on conflict of interests (including gifts and hospitality). The trust’s induction programme includes the Bribery Act and there is an active counter fraud service.
Choice and Competition Condition 2: Competition oversight TW/MF Yes The Board of Directors have signed a code of conduct consistent with the Nolan Principles which This condition prevents providers from entering into or maintaining agreements include the requirement to “be honest, and act with integrity and probity”. that have the object or effect of preventing, restricting or distorting competition to the extent that it is against the interests of health care users. It also prohibits The Trust is aware of laws prohibiting anti-competitive behaviour (Competition Act 1998) and the licensees from engaging in other conduct which has the effect of preventing, Procurement, Choice and Competition Regulations 2013. restricting or distorting competition to the extent that it is against the interests of health care users. The Trust understands that the Health and Social Care Act 2012 marks a major milestone for the NHS in England’s 20-year journey from a planned system to a competitive market for the supply of health care services.
The Trust recognises that while it is the role of commissioners to decide if, and when, to use competition, NHSI polices the rules and makes sure that choice and competition operate in the best interests of patients. In particular, to prevent anti-competitive behaviour by commissioners or providers where it is against patients’ interests. This was the role of Monitor’s co-operation and competition directorate. Integrated care condition The Integrated Care Condition applies to all licence holders. The Integrated Care AR/JM Yes The Trust works closely with its commissioners and partners in social care. Condition is a broadly defined prohibition: the licensee shall not do anything that could reasonably be regarded as detrimental to enabling integrated care. CLCH’s wide geographical spread means the trust has a footprint in 4 sustainability and It also includes a patient interest test. The patient interest test means that the transformation plan (STP) areas. The trust is actively engaged in the STP work. Each STP has a obligations only apply to the extent that they are in the interests of people who central focus on collaboration and integration and as community providers we are actively use health care services. engaged.
We are actively working with other emerging providers in primary care to develop new models of integrated care that would improve patient outcomes and experience and add value to the wider system.
As a member of Imperial College Partners, we are committed to achieving population wide health benefits in NW London and beyond through collaborative research and the more systematic dissemination of proven innovation and best practice (closing the gap between "what we know and what we do").
The Trust recognises that equality is key to achieving our mission to provide the best healthcare for people in their homes and in their community. We work within a multi-cultural and diverse community and we are committed to ensure: that we treat all individuals fairly, with dignity and respect; that the healthcare we provide is open to all; that we provide a safe, supportive and welcoming environment - for patients and staff.
The Trust is actively engaging with the formalisation of integrated care arrangements in a number of geographies. For example an Alliance Agreement for an Integrated Community Team was Continuity of Services condition General Condition 9: Application of Section 5 (Continuity of Services) TW/MF N/A NHS Trusts are exempt from CRS designation, but CLCH works with commissioner to ensure This condition applies to all licensees. It sets out how services may be designated continuity of services subject to transfer. as Commissioner Requested Services. If a licensee provides Commissioner Requested Services, the Continuity of Services Conditions apply.
Continuity of Services Condition 1: Continuing provision of Commissioner TW/MF N/A This condition is not applicable until commissioner requested services have been designated by Requested Services the commissioner, but CLCH works with commissioner to ensure continuity of services subject to This condition prevents licensees from ceasing to provide Commissioner transfer. Requested Services, or from changing the way in which they provide Commissioner Requested Services, without the agreement of relevant commissioners. Continuity of Services Condition 2: Restriction on the disposal of assets TW/MF N/A This condition is not applicable until commissioner requested services have been designated by This licence condition ensures that licensees keep an up-to-date register of the commissioner. CLCH maintains a full asset register. relevant assets used in the provision of Commissioner Requested Services. It also creates a requirement for licensees to obtain Monitor’s consent before disposing of these assets when Monitor is concerned about the ability of the licensee to carry on as a going concern. Continuity of Services Condition 3: Monitor risk rating TW/MF N/A Annual accounts are subject to external audit, amongst other things, to ensure that the This condition requires licensees to have due regard to adequate standards of requirements of the DH&SC Group Accounting Manual (GAM). corporate governance and financial management. Finance systems undergo regular internal audit in line with the internal audit plan. Control issues in relation to finance are reported to the Audit Committee. Recent issues identified in relation to the South Division (external report) are being addressed and will be used to inform future controls and assurance processes. Corporate governance arrangements are described in the annual governance statement The CQC inspection in 2017, including well-led and the Trust achieved a rating of ‘good’. Corporate governance arrangements will be reviewed in 2019. Continuity of Services Condition 4: Undertaking from the ultimate controller TW/MF N/A As an NHS trust we are our own ulitmate controller. The condition is designed to address FT This condition requires licensees to put in place a legally enforceable agreement organisations with potentially more complex corporate structures. with their ‘ultimate controller’ to stop ultimate controllers from taking any action that would cause licensees to breach the licence conditions. This condition specifies who is considered to be an ultimate controller.
Continuity of Services Condition 5: Risk pool levy TW/MF N/A This condition is not applicable until commissioner requested services have been designated by This licence condition obliges licensees to contribute, if required, towards the the commissioner. Some contracts require us to underwrite losses where there is a contract funding of the “risk pool” - this is like an insurance mechanism to pay for vital failure. services if a provider fails.
Continuity of Services Condition 6: Cooperation in the event of financial stress TW/MF N/A This condition is not applicable until commissioner requested services have been designated by This licence condition applies when a licensee fails a test of sound finances, and the commissioner. obliges the licensee to cooperate with Monitor in these circumstances. CLCH in surplus, achieving control total/segment 1.
Continuity of Services Condition 7: Availability of resources TW/MF N/A This condition is not applicable until commissioner requested services have been designated by This condition requires licensees to act in a way that secures access to the the commissioner. resources needed to operate Commissioner Requested Services. CLCH negotiates contracts and process on annual basis. Has saught mediation where consider settlement offered would leave us unable to provide service safely.
247 Appendix 6: Single Oversight Framework (SOF) action plan
Assessment Area Component Action Owner Leads Due Status Notes
An internal update of our NHSI Well-led Framework assessment has been carried out and will be submitted to October Board. External review of this assessment Review and refresh Trust Associate Director of Associate Director 2018 will be deferred till 2019 (subject to NHSI Well-Led framework action Resilience & of Resilience & On track (Internal) agreement). plan Compliance Compliance The NHSI framework uses the same 10 KLOE as the CQC but goes into further depth with sub questions.
Effective Board and Governance
Following the CQC well led assessment in October 2017 and reported outcome of ‘good’ the external assessment has been considered and the Board has concluded Schedule an external well that the external assessment planned for Trust Secretary Trust Secretary N/A N/A led assessment the summer of 2018 does not need to be undertaken as this would be repetitive.
The external well-led review will take place Leadership and in May 2019. Improvement Capability (Well- led)
The Trust now has an operating data warehouse, with both SystmOne and Emis, pulling data into a conformed layer. The delivery of corporate services data into the conformed layer is now on track.
The Data Quality forum continues to review Ensure action plans to CIO, BIPA Director Director of data quality issues, with change control Use of Data address data concerns are and Business 31-Oct-18 Ongoing Improvement managed by the Change Authority Board. up-to-date Managers Data performance is monitored by the Executive Team and monthly performance review.
Further development work is underway to build and report clinical outcomes directly from the data warehouse.
248 Appendix 7 - SOF Use of Resources Quantitative Indicators Assessment Current Area UoR Indicator Definition Lead Current Internal Assessment / Comments Performance
This metric looks at the length of stay between admission and an emergency procedure being carried out – the aim being to Pre-procedure non-elective bed minimise it – and the associated financial productivity N/A N/A Not applicable to CLCH days opportunity of reducing this. Better performers will have a lower number of bed days.
This metric looks at the length of stay between admission and an elective procedure being carried out – the aim being to Pre-procedure elective bed days minimise it – and the associated financial productivity N/A N/A Not applicable to CLCH opportunity of reducing this. Better performers will have a lower number of bed days.
Clinical Services: This metric looks at the number of emergency readmissions Emergency readmissions (30 within 30 days of the original procedure/stay, and the N/A N/A Not applicable to CLCH days) associated financial opportunity of reducing this number. Better performers will have a lower rate of readmission.
DNAs - Number of pre-booked first A high level of DNAs indicates a system that might be making contact unnecessary appointments or failing to communicate clearly appointments = 931 with patients. It also might mean the hospital has made Children's and Inner Divisions DNA rates incorporated into (46.3%) Did not attend (DNA) rate appointments at inappropriate times, eg school closing hour. DDO to be assigned September current performance. BIPA to follow with the complete Patients might not be clear how to rearrange an appointment. DNA rate for all Divisions DNAs - Number of Lowering this rate would help the trust save costs on pre-booked follow up unconfirmed appointments and increase system efficiency. appointments = 1084 (53.7%)
249 As this metric concentrates on the overall reduction of higher levels of leavers that the organisation should seek to reduce, the most apt metric is that on voluntary turnover.
Apr 17: 13.47% May 17: 13.23% Jun 17: 13.49% Jul 17: 13.61% Aug 17: 14.14% Sep 17: 14.13% Oct 17: 14.54% Nov 17: 14.66% Dec 17: 15.42% Jan 18: 15.77% Feb 18: 15.84% This metric considers the stability of the workforce. Some Mar 18: 15.74% turnover in an organisation is acceptable and healthy, but a Apr 18: 15.41% Louella May 18: 15.45% Staff retention rate (voluntary high level can have a negative impact on organisational Johnson/Julian St 14.60% Jun 18: 14.84% turnover rate) performance (eg through loss of capacity, skills and Clair Gribble Jul 18: 14.84% knowledge). In most circumstances organisations should seek Aug 18: 14.77% to reduce the percentage of leavers over time. Sep 18: 14.60%
During the 2017/18 period, the Trust experienced operational and commissioning environment changes that caused the turnover rate to deteriorate (reflecting the run of 7 increasing data points on the SPC chart above).
The statistical process control also shows that we have set the 2018/19 target rate at the very lower control target which means it is extremely unlikely that the target rate can be achieved, however, it should be noted that after the apex in Feb 2018 there have been 6 reduced points. A 7th would indicate a positive stepped change in turnover rates.
The Trust has refocused the remit of Recruitment and Retention Group to look at Divisional retention plans and will be monitoring and steering both local and centralised retention initiatives.
250
The Trust has proactively targeted reducing sickness absence levels over the last 3 years and the recurrent rates of sickness for the Trusts hold in a healthy and stable position. Factoring in that the Trust has expanded twice in the period (April with Merton and October with Wandsworth Adults) maintaining a stable rate vindicates the continued effort by managers and support services and services continue to monitor the sickness levels in monthly performance oversight meetings.
Apr 17: 3.25% May 17: 3.29% Jun 17: 3.30% Jul 17: 3.36% Aug 17: 3.43% Sep 17: 3.42% Oct 17: 3.45% People: Nov 17: 3.49% Dec 17: 3.53% How effectively is the Jan 18: 3.56% trust using its Feb 18: 3.61% workforce to maximise Mar 18: 3.65% High levels of sickness absence can have a negative impact on Apr 18: 3.71% patient benefit and Louella organisational performance and productivity. Organisations May 18: 3.74% provide high quality Sickness absence rate Johnson/Julian St 3.83% should aim to reduce the number of days lost through sickness Jun 18: 3.77% care? Clair Gribble absence over time. Jul 18: 3.8% Aug 18: 3.79% Sep 18: 3.83%
Applying statistical process control to sickness rates we can see that although the rate is within the targeted tolerances, until the month of August, there was a statistically material increase in the sickness rates. Between April 17 and July 18 the highest specific reasons quoted for sickness absence were:
Anxiety/Stress/Depression/other psychiatric illness (22.26%) and Back and Other MSK issues (14.53%) (all other reasons were under 10% of the overall sickness). Stress and Anxiety has been an area that has been on the increase and although no root cause analysis can be conducted, the level of pressure on staff in delivering quality, effective care whilst balancing resources and financial restraint is likely to be having an impact.
All cases that Trigger via the Trusts sickness absence policy should be proactively managed by the operational line manager with support from the transformation team.
251
This metric shows the staff element of trust cost to produce one WAU across all areas of clinical activity. A lower than Pay cost per weighted activity average figure is preferable as it suggests the trust spends less Krishna Methodology for metric to be developed as part of annual N/A unit (WAU) on staff per standardised unit of activity than other trusts. This Vivekandandan reference costs project for completion by the end of July allows trusts to investigate why their pay is higher or lower than national peers.
This is a doctor-specific version of the above pay cost per WAU metric. This allows trusts to query why their doctor pay is Krishna Methodology for metric to be developed as part of annual Doctors cost per WAU higher or lower than national peers. Consideration should be N/A Vivekandandan reference costs project for completion by the end of July given to clinical staff mix and clinical staff skill mix when using this metric.
This is a nurse-specific version of the above pay cost per WAU metric. This allows trusts to query why their nurse pay is higher Krishna Nurses cost per WAU or lower than national peers. Consideration should be given to N/A Methodology for metric to be developed Vivekandandan clinical staff mix and clinical staff skill mix when using this metric.
This is an AHP-specific version of the above pay cost per WAU metric. This allows trusts to query why their AHP pay is higher Allied health professionals cost Krishna or lower than national peers. Consideration should be given to N/A Methodology for metric to be developed per WAU (community adjusted) Vivekandandan clinical staff mix and clinical staff skill mix when using this metric.
As part of the top 10 medicines project, trusts are set trust- specific monthly savings targets related to their choice of medicines. This includes the uptake of biosimilar medicines Top 10 medicines - percentage (complex medicines that are clinically comparable to the N/A - This metric is relevant to acute trusts not community health Arfana Butt N/A delivery of savings target branded product), the use of new generic medicines and choice services. We do not use these types of medicines at CLCH. of product for clinical reasons. These metrics report trusts’ % achievement against these targets. Trusts can assess their success in pursuing these savings (relative to national peers).
Clinical Support Services:
252
Services:
The cost per test is the average cost of undertaking one pathology test across all disciplines, taking into account all pay and non-pay cost items. A low value is preferable to a high value but the mix of tests across disciplines and the specialist Overall cost per test Arfana Butt N/A N/A - Pathology is not related to medicines management. nature of work undertaken should be considered. This should be done by selecting the appropriate peer group (‘Pathology’) on the Model Hospital. Other metrics to consider are discipline level cost per test.
This metric shows the non-staff element of trust cost to produce one WAU across all areas of clinical activity. A lower than average figure is preferable as it suggests the trust spends Krishna Methodology for metric to be developed as part of annual Non-pay cost per WAU N/A less per standardised unit of activity than other trusts. This Vivekandandan reference costs project for completion by the end of July allows trusts to investigate why their non-pay spend is higher or lower than national peers.
This metric shows the annual cost of the finance department Finance cost per £100 million for each £100 million of trust turnover. A low value is Malcolm Hall 0.7% at the end of Q2 Produced monthly turnover preferable to a high value but the quality and efficiency of the department’s services should also be considered.
This metric shows the annual cost of the HR department for Human resources cost per £100 each £100 million of trust turnover. A low value is preferable to Malcolm Hall 1.0% at the end of Q2 Produced monthly million turnover a high value but the quality and efficiency of the department’s services should also be considered.
C t S i
253 Corporate Services, Procurement, This metric provides an indication of the operational efficiency Currently community and mental health Trusts are not being Estates and and price performance of the trust’s procurement process. It measured on performance from the PPIB tool. Although we do Facilities provides a combined score for five individual metrics which submit data and benchmark well against other community Procurement Process Efficiency assess both engagement with price benchmarking (the process providers (as seen in the data presented at NHSI procurement Paul Betts N/A and Price Performance Score element) and the prices secured for the goods purchased workshop), this is not currently a meaningful measure due to the compared to other trusts (the performance element). A high majority of community spend not being in this tool. Therefore, it score indicates that the procurement function of the trust is should not have any weight in assessment of Trust procurement efficient and is performing well in securing the best prices. performance
As at the 31st March 2018 – ie end of full year
Total Sqm 42247.31 Total budget (all This metric examines the overall cost-effectiveness of the sites) trust’s estates, looking at the cost per square metre. The aim is Krishna £17,626,384.00 Estates cost per square metre Ian Daccus, Awase Bhatti, Krishna Vivekanandan to reduce property costs relative to those paid by peers over Vivekandandan Income time. £1,329,754.00 CCG pass through/market rent £3,631,720.00 Total less income £ 12,664,910.00 Cost psqm to Trust £299.78
This metric assesses the degree to which the organisation’s Capital service capacity Andrew De Swarte 3.157 Produced on a monthly basis generated income covers its financing obligations.
This metric measures the days of operating costs held in cash or cash equivalent forms. This reflects the provider’s ability to Liquidity (days) Andrew De Swarte 18.097 Produced on a monthly basis pay staff and suppliers in the immediate term. Providers should maintain a positive number of days of liquidity.
This metric measures the degree to which an organisation is operating at a surplus or deficit. Operating at a sustained deficit 1.6% surplus margin Income and expenditure margin Malcolm Hall Produced on a monthly basis indicates that a provider may not be financially viable or in M5 (0.3% YTD) sustainable. Finance
254 This metric measures the variance between the trust’s annual financial plan and its actual performance. Trusts are expected £34k favourable to be on, or ahead, of financial plan, to ensure the sector variance in Month 5 Distance from financial plan Malcolm Hall Produced on a monthly basis achieves, or exceeds, its annual forecast. Being behind plan (£1,014k adverse may be the result of poor financial management, poor financial variance YTD) planning or both.
Over reliance on agency staff can significantly increase costs £342k in Month 5 Agency spend without increasing productivity. Organisations should aim to Malcolm Hall Produced on a monthly basis (£1,726k YTD) reduce the proportion of their pay bill spent on agency staff.
SOF Use of Resources Qualitative Indicators Assessment Area Lead Prompts Comments • How far are delayed transfers of care that are within the Clinical Services: trust’s control leading to a lack of bed capacity and/or TBC cancellations of elective operations? How well is the trust using its resources to • Is the trust improving clinical productivity (elective and non- provide clinical services elective) by doing what could reasonably be expected of it in co- TBC DDO to be assigned that operate as ordinating services across the local health and care economy? productively as • What percentage of elective and non-elective cases are possible and thereby TBC maximise patient admitted on the day of surgery for each specialty? benefit? • Has the trust engaged with the GIRFT programme? What TBC improvements have been made as a result?
The Trust takes a holistic view of pay and budget management. We triangulating substantive, bank and agency • How is the trust tackling excessive pay bill growth, where pay costs against the allowable budget to ensure pay bills are with expected tolerances and do not escalate by relevant? putting into place remedial actions where required.
The Trust adopts a robust oversight and management of agency usage and pay costs balancing clinical need and good financial governance. At the close of 2017/18 against the internally set stretch target of £8,003,000 we posted £6,350,404.70.
M6 YTD in 2018/19 we are under spent against our stretch target posting £2,066,397.90 against the trajectory • Is the trust operating within the agency ceiling? target of £2,628,023.58.
The Trust will continue to maintain the balance ensuring clinical need is met whilst applying robust oversight so that no spend that is avoidable is incurred. We have also formed a Zero Agency group to target reducing agency spend to 0 in a three year period.
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The Trust has managed the lowest vacancy rate in the last 21 months at the start of April 2018 (10.37%) however since that naider, there have been 5 increased data points is beginning to indicate a possible stepped change from the April position. Analysis of the movement of the Divisional vacancy rates shows different pressures on Divisions. CHD remains within targeted tolerances; Inner and the South have experienced both an increase in the establishment and a negative starters rate but the North positions detrition is due to an increase in • How well is the trust reducing its reliance on temporary staff, establishments. in particular agency nurses and medical locums? The close of 2017/18 the Trust had targeted new bank recruitment of 285 which was exceeded with 321 recruited to the bank. The 2018/19 position unfortunately has not maintained the same pace with lower vacancy rates experienced at the start of the year as well as agency usage reducing pressure on the need for bank staff. Throughout the period a fill rate of circa 90% has been achieved.
Services assess their operational rosters identifying gaps and prioritising cover and mitigation as required. Areas • Are there significant gaps in current staff rotas? What has the of significant challenges are escalated to the recruitment and retention group for co-ordinated Trust initiates to trust been doing to address these? retain current staff and to recruit to those vacant posts. In instances of significant need, Workforce Action Teams are mobilised for a quicker Trust response.
The Trust has completed roll out the Allocate health Roster system across the Trust. Coverage is now universal People: (exempt for new services recently acquired) and includes all staff groups bar those on non AfC terms and Louella Johnson/Julian St Clair conditions (for which the Trust is exploring the most effective way of rostering with the Allocate Central team). • Is the trust making effective use of e-rostering or similar job Gribble The Trust operates over 250 active rosters on the system and is focusing on payroll enabling all rosters. Transfer How effectively is the management software systems for doctors, nurses, midwives, from programme roll out to Business as usual was successful at the close of August 2018. trust using its AHPs, healthcare assistants and other clinicians? How many workforce to maximise weeks in advance are the trust’s rosters signed off? patient benefit and The Trust monitors the compliance rate with the Carter recommendation of fully approved rosters being in place provide high quality 6 weeks in advance but during the last 3 periods has struggled in the 80% compliance bracket short of our care? previous levels of over 90% recurrently.
• Is there an appropriate skill mix for the work being carried For Quality & Learning and Operations Directorate to comment out (clinical and otherwise)?
• Are new and innovative workforce models and/or new roles being investigated? Is the trust making effective use of AHPs to For Quality & Learning and Operations Directorate to comment improve flow?
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Sickness Absence –
Reviewing the monthly sickness rates using SPC we can see that The overall monthly rates fluctuate but have tended to be at or above the mean rate (for the last 21 months data) indicating a pressure on sickness absence
When looking at the rolling 12 month rates there has been increasing pressure with a upwards trend in sickness absence.
Reviewing the reasons for sickness at a granular staff group and CBU level for the breach areas, analysis shows that there is no specific pattern to the core absence reasons. However, it is notable that • Is the trust an outlier in terms of sickness absence and/or Anxiety/Stress/depression was the main reason for sickness in the quarter for these areas. staff turnover? Managers continue to be supported by the HR Transformation team to actively manage sickness triggers.
Turnover –
SPC analysis for the last 21 months of rolling voluntary turnover shows that after reaching the apex of 15.84% in Feb 2018, we have multiple reducing data points indicates a stepped change (improvement) in performance to the close of September and the rate is within 0.5% of the mean rate.
The Recruitment and retention group has tasked Divisions with developing localised retention plans focused on improving retention rates in their areas.
100% of CLCH employed Consultants have a job plan in place. The data is captured via all completed and signed • What proportion of consultants has a current job plan? How Nish Matenjwa job plans. These are subsequently forwarded to the Medical Directorate’s Appraisal Facilitator who collates and is job plan data captured? inputs them into a Medical Directorate database
• Is the trust collaborating with other service providers to Pathology is not a Medicines Management remit Clinical Support deliver non-urgent pathology and imaging services? Services:
• Is the trust an outlier in terms of medicines spend? No How effectively is the trust using its clinical Arfana Butt support services to • Is the trust using technology in innovative ways to improve deliver high quality, operational productivity? For example, patients receive sustainable services for N/A - Our patient facing services are on wards telephone or virtual follow-up appointments after elective patients? treatment.
257 Trust in 2015 undertook a major process of review and subsequent outsourcing of corporate functions to Capita (7 year contract) which consolidated and delivered savings. This contract is under constant review for additional • What is the trust doing to consolidate its corporate service savings and the Trust will shortly be commencing a programme to look at whether to extend or otherwise. functions? Which functions are being consolidated and how? This contract includes most transactional services and some entire functions across HR, Finance, Payroll, Estates, Business Intelligence, IMT and procurement. Additionally, procurement service is working collaboratively across Corporate Services, NWL and NCL STPs Procurement, Estates and Trust procurement costs are in the lowest quartile under Carter benchmarks under model hospital. The service is • Is the trust an outlier in terms of procurement costs? Facilities: outsourced to Capita
How effectively is the The Trust is always reviewing procurement opportunities and efficiencies. This includes using the new category Paul Betts towers under the Procurement FOM where relevant. The existing SFIs and processes Trust leads must follow trust managing its • Is the trust looking for and implementing appropriate have been reviewed. corporate services, efficiencies in its procurement processes? procurement, estates The procurement model that has been agreed with Capita builds in flexibility and access to specialist category and facilities to expertise as well as incentivising savings via the commercial model maximise productivity • What is the value of the trust’s backlog maintenance (as cost to the benefit of TBC patients? per square metre) and how effectively is it managed?
• How efficiently is the trust using its estate and is it maximising the opportunity to release value from NHS estate TBC that is no longer required to deliver health and care services?
• Did the trust deliver, and is it on target to deliver, its control total and annual financial plan for the previous and current Yes financial years respectively?
The Trusts control total without STF funding is £1.6m; the underlying position is currently £3.3m short of this • What is the trust’s underlying financial position? surplus
The Trust has a good track record of finding non recurrent schemes to cover in year gaps in QIPP delivery (e.g. • How far does the trust rely on non-recurrent cost where a key scheme only delivers a part year effect in year or has its start date delayed). Approx 20% of delivery improvement programmes (CIPs) to achieve financial targets? Finance: in 17/18 was related to non recurrent schemes
How effectively is the The Trust has had gaps in recurrent delivery in past years, however has managed to continually meet its surplus trust managing its • What is the trust’s track record of delivering CIP schemes? requirements through built in CIP contingencies and non recurrent schemes. Gaps in recurrent delivery have Krishna Vivekandandan financial resources to always been picked up in future year CIP targets to ensure underlying sutainability deliver high quality, sustainable services for • Is the trust able to adequately service its debt obligations? Yes patients?
• Is the trust maintaining positive cash reserves? Yes • Is the trust taking all appropriate opportunities to maximise Yes its income? Primarily through contract based budgeting which highlights controllable support cost proportions to services • How does the trust use costing data across its service lines? and profit and loss position on individual contracts
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• To what extent does the trust rely on management All usage would need to be approved through ZAG/business case consultants or other external support services?
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BOARD OF DIRECTORS 31 October 2018
Report title: Update following Audit Committee meeting 11.10.18
Agenda item number: 4.6.1
Lead director responsible for Audit Committee Chair approval of this paper
Report author Trust Secretary
Relevant CLCH strategic Trust objective 2018/19 priorities Strategy implementation Implement strategic priorities of integration and place Quality Maintain and improve the quality of services delivered by CLCH Finance Deliver the 2018/19 financial plan Freedom of Information Can be published status Executive summary: Together with routine items, the Committee considered a number of important and interesting reports. A summary of the key issues is attached.
Further assurance in relation to disclosure and barring service checks; salary overpayments and planned QIPP savings for 2018/19 has been requested.
Assurance provided: The Audit Committee is a statutory Committee and has an agreed work programme in support of the Trust and Board. Report provenance: The Audit Committee discussed these issues in full on 11.10.18. Members of the executive and management team were in attendance. A copy of audit papers is routinely shared with all Board members. Report for: Decision Discussion Information x
Recommendation: To note the report.
260 1 Internal audit progress report 1.1 HR – management of HR and recruitment (limited assurance) The assurance review had resulted in a number of recommendations in relation to: induction, work permits and disclosure and barring service (DBS) checks. Members were concerned that adherence to policy and process had been found to be poor.
1.2 The Committee was assured that robust management ownership, action and follow-up, rather than a change of process, was needed to improve compliance and mitigate risks. Members have requested that, together with consideration by the Workforce Committee, that the Quality Committee considers the report and related clinical risks at the next meeting on 24.10.18. This has been agreed with the Committee Chair.
1.3 Medicine management – pharmacy stock (limited assurance) A number of recommendations had been made in relation to compliance with the policy and process for ordering and managing pharmacy stock. Members were assured that the recent move to a single provider would enhance the ordering process.
1.4 It has been suggested that it would be useful to look at stock levels annually, to determine optimum levels as part of routine audits already undertaken.
1.5 Since there is no legal requirement for controlled drugs to be countersigned by a doctor, it was agreed that the practicality of this requirement should be considered at the next policy review – in November 2018.
1.6 Internal audit progress report Members have reiterated the importance of the Board considering the draft internal audit plan each year and the necessity of all audits being completed, including the management response, for report before year end1 to inform the annual governance statement and head of internal audit opinion.
1.7 Members were concerned that recent limited assurance reports had identified issues in relation to basic controls, processes and compliance. ELT have been asked to consider how they can strengthen monitoring arrangements for routine business functions in order to give the committee greater assurance.
1.8 It was also agreed that it would be useful for the executive lead for any further limited assurance reports to attend the Audit Committee when these are considered.
2 Counter fraud 2.1 Two new referrals had been closed during the reporting period; 2 further referrals had been received since preparation of the report and would be reported in December (or sooner if indicated). A private meeting between members and the counter fraud team had been held prior to the meeting to discuss an allegation of fraud received in September 2018. A number of proactive fraud initiatives have been planned including an analysis of the Trust’s compliance with standing orders and standing financial
1 For consideration on 11.04.19.
261 instructions (SOFIs) and a national payroll integrity initiative.
3 Single tender waivers 3.1 There have been 8 waivers during the reporting period (£235k in total).
4 Losses and special payments 4.1 Two payments (total £145.60) have been made since July 2018.
5 Salary overpayments / aged debt 5.1 There was a lengthy and detailed discussion about recent debt write-off and potential future write-offs. Members were assured that action to reduce the number and level of salary overpayments, and to increase the level of debt recovered where over- payments had been made, would be strictly applied.
5.2 Members were disappointed that basic controls, for example records to substantiate cases to recover debt had been missing in a large number of the cases listed as uneconomical or unlikely to be recovered which was unacceptable.
5.3 It was agreed that the Committee would receive a report in relation to salary overpayments every six months.
6 Contract management 6.1 The Committee noted action taken to resolve a significant contract dispute and to improve the management of third party contracts.
7 External audit 2017/18 recommendations - update 7.1 Members welcomed the assurance that progress was being made in implementing KPMG’s recommendations and that quarterly journals had improved.
8 Data quality strategy – monitoring and implementation plan 8.1 Accurate, weekly data reports are now being produced. It was agreed that it would be helpful to consider the revised strategy and plan in April 2019 (at the latest).
9 Risk management strategy – annual review 9.1 There were no recommended changes to the risk management strategy.
10 Board assurance framework (BAF) Q2 10.1 A number of changes to the report were agreed and the Committee reiterated their concern that in Q3 assurance in relation to achievement of current year QIPP savings had not yet been provided. The senior leadership team will review gaps in control and assurance related to QIPP project plans for 2018/19 and, if possible, eliminate them. They will also identify the percentage / value of schemes at risk for inclusion in the report to Board in October.
10.2 The KPMG benchmarking report will be considered with the findings from the internal audit review together with Quality Committee consideration of clinical risks – for report in December 2018.
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11 New and outstanding control issues 11.1 It was agreed that the control issues in relation to the South Division and Speech and Language Therapy could be closed as recommended but that it would be helpful for ELT to consider how the broader lessons from these events, for example cultural issues, could be addressed through a structured approach and applied systematically.
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Board of Directors 31 October 2018
Report title: Terms of reference, Quality Committee - annual review
Agenda item number: 4.6.3 Lead director responsible for approval of this paper Andrew Ridley, CEO Report author Jayne Walbridge, Trust Secretary
Relevant CLCH strategic Trust objective 2018/19 priorities Strategy implementation Implement strategic priorities of integration and place Quality Maintain and improve the quality of services delivered by CLCH Freedom of Information Can be published status Executive summary: The terms of reference were last reviewed in September 2017 with only minor amendment.
Changes proposed this year - shown tracked – support the revised Board composition and changes proposed over the past 12 months, for example that the FRIC, rather than the Quality Committee will review information governance risks and that the Committee will monitor performance and seek assurance in relation to clinical audit, as recommended by the Audit Committee.
Given the move to quarterly meetings – the frequency of attendance by members and the CEO has been revised, together with including how exceptions, in relation to risks to high quality care, will be communicated to members.
Following approval by the Board later in November, a supporting annual programme will be prepared, commencing in January 2019. This will show how the Committee will deliver against each responsibility and will include the lead director and form of assurance to be provided.
Assurance provided: The current terms of reference have been approved by the Board and remain generally consistent with the foundations of good governance, compendium of best practice (third edition) published by the NHS Providers and DACbeachcroft in November 2015.
Report provenance: The Trust Board approved the current terms of reference in October 2017. Proposed changes have been discussed with the Committee Chair, Trust Chair, CEO and considered by ELT and agreed by the Quality Committee
Report for: Decision Discussion Information x Recommendation: For Board approval and publication.
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QUALITY COMMITTEE TERMS OF REFERENCE
Role The role of the Quality Committee is to seek assurance on quality and risk issues including the clinical agenda to ensure that appropriate governance structures, systems and processes are in place across the Trust and to provide such assurance to the Board.
Definitions “the Trust” means Central London Community Healthcare NHS Trust “the committee” means the Quality Committee “the Directors” means the Trust’s Board of Directors.
1 Membership 1.1 Members of the committee shall be appointed by the Board of Directors. The committee shall be made up of 7 members. There will be an equal number or majority of Non-Executive Directors shall be in the majority. Members may appoint a deputy to represent them at a committee meeting. Members of the Quality Committee are as follows: • 4 x Non-Executive Directors • Chief Nurse and • Chief Operating Officer • Director of Improvement • Executive Medical Director
1.2 The Chief Executive shall attend at least quarterly twice a year 1.3 Only members of the committee have the right to attend and vote at committee meetings. The committee may require other officers of the Trust and other individuals to attend all or any part of its meetings. 1.4 The chair of the committee will be an independent Non- Executive Director. In the absence of the committee chair and/or an appointed deputy, the remaining members present shall elect another member who is a Non- Executive Director to chair the meeting.
2 Secretary 2.1 The Trust Secretary or their nominee shall act as the secretary of the committee.
3 Quorum 3.1 The quorum necessary for the transaction of business shall be 2 Non- Executive Directors and one Executive Director. A duly convened meeting of the committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the committee.
4 Frequency of meetings and attendance requirements
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4.1 The committee will normally meet ten 4 times a year at appropriate times in the reporting cycle and otherwise as required; 4.2 Committee members should aim to attend all scheduled meetings but must attend a minimum of seven 3 meetings unless otherwise agreed with the Chair. The Secretary of the committee shall maintain a register of attendance which will normally be published in the Trust’s annual report.
5 Notice of meetings 5.1 Meetings of the committee may be called by the secretary of the committee at the request of any of its members. 5.2 Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member of the committee, any other person required to attend and all other non-executive directors, no later than working days - before the date of the meeting. Supporting papers shall be sent to committee members and to other attendees as appropriate, at the same time.
6 Minutes of meetings 6.1 The Trust Secretary, or nominated deputy, shall minute the proceedings of all meetings of the committee, including recording the names of those present and in attendance. 6.2 Members and those present should state any conflicts of interest and the secretary should minute them accordingly. 6.3 Minutes of committee meetings should be circulated promptly to all members of the committee and, once agreed, to all members of the Board of Directors unless a conflict of interest exists.
7 Annual General Meeting 7.1 The Chair of the committee will normally attend the Annual General Meeting prepared to respond to any questions on the committee’s activities.
8 Duties The committee should carry out the following duties for the Trust:
8.1 Quality 8.1.1 To review implementation of all elements of the quality strategy, as set out in the underpinning quality campaigns as follows. In particular, to obtain assurance that the measures for success are achieved within appropriate time scales.
8.1.2 The Quality Campaigns: Campaign Description Campaign 1 Changing behaviours and care to A Positive Patient enhance the experience of our patients Experience and service users
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Campaign 2 Preventing Reducing unwarranted variations in care Harm and increasing diligence in practice
Campaign 3 Ensuring patients and service users Smart, Effective Care receive the best evidence-based care, every time
Campaign 4 Modelling Providing world-class models of care, the Way education and professional practice
Campaign 5 Recruiting and retaining an outstanding Here, Happy, Healthy clinical workforce and Heard
Campaign 6 Using continuous improvement Value Added Care methodologies to manage resources well including staff, time, equipment and referrals
8.1.3 To receive monthly assurance reports and performance updates for the following campaigns (note Modelling the Way and Here Happy Heard and Healthy) are reviewed at Workforce Committee, however Quality Committee receives the full KPI each month and a quarterly quality strategy update on all 6 campaigns
• Preventing Harm • A Positive Patient Experience • Smart Effective Care • Value Added Care
8.1.4 To gain assurance over the full range of quality performance via the quality report, and quality dashboard, and minutes of the fourtogether with exception reports from the 4 groups which report into the Quality Committee. This will include reports from the Strategic Improvement Group (which considers strategic developments in quality improvement). (including unconfirmed minutes if necessary. Note – following the move to quarterly meetings in 2017, it has been agreed that a monthly note regarding quality performance is circulated to all members – including any exceptions) 8.1.5 To meet with representatives of the quality stakeholder reference groups at least twice annually.consider receive plans for the annual co-design event with patients 8.1.6 To receive reports as appropriate and as the committee may request from any of the work groups that feed into the quality campaign groups. 8.1.7 To monitor the production of the quality account; ensuring they are produced annually and in accordance with the relevant guidance. 8.1.8 To receive additional reports on delivery of annual objectives as defined within the quality account.
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PREVENTING HARM
8.2 Risk 8.2.1 To scrutinise and review risks rated 15 and above for the following risk categories: clinical, and environmental. and information governance. 8.2.2 To receive a regular update on new, removed and changes in scoring of risks on the corporate risk register as they pertain to the above risk categories. 8.2.3 To obtain assurance that risks are being managed appropriately and to escalate any particular concerns to the board or relevant directors. 8.2.4 To identify any new risks and issues arising during meetings and agree any action required. 8.2.5 To obtain assurance that the Trust has effective mechanisms for improving service user safety, learning from incidents, and taking action to reduce risks.
8.3 Care Quality Commission (CQC) - Fundamental Standards 8.3.1 To monitor compliance against the CQC’s Fundamental Standards and obtain assurance that standards are being met and that improvement reviews are implemented1. A POSITIVE PATIENT EXPERIENCE
8.4 Involving and learning from service users 8.4.1 To obtain assurance that the experience of users, carers and voluntary groups are central to the Trust’s work. 8.4.2 To obtain assurance that the implementation and maintenance of programmes for measuring, monitoring and improving the experience of service users and carers are appropriate and relevant. 8.4.3 To obtain assurance that lessons learnt from involving service users are used to improve the quality of service provided. 8.4.4 To monitor the delivery of the Trust’s patient engagement plans, including a programme of events across our geography. SMART EFFECTIVE CARE
8.5 Monitoring and improving clinical performance 8.5.1 To approve the annual programme of Trust-wide clinical audits and to monitor performance and seek assurance in relation to clinical audit2 8.5.2 To obtain assurance that clinical recommendations resulting from complaints investigated by the Parliamentary and Health Service Ombudsman, the implementation of NICE Guidelines and Technology Appraisals and recommendations for improving clinical performance resulting from national reviews and other external inquiries are appropriately managed. 8.5.3 To receive, at least annually, the log in relation to Caldicott approval of requests for information. VALUE ADDED CARE
8.6 Using enhanced tools, technology and lean methodologies to
1 the Audit Committee will consider, annually, the CQC statement of purpose prior to Board approval 2 Ref Board of Directors 29.03.18
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manage resources well including time, equipment and referrals 8.6.1 To seek assurance that development plans and resources are being aligned to identified needs in support of quality improvement.
See also 8.1.4 above
8.7 Clinical Governance 8.7.1 To obtain assurance that appropriate clinical governance structures groups, systems, and processes are in place, and developed in line with national, regional and commissioning expectations.
9 Reporting responsibilities 9.1 The committee will report to the Board of Directors on its proceedings after each meeting. 9.2 The committee shall make whatever recommendations to the Board of Directors it deems appropriate on any area within its remit where action or improvement is needed. 9.3 The committee will produce an annual report to the Board of Directors. 9.4 The committee will identify any control issues and bring these to the attention of the Audit Committee
See also 8.1.3 above.
10 Other matters The committee should: 10.1 have access to sufficient resources in order to carry out its duties, including access to the Trust secretariat for assistance as required; 10.2 be provided with appropriate and timely training, both in the form of an induction programme for new members and on an on-going basis for all members; 10.3 give due consideration to laws and regulations; 10.4 at least once a year, review its own performance and terms of reference to ensure it is operating at maximum effectiveness and recommend to the Board of Directors for approval, any changes it considers necessary.
11 Authority 11.1 The committee is a committee of the Board of Directors and has no powers, other than those specifically delegated in these terms of reference. The committee is authorised: 11.1.1 to seek any information it requires from any employee of the trust in order to perform its duties 11.1.2 to obtain, outside legal or other professional advice on any matter within its terms of reference via the Trust Secretary 11.1.3 to call any employee to be questioned at a meeting of the committee as and when required.
12 Monitoring and Review:
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12.1 The Board will monitor the effectiveness of the committee through receipt of the committee's minutes and such written or verbal reports that the chair of the committee might provide. 12.2 The secretary will assess agenda items to confirm they comply with the committee’s responsibilities and programme. 12.3 Terms of reference agreed by Quality Committee on 24.10.18 for approval by by the Board on 31.10.18 12.4 Date of next review October 2019.
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Quality Committee Minutes of the meeting held on Tuesday, 24 July 2018 In Boardroom, Ground Floor, 15 Marylebone Road, London NW1 5JD
Present Louise Ashley Chief Nurse and Chief Operating Officer Carol Cole Non-Executive Director (Committee Chair) Angela Greatley Non-Executive Director (Trust Chair) Joanne Medhurst Medical Director (part) Jane Slatter Non-Executive Director
In attendance Holly Ashforth Director of Nursing and Therapies (Patient Experience and Education) Paula Constant Associate Non-Executive Director Glenda Esmond Respiratory Nurse Consultant (part) Elizabeth Hale Director of Transformation Brenda Persaud Head of Research and Development (part) Dr Kay Roy Respiratory Consultant (part) Shirley Rush Corporate Governance Manager (minutes) Charlie Sheldon Director of Nursing and Therapies (Quality and Patient Safety) Lori Taylor Team Leader, Children’s Health and Development Service (Observer) Jayne Walbridge Trust Secretary
QC/70/18 Welcome, introduction and apologies 70.1 Apologies had been received from David Sines, Non-Executive Director and James Benson, Director of Improvement.
70.2 The Committee welcomed Jane Slatter, NED, to her first meeting as a member.
QC/71/18 Declarations of interest 71.1 There were no interests declared.
QC/72/18 Minutes of the meeting held on 18 April 2018 72.1 The minutes of the meeting held on the 18 April 2018 were agreed as a true and accurate record subject to the amendment of minute 52.3, with reference to Care Hours Per Bed Day initiative, which L Ashley will re-draft.
QC/73/18 Action log, matters arising, sustainability action log Action log and matter arising 73.1 All actions were marked as complete and it was agreed these actions could be closed.
73.2 AQC/26/18 - PLACE - meal time E Hale confirmed that evening meals were being served at a later time (than 5.30pm), which had been reported by patients as being too early.
73.3 AQC/27/18 - PLACE - triangulation of data along with health and safety In response to a question from C Cole, E Hale confirmed that PLACE information is discussed at both health and safety and strategic estates meetings, both chaired by the Director of Improvement. C Cole would check that D Sines is assured on this point.
73.4 AQC/28/18 - risks not under the responsibility of the quality committee The Committee supported the proposal that only risks attributable to the Committee (clinical and environmental) would be presented for consideration. 271
Sustainability of assurances log 73.5 The sustainability of assurances log was considered and it was noted that the workforce action team for Inner London community nursing would be closed in response to the significant progress that had been made to reduce vacancies. The WAT team will undertake a follow-up in six months to ensure the good progress is sustained.
73.6 The updates relating to item 2.17.1 NICE arrangements and clinical audits were noted. The item will remain on the log.
QC/74/18 Delayed transfer of care (DTOC) exception reporting 74.1 The Committee discussed the DTOC report which had been prepared at the suggestion of the Finance, Resources and Investment Committee, to consider current actions to reduce delays and improvement to achieve this Board strategic key performance indicator (KPI) - maximum 3.5% of bed days lost to DTOC (a national target).
74.2 Members acknowledged the challenges, both within and outside of the control of the Trust, including patient choice and reliance on social care agencies. In response, to a question from J Slatter regarding achievement of the target, L Ashley reported that focus on internal factors, such as reviews of discharge coordination, to improve performance would continue. It was acknowledged that achievement of the target, met only in February 2018, would be challenging.
Resolved 74.3 The delayed transfer of care exception report was noted and that the Board would continue to monitor performance.
QC/75/18 Service presentation – research and quality improvement in respiratory medicine 75.1 Dr Kay Roy, Respiratory Consultant and Glenda Esmond, Respiratory Nurse Consultant provided an interesting presentation on their work and research to improve the quality of care for patients, highlighting the positive impact for staff engaged in research work.
75.2 The research goals, which were driven by continuous improvement aspirations, aim to develop better outcomes for patients with a range of conditions including COPD, asthma, bronchiectasis, interstitial lung disease and sleep apnoea. The various research projects funded by international, European and pharmaceutical companies will develop new patient pathways, improve the use of technology in the community and create and support patient educational tools.
75.3 Responding to a number of questions from members, Glenda, Brenda and Dr Roy reported: • that it was not anticipated that funding for European studies would be impacted by Brexit • the research team were preparing a business case for further resources • declarations for funding from pharmaceutical companies sat within the finance and medical directorate teams.
Resolved 75.4 The Committee thanked Glenda and Dr Roy for a very interesting presentation and were pleased to note the benefits and impact of continuous improvement projects for patients and the way they were described.
QC/76/18 Quality Report, Q1 2018/19 76.1 C Sheldon presented the quality report for Q1 2018/19 noting the positive trend
WP Denotes an item has been added to the Committee work programme 272 against indicators. The red indicators (3 for June, 5 year-to-date) were discussed. The red indicator for a 5% reduction in pressure ulcers (PUs) grade 3 / 4 (17 against a target of 8) and two PUs (YTD) in the rehabilitation units, for which action has been taken, was discussed in detail.
76.2 Members were disappointed and concerned to note the increase in PUs and sought to further understand what factors had contributed to the increase, such as acuity and sickness of patients and adherence of staff groups with high turnover, to methodologies. C Sheldon reported that despite in-depth analysis and statistical process control (SPC) no trend or pattern for the increase had emerged. The focus continues to be on preventative care, which should be achievable in bedded units. It was noted that the acquired PUs had not been severe and healed quickly. Additionally all nursing and care staff should be fully aware of the principles of care around PU prevention and were provided with information on appointment, regular updates and access to further information and resources.
76.3 Members discussed the red indicator for clinical staff turnover rate 16.52% against a target of 10% and what action and measures would need to be taken into consideration for how this target would be met. It was noted that the Board would be discussing approaches to targets at a future meeting. The Committee requested that Workforce Committee colleagues review measures for achievement at their next meeting in the Autumn. Action AQC/32/18 (S Rush for D Sines)
76.4 The Committee commended the quality team for their recent, prestigious, HSJ patient safety award ‘organisation of the year’ for our Quality Strategy, ‘Simply the Best, Every Time’ and heard that the judges had very positively commented on the implementation of the shared governance model.
Resolved 76.5 The Quality Report for quarter 1, 2018/19 was noted.
76.6 It was agreed that the content of the, now somewhat lengthy, report would be reviewed - together with that of the assurance reports. Action AQC/33/18 (C Sheldon)
QC/77/18 Quarterly red flag report 77.1 C Sheldon presented the red flag report, reminding members that services needed to meet two of the seven key criteria for two consecutive months, to flag. There were 47 red flag areas to note overall.
77.2 Members observed that the flags for vacancies and sickness, whilst not high, were rising and asked what resilience training and support was being provided to staff. C Sheldon and L Ashley reported that vacancies are monitored both in ELT and divisionally as part of performance reviews. Additionally, there are a number of initiatives underway in the South Division in support of staff as the division undergoes transformational change and financial recovery.
Resolved 77.3 The quarterly red flag report was noted.
QC/78/18 Annual CQC update 78.1 L Ashley introduced the annual CQC update and explained that that statement of purpose had not been included as this was being considered at the Board meeting.
78.2 It was confirmed that there were no outstanding actions to be undertaken and ‘must do’ and ‘should do’ recommendations were being worked through by divisions.
WP Denotes an item has been added to the Committee work programme 273 78.3 L Ashley reported that the CQC will undertake an inspection of one core service and the well-led framework ‘annually’ – next inspection anticipated one year following publication of the Trust’s ‘good’ rating in February 2018 – ie February 2019.
78.4 Members were assured that the Trust continues to meet all regulatory requirements – led by an extremely competent compliance team.
Resolved 78.5 The annual CQC update was noted and the quality team were thanked for their excellent work.
QC/79/18 Chief Nurse and Medical Director (CNMD) report Medical Director’s report 79.1 No MRSA bloodstream infections for C. difficile attributable to CLCH were reported between April to June 2018. There had been three cases of CAUTI identified and reviewed - the Trust is not an outlier in this area.
79.2 Co-design with staff to refresh the clinical strategy is underway, with a final summative conference planned for October. Staff have been responsive and engaged.
Chief Nurse report 79.3 Highlights in the chief nurse report include NHS @ 70 celebrations, removal of visa cap for doctors and nurses and the co-design conference held in June, which had been a very well attended and successful event. Recent conversations with Health Education England regarding funding for the CLCH academy had taken place and the plan to launch the academy in September is underway.
Resolved 79.4 The Chief Nurse and Medical Director’s report was noted.
QC/80/18 Assurance report from the Patient Experience Coordinating Council Chair 80.1 The performance indicators for patient experience show good performance, with the Friends and Family test score just falling short of its target at 94.2% (95%) for which actions continue to be taken to achieve the target.
80.2 The patient experience stories Annual Report 2017/18 had erroneously been omitted from the pack and would be circulated following the meeting. The report highlighted the volume and range of engagement activity in support of a positive patient experience. Action AQC/34/18 ( S Rush)
Resolved 80.3 The assurance report from the Patient Experience Coordinating Council Chair was noted along with the minutes of the meeting held on 19.04.18 and 14.05.18.
QC/81/18 Patient and public engagement strategy 2018 - 2020 81.1 H Ashforth presented the patient and public engagement strategy 2018 - 2020 that had been developed, from the previous strategy agreed in March 2016, using NHS Improvement’s patient experience framework and through a co-design event involving patients and staff. The strategy aims to achieve three objectives: • Change staff behaviours and care to improve the experience of patients • Ensure that patients are involved in all decision about their care and the service they are using • Ensure that we engage with all patient with a specific objective of engaging community less frequently heard
Resolved
WP Denotes an item has been added to the Committee work programme 274 81.2 The Committee was pleased to provide their support to the patient and public engagement strategy 2018 – 2020, which was comprehensive, explicit and included local engagement and working in partnership. Members applauded the patient experience team for their excellent work in support of engagement and quality improvement.
QC/82/18 Safeguarding adults and children annual report 2017/18 and annual safeguarding declaration 2018/19 82.1 C Sheldon introduced the annual Safeguarding Report 2017/18 and declaration for 2018/19 which had been refreshed. The report reflected that the Trust was compliant with all statutory requirements. There had been an improvement in training supported by the well-attended and very successful safeguarding conference which has received very positive feedback from staff and would be held again in 2018.
82.2 A Greatley commended the report that reflected a very successful year.
Resolved 82.3 The safeguarding adults and children Annual Report 2017/18 was noted, together with the safeguarding declaration 2018/19. The Committee congratulated Trish Stewart and her team for their tremendous work in this important area.
QC/83/18 PLACE update 83.1 The PLACE update and immediate actions, relating to cleaning, for which Sanctuary had handed over the contract, and food concerns were reviewed.
83.2 J Slatter asked whether action plans from 15 step challenge visits were reviewed alongside PLACE actions. It was agreed it would be helpful for both 15 steps and PLACE actions plans to be reviewed together.
Action AQC/35/18 (H Ashforth / J Benson)
Resolved 83.3 The Committee noted the PLACE update.
83.4 The Committee requested to review the PLACE action plan which would be circulated to members. Action AQC/36/18 (J Benson)
QC/84/18 Assurance Report from the Patient Safety and Risk Group Chair 84.1 The assurance report for the patient safety and risk group was reviewed. A drop in ‘being open’ performance was noted in June, which had been followed up and was now recorded (on Datix) (It was clarified being open performance is recorded on Datix in order to monitor and measure performance but is also noted on the patient record - compliance relates to the record on Datix). C Sheldon reported that for patients with pressure ulcers the opportunity was taken with the being open letter to remind patients about self-care and education.
84.2 Guidance issued by NHS Improvement regarding the terminology (categories rather than grades) and some processes relating to pressure ulcers has been issued. The Trust will adopt the new guidance from October 2018, mandatory from April 2019.
Resolved 84.3 The patient safety and risk group assurance report was noted along with the minutes of the meetings held on 23.04.18, 21.05.18 and 25.05.18.
QC/85/18 Quarterly risk register 85.1 Nil risks at 15 or above (clinical and environmental).
WP Denotes an item has been added to the Committee work programme 275 QC/86/18 Medicines incident report Q4 2017/18 86.1 The Q4 2017/18 medicines incident report, showing 187 medication-related incidents and 26 controlled drug incidents, was reviewed. All of the incidents had caused low/minimal harm.
86.2 A Greatley was concerned to note the numbers of omitted or delayed doses was still quite high and hoped to see in future reports that actions taken to address this, would have a positive impact.
Resolved 86.3 The Committee noted the medicines incident report for Q4 2017/18 and were satisfied with the method for reviewing medication incidents across the Trust.
QC/87/18 Infection control Annual Report 2017/18 87.1 The infection control Annual Report 2017/18 was considered together with key achievements including zero MRSA, increased uptake of e-learning and excellent work relating to sepsis management.
Resolved 87.2 The Committee was pleased to note good performance and approved the infection control Annual Report 2017/18 on behalf of the Board who will receive the report for information.
QC/88/18 Caldicott log 88.1 Resolved The Committee noted the Caldicott log.
QC/89/18 Assurance report from the Clinical Effectiveness Group Chair Resolved 89.1 The Committee noted the Clinical Effectiveness Group Chair assurance report, together with the minutes of the meeting held on 21.05.18.
QC/90/18 Clinical audit: 2017/18 year-end report and programme for 2018/19 90.1 Good progress was noted in the clinical audit 2017/18 year-end report, which had been reviewed at the Audit Committee. Members were pleased to note processes for ‘check and challenge’ which was bringing a good level of rigour.
Resolved 90.2 Clinical audit: 2017/18 year-end report and programme for 2018/19 was noted.
QC/91/18 Clinical health records audit results 91.1 The clinical health records audit 2018 highlighted areas of good practice and areas requiring improvement.
91.2 Members were concerned to see the result for compliance to standard 4, recording patient’s allergies and sensitivities at 71% and 72 services remaining non-complaint with the target.
91.3 A Greatley was disappointed with the result relating to consent and asked how compliance might be improved. H Ashforth reported that some work was being undertaken in the dementia steering group that may help with improvement.
Resolved 91.4 The clinical health records audit results were noted and requested an update report in three months’ time.WP
QC/92/18 Medical records management – archiving and off-site records update 92.1 E Hale presented the medical records management of archiving and off-site records
WP Denotes an item has been added to the Committee work programme 276 update, following the limited assurance report received by auditors in 2016/17. The report provided assurance and action taken in response to the audit recommendation specifically relating to change location forms and retention periods for future decommissioning projects. Additionally, a briefing had been provided to staff at a recent Trust Business Meeting regarding records management and decommissioning.
Resolved 92.2 The Committee noted the medical records management – archiving and off-site records update.
QC/93/18 Assurance report from the Strategic Improvement Group Chair 93.1 E Hale presented the assurance report from the Strategic Improvement Group Chair that provided a summary of key activities relating to the value added care quality campaign and reported good progress. The challenge from the Quality Committee at previous meetings, relating to setting more ambitious targets, was being addressed.
93.2 Members welcomed the summary information provided in section 5 together with the plan to increase the use of nudge theory across the Trust to influence behaviour change.
Resolved 93.3 The assurance report from the Strategic Improvement Group Chair was noted, together with the minutes of the meeting held on 05.04.18.
QC/94/18 Clinical and quality risk assessment of QIPP – year-end post implementation report and mid-year report 94.1 It was agreed that a report would be provided in October, in line with the QIPP policy, providing a year-end report for 2017/18WP. A mid-year report would be more challenging as the QIA process was ongoing.
94.2 L Ashley expected to see a reduction in patient experience performance as divisions and services identified and implemented QIPP projects and focused on ensuring patient safety and effectiveness was not impacted.
Resolved 94.3 The clinical and quality risk assessment of QIPP – year-end post implementation report and mid-year verbal update was noted.
94.4 A presentation on the QIPP process was also requested for the October meeting.WP
QC/95/18 Quality related internal audit reports (if any) 95.1 The records management audit (limited assurance), had been considered at the Audit Committee, where responses to recommendations were been monitored.
Resolved 95.2 The Committee noted the record management audit report and welcomed sight of the report to understand any impact regard quality and performance.
QC/96/18 Risks and issues arising for which further assurance is required and items to be added to the sustainability log 96.1 A risk in relation to non-compliance with clinical audit standard 4, recording of allergies and sensitivities was noted for which the Committee would receive an update in October.
96.2 It was agreed the issues relating to records management would be added to the sustainability log. Action AQC/37/18 (J Benson)
WP Denotes an item has been added to the Committee work programme 277
QC/97/18 Committee programme review Resolved 97.1 The committee programme mid-year review was noted.
QC/98/18 Update on new regulation and guidance Resolved 98.1 The Committee noted the update on relevant regulation and guidance.
QC/99/18 Meeting reflections / comments on what has worked well or otherwise 99.1 Members were agreed it had been a good meeting that had been very well chaired, resulting in an earlier than planned finish.
99.2 Members had enjoyed the research presentation which they found very interesting.
99.3 A number of changes were suggested including: moving the presentation item ahead of the minutes and action log item, to better utilise the time of presenting guests. Action AQC/38/18 (S Rush)
99.4 It was also agreed the coordinating council and group minutes, in support of assurance reports, would be made available upon request, preferably in a shared area that members would be able to access.
QC/100/18 Date and time of next meeting 100.1 Wednesday 24 October 2018, 1000 – 1300, Boardroom A&B, Parsons Green Health Centre, 5-7 Parsons Green, London, SW6 4UL. The meeting closed at 1620.
Signed ………………………………………………….. Carol Cole, Committee Chair
Date ……………………………………………………..
WP Denotes an item has been added to the Committee work programme 278
Audit Committee Minutes of the meeting held on 12 July 2018 Boardroom, Ground Floor, 15 Marylebone Road, London, NW1 5JD Present: Jitesh Chotai Non-Executive Director Jane Slatter Non-Executive Director Clive Sparrow Non-Executive Director (Committee Chair)
In attendance: Andrew DeSwarte Head of Financial Control Mike Fox Director of Finance, Contracting and Performance Neil Hewitson Director, KPMG (external audit) Ruta Jamantiene Deputy Director of Finance Janet Lewis Divisional Director of Operations – Children’s Services Kevin Limn TIAA Ltd (Internal Audit) Nish Matenjwa Clinical Audit Manager (part) Joanne Medhurst Medical Director (part) Charlie Sheldon Director of Nursing Jayne Walbridge Trust Secretary
AC/41/18 Welcome, introductions and apologies 41.1 All members were present.
41.2 A private meeting between members counter fraud had been held prior to the meeting.
AC/42/18 Interests to declare 42.1 No new interests were declared.
AC/43/18 Minutes of previous meeting 43.1 The minutes of the meeting held on 23.05.18 were agreed as an accurate record.
AC/44/18 Matters arising and action log 44.1 It was agreed that completed actions could be closed.
44.2 AAC/69/17 Journal templates M Fox confirmed that the ledger upgrade was complete and that issues in relation to budget journals had been resolved, including unique identifiers. Therefore action closed.
44.3 AAC/74/17 – Counter fraud progress report G Higginson would ask the HR team to provide a deadline to complete the action in relation to matches.
44.4 AAC/20/18 – Policy in relation to single tender waivers M Fox reported that the procurement team would not meet the agreed July 2018 deadline to produce written guidance and that a new deadline would be confirmed – however, he had no concerns about the delay.
44.5 AAC/22/18 – Committee objectives (policies supporting the standing orders and standing financial instructions (SOFIs)
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M Fox confirmed that of the 8 policies identified for review, 2 had been updated, 3 were in progress and the remaining 3 would be completed by the end of August. J Chotai reiterated the importance of linking policies to the SOFIs to ensure that they are complementary and effective - for example establishment control and the sanctions for failing to implement policies / comply with the SOFIs.
44.6 AAC/35/18 - Internal audit – client briefing C Sheldon was confident that relevant sites had stocks of acid neutralising supplies - however he would confirm this by email1.
AC/45/18 Internal audit progress report 45.1 K Limn introduced the progress report, confirming that there were no overdue actions in relation to recommendations made and that the plan for the year was on schedule. M Fox had emphasised the importance of engaging with internal auditors, responding to reports and providing updates on recommendations in a timely manner at the Trust’s business meeting in June 2018.
45.2 The limited assurance review of records management and archiving (2017/18) was discussed, including the failure to apply Trust policy in relation to recording any change to the location of paper records. There was a lengthy discussion regarding the wider impact for all services; J Lewis confirmed that an information governance lead was routinely included in service mobilisation and demobilisation exercises.
45.3 In response to questions, K Limn was confident that processes had been addressed – though there was some concern expressed by members regarding the management comments - ie whether the ‘urgent’ and ‘important’ actions had been taken or were planned. An update for the Quality Committee – which would consider the report in July 2018 – was requested.
Action AAC/37/18 (K Limn) Resolved 45.4 The internal audit progress report was noted.
AC/46/18 Counter fraud – plan 2018/19 46.1 The work plan for 2018/19, including all 4 key areas2 to achieve compliance with counter fraud standards, had been circulated for comments in December 2017 and was included for approval.
Resolved 46.2 The counter fraud work plan for 2018/19 was agreed, subject to including more detail in the ‘hold to account’ section. Action AAC/38/18 (G Higginson) AC/47/18 Counter fraud – annual report 2017/18 47.1 At the private meeting with Audit Committee members earlier the same day, the level and sources of referrals had been discussed (which appeared low at just 15). While there had been a slight increase towards the end of the reporting period, this was the result of the National Fraud Initiative (NFI). G Higginson was confident, given the results of the counter fraud survey, that staff knew how to make referrals – however, it was suggested that it would be helpful to consider the response rate and how awareness might be increased. Action AAC/39/18 (G Higginson) Resolved
1 Reminder sent 13.07.18 2 Strategic governance; inform and involve; prevent and deter; hold to account
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47.2 The counter fraud annual report 2017/18 was noted including the overall self-review tool rating of amber.
AC/48/18 Counter fraud – progress report 48.1 G Higginson provided an update on activity undertaken and the 6 ongoing investigations – the majority of which related to fraud by false representation (working while sick). There had been no referrals since April 2018.
48.2 Members requested the provision of more granular detail about the reason for the closure of cases, and to understand if there were issues which needed to be addressed in investigating and progressing cases with CLCH / Capita HR staff. G Higginson confirmed that M Fox had been supportive in escalating issues to ensure more timely conclusion of investigations.
Resolved 48.3 The counter fraud progress report was noted.
48.4 It was agreed that the detailed reason for closure of investigations would be stated in future reports. Action AAC/40/18 (G Higginson) AC/49/18 Single tender waivers 49.1 A sharp increase in the number (n29) and value (£1.5m) of waivers between March and May 2018 was reported. A helpful table had been included - providing a breakdown by reason, including ‘corrective action’ (n6, value £156,250). Members discussed in detail the use of waivers within the context of public accountability, acknowledging that there were circumstances where waivers could appropriately be applied, however that retrospective waivers must be avoided and that market testing was vital to ensure value for money, transparency and compliance with SOFIs.
Resolved 49.2 The single tender waiver report was noted.
AC/50/18 Losses and special payments 50.1 Resolved A loss of £1,860 for patient property (October 2017) was noted.
AC/51/18 Bad debt write-off 51.1 Resolved No debt had been written off in 2018.
AC/52/18 Salary overpayments - update and action planned 52.1 M Fox acknowledged that the position was unfortunate and that urgent action was required. An action plan (including responsible officers and completion deadlines) was tabled to prevent and ensure prompt recovery of salary overpayments through an agreed protocol. Failure to complete / process leavers’ forms had been identified, however this could not be considered in isolation given the need to maintain establishment control and for proactive management by local managers, HR and finance teams.
52.2 Members discussed the likelihood of recovering overpayments – noting that while immediate action was often successful, this diminished with time and that Courts were unlikely to be helpful or cost effective.
52.3 M Fox agreed to ascertain how the value of pay errors attributable to Capita might be recovered and to review and strengthen action 11 of the plan.
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Action AAC/41/18 (M Fox)
Resolved 52.4 The action planned to manage, recover and prevent salary overpayments was noted.
52.5 It was agreed that a further report to monitor delivery of the plan and controls (governance) would be considered by the Committee in October - including debts which had been written off and that FRIC would be kept informed of the financial implications (though this was well below a level which would normally feature at a FRIC meeting).
AC/53/18 South division – financial position 53.1 M Fox introduced the report which provided an update on 25 consolidated recommendations from the internal and external investigations. Due to the preparation of the two major bids, the commercial team had unfortunately been unable to complete the new ‘transformation manual’ – which would include the required post mobilisation internal ‘true-up’ process. This action was, therefore, RAG rated ‘red’.
53.2 Members emphasised that a robust documented process is essential, to link clinical and financial due diligence and thus ensure the cost of delivering a high quality service can be met – at the bidding stage and for the true-up to be undertaken at an early stage (2-3 months after go-live) to identify issues for correction and to inform contract discussions.
53.3 The importance of ensuring that new services are able to make a positive financial contribution was reiterated, given the risk and impact on other patient services which already had challenging savings targets.
53.4 Resolved Action taken and planned to improve controls was noted; FRIC would continue to review the financial performance of the South Division.
53.5 It was agreed that a further action in relation to establishment control and the role of HR should added to the plan (including completion timescale) - to be monitored by the Workforce Committee. Action AAC/42/18 (M Fox) AC/54/18 External audit progress report Resolved 54.1 The KPMG progress report was noted.
AC/55/18 External annual audit letter 2017/18 Resolved 55.1 The annual audit letter was approved for publication and inclusion with Board papers on 26.07.18. Action AAC/43/18 (J Walbridge) AC/56/18 KPMG risk benchmarking report 56.1 Members discussed the risk management benchmarking report prepared by KPMG – looking at top strategic and emerging risks across 38 London NHS providers. N Hewitson confirmed that there were no concerns about CLCH’s BAF content (11 risks compared to an average of 8) benchmarked to other organisations.
56.2 C Sheldon had considered the report in detail and suggested that the greater number of BAF risks reflected the complexity of business, for example business intelligence and workforce issues, together with financial risks relating to contracts.
Resolved
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56.3 The interesting and informative report was noted.
AC/57/18 Update on 2017/18 external audit recommendations 57.1 M Fox provided an update on the implementation of recommendations made in May 2018. Unfortunately, it had not been possible to complete the outstanding recommendation in relation to the contracts with local authorities (Barnet) raised in 2016/17.
57.2 In response to J Chotai’s question regarding the delay to the fixed asset register review (October); A DeSwarte advised that some leases and assets had negative values. It was agreed that it would be helpful to receive a written update in relation to the fixed asset register recommendations. Action AAC/44/18 (M Fox)
57.3 Members discussed the audit differences, some of which were significant - it was agreed that it was not appropriate to use the KPMG report for this purpose (particularly since the information was different to that prepared and issued by KPMG in May 2018). M Fox to review audit differences with KPMG and provide an update to the Committee.
Action AAC/45/18 (M Fox) Resolved 57.4 The update in relation to recommendations following the 2017/18 audit was noted.
AC/58/18 Audit Committee – annual report to Board 2017/18 Resolved 58.1 The annual report to the Board was agreed for submission in July 2018.
AC/59/18 Board assurance framework (BAF) – review 59.1 Members considered the proposed changes to the BAF including 2 new risks relating to the partnership with Capita and market share – with a potential 3rd new risk following a recent data transfer issue (Virgin Media).
59.2 It was proposed that new risk 2086 could be expanded to cover all commercial suppliers (rather than just Capita). Action AAC/46/18 (C Sheldon)
59.3 C Sparrow asked how strategic risks are identified for inclusion in the BAF and then scored. C Sheldon confirmed that, as per the risk management strategy, there are a number of different routes. While the Executive Team could suggest risks, these needed the input of the Non-Executive Directors at the Audit Committee prior to collective consideration at the Board.
59.4 C Sparrow reiterated his concerns that, the 2 new risks; and, therefore, 7 of the 11 BAF risks sit with the Director of Improvement, which he believes represents a significant strategic risk for the organisation.
59.5 Members discussed the absence of clinical risks in the BAF. C Sheldon was confident that there were no identified clinical risks which would affect the Trust’s strategic objectives. Sources of assurance included the CQC inspection and regular review of quality related risks by the Quality Committee.
59.6 It was agreed that the gaps in control for risk 831 and gaps in assurance for risk 1218 needed to be reviewed with risk leads.
Action AAC/47/18 (C Sheldon with M Fox and J Benson)
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Resolved 59.7 Members agreed the 2 new risks, subject to the comments above – for the Board to consider on 26.07.18.
AC/60/18 Risk register 60.1 There were no event or reputational risks rated 15 or above.
AC/61/18 CQC statement of purpose Resolved 61.1 The CQC statement of purpose was noted – for inclusion with Board papers in July 2018 and publication on the website.
AC/62/18 Clinical audit annual report 2017/18 62.1 J Medhurst introduced the report and confirmed that, following the limited assurance opinion in 2017, a further internal audit had been agreed for 2018/19.
62.2 Members emphasised the role of the Audit Committee – to satisfy itself that controls are adequate and assurances are sound and sufficient in relation to the clinical audit process.
Resolved 62.3 It was agreed that a supplementary note should be circulated to members: the process to agree audits and the numbers - proposed, agreed, implemented, completed - together with action themes. Action AAC/48/18 (J Medhurst) AC/63/18 New and outstanding control issues Resolved 63.1 The report, including 2 existing and 2 new control issues was noted.
AC/64/18 Update on regulations and guidance Resolved 64.1 Report noted.
AC/65/18 Risks and issues identified for which further assurance is required 65.1 Further assurance in relation to the clinical audit process – see action AAC/46/18 above.
AC/66/18 Meeting reflections / comments 66.1 A good meeting covering a lot of different topics with efficient use of time.
AC/67/18 Dates of next meetings 67.1 Thursday, 11 October 2018 and Thursday, 20 December 2018.
The meeting closed at 1645 hours
Signed……………………………………………………. Date …………………………………….. Clive Sparrow, Audit Committee Chair
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284 Acronym Description Alphabetical by abbreviation A&E Accident & Emergency ACO Accountable Care Organisation ACP Advanced Care Plan ADQ Associate Director of Quality AHP Allied Health Professional ALB Arms Length Bodies AQP Any Qualified Provider APCS Allied Primary Care Services BAF Board Assurance Framework BAIR Bank, agency and interim reduction (internal project) BAU Business As Usual BCM Business Change Management BCP Business Change Management BGAF Board Governance Assurance Framework BGM Board Governance Memorandum BHH Brent, Harrow, Hillingdon (Clinical Commissioning Groups) BIPA Business Intelligence Performance Analytics CAS Central Alerting System BPM Business Process Management BPO Business Process Outsourcing CAF Common Assessment Framework CAMHS Child and Adolescent Mental Health Services CASH Contraceptive and sexual health CBU Clinical Business Unit CCG Clinical Commissioning Group CCN Change Control Notice CCN Children’s Community Nursing CDS Child Development Service CDS Commissioning Data Set CEG Clinical Effectiveness Group CET Clinical Effectiveness Team CFT Community Foundation Trust CHC Continuing Health Care CHD Children’s Health and Development (one of our operational divisions) CHIH Child Health Information Hub CHIN Community Health Integrated Networks CHIS Child Health Information System CIG Capital Investment Group CIO Chief Information Officer CIP Cost Improvement Programme CIP Continuous Improvement Plan CIS Community Independence Service CLCH Central London Community Healthcare NHS Trust CLIPS Complaints, Litigation, Incidents, PALS and Safeguarding CMDB Configuration Management Database CoHo Community Hospital
285 COPD Chronic Obstructive Pulmonary Disorder COT College of Occupational Therapists CP Child Protection CPC Capita Private Cloud CPP Child Protection Plan CQC Care Quality Commission CQUIN Commissioning for Quality and Innovation CRS Care Records Service CSRR Continuity of Service Risk Rating CSU Commissioning Support Unit CSV Comma-Separated Variable CWHHE Central London, West London, Hammersmith & Fulham, Hounslow and Ealing CYP Children & Young People CTOP Children & Young People’s Occupational Therapy Datix Trust’s software package for recording risk and incidents. DBS Disclosure and Barring Service DDO Divisional Director of Operations DH Department of Health DN District Nursing DNA Did Not Attend DNACPR Do Not Attempt Cardio Pulmonary Recusitation DPwSI Dental Practitioner with Special Interests DQ Data Quality EBCD Experienced Based Co-Design EBITDA Earnings Before Interest, Taxes, Depreciation and Amortisation ECH Edgware Community Hospital EIA Equality Impact Assessment ELT Executive Leadership Team EMIS Egton Medical Information Systems – a particular supplier of electronic patient record systems. ENP Emergency Nurse Practitioner EOH Education Outcomes Framework EOLC/EOL End of Life Care/End of Life EPR Electronic Patient Record EPRR Emergency Preparedness, Resilience and Response EPS Electronic Prescription Service ESR Electronic Staff Record FAQ Frequently Asked Questions FGM Female Genital Mutilation FHIR Fast Healthcare Interoperability Resources (pronounced ‘fire’) is a message standard for exchange of electronic health records between different electronic systems FMH Finchley Memorial Hospital FNP Family Nurse Partnership FOI Freedom of Information FRR Financial Risk Rating FRIC Finance, Resources and Investment Committee FT Foundation Trust FTE Full Time Equivalent – see WTE
286 GAS scores Goal Attainment Scaling GP General Practitioner GPwSI General Practitioner with Special Interests GRR Governance risk rating GUM Genito-Urinary Medicine HAT Health Assessment Tool HARI Holistic Assessment and Rapid Investigation HASU Hyper Acute Stroke Unit HCA Health Care Assistant HDD Historical Due Diligence HEE Health Education England H&F Hammersmith & Fulham HLD High Level Design HLSD High Level Service Design HOT Heads of Terms HPV Human Papilloma Virus HR Human Resources HRCH Hounslow & Richmond Community Healthcare NHS Trust HSCIC Health and Social Care Information Centre – now superseded by NHS Digital HSE Health and Safety Executive HSJ Health Service Journal HUB Trust’s Intranet HV Health Visiting HWB Health and Wellbeing Board HWE Herts and West Essex IAO Information Asset Ower IAP Indicative Activity Plan IAPT Improving Access to Psychological Therapies IAPTus IT Clinical Record System used in the IAPT service IBP Integrated Business Plan ICAS Independent Complaints Advocacy Service ICE Integrated Clinical Environment ICN Integrated Complex Needs ICO Information Commissioner’s Office (1) ICO Integrated Care Organisation (2) ICP Integrated Care Pathway I&E Income and Expenditure IG Information Governance IM&T Information Management and Technology Integra Trust’s procurement software supported by Capita partners IPA Individual Patient Activity IPC Infection Prevention and Control IPN Infection Prevention Nurse ITT Invitation to Tender JSCC Joint Staff Consultative Committee K&C Kensington & Chelsea KPI Key Performance Indicator KSF Knowledge and Skills Framework LA Local Authority
287 LAC Looked After Children LBB London Borough of Barnet LBHF London Borough of Hammersmith & Fulham LETB London Education Training Board LNWH London North West Healthcare NHS Trust LOINC Logical Observation Identifiers Names and Codes - a universal coding standard for medical laboratory observations LSP Local Service Provider LTC Long Term Conditions LTFM Long Term Financial Model MASH Multi Agency Safeguarding Hubs - Led by councils these bring together specialists in safeguarding from various organisations MAU Medical Admissions Unit MCP Multispecialty Community Provider MIR Monthly Information Return M&H Moving and Handling MHMDS Mental Health Minimum Data Set MoPS Medicines Optimisation Service MOU Memorandum of Understanding MPLS Multiprotocol Label Switching - is a type of data-carrying technique for high- performance telecommunications networks MUST Malnutrition Universal Screening Tool N3 A private, national computer network dedicated to the NHS. For security reasons, many NHS systems are only accessible if you are on the N3 network. NAO National Audit Office NBO National Back Office - a centralised team supporting medical records on the national NHS Spine. They centrally manage issues such as NHS number duplications, record confusions, NHS number invalidations etc NBV New Birth Visit - Health Visitors have to perform a New Birth Visit within 14 days of a baby's birth NCL North Central London NCNR Networked Community Nursing and Rehabilitation - previously one of our operational divisions prior to the latest organisational restructure NED Non-executive Director NELFT North East London NHS Foundation Trust NHS National Health Service NHSE NHS England NHSLA National Health Service Litigation Authority NICE National Institute of Clinical Excellence NMC Nursing and Midwifery Council NRLS National Reporting and Learning System NTDA NHS Trust Development Authority NWL North West London OBD Occupied bed days OD Organisational Development ODS Organisation Data Services - a centralised division in the NHS responsible for setting up national codes for organisations and sites. For instance, the ODS code for CLCH is 'RYX' OOH ‘Out of Hospital’ agenda or Out of Hours ORSA Organisational Readiness Self-Assessment OT Occupational therapist/therapy PALS Patient Advice and Liaison Service PASA Purchasing and Supply Agency
288 PCE Performance and Contracts Executive
PDS Personal Demographics Service - this is the demographic portion of the centralised Summary Care Record (SCR) stored on the NHS Spine. Spine-enabled clinical record systems provide the facility to synchronise patient demographics with the PDS allowing NHS services to maintain synchronicity of patient demographic details across multiple organisations and sectors PE Patient Experience PFI Private Finance Initiative - an initiative to create public-private partnerships (PPPs) by funding public infrastructure projects with private capital PHQ Patient Health Questionnaire PID Patient Identifiable Data PID Project Initiation Document PIP Personal Independence Payment - replacement for Disability Living Allowance or DLA PLACE Patient Led Assessment of the Care Environment PLD Patient Level Data PMH Perinatal Mental Health PMO Project Management Office/Officer PO Purchase Order PPE Patient and Public Engagement PPI Patient and Public Involvement PPP Public-Private Partnership PREM Patient Reported Experience Measure PROM Patient Reported Outcome Measure PQQ Pre-Qualifying Questionnaire PSF Provider Sustainability Funding (previously Sustainability Transformation Funding) PSO Project Support Officer PSRG Patient Safety and Risk Group PST Patient Safety Thermometer PT Physiotherapy/Physiotherapist PTS Patient Transport Service QAT Quality Action Team QGAF Quality Governance Assessment Framework QI Quality Improvement QIA Quality Impact Assessment QIPP Quality, Innovation, Productivity and Prevention QIST Quality Improvement Support Teams QIT Quality Inspection Team - CLCH's internal mock-CQC inspection programme QRG Quick Reference Guide QSRG Quality Stakeholder Reference Group RA Registration Authority RAA Registration Authority Agent RAID Risks, Actions, Issues & Dependencies RAM Registration Authority Manager RBAC Role Based Access Control RBKC Royal Borough of Kensington & Chelsea RCA Root Cause Analysis RCN Royal College of Nursing R&D Research and Development RES Race Equality Standard
289 RFC Request for Change RIO Is the name of a clinical system, it is not an abbreviation, it is a Spanish word which correlates to ‘flow of work’. ROM Rough Order of Magnitude RTT Referral to Treatment S1 SystmOne - the product name of our main clinical system S&A Sickness and Absence SaHF Shaping a Healthier Future SCD Social and Communication Disorder SCR Summary Care Record - Centralised demographic and clinical record stored on the NHS Spine SDIP Service Development Improvement Plan SDM Service Delivery Manager SDQ Strengths and difficulties questionnaire SEG Strategic Estates Group SI Serious Incident SID Senior Independent Director SIRO Senior Information Responsible Officer SLA Service Level Agreement SLAM Starters, Leavers and Movers SLR Service Line Reporting SLT Speech and Language Therapy SME Small to Medium Enterprise SMT Senior Management Team SMW Senior Managers Workshop SOF Single Oversight Framework SOP Standard Operating Procedure SOW Statement of Work SPOR Single Point of Referral SRD Service Request Definition SRO Senior Responsible Officer STEIS Strategic Executive Information System SPA Single Point of Access SPC Statistical Process Control STP Sustainability and Transformation Plan SUS Secondary Uses Service - the Secondary Uses Service (SUS) is a single, comprehensive repository for healthcare data in England, hosted on the Spine, SWL South West London TA Technical Analyst TAG Technology Appraisal Guidelines (NICE) TDA Trust Development Authority TOMS Therapy Outcome Measures TPP The Phoenix Partnership - This is the company that designed and maintains the SystmOne clinical record application. SystmOne is the application; TPP is the company. TUPE Transfer of Undertakings (Protection of Employment Regulations 1981 UAT User Acceptance Testing UCC Urgent Care Centre URN Unique Reference Number VFM Value for Money VOIP Voice Over Internet Protocol - techy thing for phones being routed through internet lines. Allows for free internal calls among other things. The phone system used in the Trust.
290 VSM Very Senior Managers WIC Walk-in Centre WIGWAM When it’s great we are mobile WP Work Package WTE Whole Time Equivalent – see FTE
291 KEY PERFORMANCE INDICATOR SCORECARD
Strategy Implementation: Implement strategic priorities of integration and place
End of Year KPI Name KPI Description of calculations Target
Percentage of Sustainability and Transformation Plan meetings attended by CLCH in the four STP areas where CLCH provides 1.1 STP meeting attendance N/A services
Quality: Maintain and improve the quality of services delivered by CLCH moving from good to outstanding
End of Year KPI Name KPI Description of calculations Target Proportion of clinical incidents that do not cause harm 2.1 96% This KPI will compare like for like incidents across the Trust that were reported as moderate or above (moderate to catastrophic categories)
The calculation of this KPI reflects the percentage of those respondents that gave either an "extremely likely" or "likely" Friends and family test - percentage of people that would response to the survey question 'How likely is it that you would recommend this service to a friend or family if they needed it', 2.2 95% recommend the services minus those who would not recommend (response categories; "neither likely or unlikely", "unlikely" and "extremely unlikely"). The survey to generate the responses for this KPI is the monthly patient experience survey
Percentage of deaths requiring PRISM for which a review 2.3 100% Percentage of eligible deaths in CLCH that are reviewed using CLCH screening tool in line with policy was conducted
Percentage of statutory and mandatory audits undertaken by 2.4 100% Percentage of statutory and mandatory audits undertaken by the Trust the Trust
Percentage of staff recommending CLCH to their friends and 2.5 75% % of staff recommending CLCH to their friends and family as a place for treatment family as a place for treatment
Finance: Deliver the 18/19 financial plan
End of Year KPI Name KPI Description of calculations Target
This KPI reflects the financial position of the year to date 'actual' QIPPS achieved as a percentage of the year to date planned 3.1 Recurrent value of QIPP delivered against target (%) 100% position
£5,013k (year 3.2 Income and expenditure performance Income and expenditure surplus compared to plan end)
£7,983k (year 3.3 Cash balance performance Cash balance compared to plan end)
Operations: Deliver all NHS constitutional and contractual standards
End of Year KPI Name KPI Description of calculations Target
292 4.1 18 week wait RTT 92% A patient on a referral to treatment (RTT) within 18 weeks (national rules apply)
A&E/UCC maximum waiting time of 4 hours from arrival to admission/transfer/ discharge 4.2 A&E 4 hour wait 95% (national definition)
4.3 Delayed Transfer of Care (DTOC) 3.5% % of bed days lost to DTOC
4.4 Contract Performance Notices 0 Number of contract performance notices received from our commissioners
The % of CLCH relevant patches applied and tested within appropriate security timescale as defined by priority and technical assessment, to provide assurance of the ability to resist a cyber attack* 4.5 Cyber security 100% *Patches will be defined as relevant if they apply to the CLCH IM&T Infrastructure and systems in use. Alerts deemed urgent or critical will be applied at either the next monthly patch window or as an emergency release, otherwise patches will be applied in the patch window following alert to allow time for impact assessment and testing.
The improvement in the Digital Maturity Assessment (DMA) against Trust target improvement plan* 954/1500 Target defined as: 15 measures each with a potential score of 100 (ie. max score =1500) 4.6 Digital maturity (Target of an *Trust Digital Maturity Assessment (DMA), target improvement plan based upon CLCH areas of improved digital maturity from increase by 29 the 2018 IM&T Strategy refresh and in comparison to Community Trust average as presented to Board January 2018. This will each quarter) be monitored quarterly with a trajectory towards the March 2019 target maturity, (increased score of 114 split into 29 each quarter). The quarterly calculation being (target maturity-2017 score/4)
Workforce: Make CLCH a great place to work for everyone
End of Year KPI Name KPI Description of calculations Target
This KPI is collected quarterly via the Trust's Pulse Survey for Q1, Q2 and Q4 with the national staff survey covering Q3. The 5.1 Percentage of staff that recommend CLCH as a place to work 62% measure reflects those staff who agree or strongly agree with the question asking staff whether they would recommend the Trust as a place to work. The percentage is calculated against total number of responses for that question
12% for April 2018 This KPI reflects the vacant full time equivalent (less frozen posts) divided by the budgeted establishment. Data is taken from 5.2 Vacancy level - all staff (clinical staff in commentary) two sources namely the ESR system and the General Ledger. 10% by March 2019
This KPI shows the number of staff assignments appraised as a percentage of the number due for appraisal in the same period. 5.3 Staff appraisal rates 90% The ESR and E-PADR systems provide this data
Taken from the Trusts ESR system, this KPI shows the percentage of all staff that self classify as BME. The denominator figure 5.4 Staff from BME backgrounds at bands 7 and above 33% includes those staff whose classification is recorded as not known and not stated
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