Meeting of the Board of Directors to be held in public on Thursday 27 July 2017 at 2pm in the Brooke Suite, Warwick Hospital
AGENDA
1. Apologies for Absence –
2. Declarations of Interest
3. Minutes of the Meeting held on 5 July 2017 Enclosure A
4. Matters Arising and Actions Update Report Enclosure B
5. Items for Approval 5.1 Operational Capacity Plan 2016/17 Enclosure C Jane Ives
6. Performance Review and Assurance Monthly Reports 6.1 Chief Executive’s Report Enclosure D Glen Burley 6.2 Integrated Performance Dashboard Enclosure E Glen Burley - Mortality Update 6.3 Nurse Staffing Report Enclosure F Helen Lancaster 6.4 Clinical Governance Committee Report for 12 July 2017 Enclosure G Bruce Paxton
Other Reports 6.5 Finance and Capital Quarterly Report Enclosure H Kim Li 6.6 Patient Experience Quarterly Report Enclosure I Helen Lancaster 6.7 Out of Hospital Care Collaborative Quarterly Update Report – Leg Enclosure J Anne Coyle Ulcer Clinics
7. Items for Noting and Information 7.1 Updated Register of Directors’ Interests Enclosure K Sarah Collett 7.2 Summary of Ratified Policies Enclosure L Glen Burley 7.3 Healthy Foods CQUIN 2016/17 Enclosure M Helen Lancaster 7.4 Board Committee Minutes Enclosure N - Clinical Governance Committee on 14 June 2017 Bruce Paxton
8. Any Other Business
9. Questions from Governors and Members of the Public
10. Adjournment to Discuss Matters of a Confidential Nature (to adjourn to confidential business at 3.45pm)
11. Apologies for Absence –
12. Declarations of Interest
13. Confidential Minutes of the Meeting held on 5 July 2017 Enclosure 1
14. Confidential Matters Arising and Actions Update Report Enclosure 2
15. Group Strategy Committee Terms of Reference Enclosure 3 Glen Burley
Page 1 of 2 16. Report on Tender Returns for Hotel Services Enclosure 4 Jane Ives
17. Report on Tender Returns for A&E Enclosure 5 Jayne Blacklay
18. Report on Tender Returns for the Stratford Hospital MRI and Enclosure 6 Jayne Blacklay Associated Building Works
19. Midwifery Led Unit (MLU) Update Verbal Jayne Blacklay
20. Lorenzo Requests and Results, and ePrescribing Options Enclosure 7 Jane Ives Appraisal
21. Lorenzo and Electronic Patient Record Monthly Update Verbal Jane Ives
22. Board Committee Confidential Minutes Enclosure 8 - Clinical Governance Committee on 14 June 2017 Bruce Paxton
23. Any Other Confidential Business
24. Date and Time of Next Meeting
The next meeting will be held on Wednesday 6 September 2017 at 2pm in the Brooke Suite, Warwick Hospital.
Overall Finish Time – 5.00pm
Page 2 of 2 Enclosure A SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017 at 2.00pm in the Brooke Suite, Warwick Hospital
Present: Russell Hardy (RHa) Chairman Charles Ashton (CA) Medical Director Jayne Blacklay (JB) Director of Development (from Minute 17.197.07 onwards) Angela Brady (AB) Non-Executive Director (NED) Glen Burley (GB) Chief Executive Alan Harrison (AH) NED Rosemary Hyde (RHy) NED Helen Lancaster (HL) Director of Nursing Kim Li (KL) Director of Finance Simon Page (SP) NED Bruce Paxton (BP) NED Sue Whelan Tracy (SWT) NED
In attendance: Tony Boorman (TB) NED (Non-Voting) Sarah Collett (SC) Acting Trust Secretary Anne Coyle (AC) Managing Director for Out of Hospital Care Collaborative (OOHCC) Simon Illingworth (SI) Associate Director of Operations (ADO) for Elective Care Ann Pope (AP) Director of Human Resources Mary Powell (MP) Communications Manager Danny Roberts (DR) Chief Technology Officer (from Minute 17.208 onwards)
There were also 5 Governors, 1 member of public and 2 members of press present.
MINUTE ACTION 17.194 APOLOGIES FOR ABSENCE
Apologies for absence were received from the Director of Operations.
17.195 DECLARATIONS OF INTEREST
No declarations of interest were made.
17.196 MINUTES OF THE MEETING HELD ON 24 MAY 2017
Resolved – that the Minutes of the meeting held on 24 May 2017 be confirmed as an accurate record of the meeting and signed by the Chairman.
17.197 MATTERS ARISING AND ACTIONS UPDATE REPORT
17.197.01 Actions Listed as Complete
The actions listed as complete in the Actions Update Report were noted and would now be removed from the report.
Resolved – that the position be noted.
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017
MINUTE ACTION 17.197.02 Comment from the Chairman on behalf of a Public Governor (Minute 17.091.04 refers)
The Medical Director provided an update on stroke patients from the Trust accessing University Hospitals Coventry and Warwickshire NHS Trust (UHCW). The issue had related to Transient Ischaemic Attack (TIA) access at weekends, assurance had been received from the Trust’s Stroke Service that the issue was now resolved. The Medical Director would inform the Board of any further issues.
Resolved – that the position be noted.
17.197.03 Integrated Performance Dashboard (Minute 17.159.02 refers)
The Director of Nursing provided an update on the React to Red campaign under the Integrated Performance Dashboard agenda item (Minute 17.199 refers).
Resolved – that the position be noted.
17.197.04 Nurse Staffing Report (Minute 17.159.03 refers)
The Director of Nursing confirmed that a national average line had now been included on the Care Hours per Patient Day charts (Minute 17.200 refers).
Resolved – that the position be noted.
17.197.05 Integrated Performance Dashboard (Minute 17.166 refers)
The Managing Director for OOHCC explained that arrangements had commenced to hold one Board meeting per year in the community and the Board would be notified of the confirmed date for 2017/18 in due course.
The Director of Finance explained that from the next report, Cost Improvement Programme (CIP) charts would include how much of the £8.7m CIP target had been identified. The Board had considered in detail progress against the CIP target at the Board Workshop earlier that day, with the Divisions providing assurance on progress and plans to achieve the divisional targets.
Resolved – that (A) the Managing Director for OOHCC and the Acting Trust AC/SC Secretary arrange one Board meeting per year to be held in the community, and (B) the Director of Finance ensure that future CIP charts include KL how much of the £8.7m CIP target had been identified.
17.197.06 Nurse Staffing Report (Minute 17.167 refers)
The Director of Nursing confirmed that the ‘at a glance’ dashboard now included how many months the wards had previously been a concern (Minute 17.200 refers). Also the ‘unregistered staff unavailability’ chart now included Page 2 of 12 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017
MINUTE ACTION Thomas Ward.
Resolved – that the position be noted.
17.197.07 Patient Experience Quarterly Report (Minute 17.171 refers)
The Director of Nursing confirmed that the response to complaint ID 3806 on page 11 had been reviewed. The A&E Consultant felt that clinical management was appropriate at the time of presentation to A&E. However on reflection, the patient could have been observed for more time but this would not have prevented the patient being sent home or changed the position.
The Director of Nursing explained that the full data of the A&E patient survey results was not yet available and would submit them to the Board once the information had been published.
Resolved – that the Director of Nursing submit the A&E patient survey HL results to the Board once the information had been published.
17.197.08 End of Life Strategy Update (Minute 17.173 refers)
The Director of Nursing explained that the actions were ongoing and would be addressed as the End of Life Strategy was developed.
Resolved – that the position be noted.
17.197.09 Annual Equality and Diversity Report (Minute 17.175 refers)
Mrs Whelan Tracy (NED) explained that the action to provide the Director of Human Resources with an example of an online tool to analyse equality and diversity areas, was in progress.
Resolved – that Mrs Whelan Tracy (NED) provide the Director of Human SWT Resources with an example of an online tool to analyse equality and diversity areas.
17.198 CHIEF EXECUTIVE’S REPORT
The Chief Executive presented this report and highlighted the key points. Of particular note were the Healthcare Safety Investigation Branch (HSIB), new Care Quality Commission (CQC) Assessment Framework and Fire Safety Reviews sections. Also the Chief Executive noted that it was the 69th birthday of the NHS.
Resolved – that the Chief Executive's Report be received and noted.
17.199 INTEGRATED PERFORMANCE DASHBOARD
The Chief Executive introduced this report and the Director of Nursing, ADO for Elective Care, Managing Director for OOHCC, Director of Human Resources and Director of Finance in turn gave updates on their respective Page 3 of 12 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017
MINUTE ACTION areas of performance.
The Chairman invited questions and perspectives, and of particular note were the following points:
(a) the Chief Executive clarified the last paragraph of his commentary and explained that this related to the national target to reduce the number of mothers smoking at delivery; (b) the Chairman explained that Delayed Transfers of Care (DTOC) related to patients who had an agreed package of care but their discharge was delayed due to circumstances such as adjustments at their home not being completed or a community bed not being available. The Chief Executive added that there was an opportunity to make the process more effective and ensure patients were in an appropriate setting; (c) Mr Paxton (NED) noted that performance against the A&E 4 hour standard had reduced to 94.5% in May 2017, this was good compared to national performance but was a decline for Trust performance. Mr Paxton (NED) sought assurance around whether this related to DTOC and if this was a concern. The Chief Executive explained that DTOC performance was a concern, although comparisons with other systems were fraught with data accuracy issues. Also the Trust had seen an increase in A&E activity which was believed in part to relate to patients choosing to attend A&E at Warwick Hospital due to its good performance. The Chief Executive provided assurance that the A&E performance for quarter 1 was 95.6%, the Trust would therefore achieve the performance element of the Sustainability and Transformation Fund (STF) funding for quarter 1; (d) the Director of Nursing provided an update on the React to Red campaign. As part of the campaign, 41% of nursing and residential homes had completed the training and 59% had not taken part. The carers that had attended the training were found to have improved their knowledge to help prevent pressure ulcers; (e) the Director of Nursing noted that there were 91 falls during May 2017, however there had been improvement in June 2017 with 59 falls reported. This data would be reported to the next Board meeting. The Board had received a patient story at the Board Workshop earlier that day from Physiotherapy which highlighted the need to improve the mobility of patients to help with their welfare; (f) Dr Harrison (NED) highlighted the Deaths/Preferred Place of Care (PCC) section. He noted that there had been a slight improvement in the rate of documented PCC in the south of the county but it still remained low. The Director of Nursing provided assurance that there started to be good engagement amongst the teams and an audit plan was in place. The results of the audits were reported to the teams which had helped to make improvements; (g) the Medical Director provided an update on mortality performance. A review of all avoidable deaths was undertaken. The identification of deteriorating patients could be improved, subject to the implementation of an electronic patient observation system which the Board was considering a business case in the confidential section of Page 4 of 12 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017
MINUTE ACTION the meeting (Minute 17.218 refers). National guidance on learning from deaths had recently been introduced and the Trust was expected to be compliant by September 2017. Also deaths from sepsis was significantly below the statistically predicted level, there had been 18 less deaths than the previous year; (h) Mr Paxton (NED) sought assurance around the process for capturing 2 week wait cancer referrals. The ADO for Elective Care confirmed that a robust process was in place and that the issues related to capacity rather than process; (i) Mrs Hyde (NED) sought assurance around reporting against the new breach allocation performance criteria (38 days rule). The ADO for Elective Care explained that the national reporting system was due to go live with a revised template for collecting and reporting treatments and breaches against the new methodology from April 2017. However this did not happen and a revised timescale was not known. Therefore Trusts were manually collecting the data and reporting locally which did create some risk to accuracy; (j) Mr Paxton (NED) sought clarification around how end of life care and PCC was progressing in the community. The Director of Nursing explained that there had been progress and there were further improvements to be made which should start to be reflected in the data in the coming months; (k) Mrs Whelan Tracy (NED) noted that an update on retention was scheduled for a future Board Workshop, however she sought assurance around any concerns across the Trust in light of the recent press articles on insufficient numbers of nursing staff. The Director of Human Resources explained that the press had focused on local and national retention. Work was taking place with Managers where retention of staff was more of a problem. Performance against areas such as appraisals, incidents and nurse care indicators were triangulated to identify areas of concern and where Managers may benefit from additional support. The Workforce Strategy and action plan would be submitted to the Board later in the year; (l) Dr Harrison (NED) noted that 150 members of staff were identified as not having an appraisal in more than 12 months and sought clarification around whether the staff were within particular areas or across the Trust. The Director of Human Resources explained that she had been monitoring this very closely. More than half had actually received an appraisal but the information had not been recorded, the remainder were spread across a number of wards/departments; (m) the Director of Finance noted that the ADOs had attended the Board Workshop earlier that day to provide the Board with assurance on their CIP plans and delivery of their CIP targets; (n) the Director of Finance confirmed that the Trust was likely to achieve the financial element of the STF funding for quarter 1, and (o) Dr Harrison (NED) highlighted the penultimate paragraph of the Director of Finance’s Executive Summary on page 28. He sought clarification around whether the operating expenditure was above plan, rather than below plan as detailed in the report, and the operating income was below plan, rather than above plan as detailed in the report. Dr Harrison (NED) also felt that the Statement of Page 5 of 12 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017
MINUTE ACTION Comprehensive Income (SOCI) table was not correct. The Director of Finance explained that the commentary had related to overspend against plan, however she agreed to review the terminology to ensure KL it was clearer in future reports. She would also review the SOCI table.
Resolved – that (A) the Integrated Performance Dashboard be received and noted; (B) the Director of Finance review the terminology when referring to KL above and below plan to ensure it was clearer in future reports, and (C) the Director of Finance review the SOCI table to ensure it was KL correct.
17.200 NURSE STAFFING REPORT
The Director of Nursing presented this report and highlighted the key issues. Of particular note was an error on page 2 of the report as the overall gap, in nurse staffing between the planned and actual numbers reported on duty across the inpatient ward areas in May 2017, should be 7% and not 3%. The Director of Nursing explained that the gap had consistently been between 3- 4% and therefore the increase was a concern. A number of actions were in place and the Matrons and Heads of Nursing were working closely with the Ward Managers to monitor and improve performance.
The Chairman reconfirmed that patient safety was the Board’s primary concern and therefore the Director of Nursing should request additional funding if there were concerns.
The Chairman invited questions and perspectives, and of particular note were the following points:
(a) Mr Boorman (NED) sought assurance around the Care Hours per Patient Day chart on page 10. The Director of Nursing provided assurance that May 2017 had been a challenging month. There would at times be challenges, however the data for June 2017 would be reported to the next Board meeting which would enable a comparison of performance, and (b) Dr Harrison (NED) noted that the Trust had previously recruited a number of nurses from Europe and sought clarification around whether any of the nurses had left the Trust. The Director of Nursing and Director of Human Resources provided assurance that a very small number of these nurses had left the Trust, however there was a general issue around the recruitment of nursing staff. Work was taking place on the Workforce Strategy, in particular to review skills and competencies of staff and to develop bespoke recruitment strategies for specific areas.
Resolved – that the Nurse Staffing Report be received and noted.
Page 6 of 12 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017
MINUTE ACTION 17.201 CLINICAL GOVERNANCE COMMITTEE REPORT FOR 14 JUNE 2017
Dr Brady (NED) presented this report as she had Chaired the meeting on behalf of Mr Paxton (NED). The main point to note was that the lack of an Orthogeriatrician did not mean that a poor service was being provided. This concern was being considered again at the Clinical Governance Committee meeting in July 2017. Assurance was provided that a meeting was taking place that day to explore solutions.
Resolved – that the Clinical Governance Committee Report for the meeting held on 14 June 2017 be received and noted.
17.202 BUSINESS PERFORMANCE AND INVESTMENT COMMITTEE REPORT FOR 1 JUNE 2017 – OPEN MEETING
Mr Page (NED) presented this report and highlighted the key issues. Of particular note was the need for greater visibility of the major themes of cost reduction that ran across the Divisions which would be beneficial for the Board to understand where the major opportunities existed. Also significant work had been undertaken on Service Line Reporting (SLR), the report submitted to the Committee was attached to the Committee report to the confidential section of the Board meeting (Minute 17.219 refers).
Resolved – that the Business Performance and Investment Committee Report for the meeting held on 1 June 2017 be received and noted.
17.203 REPORT FROM THE COUNCIL OF GOVERNORS MEETING ON 18 MAY 2017
The Chairman presented this report and highlighted the key issues. Of particular note was that the Chairman and Chief Executive were reviewing the format of the Board and Governor Round Table events to ensure they were more effective and integrated with the Trust’s strategic plans.
Resolved – that the Report from the Council of Governors meeting held on 18 May 2017 be received and noted.
17.204 CAPITAL PROGRAMME QUARTERLY UPDATE REPORT
The Director of Development presented this report and highlighted the key points. Of particular note were the new Stratford Hospital and the new Pharmacy Aseptic Unit schemes. The Trust would take ownership of the new Stratford Hospital on 7 July 2017 with the first services being delivered from 24 July 2017. The new Pharmacy Aspectic Unit had been handed over to the Trust and would open on 7 July 2017. A tour of the unit had been organised for the Board on 27 July 2017.
The Board commended the significant amount of work undertaken to ensure the Stratford Hospital Development was back on track following a recent water leak. The Chairman asked the Director of Development to provide him JB with the names of staff so he could thank them for their efforts.
Page 7 of 12 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017
MINUTE ACTION Resolved – that (A) the Capital Programme Quarterly Update Report be received and noted, and (B) the Director of Development provide the Chairman with the JB names of staff who had worked to ensure the Stratford Hospital Development was back on track, so he could thank them for their efforts.
17.205 PATIENT EXPERIENCE ANNUAL REPORT
The Director of Nursing presented this report and highlighted the key issues. Of particular note was that the Trust had received 179 formal complaints in 2016/17 compared to 150 in 2015/16. During 2016/17, 30,000 patients had participated in the Friends and Family Test (FFT) with 96% of those patients would recommend the Trust. Also the report included the significant work that had been undertaken on the Night Charter.
The Chairman invited questions and perspectives, and of particular note were the following points:
(a) Mr Paxton (NED) highlighted the ‘upheld complaints by specialty’ graph on page 4 and noted that the number of bars did not match the number of labels. The Director of Nursing agreed to review the HL graph, and (b) the Medical Director highlighted the red graded upheld complaint Datix ID 3298 on page 4. He explained that there were two components to this complaint and only one had been upheld. The patient had received hormone treatment for breast cancer which could have been avoided. However the component relating to the bone scan not being undertaken was not upheld as the patient’s care was found to be consistent with usual clinical practice.
Resolved – that (A) the Patient Experience Annual Report be received and noted, and (B) the Director of Nursing review the ‘upheld complaints by HL specialty’ graph to ensure the number of bars and labels matched.
17.206 BOARD ASSURANCE FRAMEWORK (BAF) AND RISK QUARTERLY REPORT
The Chief Executive presented this report which proposed that the end of year BAF for 2016/17 be agreed, the BAF for 2017/18 be approved and the 15-25 (red) risks on the Risk Register be received and noted.
The Chairman invited questions and perspectives, and of particular note were the following points:
(a) Dr Brady (NED) highlighted the Director of Finance’s section of the Integrated Performance Dashboard (Minute 17.199 refers) which noted an underperformance of income across high cost drugs, Page 8 of 12 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017
MINUTE ACTION maternity and the Central England Rehabilitation Unit (CERU). She sought clarification around why this was not included on the risk register. The Chief Executive explained that the rating of these areas as individual risks was not sufficient enough to be on the risk register to the Board; (b) Dr Harrison (NED) felt that the X and Y format was not correct to create the right mitigation rating. The Chief Executive agreed to GB ensure this was reviewed at the next Risk Management Board meeting; (c) Mrs Hyde (NED) raised concern that cyber security was not appropriately rated. The Chief Executive explained that the Risk Management Board had not met since the recent national cyber- attack; (d) Mrs Whelan Tracy (NED) noted that the 2016/17 risk around the failure to recruit nursing staff had been closed and sought assurance as this remained a significant concern. The Chief Executive explained that this risk was included on the divisional risk registers for the specific areas that had challenges in recruiting staff, and (e) Mrs Whelan Tracy (NED) raised concern that the downtime of IT systems which effected clinics and operational performance was not included. This was an issue raised at the last Clinical Governance Committee meeting. She therefore sought assurance around how system availability was being monitored and the level of assurance being provided to the Board. The Director of Nursing explained that since the last Clinical Governance Committee meeting, she had met with the Chief Technology Officer and an Audit and Operational Governance Group (AOGG) would be established for IT. The Chief Technology Officer was scheduled to provide an update to the next Clinical Governance Committee meeting.
Resolved – that (A) the end of year BAF for 2016/17 be approved and ratified; (B) the BAF for 2017/18 be approved and ratified; (C) the 15-25 (red) risks on the Risk Register be received and noted, and (D) the Chief Executive ensure the X and Y format be reviewed at the GB next Risk Management Board to ensure the mitigation rating was correct.
17.207 UPDATED REGISTER OF DIRECTORS’ INTERESTS
The Acting Trust Secretary presented this report which included an update to Dr Brady’s (NED) interests. The Acting Trust Secretary explained that since submitting the report, further updates had been received from Dr Harrison (NED), Mrs Hyde (NED) and Mrs Whelan Tracy (NED) therefore a revised Register of Directors’ Interests would be submitted to the next Board meeting. Board members were reminded to advise the Acting Trust Secretary promptly of any changes to their register entries.
The Chairman clarified that he was Chairman and majority owner of Maranatha 1 Ltd which owned Fosse Healthcare Limited.
Page 9 of 12 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017
MINUTE ACTION Resolved – that the Updated Register of Directors’ Interests be received and noted.
17.208 SUMMARY OF REPORTS FOR NOTING AND INFORMATION
The ADO for Elective Care presented this report which included a summary of the Health and Safety Annual Report, and the Annual Security Report 2016/17.
Dr Harrison (NED) sought clarification around whether the Trust had received fines for any of the Reporting of Injuries, Diseases and Dangerous Occurrence Regulations (RIDDOR) incidents that had been reported to the Health and Safety Executive outside the legal timeframes. The Chief Executive provided assurance that the Trust had not received any fines.
Resolved – that the Summary of Reports for Noting and Information be received and noted.
17.209 SUMMARY OF RATIFIED POLICIES
The Chief Executive presented this report which provided a summary of SWH 00592 Organisational Change Policy, SWH 01721 Asbestos Policy, SWH 00554 Dignity at Work Policy, and SWH-01626 Internet Usage Policy.
Mrs Hyde (NED) highlighted the summary of SWH 00592 Organisational Change Policy and sought clarification around the changes to the protection arrangements. The Director of Human Resources clarified that the protection arrangements had been renegotiated with Staff Side and were in line with other Trusts.
Resolved – that the Summary of Ratified Policies report be received and noted.
17.210 BOARD COMMITTEE MINUTES
Mr Paxton (NED) referred to the Minutes of the Clinical Governance Committee meeting held on 10 May 2017 and highlighted the A&E FFT response rate in the Patient Experience Quarterly Report (Clinical Governance Committee Minute 17.099 refers). The national target was 20% FFT response rate within A&E and the Committee had received assurance that iWantGreatCare felt assured that the Trust could achieve the target. The Committee was therefore looking forward to receiving an update on performance at their next meeting.
Resolved – that the Minutes of the Business Performance and Investment Committee meeting held on 13 April 2017 and Clinical Governance Committee meeting held on 10 May 2017 be received and noted.
17.211 ANY OTHER BUSINESS
There was no further business. Page 10 of 12 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017
MINUTE ACTION
Resolved – that the position be noted.
17.212 QUESTIONS FROM GOVERNORS AND MEMBERS OF THE PUBLIC
17.212.01 Comment from a Public Governor (East Stratford and Borders)
The Public Governor raised concern that falls within the community had not been included in any of the Board reports. He explained that a Community Falls Group had been set up and a meeting was held in May 2017, however no further meetings had been arranged.
The Director of Nursing explained that the Falls Prevention Steering Group had not received an update from the Community Falls Groups. She would therefore ensure that an update was included in the Integrated Performance HL Dashboard to the next Board meeting.
Resolved – that the Director of Nursing ensure community falls be HL included in the Integrated Performance Dashboard to the next Board meeting.
17.213 ADJOURNMENT TO DISCUSS MATTERS OF A CONFIDENTIAL NATURE
17.214 APOLOGIES FOR ABSENCE
17.215 DECLARATIONS OF INTEREST
17.216 CONFIDENTIAL MINUTES OF THE MEETING HELD ON 24 MAY 2017
17.217 CONFIDENTIAL MATTERS ARISING AND ACTIONS UPDATE REPORT
17.218 ELECTRONIC PATIENT OBSERVATION SYSTEM BUSINESS CASE
17.219 BUSINESS PERFORMANCE AND INVESTMENT COMMITTEE REPORT FOR 1 JUNE 2017 – CLOSED MEETING
17.220 AUDIT COMMITTEE REPORT FOR 24 MAY 2017 – OPEN AND CLOSED MEETING
17.221 ASSURANCE REPORT ON PATERSON ENQUIRY
17.222 ICT STRATEGY
17.223 LORENZO AND ELECTRONIC PATIENT RECORD (EPR) MONTHLY UPDATE
17.224 FOUNDATION GROUP PROPOSAL
17.225 BOARD COMMITTEE CONFIDENTIAL/CLOSED MINUTES
17.226 ANY OTHER CONFIDENTIAL BUSINESS
Page 11 of 12 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting Held on Wednesday 5 July 2017
MINUTE ACTION
17.227 DATE AND TIME OF NEXT MEETING
The next meeting would be held on Thursday 27 July 2017 at 2pm in the Brooke Suite, Warwick Hospital.
Signed ______(Chairman) Date ______Russell Hardy
Page 12 of 12 Enclosure B SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
ACTIONS UPDATE: PUBLIC BOARD OF DIRECTORS MEETING – 27 JULY 2017
AGENDA ITEM ACTION LEAD COMMENT ACTIONS COMPLETE
ACTIONS IN PROGRESS 17.166/17.192.05 To arrange one Board meeting per year to be held in the community. AC/ Board meeting on 26 Integrated Performance SC October 2017 to be held in Dashboard the community. Details to (24.05.17) be confirmed with the Board once finalised. To ensure that future CIP charts include how much of the £8.7m CIP target had KL been identified. 17.171/17.197.07 To submit the A&E patient survey results to the next Board meeting. HL Full data not yet available Patient Experience Quarterly so will be submitted to the Report Board once the information (24.05.17) has been published. 17.175/17.197.09 To provide the Director of Human Resources with an example of an online tool SWT Annual Equality and Diversity to analyse equality and diversity areas. Report (24.05.17) 17.199 To review the terminology when referring to above and below plan to ensure it KL Integrated Performance was clearer in future reports. Dashboard To review the Statement of Comprehensive Income (SOCI) table to ensure it KL (05.07.17) was correct.
17.204 To provide the Chairman with the names of staff who had worked to ensure the JB Capital Programme Quarterly Stratford Hospital Development was back on track, so he could thank them for Update Report their efforts. (05.07.17)
17.205 To review the ‘upheld complaints by specialty’ graph to ensure the number of HL Patient Experience Annual bars and labels matched. Report (05.07.17)
1 AGENDA ITEM ACTION LEAD COMMENT
ACTIONS IN PROGRESS (continued) 17.206 To ensure the X and Y format be reviewed at the next Risk Management Board GB Next Risk Management Board Assurance Framework to ensure the mitigation rating was correct. Board to be held on 11 (BAF) and Risk Quarterly Report September 2017. (05.07.17) 17.212.01 To ensure community falls be included in the Integrated Performance Dashboard HL Comment from a Public Governor to the next Board meeting. (East Stratford and Borders) (05.07.17)
REPORTS SCHEDULED FOR FUTURE MEETINGS 17.172 To provide the Board with an update in 6 months. CA Scheduled for the Board National Guidance on Learning meeting on 6 December from Deaths 2017. (24.05.17)
ACTIONS REFERRED TO BOARD OF DIRECTORS SUB-COMMITTEES
2 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Operational Capacity Plan Update Enclosure C 2017/18
Nature of item For information For approval For decision
Decision The Board is asked to approve the update of the Operational Capacity required (if any) Plan in preparation for winter 2017/18 and note the risks and mitigations.
General Report Author Jane Ives, Director of Operations Information Rose Gardiner, Associate Director of Operations – Emergency Care Anne Coyle, Managing Director for Out of Hospital Care Collaborative Lead Director Jane Ives, Director of Operations
Received or Meeting approved by Date
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Operational Capacity Plan Update 2017/18
1.0 Executive Opinion
Providing sufficient capacity to meet predicted demand for our services is going to remain challenging in the forthcoming year.
The match between predicted demand and available capacity has been modelled for acute beds, community capacity and operating theatres. Without mitigating actions there is a shortfall of 69 adult beds (based on predicted growth and 93% occupancy) across the year.
A capacity development plan is in place across the divisions to manage the service redesign that is required to manage demand within our available capacity and as it is implemented will provide sufficient capacity. The plan is built on previous changes and service principles. If either increases in demand or less capacity improvement than anticipated further mitigation is possible through the delay of CIP plans.
In April 2017 the Discharge Transitional Unit (DTU) closed and was replaced by transitional beds in the community. The space vacated has created the accommodation needed for the development of a Midwifery Led Unit.
The Board of Directors is requested to approve the operational capacity plan for 2017/18 and note the risks and mitigations to delivery of the plan.
2.0 Bed Modelling Assumptions
The following assumptions have been made in modelling the required bed numbers below:
• activity plans are based on activity projections which are based on outturn figures plus demographic growth (2.8%), as per contracted activity with no assumptions made by commissioners regarding the impact of Quality Innovation Productivity and Innovation (QUIPP) on emergency demand; • our experience suggests occupancy levels >93% will not meet variations in demand, so bed requirements have been modelled at 93% occupancy, and • seasonal variation has not been factored in to the overall figures, but is factored in to capacity plans. The demand for beds in winter includes increased numbers of patients and increased length of stay which historically is approximately 1 day longer.
2 Fig 1 Summary Bed Requirement 2017/18 Bed gap at Bed gap at Bed Capacity 100% Occ 100% 93% Occ 93% occupancy occupancy Surgical 119 118 1 132 -13 Medical 240 267 -27 296 -56 Sub total 359 385 -26 428 -69 Paediatrics 17 11 6 12 5 Maternity 27 23 4 25 2 Total 403 419 -16 465 -62
N.B. Bed numbers plus 2.8% demographic growth N.B. Medical beds do not include 5 A&E observation beds N.B. Current bed capacity does not include 28 'spare' capacity beds N.B. Bed occupancy (total beds) in paediatrics appears low because many children are discharged before midnight (census)
The table above details the total bed numbers based on the last 12 months (July 2016 to June 2017) activity plus 2.8% growth and then adjusted for occupancy at 93%.
2.1 Adult Bed Capacity
For combined emergency and elective demand, there is a 69 bed shortfall to meet predicted demand (based on 93% occupancy). There are a number of Trust and, Health and Social Care system actions in place to reduce demand for beds and a range of plans to improve bed utilisation and reduce length of stay further. These are outlined below and the impact on bed requirements is detailed in Section 3.
Operational Capacity Plans
2.1.1 Reducing Emergency Demand
A&E Streaming A workshop is planned for both A&E and Care UK to explore improved access to Out of Hours (OOH) GP appointments. Plans to relocate the current OOH GP provision are under discussion which would improve the current service provision for evenings and weekends.
7 day Ambulatory Emergency Clinic (AEC); 7 day Acute Decision Unit (ADU); 7 day Frailty The national drive is for all acute services to provide 7 day access to both ambulatory emergency care and frailty services. This has been under development for the past 18 months. Within the Guy Ward footprint, redesign work is set to commence in September 2017 and complete December 2017 (pre-Christmas), which will provide a new AEC area with reception and waiting facilities. This will ensure more efficient use of front door capacity.
In support of this expansion, a business case for Advanced Clinical Practitioners (ACPs) will support 7 day front door services with extended hours. The business case will go to Board this summer. This is aligned to the Advanced Practice Strategy, essential for the evolution and provision of 7 day services.
3 2.1.2 Reduce Emergency Length of Stay (despite increasing ambulatory pathways)
Out-Patient Antimicrobial-Intravenous Therapy (OPAT) The OPAT service has evidenced real impact in reducing length of stay through early discharge for a complex group of patients. The service either teaches the patient to self- administer intravenous antibiotics, provide care at home or return to the AEC for treatment.
Home to Assess This is a service designed and delivered by the Allied Health Professional (AHP) teams. Based on specific criteria, patients can be taken home for Occupational Therapy (OT) assessments to be undertaken in their own environment. The initial pilot was contained to specific medical wards and saved on average 2 days length of stay per patient. This will now expand across all wards.
Cardiology Ambulatory Early Supported Discharge (Yasser Haider Suite (YHS)) This new approach is for complex cardiac conditions such as Heart Failure and Atrial Fibrillation. Previously this cohort could remain an in-patient for an extensive period of time. The aim is to support early discharge and return daily for treatment with the safety net of the YHS should their condition deteriorate. Already showing huge potential, this approach has been limited by its environment but with support is set to expand over the coming months.
Red to Green Red to Green has rolled out across multiple medical wards and is becoming embedded. The next stage is the development of electronic dashboards and scorecards which will provide rich intelligence to enable teams to identify trends and develop plans for improvement in areas which cause most delay.
Stroke Pathway Identification of internal inefficiencies through the use of Service Line Reporting (SLR) has resulted in a project team to assess the current process and identify improvements necessary. This is currently underway and will generate an improvement plan by September 2017 which will reduce length of stay and improve acute stroke flow into the rehabilitation beds and improving the Sentinel Stroke National Audit Programme (SSNAP) performance.
2.1.3 Escalation Medical Bed Capacity (Fairfax Ward)
This capacity will remain in place as part of the front door delivery of care for the Emergency Division, this proved to work successfully last year and will be maintained. Flexibly utilising surgical capacity when there is not elective surgical demand (particularly at weekends) will also need to continue to be utilised for some of the year. This is particularly to manage the winter demand.
If redesign plans do not release the level of productivity and capacity required, the planned bed closures will be halted at financial and opportunity cost.
2.1.4 Right Sizing Community Capacity
Pathway 1 (Care at Home Step Up and Step Down)
4 The benefits of integration of Community Early Response Team (CERT), Intermediate Care and Warwickshire County Council’s (WCC) reablement have been slightly slower to realise due to the complexities of the Section 75 legal frameworks. The value of co- location has already seen an improved partnership approach to demand and capacity responses.
Daily huddles cross-referencing referrals and delays and implementing new processes across the services now known as HomeFirst has enhanced response times with HomeFirst (Health) responding, year to date, to 72% of urgent referrals on the same day; this is against an 80% target for urgent responses.
The ambition to meet demand on the day for every patient who needed their care has not yet been realised due to exit blocks. There are three main exit blocks and actions to address these are:
1. Financial assessment delays - evidence suggest this can take 3-5 days. To address this Self Directed Support (SDS) worker numbers were increased by HomeFirst (LA). The new staff will have completed their induction period and commenced working within the HomeFirst (LA) team by September 2017. 2. Home care package delays particularly in rural areas of the County remain an issue. 3. In South Warwickshire, Continuing Healthcare (CHC) placement delays create exit blocks. A work stream has been established to understand reasons for placement delays and identify sustainable solutions.
In 2017/18 a predictive modelling tool will be implemented across HomeFirst (Health). The tool is being trailed in Rugby locality with planned roll out in August 2017.
Pathway 2 (Community Hospitals, Discharge Transitional Unit (DTU) and Local Authority (LA) Moving on Beds)
The community hospitals improvement group continues to work on improving patient’s journey home plans, with a focus in 2017/18 on pathway reviews. Red to Green has been implemented at Ellen Badger with plans to roll out to the Nicol unit in July 2017.
In line with the Trust’s escalation plan, three beds will be available; 2 at Ellen Badger and 1 on Nicol unit to support surge in demand for Community Hospital beds.
Discharge Transitional Unit (DTU) capacity was right sized to 13 beds, with flexibility to increase capacity as required to meet surge in demand. As a result, (Length of Stay) LOS has reduced from 15 days to 11 days.
The Local Authority ‘moving on beds’ remain funded within the system and access to and flow through them is yet to be reviewed. WCC is considering purchasing extra care housing beds to increase Pathway 2 capacity.
Pathway 3 (Discharge to Assess Beds Commissioned in Nursing Homes)
There are now 22 Pathway 3 beds commissioned on our behalf by WCC. There is inbuilt flex for an additional 3 beds for winter pressures. Whilst the point prevalence audit demonstrated that there is sufficient capacity to meet demand for these beds, there will always be some patients who do not wish to take up a pathway 3 commissioned bed,
5 however, we have broadly the right level of capacity. The point prevalence study showed less demand than the previous year.
2.1.5 Reducing Delayed Transfers of Care (DTOC)
Following DTOC system workshops held in early summer it was agreed that to inform DTOC improvement initiatives, a review of integrity of DTOC data held by WCC was an essential first step on our improvement journey. This review is well underway; it has included development of a new weekly WCC reporting DTOC dashboard, which will include Warwickshire performance and individual site performance. The new reporting process is standardised and will give transparency to issues which affect DTOC target and impact on patients by delaying their discharge.
The injection of funds following the Spring Review will help the health and care system in Warwickshire reduce delayed transfers of care. Warwickshire Care Better Together Board (WCBT) has a focus on managing transfers of care and are collating system wide DTOC plan as part of September’s ‘Better Care Fund’ submission. Through Trust membership on Warwickshire Care Better Together Board and informed by evidence on areas requiring investment to reduce DTOC there is increased likelihood of delivery on improved DTOC performance.
2.2 Paediatric Capacity
There is some spare capacity for Paediatric admissions, however, of all the specialties Paediatrics is the most variable for peaks and troughs of demand related to seasonality. This therefore suggests capacity can be constrained during winter (and reciprocal arrangements for diversion to other local providers at times of surge is already well established) with excess during the summer months and staffing flexed accordingly.
2.3 Maternity Capacity
There is a small amount of spare Maternity bed capacity to meet current demand and our experience is of very few Maternity unit closures due to demand pressures. We have seen an increase in demand since the Horton Hospital, Banbury, changed from an obstetric unit to a standalone Midwifery Led Unit (MLU), (this is currently an interim measure pending the outcome of a public consultation). With the Sustainability Transformation Porgramme (STP) potential changes in Coventry & Warwickshire and across the borders, Oxfordshire and Worcestershire, we expect to see a further increase in demand.
2.4 Theatre Capacity
The modelling undertaken has demonstrated that there is now insufficient capacity in some specialities to manage contracted activity if case mix and demand remain as planned. A Vanguard theatre has already helped for a short period of time this year to meet Trauma and Orthopaedic (T&O) demand specifically. There will be a further requirement later this year to use the Vanguard theatre for T&O. The period of use may also be extended if additional elective work is attracted to our facilities or demand or case mix changes beyond plan.
A piece of work is currently underway to review the long-term theatre requirements for the Trust. It is expected that this will require the capital development of another theatre.
6 Ongoing opportunities for improvements to theatre productivity, such as reducing elective cancellations will continue to help mitigate some of the requirement for additional theatre and could contribute to cost improvement in the elective division in the medium term.
2.5 Summary Demand Pressures
The operational bed plan for the year is challenging and service redesign or capacity increases in the out of hospital system need to take out the equivalent of 69 beds of emergency and elective demand to meet the predicted adult activity. The challenge will be significant in the winter when the capacity shortfall could be as much as 77 beds. The capacity development plan detailed below is the organisational and system response to meet the challenge.
3.0 Impact Assessment Summary
Impact Assessment of Capacity Plan:
Impact Capacity Development Plan Theme Assessment - No. of beds
Reducing emergency demand – objective to reduce the demand for emergency beds
A&E Streaming (OOH workshop to improve access) TBC 7/7 AEC (supported by front door environmental redesign) & 7/7 ADU 3 Frailty Unity with 7/7 Frailty (all above are ACP BC dependent) 7 Multi-agency PDSA’s to reduce demand and manage via alternative TBC pathways SUB TOTAL 10
Reduce emergency length of stay despite increasing ambulatory pathways
Further develop the capacity of out-patient antibiotic intravenous 3 therapy team (OPAT) Home to Assess (AHP delivered) TBC Cardiology early supported discharge (Yasser Haider Suite) 1 R2G Dashboard development identification of external and internal 3 reasons for delay Improved Stroke Pathways 2 SUB TOTAL 9
Increasing community capacity
Delayed Transfers of Care (DTOC) working group 3 Meet demand on the day every day for both community and hospital 5 referrals for pathway 1 and increase productivity for pathway 2 SUB TOTAL 8
Increasing elective capacity – objective to increase elective productivity and flexibility to reduce cancellations and increase capacity
7 Elective demand and capacity project 0 PDSA for Non-elective surgical patients TBC Orthopaedic pathways improvement group 2 Utilise medical capacity and new pathways to enable the reduction of TBC medical outliers SUB TOTAL 2 Paediatric Capacity – objective to provide a more effective urgent care pathway for children reducing the need for children to be admitted Explore potential for paediatric assessment unit to reduce demand in 0 beds A&E and requirement for paediatric beds SUB TOTAL 0 Escalation Capacity Community Escalation capacity identified for P3 Pathways 3 Escalation capacity identified for P2 Pathways (2 EBH/ 1 Nicol) 3 Acute Escalation capacity identified across medicine (A&E Observation 5 beds, Fairfax Ward 15 beds, Cardiology 2 beds, Beaumont 4 beds, Squire 32 6 beds) Exception capacity - Swan Ward 6 SUB TOTAL 44 TOTAL Impact of Capacity plan and escalation capacity 73 Capacity challenge is estimated 69 beds positive / negative 4
4.0 Risks
The risks to delivery of the capacity plan:
• Demand increases above our predicted levels • Implementation of the capacity development plan is slower than required to meet demand
Assurance against the delivery plans will be provided through the Programme Delivery Board and Finance and Performance Executive.
5.0 Summary
There is no doubt that the modelled activity represents a challenging picture.
The match between predicted demand and available capacity has been modelled for acute beds and theatres, and without mitigating actions there is a shortfall of 69 adult beds (based on 93% occupancy).
However, there are a range of plans in place that are building on our experience and tested models. Mitigation plans are available for increased bed capacity if either demand increases above expected levels of the plans do not provide the level of improvement expected.
8
Jane Ives Director of Operations
9 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Chief Executive’s Report Enclosure D
Nature of item For information For approval For decision
Decision The Board is asked to receive and note this report. required (if any)
General Report Author Glen Burley, Chief Executive Information Lead Director Glen Burley, Chief Executive
Received or Meeting approved by Date
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public
South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Chief Executive’s Report
Changes to Stroke Services
The Coventry and Warwickshire Clinical Commissioning Groups (CCGs) are currently consulting on changes to stroke services. These are referenced in the Sustainability and Transformation Plan (STP) but the proposals pre-date the STP process. The proposals complete the implementation of the national best practice model for stroke services and as a consequence we support them in principle.
This is not a savings initiative. Whilst the costing of the model is still being worked on, the expectation is that the model is likely to be more expensive overall, at least initially.
Historically home rehabilitation capacity has been poor locally and we have been keen for some time to address this. The model will see an investment in an 'early supported discharge' service. As a result of the current imbalance, patients spend longer than they should in hospital and consequently have worse outcomes.
The main drive for the revised national model is scarce staffing and clinical specialisation. It would not be possible to run a 24/7 thrombolysis service in all 4 local hospitals. Even if the staff were available, they would soon become deskilled due to the low volumes that would come through each door. This argument is also applicable to other specialist roles such as therapy staff.
So investment in one high quality 24/7 service makes sense. The movement of our acute beds to University Hospitals Coventry and Warwickshire NHS Trust (UHCW) simply recognises the fact that interventional stroke physicians will ultimately want to work in the hyper acute facility.
The most positive thing for Warwickshire is the investment in community rehabilitation and the recognition in South Warwickshire that Leamington Hospital should be maintained (and strengthened) as the inpatient rehabilitation facility for South, Coventry and Rugby.
Quarter 1 Sustainability and Transformation Fund (STF) Position
It is pleasing to see that the Trust has met the criteria to receive the first instalment of this year's STF payment. We also recently received the payment for the final part of last year to the full level assumed in last year's accounts.
The use of the STF mechanism to improve the overall financial position of the NHS has led to some confusion nationally but I feel that it has helped to restore some control of provider finances. In our case it incentivised us to make additional efficiency savings which moved our position from an initial plan of break-even to a surplus of just over £2m. By doing so we eventually received additional cash payments of around £7.4m.
Our surplus was then applied to the overall national position to offset other deficits resulting in the provider side of the NHS ending the year with an overall deficit of just under £800m.
2
We were not able to spend this funding last year on revenue items as to do so would have led to missing the control total and not receiving the incentive. But the additional cash has helped our liquidity which in turn has supported this year's capital programme. This includes schemes like the completion of Stratford Hospital, the Midwifery Led Unit and the business case we approved last month to invest in technology to help to identify and respond quickly to deteriorating patients.
We are also looking at further projects which would either improve safety or efficiency and in doing so we further incentivise our clinical teams to improve productivity by rewarding their efforts in this way.
Stratford Hospital
With the building programme complete, the Trust’s team is now commissioning the fabulous new Stratford Hospital facility. The Project Team has done a great job and I was delighted to see the Eye Unit Team excitedly installing their new state of the art equipment when I called in a few weeks ago. The first operating list will have taken place by the time the Board meet and shortly after then we will treat our first cancer patients on the new Rigby Cancer Unit.
Everyone involved in the project, from the architects to the fundraisers should be in incredibly proud of what they have achieved.
Out of Hospital Contract
All three local CCGs have now formally agreed the contract with the Trust as lead provider in Warwickshire for Out of Hospital Services for the foreseeable future. This ends a long night period of uncertainty for our community based staff.
The Trust first took on the running of community services in 2011 as part of the Transforming Community Services programme. At that stage we were awarded a 3 year contract and the intention was that a procurement process would then put a new arrangement in place by 2014. Since then much has changed locally and over this time the Trust has had some great successes in redesigning services and developing our Home First model.
Since 2014 we have worked with CCG colleagues through annual contract extensions to put in place a proposal to continue to deliver these services across Warwickshire. Last year this was included as a work stream in the STP.
Trust Sustainability Strategy
The sustainability challenges faced by the NHS mean that our organisations must look at new ways of working to ensure we can deliver high quality health and care services for our local population. It is important that the Trust focuses on the local priorities of integration, supporting more services to be delivered in an out of hospital setting and preventing ill health. With this in mind it is important to understand our key strengths that we are relatively small, local and able to respond effectively to the needs of our communities. To achieve integrated services between primary, community, acute and social care we need to retain our ability to operate at this local level with our individual organisation culture and leadership.
3
At last month’s confidential Board meeting we agreed in principle to solidify our partnership with Wye Valley NHS Trust through the creation of a Foundation Group. Wye Valley NHS Trust (WVT) has a similar set of challenges and strengths to ourselves. Through this arrangement we will appoint a joint Board Committee with Directors from the Trust and WVT, to look at areas such as service improvement and to formalise sharing of best practice. It will also create a platform for both organisations to work closer with health and care professionals, moving towards accountable care systems, delivering truly integrated services.
The Foundation Group model that we are proposing retains the identity of separate organisations and supports each to move to a model of accountable care with local partners. The new joint Board Committee creates a linkage which supports the sharing of best practice to improve efficiency of both Trusts and which helps to accelerate the local implementation of the agreed strategy.
The terms of reference for the Committee are being finalised for approval by both Boards.
Glen Burley Chief Executive
4 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Integrated Performance Dashboard Enclosure E
Nature of item For information For approval For decision
Decision The Board of Directors is asked to receive the report and note this required (if any) report.
General Report Author Glen Burley, Chief Executive Information Helen Lancaster, Director of Nursing Jane Ives, Director of Operations Anne Coyle, Managing Director for Out of Hospital Care Collaborative Ann Pope, Director of Human Resources Kim Li, Director of Finance Lead Director Glen Burley, Chief Executive
Received or Meeting approved by Date
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Integrated Performance Dashboard
Chief Executive’s Commentary
The total number of falls is significantly down in June 2017 with a level of 59 compared to the previous 3 months average of just over 92. Falls with harm are also significantly lower with 15 falls compared to the previous 3 months average of just over 25. There were no reported moderate to severe falls in the month. The Safety Thermometer score for the month is still stubbornly just below the target 96% level, the detail shows that Emergency and Out of Hospital Divisions have the most scope for improvement. Some new patient surveys have commenced in July 2017 with data being fed back later in the year, this includes a Care of the Dying evaluation.
The detailed report also identifies the reporting of potentially preventable deaths in line with new national requirements. The data demonstrates that we had two potential cases over the past rolling 12 months. These are routinely reported to the Clinical Governance Committee and the Clinical Commissioning Group (CCG) and each will trigger the development of an action plan overseen by the CCG and generally delivered at Divisional Audit and Operational Governance Group level. This month also sees the introduction of some new quality measures in the Out of Hospital Care Collaborative, these look at communication and the impact of care on the ability of users to complete activities of daily living. It will be interesting to see how this data shapes up over the next few months.
Whilst it is encouraging that the Trust met the 62 day cancer standard in the month, the other cancer targets were missed. In each case this was down to one single patient breach. So whilst the scale is less concerning, it indicates that we could have met all targets with slightly more grip of processes.
The 18 weeks Referral to Treatment (RTT) standard was also not met in the month, we achieved 90.86% against the target of 92%. The month saw some improvements in Orthopaedics due to additional lists taking place but we continue to have pressures in a number of specialties. We are reviewing referral levels with the CCG to see if more controls could be applied. The increase in activity in many specialties is contributing to these performance issues but will also present affordability challenges to our main referrer, South Warwickshire CCG.
Despite increases in emergency demand, the 4 hour A&E standard was met for the month and for the quarter overall. Notable increases in patients treated through ambulatory pathways and reductions in length of stay for admitted patients have contributed to our continuing delivery of this key national target.
Stroke performance indicators continue to show a positive trend, as does diagnostic performance. There is however a need to improve compliance with the fractured neck of femur best practice tariff through changes to the medical workforce.
2 The Trust has agreed a £7.769m control total surplus with NHS Improvement. The month 3 position demonstrates that we are on target to deliver this plan. In line with discussions at last month’s Board Workshop, the position on Cost Improvement Plan delivery is much improved. There is still further work required, however to ensure recurrent delivery of the plan. As a result, the Trust anticipates that the Sustainability and Transformation Fund (STF) payment will be earned in full. It is worth noting, however that the phasing of the payment in 2017/18 is more heavily weighted towards the latter part of the year. This approach has been applied to all providers as part of a strategy to improve the consistency of planning and reporting. Encouragingly, our performance against the national agency reduction target is positive with the Trust being ahead of the improvement plan. This reports that agency spend is at 2.61% of staff costs which is significantly below the NHS average. The cash position remains positive and has been further bolstered since closure of the month 3 position through the receipt of last year’s final STF payment.
3 Integrated Performance and Quality Dashboard June 2017
Performance Against Target (Status) Meeting Target Not Meeting Target
Regulatory Performance Measures Target June 2017 YTD Quarter Month A&E max wait time 4hrs from arrival to departure 95% 96.5% Referral to Treatment Times - Open Pathways (92% within 18 weeks) 92% 90.9% Cancer 62-Day 2WW Ref to treat, all cancers revised breach allocation methodology 85% 94.8% Cancer 62-Day National Screening Programme - one month in arrears 90% 88.9% Waiting Times - Diagnostic Waits <6 weeks 99% 99.0%
Single Oversight Measures Achieved
Financial Compliance Target June 2017 YTD Quarter Month Liquidity (Days) - one month in arrears 3 1 Capital Service Capacity (Times)- one month in arrears 1 1 I&E Margin % - one month in arrears 2 1 Variance in I&E Margin % - one month in arrears 2 1 Agency Ceiling % - one month in arrears 2 1 Overall Financial Sustainability Risk Rating - one month in arrears 2 1
4 Integrated Performance and Quality Dashboard June 2017
Performance Against Target (Status) Activity Performance Only Meeting Target Over 5% above Target Not Meeting Target 5% above to 2% below Target Agreed threshold above / below target More than 2% below Target to 5% below Target Over 5% below Target
Activity Trend Monthly YTD Target YTD June 2017 YTD Quarter Month Target A&E Activity 17,516 18,763 5,775 6,328 Emergency Ambulatory Pathways - First Attendances 827 932 298 337 Non Elective Activity - Adult Acute 4,768 4,954 1,572 1,683 Non Elective Activity - Paediatric Acute 944 1,070 311 351 Maternity Activity (Deliveries) 651 709 215 232 Maternity Activity (Non Deliveries) 208 225 68 68 Total Non Elective Activity (Exc A&E) 6,570 6,958 2,166 2,334 Elective Activity 7,900 8,480 2,849 3,006 Outpatient Activity - New (excl AHP & AEC) 22,132 23,526 7,982 8,205 Outpatient Activity - Follow Up (excl AHP, incl AEC) 45,682 45,862 16,476 15,799 Outpatient Activity - AHP 20,168 22,051 7,274 7,640 Outpatient Activity - Total 87,982 91,439 31,731 31,644 Community Service Contacts - OOH&CC 150,807 144,453 50,678 48,181 Community Service Inpatients - Support Services 28,036 27,914 9,847 9,689 Community Service Contacts - Women & Childrens 18,472 15,608 6,178 5,784 Community Service Contacts - Support Services 15,079 16,055 5,087 5,687 Community Service Contacts - Elective 1,063 1,069 339 363
Community Service Contacts - Total 213,456 205,099 72,129 69,704
Access Trend Target June 2017 YTD Quarter Month Cancer 31-Day Surgery, subsequent treatments - one month in arrears 94% 95.5% Cancer 31-Day Drugs, subsequent treatments - one month in arrears 98% 100.0% Cancer 31-Day Diag to treat, all new cancers - one month in arrears 96% 100.0% Cancer 2WW all cancers, Urgent GP Referral - one month in arrears 93% 95.3% Cancer 2WW Symptomatic Breast - one month in arrears 93% 97.5% RTT Data Quality Audit: Error Rate (1 month in arrears) 90% 57.5% A&E - Ambulance handover within 30 minutes 98% 98.2% A&E - Ambulance handover over 60 minutes 0% 0% A&E Quality Indicator - 12 Hour Trolley Waits 0 0 A&E - % of admitted patients who are admitted within 4 hours 90% 91.1% Cancelled Operations 0.8% 0.4% Over 28 Day readmission following short notice cancelled operation 0 3 Outpatient - Short Notice Cancelled Clinics 2% 1.3% Outpatient Hospital Reschedules 6% 4.8% Delayed Transfers of Care - Acute 2.5% 7.3% Delayed Transfers of Care - Community 7.5% 28.4% Delayed Transfers of Care - CERT North (average calls per week) 100 66 Delayed Transfers of Care - CERT South (average calls per week) 200 571 Delayed Transfers of Care - CERT Rugby (average calls per week) 20 38 Stroke Indicator 80% patients = 90% stroke ward 80% 77.8% Avg Patients admitted to South CERT Per Week 60 64.4 Avg Patients admitted to North CERT Per Week 40 25 Homefirst Referral > 1st Assessment; completed on same day as referral 80% 71.6% Stroke Admissions - Admitted to stroke ward within 4 hours of presentation 65% 52.6% Stroke Admissions - CT Scan within 24 hours 80% 100.0% iSPA call Response Rate within 1 minute (NB Amended from 30 secs) 95% 67.6% Main call Centre Response Rate within 1 minute 95% 72.8% Trust Admissions - % recorded within 30 minutes 90% 71.2% Trust Discharges - % recorded within 30 minutes 90% 71.7% Trust Transfers - % recorded within 30 minutes 90% 76.2%
5 Local Performance Targets and Measures Trend Target June 2017 YTD Quarter Month Emergency Ambulatory Care - % of total adult emergencies (Ambulatory or 0 LOS) 35% 35.4% ALoS - Adult Emergency Inpatients 6.0 5.1 ALoS – Elective Inpatients 2.5 2.6 ALoS – D2A Pathway 2 <28 days 28.3 ALoS – D2A Pathway 3 <42 days 32.1 Elective - Theatre Productivity 75% 77.1% Elective - Theatre Utilisation 85% 85.3% Elective - Daycase rate 85% 83.9% Outpatient - DNA rate (consultant led) 7.5% 7.8% Outpatient - % OPD Slot Utilisation (All slot types) 95% 90.2% Outpatient - Number of patients waiting over 6 weeks without a date 0 301 Outpatient - Number of patients waiting longer than 16 weeks over their due appointment date 0 1298 Outpatient - Advance Booking (new patients only - excluding patients seen within 3 weeks) 80% 76.0% BPT - Fracture Neck of Femur - Data one month in arrears 75% 63.4% BPT - Laparascopic Cholesystectomies 60% 66.7% BPT - Stroke 60% 31.0% Occupancy Acute Wards Only 90% 85.3% Maternity - Smoking at Delivery 8% 1.8% Maternity - Breast Feeding Initiation Rate (Warwick Hospital) - 1 month in arrears 80% 81.3% Maternity - Breast Feeding at 6 - 8 weeks (Community Midwives & Health Visitors) - (Q4) 45% 45.1% Maternity - % of women who have seen a midwife by 12 weeks and 6 days of pregnancy 90% 94.6% Community Family Services - Family Nurse Partnerships - Activity during pregnancy achieving plan 70% 53.0% Health Visitor - Birth to first visit within 14 days - Quarterly (Q4) 90% 88.0% School Nursing - National Child Measurement Program (Reception aged pupils) 90% 98.0% School Nursing - National Child Measurement Program (Year 6) 90% 97.4% Child Development - % Children accepted / declined within 12 weeks 95% TBC - - -
Workforce Measures Trend Target June 2017 YTD Quarter Month Midwife to birth ratio - last 12 months 1:30 1:28.3 - Overall Sickness - one month in arrears 3.8% 4.1% Appraisals - last complete quarter (Q4 Data) 85% 78.3% Vacancies - percentage of unfilled posts against budget - Arrears 8% 7.4%
6 Integrated Performance and Quality Dashboard June 2017
Performance Against Target (Status) Meeting Target Not Meeting Target
Clinical Outcomes Target June 2017 YTD Quarter Month Mortality RAMI - one month in arrears 100 92.5 Mortality SHMI - rolling 12 months 0.89 - 1.12 1.06 - - HSMR - Rolling 12m avg 100 98 Avoidable Death (Rolling 12 Months) - May 16 - Apr 17 0 2 MRSA Bactereamia 0 0 Combined MRSA Screening 98% 96.6% Hand Hygiene - saving lives 80% 96.7% Leg Ulcer Clinic - Healing Rate @ 12 weeks (Latest position Feb 2017) 70% 75.0% - - Normal Delivery Rate 60% 52.3% % of patients feeling involved with their care planning 90.0% 93.9% % of patyients stating they received timely information 90.0% 91.3% OOHCC - Improvement or return to ADL at discharge from rehabilitation TBC
Patient Experience Target June 2017 YTD Quarter Month Complaints resolved within agreed timeframe 90% 92.0% Patient ward moves emergency admissions (acute) 3% 1.6% Mixed Sex Accommodation Breaches 0 0 Friends and Family Test: Response rate (A&E) >20% 2.7% Friends and Family Test: Response rate (Acute inpatients) >20% 18.6% Friends and Family Test: Response rate (Maternity) >20% 16.7% Friends and Family Test Score: Acute % Recommended by Patients >96% 97.5% Friends and Family Test Score: Community % Recommended by Patients >96% 97.9% Mothers stating given a choice for place of birth (Arrears) >95% 99.2% Mothers stating left alone when worried during labour/birth 0 0 Staff Friends and Family Test: Recommended place for Care / Treatment - Quarter 4 >85% 85.2% Catering Surveys (Patients rating food as Good or Excellent) 85% 96.5%
Reducing Harm Target June 2017 YTD Quarter Month The Safety thermometer 96% 95.5% VTE Risk Assessments - one month in arrears 97% 97.1% Pressure sores (Confirmed avoidable Grade 3,4) 0 0 Falls with harm (per 1000 bed days) 1.53 1.18 Sepsis screening - A&E (% screened) - ARREARS 90% 98% Sepsis screening - Inpatients (% screened) - ARREARS 90% 100% Serious Incidents 0 1 Never events 0 0 Nurse Care Indicators Total 97% 99.0% Medication Errors (with harm) <10% 3.8% Cleaning Standards: Acute (Very High Risk) 95% 97.4% Cleaning Standards: Community (Very High Risk) 7 95% 98.5% WHO Checklist 100% 98.8% Director of Nursing – Performance Exceptions
1. Reducing Harm
1.1 Serious Incidents (SIs)
One (1) SI occurred in June 2017 (deteriorating patient - Emergency). All SIs are undergoing a full investigation to identify the root cause(s) as well as any potential learning opportunities.
1.2 Duty of Candour
For the SIs reported in June 2017, all Duty of Candour checks were completed.
Duty of candour requirement June 2017 Target Compliance Patient /Next of kin/carers were informed 100% 100% Relationship to patient was documented 100% 100% Person informing patient and / or NOK 100% 100% Method of informing patient / NOK: - Face to face 100% 100% - Not recorded 0% 0% Details of information given recorded 100% 100% Statutory requirement is to confirm the discussion in writing 100% 100%
1.3 Falls with Harm
• the total number of falls reported in June 2017 has reduced when compared with the previous reporting month (May 2017: 23 falls); • of the total number of falls reported, it is positive to report that there were no falls with moderate to severe harm. This is a reduction from the previous reporting month (May 2017: 3 falls with harm);
8 • following a closer review of data collection, incidents where a patient was lowered/assisted to the floor are now included in near miss data. There were 8 such incidents in June 2017, and • learning from recent incidents has been outlined and the following remedial actions are in progress: 1. falls huddles and handovers at Board Round; 2. re-organisation of ward tasks to maximise nurses out with patients; 3. engagement of physiotherapy and pharmacy teams on the ward.
1.3.1 Falls Data Breakdown
1.3.2 Bedrails Assessments
In June 2017, the rate of completion of Bedrail Assessment Forms was 93.9% and has improved in comparison to the previous month. Data continues to be closely monitored and has been disseminated to all Ward Managers. Bedrails assessment completion is reviewed as part of the quality visits led by the Director of Nursing and Senior Nursing Team.
Bed rail assessment undertaken on patients identified as being a risk - Overall Trust Compliance (%)
94.9 95.2 93.9 93.0 91.8 92.5 90.7 89.3 89.0 88.1
84.0 83.1
1.4 WHO Checklist
In June 2017, the Trust achieved one the highest rates of compliance since it has been monitored. Close scrutiny of data reveals no specific trends or themes relating to non- compliance. No correlation was found between any patient safety incidents and WHO
9 checklist compliance. The WHO checklist compliance continues to be closely monitored and challenged at the Clinical Governance Committee.
1.5 Safety Thermometer
The Trust continues to perform better than the national target of 95%, however the Trust was slightly below the internal stretch target of 96%. Performance data is provided to the divisional areas to consider where compliance has not been achieved.
(At time of reporting national average performance data was not released by NHS Digital)
1.5.1 Divisional Performance
Division Safety thermometer Safety thermometer Harm Free % (May Harm Free % (June 2017) 2017)
Emergency 93.75% 95.67% Elective 99.28% 98.63% Women & Childrens 100.00% 100% Out of Hospital Care collaborative 95.19% 94.56%
Overall Trust 95.59% 95.52%
1.5.2 Key Points
• pressure ulcers acquired prior to the patient’s admission to the Trust’s care continues to be the highest category (59.6% of all patient harms); • there were 3 new Grade 2 pressure ulcers reported, these have been highlighted to Tissue Viability for review and investigation; • UTIs with catheters in place increased to 11 (2 of which involved newly diagnosed UTIs); • there were 2 new Venous Thromboembolisms (VTE)s reported in the Community, these are under investigation and are likely to change if it is confirmed that the VTEs were existing conditions, and • all patient harms were clarified with the leads of each area where possible.
10 2. Patient Experience
2.2 End of Life
2.2.1 Referrals
The South Community Team covers 36 GP practices Population 269,000 North Community covers 28 GP practices Population 183,000 Rugby Community covers 12 GP practices Population 97,000
Total number of Referrals
80 74 74 72
70 63 60 49 South 50 42 38 35 North 40 32 33 28 30 Rugby 20 15 Warwick Acute 10 0 April May June
2.2.2 Establishment
• South Warwickshire Community: 4 wte Band 7, 2 wte Band 6 • Warwick Hospital: 1.6 wte Band 7, 1 wte Band 6 • North Warwickshire Community: 4.4 wte Band 7 • Rugby: 2 wte Band 7
Referrals in North Warwickshire have doubled. The team went live on the GAP2/iSPA system on 6 June 2017 and this data has been extracted from the system.
2.2.3 Diagnosis/Contacts
As previously reported, the team went live on the GAP2 system on 6 June 2017. A meeting has been arranged between the Palliative Care Team and the Out of Hospital Care Collaborative (OOHCC) Service Improvement Manager to identify a methodology to enable diagnosis and contact data extraction from GAP and scheduled reporting.
2.2.4 Deaths/ Preferred Place of Care
Preferred Place of Care (PPC)/death should be discussed and updated regularly with all patients if appropriate. An after death audit is conducted on a monthly basis which includes place of death and whether PPC has been achieved or not.
Collecting this data will still have to be conducted manually at present as GAP currently does not capture this information. The team has developed an audit tool to include reasons why PPC has not been achieved which will be used from July 2017.
11 The patients who died unseen were in part due to late referrals. Occasionally patients are discharged from the acute and the referral is late in arriving. The Palliative Care Team is reviewing and accessing the possibility of accepting referrals from the acute wards via GAP to ensure a robust referral system for the acute teams.
Reasons for non-achievement of PPC included acute exacerbation of symptoms resulting in patients either being admitted into the acute setting or patients deteriorated in the acute and were too poorly to transfer to either hospice or home.
From October 2017 there will be a joint pilot with Mary Anne Evans Hospice to provide a Rapid Response Palliative Care Service From 22:00-08:00 hours. This pilot will run for 18 months.
June 2017 North South Rugby Warwick Hospital Deaths 11 26 8 6 PPC 10/11 (91%) 19/26 (73%) 8/8 100% 5/6 83% Documented PPC Achieved 6/10 (60%) 17/19 (89%) 8/8 100% 1/5 20% for those patients where it was documented Died unseen 3 4 1 0
2.2.5 Patient Satisfaction
The team has developed a patient satisfaction survey which is being sent out during July 2017. This will capture the views of patients currently on active case loads. During July 2017 the ‘Care Of the Dying Evaluation’ (CODE) survey will be introduced into the out of hospital care setting. The rich data that we have collected from the use of this survey in the acute setting which is envisaged to be replicated in the out of hospital care setting.
3. Friends and Family Test (FFT)
The Trust continues to promote and engage with patients through its FFT Survey. Feedback is reviewed by Ward Managers and is made available to all staff and improvement actions are monitored at the Patient Experience Group.
3.1 Benchmarking
April 2017 data is the latest dataset released by NHS England (NHSE) which enables the Trust to benchmark against national local peers. Benchmarking is summarised as follows:
12 Patients who recommend the ward/service (%) April 2017 (latest data released by NHSE)
A&E Inpatients Community Maternity Outpatients National average 87% 96% 96% 96% 94% Regional average 84% 95% 95% 96% 92% SWFT 91% 96% 96% 96% 94%
Response rates (%) April 2017 (latest data released by NHSE)
A&E Inpatients Community Maternity Outpatients National average 12.5% 20.3% Data not 23.9% Data not Regional average 11% 20.2% collated by 15.5% collated by SWFT 4.3% 20.0% NHSE 26.0% NHSE Lowest: 2.2% Highest: 25.7%
3.2 Improving Response Rates
A decline in response rates has been noted across the participating areas (A&E, Inpatients and Maternity). To date performance has been consistent and above national average, with the exception of A&E. FFT surveys across all areas are being reviewed by the Trust’s FFT Lead with ward managers and service leads to address the low response rates and to clarify if there were any scanning or postage delays due to the lower than usual response rates. Data will be refreshed once finalised data has been received. It is anticipated that response rate volumes will improve and return to previous higher levels achieved.
Despite the volatility in response rates, the Trust’s patient satisfaction remains notably high and significantly above the national average.
To address A&E response rates specifically, in July 2017 the following actions were implemented by the Trust’s FFT Lead:
• patient friendly and focussed marketing (i.e. posters, signage and access to survey) were designed and provided to the A&E Manager for placement in the most suitable locations, and • a tablet device was sourced from IT and is placed on a locked stand to enable patients to provide feedback online.
However due to the level of engagement from A&E staff not being as planned, a targeted action plan has been developed in conjunction with I Want Great Care (iWGC) with clear lines of accountability and delivery timescales. Progress against this will be reported in next month’s report with higher response rates to be the intended outcome.
13 4. Clinical Outcomes
4.1 Avoidable Deaths
Mortality review data for 2016/17 has been compiled to April 2017. Potentially preventable deaths have been logged from 1 January 2016 onwards. Between May 2016 and April 2017 (latest 12 month rolling position) there have been 2 potentially preventable deaths as follows:
• July 2016 – Sub-optimal care of a deteriorating patient; • Dec 2016 – Delayed cardiology clinic appointment.
All preventable deaths are treated as SIs and are reported to the Clinical Governance Committee as well as South Warwickshire Clinical Commissioning Group. Action plans from Initial Management Reviews (IMRs) and SI Root Cause Analyses (RCAs) are monitored by the Patient Safety Team and reported to the relevant Audit and Operational Governance Group (AOGG) on a monthly basis. The learning from mortality reviews is shared within the Trust, for example the Audit and Operational Governance Groups, Grand Rounds and Multidisciplinary Mortality Meetings
5. OOHCC
A new set of quality measures were introduced within the Integrated Quality Dashboard for reporting each month and progress is underway as follows:
• Patients who feel that they are informed and involved in decisions about their care – The Trust has worked with its FFT service provider to measure patients feeling involved and informed through the FFT. The division is now able to report scores on a monthly basis. The target was informed by 2016/17 performance and as per the dashboard, it is positive to report current performance is above target. Work will continue to engage with patients and to promote patients to complete the FFT surveys.
• Percentage of patients who report an improvement or return to Activities of Daily Living (ADL) at discharge from rehabilitation – The division has reviewed the best approach to measure this quality Key Performance Indicator (KPI) and is currently finalising changes to documentation to enable staff to record ADL levels and to enable auditing to take place on a monthly basis.
6. Normal Delivery Rate
Normal birth rate data has been scrutinised and although the normal birth rate was less than 60% for June 2017, the previous 12 months (June 2016-June 2017) performance has indicated an improvement and the target being achieved for 6 months of the year. This is a significant improvement from June 2015-June 2016 where the target was only met twice. The Trust’s Maternity Services have been progressing a number of work-streams aimed at increasing the normal birth rate. This has included work around induction of labour and decision making regarding elective caesarean sections. In addition, there has been a focus on multidisciplinary training for interpretation of intrapartum fetal monitoring and the promotion of normal birth on the labour ward. The future development of the Midwifery Led Unit (MLU) will support the promotion of normal birth further by providing a more appropriate environment for midwifery led women to birth successfully within.
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Director of Operations Report
7. Regulatory Performance Measures
7.1 Cancer Performance – May 2017
Cancer performance against the 62 day measure for all cancers remains strong into May 2017. Overall the Trust delivered 92%, which continues the improvements seen in April 2017. During May 2017 however, the 62 day screening, 31 day subsequent (all) and 31 day subsequent (surgery) targets were missed. While this may appear concerning, the actual number of patients breaching these standards was very small (just 1 patient in each case of the 31 day subsequent surgery and all measures, and just 0.5 patient for 62 day screening). In each of these measures the number of treatments is so few that any patient waiting longer than the standard will cause the measure to breach. These low numbers are mitigated over the quarter and should not impact longer term performance.
Table 1: Trust Cancer Waiting Times – May 2017
Performance against the new shared breach methodology also continues to be strong, delivering 94.4% in May 2017.
7.2 18 Weeks RTT Performance – June 2017
Frustratingly the RTT target was again missed in June 2017, delivering only 90.86%. This is despite the best efforts of the Operational Team to improve performance.
Orthopaedics performance has improved in June 2017 and this specialty achieved the 92% target. This was related to the additional theatre capacity (Vanguard) and the implementation of the pay per case payment system which has encouraged surgeons to pick up additional lists. However ENT, Urology, Ophthalmology and Dermatology all continue to struggle.
Dermatology continues to make use of the locum consultant to fill the existing vacancy. The service will have a substantive consultant commencing in the post in September 2017 and will also continue to employ the locum for a minimum of 3 months to create some additional capacity and help clear the RTT problem. The staffing issues within Dermatology, which have taken significantly longer to address than planned, are now also compounded with the summer months where Dermatology experiences its highest peak in two week wait referrals, causing additional pressure on the RTT target. 15
Across the other specialties, plans for additional capacity have not been delivered as planned. This has been caused by a number of factors including annual leave and high demand for surgical capacity in the private sector. The high levels of elective demand have also meant that fewer theatre lists have been sourced as backfill as usual.
The delay in opening the new Ophthalmology Unit at Stratford Hospital, even though it was for only 3 weeks, prevented planned additional capacity from being realised for another month.
However steps are being taken in order to alleviate these pressures in month, including:
1. steps taken to begin recruitment into an NHS locum post in ENT to create additional much needed capacity. This will go out to advert in the next month. In the interim the Clinical Director is working with colleagues to put on additional outpatient capacity during August 2017; 2. additional ophthalmology capacity at Stratford Hospital is now scheduled from 24 July 2017 and this will help reduce the RTT pressure across Ophthalmology during August 2017; 3. extra theatre sessions continue to be found for Urology and the locum continues to provide additional outpatient clinics, and 4. additional resource to support the validation team has also been sourced for summer to help create some capacity and improve data quality.
It is now anticipated that performance is unlikely to improve significantly until the end of the summer across sufficient specialties to enable to sustainably achieve RTT at an aggregate level despite plans to deliver this by quarter 2. Long term plans include working with the CCG to remove unnecessary follow up capacity which can then be converted into new slots, and discussions have commenced with Dermatology to consider this.
The Finance and Performance Executive will provide scrutiny of all specialty level plans to resolve performance issues by September 2017 to assure sustainable recovery of RTT performance.
7.3 A&E Performance – June 2017
Despite activity levels being particularly high through A&E in June 2017, the Emergency pathway has performed well, delivering the 4 hour target in both month and quarter 1. This reflects the clinical teams’ responsiveness, delivering both ambulance turnaround times for both 60 and 30 minutes and percentage of patients admitted within 4 hours (91.1%), which are key patient safety measures.
The Ambulatory Emergency Clinic has seen rising demand, with 35.4% against a target of 35%, and average length of stay for adult emergency inpatients improving further to 5.1 days compared to a target of 6 days. Together these markers are an indication of the ability of the system to expand and contract in response to non-elective activity variation.
8. Activity – June 2017
Activity across the Trust in June 2017 continued the trends seen each month and year to date, with levels of both elective and non-elective activity being higher than planned.
16 Elective activity (adults) is 7.3% above plan year to date and 5.5% in month. Non elective demand is up 4% year to date and 7% up in month. New outpatient attendances are also up against the plan, year to date by 6.2%. Despite this, Emergency Department’s performance remains strong, but the RTT position is under pressure.
9. Notable Performance
The main areas of notable performance for May 2017 include:
9.1 Maternity Measures
Breast feeding initiation rates have been maintained above target and the department continues to work towards the full Unicef Baby Friendly Initiative accreditation. A workshop was held in May 2017 to identify areas for further improvement.
Smoking at time of delivery percentage rate was unusually very low this month at 1.8%, against a target of 8%. Reducing smoking in pregnancy is a key strand of the RCOG/RCM Saving Babies Lives Care Bundle which has been adopted at the Trust. Compliance against the elements of the care bundle is monitored through a work stream of the Local Maternity System (LMS). Women who smoke receive a high impact intervention demonstrating the effects of smoking early in pregnancy.
9.2 Stroke Indicator (80% of patients spend 90% of admission on a stroke ward and stroke admissions with a CT scan within 24 hours)
While performance against this measure dipped slightly in month, overall year to date this measure continues to perform well. The Emergency Division continue to drive improvements in the delivery of the Stoke pathway. Discrete project work is being undertaken on the Stroke Rehabilitation Ward (Feldon) to reduce overall length of stay of its patients, and improve flow from Victoria Ward (Acute Stroke). In this way, access to Victoria Ward, the dedicated Stroke Ward, will support improvement in the key metrics aligned to this speciality.
9.3 Diagnostic Waits – June 2017
Diagnostics performance continues to be strong with delivery against the target again in June 2017 (99.0%).
9.4 Short Notice Cancellation and Reschedules (Outpatients) – June 2017
This measure continues to perform well with only 0.4% of patients receiving a short notice cancellation in June 2017.
10. Performance Concerns
The main areas of performance concern for June 2017 include:
10.1 Main Call Centre Response Rate (95% within 1 minute)
Call centre response rates continue to be an area of concern. Steps have been taken to address this which includes the removal of the Trauma and Orthopaedic (T&O) and Ophthalmology Booking Teams from Patient Access, on a 6 month trial basis, to be line
17 managed under the respective general manager rather than sitting within the Patient Access Team.
This has been done as part of the PAS Team Patient Experience Project Group with a view to creating some capacity within the PAS Team to manage the remaining booking services and provide T&O and Ophthalmology bookers (the two single largest booking teams in the Trust) with focussed line management in order to address the call centre issues. The challenge in devolving booking teams to specialties is maintenance of compliance with Standard Operating Procedures (SOP) and the pilot is testing a centralised approach to governance and oversight with a devolved specialty team.
10.2 Best Practice Tariff (BPT) for Fractured Neck of Femur – June 2017
June 2017 saw 26 patients being treated for fractured neck of femur with only 14 meeting the criteria for BPT. Of the remaining 12 that did not achieve BPT, 8 patients failed to go to theatre within 36 hours, 2 did not have delirium tests carried out and 2 did not get an orthogeriatric assessment within 72 hours.
Actions to address this include:
1. project work with the Emergency Division around the lack of medical input, and 2. some patients only miss theatre timings by 2-4 hours and Orthopaedic Service is reviewing how it can improve this.
18 Managing Director for Out of Hospital Care Collaborative
11. Delayed Transfers of Care (DTOC)
DTOC remains an area of concern affecting Hospital (7.3%) and Community (28.36%). The following actions are being progressed by the Warwickshire Care Better Together Fund DTOC project:
• data gathering and verifying DTOC data with Warwickshire sites, and • identification of improvement actions for individual sites and agreement of reporting processes.
During August 2017, a system DTOC plan identifying improvement opportunities to deliver an agreed target of 3.5% (including ambitions for reductions in both social care attributable and NHS attributable delays) and delivery plan will be submitted to Warwickshire’s Care Better Together Board.
Warwickshire Care Better Together Board has a focus on managing transfers of care and is collating a system wide DTOC plan for approval by the Health and Wellbeing Board for inclusion in September’s 2017 Better Care Fund submission.
12. HomeFirst
From this month the Board will have visibility of the percentage of urgent assessments completed by HomeFirst (Health) on day of referral. In June 2017, 71.6% of urgent assessments were completed by HomeFirst on day of referral, against target of 80%.
The chart below details team performance against target.
June: Performance against target by team 100% 90% 80% 70% 60% 50% 40% Within 30% Over 20% 10% 0% HomeFirst HomeFirst HomeFirst HomeFirst HomeFirst HomeFirst North - North - North - South - South - South - Nursing Urgent OT Urgent Nursing Urgent OT Urgent Physio Physio
19 Actions underway to improve performance include:
• daily huddles now take place with Warwickshire County Council colleagues to understand capacity across the health and social care system; • daily conference calls with brokerage; • trusted assessments are taking place with Warwickshire County Council; • demand and capacity tool is currently in pilot format to establish the true capacity for the day, supporting development of predictive modelling. This is an immediate action for HomeFirst South Nursing; • appointment of an apprentice workforce to bridge package of care, and • self-directed support (SDS) workers funded by Warwickshire County Council will commence in post in September 2017 to speed up financial assessments. This will improve patient’s access to packages of care and improve HomeFirst capacity.
13. Integrated Single Point of Access
In June 2017, 67.6% of calls were answered within one minute against a target of 95%. During June 2017 improvement activities have focussed on workforce. Revised rosters are in place which has resulted in improved weekend performance and reduction in variation in performance. Vacant posts have been recruited to, three new starters will join the team by the end of July 2017.
Director of Human Resources Report
14. Update – Buckingham Medical School
On 3 July 2017, the Trust’s Education Team travelled to the University of Buckingham Medical School to support them in their application for independent degree awarding status. Provisional feedback has been strongly positive of the application.
The next step will be for the General Medical Council (GMC) to inspect the Trust in September 2017 and the team is preparing for this. We would expect a good outcome for the Trust and our new partners.
Director of Finance Report
Please refer to the Finance and Capital Quarterly Report which is a separate agenda item.
20 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Nurse Staffing Report Enclosure F
Nature of item For information For approval For decision
Decision The Board is asked to receive and note this report. required (if any)
General Report Author Madeleine Curran, Deputy Director of Nursing Information Helen Lancaster, Director of Nursing Lead Director Helen Lancaster, Director of Nursing
Received or Meeting approved by Date
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public
South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Nurse Staffing Report
Executive Opinion
Overall the report provides assurance of the governance process for monitoring safety and performance and that escalation of staffing challenges and any potential compromise to service delivery processes are in place. When scrutinising patient safety and quality indicator data across the inpatient wards, there are still a number of wards that continue to demonstrate the challenges they face in terms of staff vacancies, staff availability and, patient safety and quality indicators. These areas are Victoria, Oken/Fairfax, Nicholas, Castle, Farries, Nicol, Willoughby and Mary Wards. These wards will be monitored closely by the Corporate Nursing Team and Director of Nursing to ensure that patient outcomes are being met and that there are plans in place to improve ward performance.
Executive Summary
This report provides information related to the current inpatient nurse staffing levels compared to the planned numbers, skill mix, patient acuity and dependency. This information has then been triangulated with national benchmarks and guidance but also patient safety and quality indicators data.
The overall gap in relation to planned staffing levels versus actual staffing levels is 1% which is an unmatched position this year.
1:8 breaches during June 2017 were 117, an improvement on May 2017 where there were 140 and April 2017, 120 breaches. The June 2017 breaches equate to 8.86% a greater than 2% reduction on the previous month. Gaps in staffing are mitigated by reviewing acuity and dependency of patients, backfilling where required and escalated to the Matron as appropriate.
Effects on quality and safety are being scrutinised especially on those wards that are triggering on 4 or more indicators.
Managing unavailability across the rosters appears to be a challenge for Ward Managers. Further work is on-going across the Trust to support this.
Recommendations
• Review the 8 wards identified and provide feedback to the Board in the next report; • Further develop the ‘at a glance’ dashboard for quality and safety measures, attached at Appendix 1; • Continue to monitor on a daily basis the staffing levels compared to patient acuity, dependency and escalating any gaps to assure all is done to reduce these; • As the Trust has now purchased SafeCare Live, to work towards implementation within the next 3-4 months; • Review roster review timetable and safecare compliance and work with managers to make required adjustments and improvements;
2
• Maintain the current recruitment activity and to prioritise those areas with the highest vacancy factor; • Bespoke recruitment strategies for specific areas e.g. A&E; • Continue to manage unavailability across all areas to ensure our staffs’ health and wellbeing is supported; • Continue to encourage staff to report staffing incidents through the DATIX incident reporting system; • Implement always event of safety huddle at each shift hand over; • Fully implement ward manager development and support program; • Support Falls Prevention Campaign with released staff resource in-house (cost neutral), and • Continue to support recruitment to substantive Ward Manager vacancies.
Helen Lancaster Director of Nursing
3
South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Nurse Staffing Report
1. Introduction
This report presents the latest nurse staffing data across all inpatient wards during June 2017. The purpose of this report is to update the Board in relation to the nurse staffing levels and specifically the gap between the planned staffing levels and the levels that actually occurred, how big the difference is and why, if this difference affected the quality of patient care and how any risks are being mitigated. It also reflects the actions taken to review the wards triggering last month on 4 or more indicators.
2. Feedback of Review of Wards Triggering in May 2017
Avon, Beaumont, Cardiology, Castle, Charlecote, Farries, Feldon, Mary, Nicholas, Nicol, Oken/Fairfax, Squire, Thomas, Victoria, and Willoughby wards were identified last month as triggering on 4 indicators or more. These wards are monitored closely by the Corporate Nursing Team and Director of Nursing to improve achieving patient safety and quality indicators and that there are appropriate plans in place to improve ward performance. A number of these wards have required further intervention to improve their work on falls reduction, improve the rosters to reflect bed numbers, there are also a number of junior and interim Ward Managers in post that require additional support. Some of this work has seen a reduction in wards triggering in June 2017.
3. Summary of Inpatient Nurse Staffing during June 2017
Graph 1 on the next page demonstrates that the overall gap in nurse staffing between the planned and the actual numbers reported on duty across the inpatient wards of the Trust in June 2017 was 1% overall, a significant improvement on last month’s nurse staffing gap. It has been discovered that there were some unidentified anomalies not picked up on the transition from the manually manipulated spreadsheet previously utilised to record staffing data to HealthRoster, in relation to the recording of a long day as opposed to separate early and late shifts. This artificially showed a gap of 1.5 hours every time a long day was used to cover an early and late shift. A long day equates to 12 working hours and an early and late equate to 13.5 working hours. HealthRoster has 2 reporting mechanisms that can generate the data and both have different functionality which has led to this discrepancy. This year quarter 1 has been revalidated and April 2017 stands correct at 3%, May 2017 was 2% and June 2017 there was a 1% staffing gap.
This gap is calculated from wards that had less staff on duty than planned and others that had more staff than planned. The decrease is reflective of the roster templates not being adjusted on HealthRoster where the information is pulled from as opposed to the spreadsheet that could be manipulated to reflect the planned and actual in a more controlled way. The spreadsheet was validated by the Corporate Nursing Team at the end of each month previously and the shift length differences were accounted for. Graph 2 on the next page identifies how these gaps and overstaffing numbers differed between the different wards in June 2017 with Avon, Oken/Fairfax, Nicholas, Squire and Willoughby Wards having large gaps due to vacancies and sickness and Greville Ward, due to the flexible use of beds and no other adult inpatient wards having gaps of greater than 5%.
4
Graph 1
All staff /all shifts staff levels % last 6 months Sum of % actual Sum of % gap
5% 4% 4% 4% 3% 7% 1% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Jan-17 Jun-17 Apr-17 Feb-17 Dec-16 Mar-17 May-17
Graph 2
All staff during both shifts Staff levels % by all Wards Sum of % actual Sum of % gap 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% -10% ITU Nicol Avon Mary SCBU Castle Squire Farries Feldon Greville Victoria Thomas Nicholas Campion Chadwick Maternity Beaumont Cardiology Charlecote MacGregor Willoughby Ellen Badger Ellen Surgical Unit Surgical Fairfax/Oken
5
A further comparison has also been made between days and nights and registered nurses/midwifes and care staff. Graphs 3, 4, 5 and 6 show these differences for the month of June 2017. This information demonstrates that the inpatient wards were understaffed in qualified nursing staff during the day and at night by 10%. This deficit was compensated this month by overstaffing of care staff during the day by 7% and compensated for by an overstaffing of care staff during at night by 21%. Graphs 3-6 demonstrate the variance brought about by adding additional duties to the roster and not adjusting the planned numbers to reflect this. This is why an over staffed position looks evident. These additional shifts are generally because of increased patient supervision (specialing) requirements.
Graphs 3-6
Registered Nurse / Midwife Staffing Registered Nurse / Midwife Staffing Levels in the Day Levels in the Night Sum of Registered % Gap Day Sum of Registered % gap Night 100% 100% 10% 10% 10% Under 10% Under 90% 90% 80% 20% Under 80% 20% Under
70% 30% Under 70% 30% Under 60% 60% 50% 50% 90% 90% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% -10% -10% -20% -20% -30% -30%
Care Staff Levels in the Day Sum of Care % Actual Day Sum of Care % gap Day Care Staff Levels in the Night Sum of Care % Actual Night Sum of Care % gap Night 100% 10% Under 100% 90% 20% Under 90% 80% 30% Under 80% 70% 70% 60% 60% 121% 50% 107% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% -7% 10% Over -21% 10% Over -10% -10% 20% Over 20% Over -20% -20% 30% Over -30% -30% 30% Over
6
SafeCare
The SafeCare module of HealthRoster enables each ward to calculate the number of staffing hours they require each shift according to the actual dependency and acuity of their patients, and compares this to their planned and actual staffing numbers. The information is being used to support the most safe and efficient use, and movement of resources on a shift by shift basis based on acuity of patients rather than just the number of patients.
The SafeCare information for June 2017 is displayed in the graphs below. The red rostered bars are the number of staff actually on duty across the month per ward on the X axis; the planned are the agreed staffing hours in the ward rosters and the required care is the hours of staff time required according to the patient acuity during June 2017. As you can see Cardiology, Castle, Mary, Nicholas, Squire, Victoria, Willoughby and Oken/Fairfax Wards are showing the biggest gaps potentially because of the number of missing SafeCare recordings or recording high patient acuity during the month. The ward that continually features to have more staff on duty than their patient acuity requires is Oken/Fairfax Ward. SafeCare does not take into account the number of patients through each bed space in 24 hours in a short stay ward, and there is a significant turnover in Fairfax Ward.
June 2017
Rostered Care Required Care Planned Hours
9000 8000 7000 6000 5000
Hours 4000 3000 2000 1000 0 Avon Ward 24052 Ward Avon Mary Ward24034 CastleWard 24030 SquireWard 24035 Surgical Unit 24428 Unit Surgical FarriesWard 24053 Fairfax Ward 24040 Ward Fairfax Greville Ward 24020 Ward Greville Victoria Ward 24036 Ward Victoria Thomas Ward 24012 Ward Thomas Nicholas Ward 24018 Ward Nicholas Campion Ward74766 Chadwick Ward 74765 Ward Chadwick Charlecote Ward 24031 Willoughby Ward 24016 Cardiology Unit (Multiple) Unit Cardiology Beaumont Ward (Multiple) Ward Beaumont
SaferCare Live has been purchased, this will enable real-time review of the acuity of the patients and staff on duty. A project and implementation team will be established to enable full implementation of the system in the latter part of the year.
7
1:8 Ratio
The number of shifts where the number of qualified nurses per patient has breached the national guidance of 1:8 ratios during the day in acute inpatient wards was 117 in June 2017, a significant improvement on the previous 2 months with 140 in May 2017 and 125 breaches in April 2017. This equates to 8.86% of all daytime shifts across the 22 acute ward areas which is a reduction of over 2% on May 2017. The wards that breached the most were Beaumont, Campion, Chadwick, Charlecote, Farries, Nicholas, Nicol and Victoria Wards. On these occasions appropriate escalation through the site team to prioritise workload is facilitated to keep patients safe. There has been a continued improvement on Willoughby Ward, with only one breach and 4 or fewer breaches in the month on Avon, Ellen Badger, Greville, Mary, Squire Hatton and 23 Hours, Thomas and Willoughby Wards. Castle and Cardiology Wards do not feature in the breach report; neither does Oken/Fairfax Ward despite the roster staffing gaps.
Incidents
During June 2017 there were 47 incidents reporting inadequate staffing levels, an increase of 8 on last month. These have been categorised as either a breach in 1:8 registered nurses during the day, a breach of 1:10 registered nurses at night and if these have had any impact on the patients. The charts below demonstrate the wards and departments where staffing incidents have been reported and the number of times patient care has reportedly been affected.
Staffing Incidents by Sub-category (June 2017) 25
20
15
23 10 16
5 8
0 Inadequate staffing levels/skills Maternity Staffing Staffing issue affecting patient mix care (inc. communication failure)
8
Staffing Incidents by Ward/Site (June 2017) 12
10 10
8
6
4 4 4 3 3 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
0 (blank) Redwood Radiology NicolUnit Swan Ward Swan SquireWard LabourWard Greville Ward Womens Unit Theatres Main NicholasWard Patients Home Patients Patients School Patients Antenatal clinic Orchard Centre Orchard Chadwick Ward Chadwick Whitnash Lodge Whitnash Beaumont Ward Beaumont Heathcote House Heathcote Helen Clarke Suite MAU/Fairfax Ward MAU/Fairfax IntensiveCare Unit Coronary Care Care Unit Coronary Special Care Baby Unit Baby SpecialCare Accident & Emergency Antenatal AssessmentUnit Community Location/Health Centre Location/Health Community
Staffing Incidents by Sub-category (June 2017)
Intentional rounding process not implemented… 1
Delay in administration of medication including pain… 1
Patient vital signs not assessed or recorded… 1
2
Communication failure - outside of immediate team 3
Delay of 2 hours + between admission/ induction of… 3
Less than 1 Qualified nurse to 10 patients - During… 4
Medical - staff shortage 5
Community - Staff Shortage 6
No impact to patient care 9
Staffing below the minimum level in all settings -… 12
0 2 4 6 8 10 12 14
9
Care Hours per Patient Day (CHPPD)
Following the publication of the Carter Review (2016), NHS Trusts have been mandated to calculate and report on a monthly basis, the care hours provided by registered nurses and healthcare support workers to each patient per day. The aim of this was to allow national benchmarking but a simultaneous reduction in variation and increased efficiency where possible. The Carter Review stated that the average care hours per patient in the pilot sites was 9.1 hours of care provided by registered nurses and healthcare support workers per patient day with a variation from 6.33 to 15.48 hours.
In the chart below you can see the average reported CHPPD per ward during the past 6 months. 12 of our inpatient adult areas were below the national minimum during the month of June 2017 were Avon, Castle, Farries, Mary, Nicholas, Nicol Unit, and Willoughby Wards. Beaumont Ward as an inpatient adult ward has been included within the Elective Division as the transition from the staffing spreadsheet to HealthRoster has raised some anomalies with the data combined with the specialist acuity tools used within the maternity and paediatric units, makes the analysis incompatible with the majority of the inpatient adult wards.
The following graphs illustrate CHPPD for June 2017 including the 6.33 minimum indicator and the divisional levels for the past 5 months.
CHPPD June 2017
22
20
18
16
14
12 23.0 10
8
6 12.5
11.5
11.2
9.0 8.9
4 8.4
7.2 7.0 7.0 6.9 6.7 6.6 6.6 6.6 6.4 6.3 5.8 5.8 5.6 5.6 5.5 5.1 2 5.1
0 ITU SCBU Mary Avon Castle Squire Farries Feldon Greville Victoria Thomas Nicholas Campion Maternity Chadwick Nicol unit Nicol Beaumont Charlecote Macgregor Ellen Badger Ellen Willoughby Surgical Unit Surgical Fairfax/Oken Cardiology Unit Cardiology
10
Elective Division & Beaumont CHPPD 6 Months Please note that from April 2017, '23 Hour' and 'Hatton' are recorded together as 'Surgical Unit'
Sum of Feb-17 Sum of Mar-17 Sum of Apr-17 Sum of May-17 Sum of Jun-17
30 25 20 15 10 5 0 ITU Hatton 23hour Greville Thomas Campion Chadwick Beaumont Willoughby Surgical Unit Surgical
Emergency Division CHPPD 6 Months Please note that from April 2017, 'CCU' and 'Malins' are recorded as 'Cardiology Unit'
Sum of Feb-17 Sum of Mar-17 Sum of Apr-17 Sum of May-17 Sum of Jun-17
12
10
8
6
4
2
0 CCU Mary Avon Castle Squire Malins Farries Feldon Victoria Nicholas Charlecote Fairfax/Oken Cardiology Unit Cardiology
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Reasons for Current Gaps in Staffing
Unavailability
The Carter Review (2016) has also given organisations the impetus to consider how they manage and monitor the unavailability of staff to ensure best use of resources. Inpatient wards are currently budgeted with headroom of 22% that is used to backfill annual leave at a percentage of 14%, sickness at 4%, and study leave at 2% and management time at 2%. If there is more staff than 22% of staff unavailable to work, then this is not budgeted for if they are backfilled. The following graphs show the unavailability of staff by reasons across the inpatient wards during June 2017. You would expect some variation in these figures during each month depending on the service and some elements Managers will not have control over i.e. maternity leave. However the Director of Nursing recommends that unavailability levels are monitored and managed closely by the Divisional Teams to ensure that we are addressing the reason for some of the staffing gaps as much as possible and managing annual leave more equitability across the 4 quarters of the year. The unregistered staff unavailability chart now includes Thomas Ward.
Registered Staff Unavailability June 2017
Sum of Annual Leave Sum of Sickness Sum of Study Leave Sum of Working Day Sum of Parenting Sum of Other Leave 40% 35% 30% 25% 20% 15% 10% 5% 0% ICU24092 Community… Beauchamp… SCBU24071 Ellen Badger… Ellen FarriesWard… Feldon Ward… Feldon Fairfax Ward… Greville Ward… Greville Victoria Ward… Thomas Ward… Thomas Nicholas Ward… Nicholas Maternity Unit… Maternity Campion Ward… Cardiology CNS… Cardiology Cardiology Unit… Cardiology Chadwick Ward… Beaumont Ward… Nicol Unit 34089 Unit Nicol CharlecoteWard… MacGregor Ward… Willoughby Ward… Avon Ward 24052 Ward Avon Mary Ward24034 CastleWard 24030 SquireWard 24035 A&E Nursing 23180 Surgical Unit 24428 Unit Surgical
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Unregistered Staff Unavailability June 2017
Sum of Annual Leave Sum of Sickness Sum of Study Leave Sum of Working Day Sum of Parenting Sum of Other Leave 40% 35% 30% 25% 20% 15% 10% 5% 0% ICU24092 SCBU24071 Cardiology Unit… Cardiology BeaumontWard… Nicol Unit 34089 Unit Nicol CharlecoteWard… MacGregor Ward… Willoughby Ward… Avon Ward 24052 Ward Avon Mary Ward24034 CastleWard 24030 SquireWard 24035 A&E Nursing 23180 Surgical Unit 24428 Unit Surgical FarriesWard 24053 Fairfax Ward 24040 Ward Fairfax Greville Ward 24020 Ward Greville Victoria Ward 24036 Ward Victoria Feldon Ward Ward (Stroke… Feldon Nicholas Ward 24018 Ward Nicholas Ellen Badger Hospital… Badger Ellen Maternity Unit 24075 Unit Maternity Campion Ward74766 Chadwick Ward 74765 Ward Chadwick
Effects on Quality and Safety
Appendix 1 provides an overview of the patient safety and patient experience indicators alongside the staffing measures. From this the Board can see which areas need closer scrutiny.
The number of falls across the Trust during May 2017 had given cause for concern and resulted in a safety summit being conducted to discuss what needed to be done to address the increase and the interventions that are required to sustainably reduce falls. June 2017 has seen a huge reduction in falls rate and rates with harm and the work continues to underpin the focussed falls prevention work.
Ward leadership is an essential part of maintaining high quality care, there are a number of ward areas that have acting or junior Ward Managers in post. A focus group has been carried out to establish what the challenges are for the role and a support and development program has been designed to meet the needs or experienced and inexperienced managers alike.
Following discussion with the Senior Nursing Team, the Director of Nursing has requested that areas requiring further scrutiny should be identified when 4 categories are triggered. Wards identified from June 2017 data are Castle, Farries, Mary, Nicholas, Nicol, Oken/Fairfax, Victoria, and Willoughby Wards. The vast majority of the wards, highlighted in yellow on the dashboard, have a vacancy Ward Manager position with acting Band 6’s or interim managers covering more than one area. The clinical nursing leadership is really an instrumental factor in providing stability and a sustained patient safety and quality culture.
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• The Nurse Care Indicator data for June 2017 indicates a continued overall improvement from 98.8% to 99% and all divisions continue to maintain the Trust’s internal target of 97%, and again in this month all divisions achieved an overall compliance of 98%. Only one ward performed lower than 95% this month which was Thomas Ward. Targeted work has already been instigated as they have been struggling over several months to demonstrate improvement. However Thomas Ward has made the greatest improvement over the last month, moving from 93.9% to 97.8%. • The Safety Thermometer results in June 2017 identified 10 wards that fell below the internal 96% target. These were Avon (95.24%), Castle (95.83%), Charlecote (90%), Ellen Badger (94.12%), Farries (90.19%), Nicholas (89.47%), Nicol (87.56%), Thomas (95.45) and Willoughby (95.83%) Wards. Many of these are an improvement on the previous month. Of the harm incidents identified (4.48%) 21.3% occurred under the Trust’s care mostly relating to new grade 2 pressure ulcers, low harm falls, catheter related urinary tract infections and 2 new VTE incidents. The latter are attributed to the community and are currently under review to establish if they were pre-existing conditions. • Friends and Family Test (FFT) results were 100% for A&E, a continued improvement on April and May 2017. Low number of returns (13) but generally very positive feedback for the department. There were only 6 areas that did not achieve the target with Nicholas and Farries Wards doing particularly poorly this month. Beaumont (90.4%), Farries (76.9%), Feldon (92.3%), Nicholas (80%) Oken/Fairfax (93.8%) and Thomas (93.1%) Wards. From all the inpatient ward results, there was only 1 response that was extremely unlikely to recommend the service on 23 Hour Ward in the Short Stay Surgical Unit.
• 23 Hour Ward – 34 reviews, 28 extremely likely, 5 likely, 1 extremely unlikely: − Positive themes – ‘excellent care delivery from a friendly, professional, informative and helpful team who listened to what the patients were saying’. − Negative feedback none recorded.
• Farries Ward – 13 reviews, 7 extremely likely, 3 likely,1 neither/nor, 1 did not know and 1 unlikely to recommend: − Positive themes – ‘cheerful and dedicated’, all staff informative and polite’, high standard of cleanliness’. − Negative feedback – ‘impatient night staff’, ‘poor communication between staff in handing over important information in regards to patient care issues’. − The unlikely review had no associated narrative.
• Nicholas Ward – 10 reviews, 4 extremely likely, 4 likely, 2 did not know: − Comments were short and there was nothing to support the low score. Neither of the did not know reviews had not left any feedback.
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4. Conclusion
In conclusion, this report has presented a large amount of information related to nurse staffing across inpatient ward teams. This aims to provide the Board of Directors with assurance of the governance process for rostering, monitoring safety and performance and that escalation of staffing challenges and any potential comprise to service delivery is in place.
There are 8 wards that require continued support and action planning to provide assurance that teams are making improvements and ensuring quality and safety indicators are met.
5. Recommendations
• Review the 8 wards identified and provide feedback to the Board in the next report. • Further develop the at a glance dashboard for quality and safety measures, attached at Appendix 1. • Continue to monitor on a daily basis the staffing levels compared to patient acuity, dependency and escalating any gaps to assure all is done to reduce these. • As the Trust has now purchased SafeCare Live, to work towards implementation within the next 3-4 months. • Review roster review timetable and safecare compliance and work with managers to make required adjustments and improvements. • Maintain the current recruitment activity and to prioritise those areas with the highest vacancy factor. • Bespoke recruitment strategies for specific areas e.g. A&E. • Continue to manage unavailability across all areas to ensure our staffs’ health and wellbeing is supported. • Continue to encourage staff to report staffing incidents through the DATIX incident reporting system. • Implement always event of safety huddle at each shift hand over. • Fully implement ward manager development and support program. • Support Falls Prevention Campaign with released staff resource in-house (cost neutral). • Continue to support recruitment to substantive Ward Manager vacancies.
Helen Lancaster Director of Nursing
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Appendix 1: Quality and safety results for all SWFT wards during June 2017
Complaints 1:8 Gaps Low care (currently breaches between hours per Nurse Trained Classic NHS under >5% gap in required patient Friends & Care Avoidable Months Nurse Safety Number review - Wards in daytime staffing and compared Family Indicators Pressure monitored availability Thermometer of Falls ward staffing hours in rostered to national Test % (target ulcers 17/18 >22% (target >96%) allocation acute numbers on minimum >97%) subject to wards Safecare (6.33) change) Avon ward Y N N Y N 95.24% 3 100 97.40% 0 0
Beaumont ward N Y N N Y 100.00% 1 90.4 99.00% 0 0
Campion ward N Y N N Y 100.00% 0 100.00% 0 0 Cardiology Unit N N N N N 100.00% 5 100 98.60% 0 0 Castle ward N N Y Y Y 95.83% 4 100 100.00% 2 0 3 Chadwick ward N Y N N N 100.00% 1 100.00% 0 0 Charlecote ward N Y N N N 90.00% 3 100.00 99.30% 0 0 Ellen badger N N N N N 94.12% 1 100 99.30% 0 0 Farries ward N Y N N Y 90.91% 3 76.9 99.70% 0 0 3 Feldon ward N Y N N N 100.00% 7 92.3 98.50% 0 0 Greville ward Y N N N Y 100.00% 1 96 100.00% 0 0 ITU N N N N N 100.00% 0 100.00% 0 0 Labour ward N 100.00% 0 0 0 Mary ward N N Y Y N 92.00% 4 100 98.00% 0 0 2 McGregor ward N 100.00% 1 100 94.10% 1 0 Nicholas ward Y Y Y Y Y 89.47% 5 80 96.30% 0 0 3 Nicol ward N Y N Y Y 87.50% 5 100 99.50% 0 0 2 Oken/Fairfax ward Y N Y N N 100.00% 4 93.8 95.60% 1 0 3 SCBU N 100.00% 0 0 Squire ward Y N Y N N 100.00% 3 100 100.00% 0 0
SSSU N N N N N 100.00% 0 98.6 98.40% 0 0 Swan ward N 100.00% 0 92.60% 0 0 Thomas ward N N N N N 95.45% 2 93.1 97.80% 0 0 Victoria ward N Y Y N Y 100.00% 5 100 97.80% 1 0 3 Willoughby ward Y N Y Y Y 95.83% 2 96.3 97.80% 0 0 3
16 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Clinical Governance Committee Report for Enclosure G 12 July 2017
Nature of item For information For approval For decision
Decision The Board of Directors is invited to receive and note the report and to required (if any) consider any items highlighted for its attention.
General Report Author Bruce Paxton, Non-Executive Director Information (Committee Chair) Lead Director Helen Lancaster, Director of Nursing
Received or Meeting approved by Date
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Clinical Governance Committee Report for 12 July 2017
Reports to the Committee
1 Patient Experience Monthly Report Good process is reported on all aspects of complaint handling and feedback was received from NHS Choices linked to booking processes. Friends and Family Test (FFT) in A&E continues to be a low response rate and the Board should note that this is considered an operational leadership issue. The Clinical Governance Committee (CGC) expects to hear of improvement in the near future.
2 Patient Experience Annual Report This report is for record and has already been considered at the previous Board meeting.
3 Women’s and Children’s Division Audit and Operational Governance Group (AOGG) Quarterly Report There is an open culture of reporting and incidents are properly investigated. There have been no new claims during the quarter. National audits are on track. Mandatory training compliance is below target. Senior medical cover for paediatrics is being extended to later in the day as peak activity continues. Gynaecology consent was discussed and a verbal update is expected at the CGC meeting in August 2017. The Committee notes that the Trust should ensure that paperwork for termination of pregnancy is completed in a timely manner. This and infant heartbeat interpretation would be audited.
4 Patient Safety Monthly Report The Trust’s results are above the national target and the indicators showing dips are receiving attention. The increase in reported cases of sepsis was discussed, including the change in coding. Assurance was given that there were fewer deaths for sepsis than would be indicated by RAMI and SHMI. The regular missing of the safety thermometer stretch targets was discussed. Out of Hospital Care Collaborative (OOHCC) will take up this subject and consider monitoring pressure ulcers for longer.
5 Falls Group – Update on Changes to Reinvigorate The collection of data has been revised and made clearer to read. It is now easier to identify areas being challenged and the levels of harm. Safety huddles, Standard Operating Procedures (SOP), pharmacy reviews on wards and physiotherapy visits are among the actions implemented. Community hospitals need some focus on standards. Ensuring continued mobility in the frail elderly population was discussed and additional work started in equipment, alarms, medication, falls awareness and post-falls management (including checking patients’ eyesight). This is an encouraging picture.
6 Women’s and Children’s Division – Maternity Update The Midwifery Led Unit (MLU) continues as a project and the draft process for governance will be presented to the Committee when available.
2 7 Emergency Care AOGG An assuring report with actions identified to uplift the safety thermometer in areas such as pressure ulcers and Urinary Tract Infections (UTI). This work needs to link to the community through the OOHCC. Mortality review rate is improving but care needs to be taken to ensure reviews are properly reported into the Patient Safety Team. National guidance is being implemented and consideration is made for a medical referee to complete an independent review. Controlled drugs audit indicated 6 areas below 90% compliance, and action plans are to be produced within the Pharmacy Group. Specific reference is requested in the next AOGG report in October 2017. Local Safety Standards for Invasive Procedures (LocSIPPs) reporting is a national standard and is now expected in all AOOGG reports to the CGC.
8 Coventry and Warwickshire Pathology Service 6-Monthly Report Actions required to improve phlebotomy have been made and encouraging improvements observed. Further discussion in the Quarterly Review and Contract meeting is needed. There was no update available on the Trust’s results being within the 95% confidence limits on over-sensitive oestrogen testing, and the CGC will ask the question again in 2018. The Integrated Clinical Environment (ICE) system performance has improved but it is not yet clear of issues, any further changes to it need to be tested in both development and live systems. The Committee considers recorded incidents to be very low and has flagged concern to the Coventry and Warwickshire Pathology Service (CWPS).
9 Serious Incident (SI) Action Plan Tracker The Tracker is reducing in size and largely updates are being received in a timely manner. Since publication, the top 3 Emergency Division actions are noted as completed. All Child and Adolescent Mental Health Services (CAMHS) incidents are now discussed at the monthly Mental Health Partnership meeting and being worked on. This report will continue as a monthly item.
10 Infection Prevention and Control Monthly Report Processes continue to operate well and low numbers of infections are reported. The dashboard has been amended to include new surveillances. The report does not currently note UTIs, and current work is being completed on this in the health economy. Figures were not available for surgical site infection for quarter 3 of 2016/7. The Committee is assured that only cleaning products which support infection control were used in the Trust.
11 Mortality Surveillance and Review of Terms of Reference (ToR) The number of deaths reviewed is acceptable and learning is collated in accordance with national guidance. Data capture needed to improve to ensure Divisional AOGG reports match the Mortality Surveillance picture. Acute Kidney Injury (AKI) was discussed and the Committee noted that the amber indicator was on the cause of admission, not cause of death. The ToR were modified to include “Reflects National Guidance on Deaths” in the remit section, and on membership to reflect changes in the organisation. The ToR were approved subject to these amendments.
12 Information Technology (IT) Update The interim report was discussed and IT is asked to form an AOGG to ensure a better governance framework. Emergency preparedness plans are requested for the Committee to consider, then to bring to the Board’s attention.
3 13 Any Other Business – Stroke Services Concern was raised by the Trust Governor regarding potential changes to stroke services. The proposal for centralised treatment in Coventry and rehabilitation locally is to go to public consultation.
Confidential Section
The Minutes of the CGC meeting held on 10 May 2017 were modified for clarity by the Chair before presentation to the Board on 5 July 2017. The modified version was agreed by the Committee.
Three SIs were recommended for closure, and closed.
Bruce Paxton Non-Executive Director and Chair of the CGC
4
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Finance and Capital Quarterly Report Enclosure H
Nature of item For information For approval For decision
Decision The Board of Directors is asked to note delivery of the month 3 position required (if any) for 2017/18.
General Report Author Ravi Basi, Associate Director of Finance Information Lead Director Kim Li, Director of Finance
Received or Meeting approved by Date
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public
South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Finance and Capital Quarterly Report
Executive Summary
The Trust agreed a financial plan with NHS Improvement (NHSI) to deliver a retained surplus of £8.881m which includes £1.344m Donated Income. Excluding the Donated Income and the impact of donated depreciation gives the Trust an agreed control total of £7.769m for 2017/18. The control total includes £4.892m of Sustainability and Transformation Funding (STF).
The financial position for the month ending 30 June 2017 is a surplus of £1.153m which is a favourable variance of £.052m compared to the control total plan of £1.101m.
The Trust’s 2017/18 Annual Plan includes a total Cost Improvement Programme (CIP) requirement of £8.7m which includes £2.4m brought forward target delivered non-recurrently in 2016/17.
Operating expenditure is overspent by £0.344m and this is offset by an over performance on Operating Income of £0.40m.
Statement of Comprehensive Income
£000's
In Month In Month In Month REVENUE including STP of £4.892m Annual Budget Budget Actual Variance YTD Budget YTD Actual YTD Variance Operating Income £273,131 £23,322 £23,482 £160 £67,887 £68,287 £400 Operating Expenses (£260,671) (£22,158) (£22,159) (£2) (£64,495) (£64,839) (£344) Operating Surplus £12,460 £1,164 £1,322 £158 £3,392 £3,448 £56 Finance Costs Finance Income £48 £4 £3 (£1) £12 £8 (£4) Finance Expense - Financial Liabilities (£943) (£79) (£79) (£0) (£236) (£239) (£3) Finance Expense - Unwinding of Discount on Prov (£6) (£1) £0 £1 (£2) £0 £2 PDC Dividend Payable (£2,678) (£223) (£225) (£2) (£670) (£670) £0 Net Finance Costs ( ) g q y (£3,579) (£298) (£301) (£3) (£895) (£900) (£5) method £0 £0 £0 £0 £0 £0 £0 Corporation Tax £0 £0 £0 £0 £0 £0 £0 Gain from transfer by Absorption £0 £0 £0 £0 £0 £0 £0 Retained surplus in SOFP £8,881 £866 £1,021 £156 £2,497 £2,548 £51
Adjusted Financial Performance Remove capital donations / grants Income Impact (£1,344) (£401) £0 £0 (£700) (£700) £0 Remove capital donations / grants Depreciation Impact £232 £20 £21 £0 £38 £39 £1
Control Total including STF Income £7,769 £485 £1,042 £156 £1,835 £1,887 £52
Sustainability and Transformation Fund Income £4,892 £244 £244 £0 £734 £734 £0
Total Trust Surplus excluding STF Income £2,877 £241 £798 £156 £1,101 £1,153 £52
Revaluation gains/(losses) straight to revaluation reserve Revaluation gains/(losses) & impairment losses property, plant & equipment £0 £0 £0 £0 £0 £0 £0
Total Comprehensive Surplus/(Deficit) £2,877 £241 £798 £156 £1,101 £1,153 £52
2
The Statement of Comprehensive Income (SOCI) above shows the year to date surplus of £1.153m including an accrual of £0.734m of funding from the STF.
STF Income
The Trust’s 2017/18 financial plan includes £4.892m of STF Income. Guidance issued by NHSI sets out the following conditions:
• achievement of financial control total for each quarter weighted at 70% of the Trust’s allocation (£3.42m), and • achievement of A&E performance trajectory weighted at 30% of the Trust’s allocation (£1.47m).
Both elements of the STF will operate on a cumulative basis so that if a Trust misses the year to date control total or performance target in a quarter, but then recovers its cumulative position in a subsequent quarter, it can still receive its full amount of funding. If a Trust fails on its financial performance target it will not be eligible for any STF in that quarter even if the A&E performance target is met.
Where a Trust earns its STF allocation in one quarter but then goes off plan in subsequent quarters (in terms of financial and /or operational performance), funds previously received will not be clawed back. However to mitigate the risk of Trusts going off plan in later quarters, STF payments have been phased with a total of 15% of funding allocated in quarter 1, 20% in quarter 2, 30% in quarter 3 and 35% in quarter 4. A summary of this is provided in Appendix 1.
The Trust delivered the A&E performance measure for month 3 and cumulatively for quarter 1. Further the Trust achieved the year to date control total for quarter 1, therefore the Trust will receive the full amount of STF for the quarter.
Income
The overperformance on income is due to a mixture of overperformance on a number of areas. Commissioners have raised a number of queries in respect of month 1 which are being resolved through the contract reconciliation process in line with the national timetable.
Expenditure
Operating expenditure is overspent by £0.344m. Some non recurrent underspends have been offset against CIP but there are remaining areas of overspend that need to be mitigated. Recruitment to vacancies, sickness and unfunded posts are all resulting in continued high medical agency expenditure.
3
Progress Against CIP
The Trust’s 2017/18 Annual Plan includes a total CIP requirement of £8.7m which includes £2.4m brought forward target delivered non recurrently in 2016/17.
The Divisions presented the detail of their schemes and progress to date to the Board of Directors at the Board Workshop session on 5 July 2017.
The charts below show the progress of CIPs in year and on a recurrent basis. In year 56% of schemes have now been presented to Management Board including recognition of non recurrent in year underspends and a further 28.8% of schemes being worked up by the divisions.
On a recurrent basis the position currently stands at 39.4% approved and a further 30% are being worked up leaving a recurrent gap of £2.6m at present.
CIP delivery with the divisions continues to be reviewed in detail at regular meetings with the Executive Directors.
New Use of Resources Metrics (UoR)
NHSI implemented a new Single Oversight Framework (SOF) from 1 October 2016 to assess the financial performance of providers via the UoR comprising the following five metrics:
• Liquidity Ratio • Capital Servicing Capacity • I&E Margin • I&E Distance from Plan • Agency
4 Providers are scored 1 (the highest / best score) to 4 (the worst / lowest score) equally weighted metrics. The average across the metrics determines the Trust’s UoR score. Based on the month 3 financial position the Trust scored a 1 (the highest score) under the new UoR metric.
YTD Capital Service Capacity (Times) 1
Liquidity (Days) 1
I&E Margin % 1 Variance in I&E Margin % 1
Agency Ceiling % 1 Overall Use of Resources Score 1
Agency Expenditure
In 2017/18 the Trust has been set an annual agency expenditure ceiling by NHSI of £6.596m. NHSI has also set the Trust a specific savings target regarding medical locums of £0.050m for 2017/18.
Total agency expenditure in June 2017 was £368k which is below the NHSI’s ceiling limit for the month of £550k. This represents 2.61% of total staff costs compared to 4.09% in June 2016. The total actual agency expenditure year to date is £1.059m and this is below the revised year to date target of £1.650m.
This is a significantly improved position and reflects the impact of tightening up the rules on the use of personal service companies and IR35.
5 Agency Analysis by Staff Group
Statement of Financial Position
As At As At As At Statement of Financial Position 31/03/17 31/05/17 31/06/2017 Debtors have remained the same in month £000s £000s £000s NON CURRENT ASSETS and the Trust continues to work on resolving Property plant and equipment 119,828 121,568 121,414 Intangible assets 2,096 2,093 1,991 outstanding queries and chasing to convert Financial assets Investments 250 250 250 these debtors into cash. Other assets 997 992 987 TOTAL NON CURRENT ASSETS 123,171 124,903 124,642 CURRENT ASSETS: Inventories 3,235 3,525 3,603 The quarter 4 STF monies were received in Trade and other receivables 24,193 28,764 29,098 Cash and cash equivalents 13,549 10,059 11,449 mid July 2017. TOTAL CURRENT ASSETS 40,977 42,348 44,150 Non-current assets held for sale TOTAL ASSETS 164,149 167,251 168,792 CURRENT LIABILITIES Trade and other payables (31,846) (33,617) (34,117) Borrowings (1,497) (1,497) (1,497) Provisions (322) (322) (322) Other liabilities (1,941) (1,881) (1,901) TOTAL CURRENT LIABILITIES (35,606) (37,317) (37,837) NET CURRENT ASSETS/(LIABILITIES) 5,372 5,031 6,313 TOTAL ASSETS LESS CURRENT LIABILITIES 128,543 129,934 130,955 NON CURRENT LIABILITIES Trade and other payables (333) (333) (333) Borrowings (28,624) (28,613) (28,613) Provisions (2,113) (2,031) (2,031) TOTAL ASSETS EMPLOYED 97,473 98,957 99,978 FINANCED BY TAXPAYERS EQUITY Public Dividend Capital 64,109 64,109 64,109 Retained Earnings 27,798 29,282 30,303 Revaluation reserve 5,566 5,566 5,566 TOTAL TAXPAYERS EQUITY 97,473 98,957 99,978
6 Cashflow Chart 4
The graph opposite shows the actual cash position, together with the prior month forecast and monthly cash balance submitted in the Annual Plan. It also includes the minimum and maximum daily cash balances during the month.
The cash balance at the end of June 2017 was £11.5m which is below the £14.7m planned. The variance from plan relates to the timing of the payment of the final quarter’s STF monies from 2016/17 which was received in mid July 2017.
The 12 monthly rolling cash forecast is shown in Capital Programme the graph below. For 2017/18 the Trust has capital funding Chart 5 totaling £12.775m which is made up of £4.723m carry forward from 2016/17, £6.694m of internally generated funds and £0.948m charitable funds and £0.4m Public Dividend Capital.
Actual spend in June 2017 was £0.190m bringing the total spend for the year to £2.899m.
Recommendation
The Board of Directors is asked to note delivery of the month 3 position for 2017/18.
7
Appendix 1
8 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Patient Experience Quarterly Report Enclosure I
Nature of item For information For approval For decision
Decision The Board is asked to receive and note this report. required (if any)
General Report Author Patient Experience Team Information Lead Director Helen Lancaster, Director of Nursing
Received or Meeting approved by Date
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Patient Experience Quarterly Report
Executive Opinion
This report provides an assuring picture on activity relating to complaints management across the Trust. All staff continue to review and learn from feedback and complaints, in particular the upheld complaints. Lessons learnt have been cascaded to Divisions through the respective Divisional Audit and Operational Governance Groups which will ensure local level learning and improvements. Friends and Family Test (FFT) response rates are below the Trust and national targets, although patient satisfaction remains high. Action plans are in place to improve response rates across the Trust.
Executive Summary
• The Trust received 38 formal complaints in quarter 1 2017/18. This compares with a total of 63 received during the previous quarter (quarter 4 2016/17). The outcomes and actions taken have been outlined within the report. • Three complaints were not acknowledged with the 3 working days target. Two of these were internal delays from the office where the complaints were received. One complaint was delayed as the original plan was for the patient to see the Consultant and go through the care and treatment plan, as opposed to a complaint and investigation. However the complainant did not wish to see the Consultant. • In June 2017 the Trust received a final report on one of its complaints investigated by the Parliamentary Health Service Ombudsman (PHSO), the details of this are outlined in the report below which was partially upheld. • No new complaints were referred to the PHSO this quarter and the Trust is awaiting the outcome on 2 other complaints that were referred.
Patient Feedback
• A decline in FFT response rates has been noted across the participating areas (A&E, Inpatients and Maternity). To date performance has been consistent and above national average, with the exception of A&E. • FFT surveys across all areas are being reviewed by the Trust’s FFT Lead with ward managers and service leads to address the low response rates and to clarify if there are logistical or operational issues leading to the lower than usual response rates. It is anticipated that response rate volumes will improve and return to previous higher levels achieved. Despite the volatility in response rates, the Trust’s patient satisfaction remains notably high and significantly above the national average. • To address A&E response rates specifically, in July 2017 a series of actions were implemented by the Trust’s FFT Lead. However due to the level of engagement from A&E staff not being as planned, a targeted action plan has been developed in conjunction with I Want Great Care (iWGC) with clear lines of accountability and delivery timescales. Progress against this will be reported in the next report with higher response rates to be the intended outcome.
Patient Experience Report
Quarter 1 2017/2018
Data extracted 10 July 2017
Data source Datix Risk Management System
3
Performance Summary
4
Overview of Complaints Data The Trust received 13 formal complaints in June 2017, making the total of 38 for Quarter 1 2017/18. This compare with a total of 63 received during the previous quarter (Quarter 4 2016/17). The charts below provide an overview of complaints received during Quarter 1. 33 complaints were closed during this quarter, 6 of which were upheld and 13 partially upheld.
Complaints by Grade Quarter 1 2017/18: Complaints by Subject Quarter 1 2017/18:
9 8 7 Green 6 5 4 Dark Amber 3 Amber 2 1 0 Communication Clinical Care Waiting Times Nursing Care (verbal)
Number of Formal Complaints Received: Complaints by Division by Quarter:
30 30
25 25
20 20
2015 15 15 Q4 2016/17 2016 10 Q1 2017/18 10 2017
5 5
0 0 Elective Emergency Womens & Out of Support Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Children Hospital Care Services
5
Quarter 1 2017-18 Overview: of Area Activity Report
This area activity report shows which area the complaints received during Quarter 1 2017/18 relate to, and the percentage of the activity for the area.
Dark Ward / Department Green Amber Amber Red Total % Activity Accident & Emergency 2 1 1 0 4 0.059% Avon Ward 1 0 0 0 1 0.13% Aylesford Unit 0 1 0 0 1 0.14% Beaumont Ward 0 1 0 0 1 0.12% Castle Ward 1 1 2 0 4 0.22% Central England Rehabilitation Unit (CERU) 0 1 0 0 1 0.40% Day Surgery Unit 1 0 0 0 1 0.11% Integrated Team 1 1 1 1 0 3 0.14% Integrated Team 3 0 1 0 0 1 0.09% Labour Ward 0 1 0 0 1 0.11% Macgregor Ward 0 1 0 0 1 0.23% MAU/Fairfax Ward 0 1 0 0 1 0.19% Observation Ward 1 0 0 0 1 0.14% Victoria Ward 0 1 0 0 1 0.16%
6
Complaints Activity During quarter, the Trust closed 33 complaints, 6 of which were upheld and 13 partially upheld. These complaints closed and have been grouped by the respective month. Complaints Closed during April 2017
Final ID Description Ward /Dept. Subject risk Closed Outcome information grading
Not Upheld After seeing the consultant the patient Patient was under the care of his GP for anti- was expecting to be measured for a coagulation. On patients discharge the doctor full length support stocking, 18 Appointments - requested compression dressings and the 3998 months later still waiting to be seen. A DVT Suite Green 03/04/2017 delay anti-coagulation service at Warwick contacted friend raised this when they attended the GP to make them aware of what was the DVT clinic and was given needed and also contacted the supplier to information about the patient. arrange made to measure hosiery.
Patient underwent an elective Not Upheld Arthroscopy on the right knee. When Symptoms of pain are not related to the she came round from the anaesthetic arthroscopy performed. Pain due to she noticed the lateral side of the patellofermoral joint involvement which knee was excruciatingly painful and Clinical Care - 4016 Orthopaedic Amber 07/04/2017 relates to symptoms around the lateral aspect when she advised the nursing staff failed procedure of knee. Patient too young for total knee she was given morphine to counter- replacement - main options of treatment act the pain. Patient reports that she would be pain control with adequate has had constant pain since the analgesia and physiotherapy. procedure was performed. Part Upheld Ward did not receive much notice that patient Patient’s husband states he was not would be going to surgery and the focus was advised that his wife had suffered a Beaumont Communication on preparing her for procedure. The meant 4051 Green 07/04/2017 fall and was also was not told that his Ward - insufficient) the ward did not have time to call her wife was going to surgery. husband. Patient fell due to standing up unassisted and losing balance before staff could react.
7
Patient attended A&E, sent home after tests, told she had a migraine. Problems continued, seen by GP, had private MRI scan and was told she Part Upheld had suffered a stroke. Unwell a few The junior doctor discussed patient case with days later, sent to hospital, seen by consultant whilst patient was in A&E - both Stroke Nurse. Informed by staff that agreed diagnosis of migraine. No indication she should not have had to pay for a Accident & Clinical Care - Dark 4012 10/04/2017 for an A&E CT scan on admission. No private scan, that there is no stroke Emergency Investigations amber emergency MRI indicated on day of cover at Warwick after lunch on a admission. Stroke team were not contacted Sunday and so it was 'unfortunate' the on day of admission as patient was perceived patient had attended then. Staff told to have a migraine. patient if she had attended at a different time she would have had a scan at Warwick and the stroke would have been identified earlier. Patient staying with his son in Warwickshire when he was admitted to hospital, it was agreed that on Part upheld discharge he would go back to his Patient transport booked through the son's home so the family could look ambulance service. Actions taken by Trust after him. staff were appropriate and the relative had On day of discharge the nurse been given the opportunity to pick the patient informed the family that an ambulance up before the ambulance was booked. had been ordered and will travel from The patient was reported to be cold when Discharge - 4057 East Grinstead where the patient lives Squire Ward Green 18/04/2017 relative arrived on the ward, staff should have arrangements to take the patient to his son's home in noticed that and in addition there was a delay Barford. The son advised he could in the medication for discharge. However no collect the patient and drove to the confusion was noted during the stay, on hospital with a wheelchair and took questioning the doctor confirmed the patient his father home. The medication was had capacity and was lucid when discussing to follow but the son was later resuscitation and his preference regarding informed that this had been collected this. by the ambulance from East Grinstead.
8
Patient's husband unhappy with care of his wife who was admitted with suspected fracture of the neck. Reports she was kept flat, was being fed while flat on her back, was unable Not Upheld to move and could not see anything Patient had to be on flat bed rest until scans around her. She had no way of completed, when choking all staff fully trained locating call bell or other things and to deal with and this can be part of the normal had to shout for quite a long time to Nursing Care - Thomas process under these circumstances and 3903 get help. She was fitted with a neck Basic nursing Green 19/04/2017 Ward staffing levels were correct at the time of the brace eventually which was too big, care admission. Investigation showed the correct when she came home the District sized collar was fitted, the relative was told Nurses refused to change the brace how to get a new collar and where to attend as it was too big. Patients husband for that to be fitted. had to ring hospital and was told the hospital would need to fit the brace and it was another 24hrs before an ambulance could return the patient to A&E. Deceased patient’s wife not happy with care delivered by Warwick Hospital from the time of her Part Upheld husband’s initial referral. She reports The clinical and nursing care found to be 3851 she is not happy with his care under Urology Clinical care Amber 24/04/2017 appropriate but there were elements of the Urologist, the nursing and medical communication which could have been better. care in A&E and continuity of care afterwards, nursing standards and medical care during admissions. Part Upheld Patient's family unhappy with After the fall it was found the rails on bed communication around their fathers could have been left down to reduce chances care. Patient has fallen in hospital Communication of patient falling out of bed – the care and risk 3996 whilst on the ward. Family feel the Farries Ward Green 24/04/2017 - Insufficient assessment updated and reviewed to reflect hospital is keen to discharge the this. Both patient and family fully involved in patient and the family are unhappy discharge planning. Patient not eligible for with discharge arrangements. CHC or FNC.
9
Patient’s mother complained about support from SALT, have had a number of concerns over a period of Part Upheld time, feels the family is having to pay Clinical pathways were followed after referral. for a private therapist because they Referral process was delayed slightly due to cannot get the service they need patient’s address being missed off the form. under the NHS. Son has not had a Speech and Language Clinical Care - There was a 5 week gap of therapy due to 4042 diagnosis and went for 12 weeks with Green 24/04/2017 Therapy - diagnosis patients settling in period at school. Trust did no support from SALT. Although Children not pass responsibility onto patient’s school, patient’s mother states she has now patient had weekly 30 min sessions. Patient’s been told that the SALT will visit, therapy has been in accordance with Trust mother remains unhappy that the pathways and recommendations to date. support is insufficient for her child’s needs. The family have lost confidence in the SALT service. Patient not happy with A&E attendance. Had recent IVG treatment & due to some results, been prescribed stockings & daily injections, also informed on symptoms to look out for Ovarian Upheld Hyperstimulation Syndrome. Arrived Patient should have been monitored for in A&E, seen by a doctor, friendly but Accident & longer - bloods should have been taken and 4204 Clinical Care Amber 25/04/2017 difficult to understand, who performed Emergency possible opinion sought from Gynaecology a brief examination, prescribed anti- team. Doctor has apologised for the difficult emetic. She was observed for 30 time that the patient had. mins. Then discharged home. She returned home remained poorly, partner contacted UHCW who told her to go there immediately, and was admitted for 6 days. Not Upheld Patient’s family unhappy with Investigations show previous discharges discharge home on previous were appropriate, patient very independent admissions and feel that current Discharge - 3997 Farries Ward Green 27/04/2017 and requiring little assistance. Patient did not admission is due to patient being sent arrangements fit criteria for CHC and Assessment home inappropriately without sufficient Notification process not required due to low support. level of need.
10
Complaints Closed during May 2017
Final ID Description Ward/Site Subject risk Closed Outcome information grading Patient’s daughter unhappy with the care options offered to patient on discharge, and Closed felt communication with the social work team Willoughby Discharge - 3691 Green 02/05/2017 Warwickshire County Council to respond to was insufficient, and found it difficult to speak Ward arrangements complainant with them. Daughter was advised that patient should receive end of life care.
Patient unhappy that he was told to arrive for procedure at 7am, when he arrived he was Upheld told his procedure was not until 1pm. He was Investigation showed incorrect time on Communication advised he could return home, but lived too far Day Surgery letter prepared by Bookings, patient 4219 (written) - Green 03/05/2017 away for that. Although reports staff were Unit advised to come in early. Apology given Incorrect very good and helpful, he is upset that his wife with payment of additional car parking lost the mornings earnings unnecessarily and costs. they paid additional parking fees.
Patient & partner complained about organisation of District Nursing service, patient required a series of injections following chemotherapy. One injection was missed when a visit failed to take place & caused anxiety for a patient who had just had Upheld chemotherapy. Patient later advised the Investigation showed a missed visit when missed injection would be added to end of Communication patient did not receive an injection due. scheduled treatment. Later when trying to Integrated 4161 (verbal) - Green 08/05/2017 This was caused by staffing issues on that contact the team, left messages but nobody Team 1 incorrect specific day and although a later visit was contacted them. They have received no booked, there was an error and visit did not explanation of why the injection was missed occur. and no apology, they feel it is not the nurses fault but the patient was simply not listed for a visit. They are concerned by the lack of organisation, and when contacting the number given, those answering calls were not able to say when the nurse would visit.
11
Upheld The incorrect patient identification sticker After a physiotherapy appointment patient was attached to the form by the went to reception to make another Communication Physiotherapist, this meant when the appointment and was given a letter confirming Physiothera 4096 (written) - Green 10/05/2017 receptionist printed the appointment letter the next appt. When patient arrived home she py Incorrect and gave it to the patient it has the wrong opened the letter handed to her to find another name on it. The sticker belonged to the patient's details on it. patient who had been seen in the appointment before. Patient attended A&E, after being triaged Partially Upheld patient was waiting to be seen for 3 hours. Patient did not need immediate treatment When she got up to get a drink from the and there were more urgent cases that vending machine she collapsed. A doctor was Accident & Staff Attitude - 4122 Amber 10/05/2017 needed to be seen first. The doctor does called and the patient reports the doctor's Emergency rudeness not feel she was rude but acknowledges attitude was extremely condescending and she could have responded to the patient insinuated that the patient was wasting the better on this occasion. hospital's time.
Partially upheld One shift not covered due to sickness although adequate & appropriate notice given and there was a problem when one Patient's father complains about the level of of the nurses could not be contacted as Community care provided to his son and reports at times there was no signal in the area she was 4123 Children's Nursing Care Green 11/05/2017 staff cancel the visits or visit at a different working in. Managers also acknowledged Nursing time. that for some incidents although investigated and reported appropriately, actions taken and recommendations had not been fed-back to parents
12
Not Upheld Healthcare records reviewed, staff spoken to. Patient had been very confused and at Daughter written in, complaining her father times delirious. Whilst on ward female was subject to attack when admitted to the patient did come into bay but was led out ward, by a female patient. She also reports gently by staff, no attack occurred, all was her father was rough handled by staff, who supervised. There were no staff on duty as 4340 Castle Ward Other Green 11/05/2017 then by dislodging his catheter caused a described by relative and although catheter blockage. She states her father remains in a became blocked, it was not through rough distressed state and has a phobia about treatment and was flushed by nurse. There having to return to hospital. was no evidence to support any element of complaint. Offer made that for any future admissions, to speak to ward manager or Matron if there are any concerns.
Partially Upheld Although the doctor did not feel that she was disrespectful or not paying attention, Mother brought her son to an appointment and this was the impression gained by the wishes to complain about the unfriendliness of patient’s mother. An apology was given. the doctor. Also feels that the doctor did not Macgregor Staff Attitude - In addition it was recognised that the 4048 give full consideration to the information she Green 15/05/2017 Ward rudeness seating arrangements of the clinic room provided about her son and his condition, and contributed to the impression gained and feels the diagnosis as stated in the letter was the doctor reports she will be mindful of that not a true reflection. for future clinics. There were no identified failings in clinical care.
Upheld Shortly after labour it became apparent that The patients Rhesus negative blood group the patient 28 week Anti-D injection had been Midwifery Clinical Care - 4098 Amber 19/05/2017 was not added to the database which missed, and the injection needed to be done Community clinical review identifies which patients require an at the hospital two days after birth. appointment for Anti D.
13
Patient's family unhappy with previous care, feeling failure to provide diagnosis and Partially Upheld appropriate support has resulted in patient Patient needed to be transferred to CCU returning to hospital. Report frequent ward because of vacant episodes. The changes, failure to take into account patients Consultant does not consider the patient short-term memory loss making it difficult for had a stroke therefore no referral to stroke her to remember her exercises and failing eye Multiple Clinical Care - outreach was required. There was an error 4023 sight, making it difficult for her to read or feed Green 24/05/2017 Ward/Sites Diagnosis on the discharge document where stroke herself. Discharged to Nicol Unit, given had been written. The Consultant feels the sporadic physiotherapy and again failure to patient did receive the appropriate clinical instruct on what patient should do daily. care. Patient was seen by Physiotherapists Discharged home to re-ablement, which was on 14 occasions, although did not have any not supplemented with stroke outreach or physio after discharge. physiotherapy resulting in no improvement in mobility. Re-admitted following another fall.
MULTI-AGENCY COMPLAINT Patients family unhappy with a number of Not Upheld service providers. Warwickshire CCG leading, Communication Integrated Investigation showed an appropriate level 4221 contacted SWFT re a few questions regarding (verbal) - Green 24/05/2017 Team 1 of care was given, staff were caring & the district nursing service. Concerns are insufficient diligent. around some aspects of communication, both verbal and written. Upheld Patient given a letter with other patient name Different patient name and address was Communication and address details clearly visible. Also visible on letter handed to patient. It 4337 (written) - Green 25/05/2017 concerned that has not received an contained nominal information only, Incorrect appointment. findings discussed and agreed with Information Governance Lead.
14
Closed during June 2017
Final ID Description Ward/Dept. Subject risk Closed Outcome information grading Patient’s mother unhappy with daughters birthing experience, feels that despite them Partially upheld saying that she had previously had a bad Patient should have been encouraged to experience, little notice was taken. Feels attend the Birth Listening Service by midwives did not take sufficient care and that Labour Clinical Care - midwife if she wanted to attend. Midwife 4323 Amber 05/06/2017 this resulted in baby being born not breathing Ward failed procedure responded appropriately regarding and had been 'pulled out by his arm' causing delivery of baby - all midwives are trained damage. Feels communication since the to manage shoulder dystocia which is an child's birth has been poor although been obstetric emergency. seen in the Birth, Listening Service. Not upheld Patient was referred for anti-coagulation Patient received appropriate treatment. therapy by his GP. During his therapy the The anti-coagulation is a nurse led patient’s family feel his health deteriorated 4117 DVT Suite Clinical Care Green 05/06/2017 service and they did liaise with patients and caused his to have depression. Patient GP during the care. The GP is now struggles with his speech and everyday responsible for treating the patient’s life skills. depression.
Not upheld Patient attended A&E complaining about Investigation showed assessment & rash on leg and inability to weight bear, given actions taken at time of attendance were antibiotics and a line drawn on patient’s leg, reasonable, although acknowledged that with advice to come back if rash goes over in hindsight observations could have the line, then sent home. Rash spread, Accident & Clinical Care - been repeated, more recording of nature 4199 patient returned to A&E and then admitted, Amber 05/06/2017 Emergency investigation and area of cellulitis and possibly further spent 10 weeks in hospital and had leg blood tests, there is no evidence that this amputated. Feel patient should not have would have changed the outcome for the been sent home but admitted the first time patient. In addition patient was given and patient feels more could have been done advice to return if symptoms did not to prevent this life changing situation. improve.
15
Upheld Matron visited care home to investigate - Son & daughter in law report concerns about wasn't clear whether the dressing had mother in residential home, 92 years old. been changed. Reported absence of up Son also works at residential care home and Integrated Nursing Care - to date recording of visits - not 4339 reports District Nurses not attended for Amber 06/06/2017 Team 3 review acceptable as patient should have been several days, there was a fly near her wound reviewed regularly for wound and service diabolical, he took photos of her assessment. District Nurse did not leg. realise there was another wound after dressing patient's left foot and heal.
Patient had previous issues with miscarriages, when seen reports not happy Partially upheld with the way she has been looked after. Patient was upset by the communication Very confusing letter of complaint, ends with 4037 Obstetrics Clinical Care Green 09/06/2017 with the SHO but praised all other staff. patient reporting cancer found and patient An apology from the doctor was relayed being treated for that. Patient reports feels via the General Manager. 'let down by the system' but initially difficult to determine details of complaint.
Upheld Patient's son complains about First antibiotic dose administered at communication during his father’s stay in 2.20pm. No documentation was written hospital. The patient did not receive his Observation Medication - after patient was transferred to 4159 Green 14/06/2017 Parkinson medication. Discharge was not Ward dispensing Observation Unit. Patient wasn't given planned which meant the patient did not any of his prescribed medication for receive his usual evening care visit. Parkinson's during time he was waiting for transport.
16
Not Upheld Senior Consultant has reviewed and sent Patient’s daughter unhappy with delay in complainant a detailed report. Patient did Palliative Communication 4218 diagnosis and failure to provide support and Green 26/06/2017 receive analgesia to relieve pain. Care (verbal) compassion. Referral to Upper Gastrointestinal MDT was made in timely fashion but patient deteriorated before appointment.
Sent to A&E by on call doctor who saw Not upheld patient because the lower arm turned dark Patient did not die as a direct result of red. Patient had had a procedure on her arm the procedure carried out at another at Rugby St Cross Hospital. hospital but a later infection. Patient Family state patient was kept on admissions remained on the Admissions Unit for a ward for 6 days. Staff on admission ward Staff Attitude - longer period of time because she 3962 Oken Ward Green 30/06/2017 were abrupt, defensive and uncaring. Feel rudeness needed to be in a side room for infection patient could not give consent to treatment prevention purposes. Report of staff because she could not see, and state family attitude feedback to team. When taking should have been contacted. patients consent the clinician will verbally As patient later passed away family feel she discuss the procedure and risks and talk did not get proper care and attention. through the consent form.
17
Quarter 1 2017/18: Lessons Learnt
The following actions have been implemented in response to a complaint received by the Trust which the investigation showed the complaint to be upheld and lessons learnt identified in the form of an action plan. Below shows the lessons learnt from complaints closed during Quarter 1 2017/18.
April 2017
Datix Accident & Emergency ID: 4204 • A&E Consultant has spoken to the Doctor involved, exploring and addressing both communication and medical concerns and how practise should be improved. • Concerns raised have been discussed in A&E Governance meeting. Reminded all members of team of importance considering OHSS in patients who have undergone fertility treatment. Datix ID: 4051 Beaumont Ward • Incident wasn't logged on Datix. The staff have been reminded that similar incidents need to be reported and reviewed. • Nursing staff have been told to report this particular incident to ensure its recorded on Datix and to check they are competent in doing so. Datix ID: 4042 Speech and Language - Children • Speech Care Pathway being reviewed. Therapists needing to complete a Nuffield Centre referral form will consult with one of two specialist SLT's for advice and support in correct completion, ensuring report is obtained efficiently by the service. • SLT asked to meet with patient's mother at least once a term to provide updates and to invite her to attend therapy sessions. Datix ID: 4012 Accident & Emergency • Case will be highlighted in the stroke teaching for all A&E junior teams. • Will also be discussed at the Governance Team meeting. Datix ID: 3996 Farries Ward • Dementia Assessment tool incident discussed with the doctor who completed the form. • Social Worker Manager will contact family directly regarding funding for patient to be placed in residential care. Datix ID: 3903 Thomas Ward • Remind all nursing staff that call bell should be placed in reach of patient. • Discussed complaint with staff to ensure they are aware of the patients/relatives perception of the admission & while no evidence was found of inappropriate care, the staff can reflect on how they could improve the patient’s experience. Datix ID: 3851 Urology / A&E • Clinical Lead Nurse in A&E working to improve flow and experience of patients whilst in A&E. • Ward manager has discussed attitude with nursing staff.
18
May 2017
Cardiology Datix ID: 4337 • Reported as Incident • Discussed with individual staff member • Discussed anonymously with staff team • Contact details of manager if wish to discuss further • Appointment being arranged. Datix ID: 4340 Castle Ward • Offer made for any future admissions, any concerns to be discussed with ward manager or matron. Datix ID: 4219 Day Surgery Unit • Additional car parking costs reimbursed • Discussion with booking staff to ensure they understand implications of giving incorrect arrival time on letter to patient. Datix ID: 4161 Integrated Team 1 • Discussed with team leader • Discussion around changes in practice to ensure no visits missed again in similar circumstances. Datix ID: 4122 Accident & Emergency • The doctor will reflect on the communication so she is able to respond better to patients in the future. Datix ID: 4123 Community Children’s Nursing • Trust has rolled out an electronic roistering system to a number of departments, and hope to deliver this within the CCN team in the near future. • Full complement of staff are expected to be in post by July 2017. • On-call team will no longer ring ambulances, parents/carers will be asked to do this. Datix ID: 4098 Midwifery - Community • Process for the administration of Anti D during pregnancy is under review to determine if it can be made more robust. • All midwives and obstetricians have been informed and advised not to ignore a bland blood group on electronic maternity records, but to look on ICE and record the blood group. • If it is noted that a woman is Rhesus negative the staff must confirm with her if she has received her Anti D. Datix ID: 4096 Physiotherapy • The Physiotherapy Teams have been asked to make sure they check the correct patient information is entered correctly. Datix ID: 4048 Macgregor Ward • Doctor to be mindful of seating arrangements of clinic room for future consultations and impression that this can give patients.
19
June 2017
Datix ID: 4339 Integrated Team 2 • District nurse asked to write statement as part of reflective practise. • Patient will receive three weekly visits until she is satisfied the wound is healing. Datix ID: 4323 Labour Ward • All community midwives reminded to remember to ensure women know they can contact the Birth Listening Service at any time after birth of their baby. • All community midwives made aware of importance of exploring past birth experiences and the implications of these on future birth plans. Datix ID: 4159 Observation Ward • Clinical Nursing Lead for A&E has spoken to the nurse working in Observation Unit at that time and has reiterated the importance of accurate documentation. • Drug omission has been fed back to doctor and the consultant team. • Issues raised will be discussed at A&E monthly team meeting and will also be shared in department newsletter.
20
Quarter 1 2017/18: PHSO
There are times when a complainant remains dissatisfied with our response and in these instances the complainant is entitled to contact the PHSO to request a review of their complaint. The PHSO will take an initial look at the complaint and then make a decision whether they will investigate the complaint. When they have completed an investigation into a complaint they will write a final report advising of the outcome and recommendations that they have made.
In June 2017 we received a final report on one of our complaints investigated by the PHSO, the details of this are shown below. No new complaints were referred to the PHSO this quarter and the Trust is awaiting the outcome on 2 other complaints.
Final Report Datix ID 3402 Description Patient died on Coronary Care Unit, Patients wife is extremely unhappy with clinical care, nursing care, communication and staff attitude and behaviour on CCU and the Oncology Unit.
Outcome The Medical Director concluded the investigation and found failings in 3 areas, and he apologised for these. Information 1. Patient unaware of the prognosis and communication led to false reassurance and raised expectations. 2. Communication and decision making during the final admission were suboptimal. Problems with continuity of care and bed management compounded this. 3. There were some areas of nursing care that were suboptimal. 4. PHSO Partially Upheld. Three areas of which the Trust failed in the care, which were: Decision 1. The Visual Infusion Phlebitis (VIP) score chart had not been completed. 2. The Consultant did not ensure the patient and his wife were aware the treatment was buying the patient more time rather than curing him. 3. On the last admission the Clinicians should have immediately informed the Oncology team so they could have formally agreed on the path of care. Whilst the PHSO recognise the Trust had identified some actions the information they had was not sufficiently detailed enough to assure robust changes. Therefore they recommend that write to the complainant to acknowledge the findings and pay a sum of £500 to the complainant and produce a detailed action plan about the actions we have taken.
21
Quarter 1 2017/18: Patient Advice and Liaison Service (PALS) 2017/18 Total number of PALS contacts: PALS provide ‘on the spot’ advice, support and information to patients, 120 relatives and visitors. 100 PALS receive 93 contacts during June 2017, which made the total number of contacts received during Quarter 1 2017/18 269. 80
The PALS Officer visited the wards to raise awareness to patients and 60 made sure the information about the service was available. The plan is to make ward visits a regular activity with the view that there may be 40 personal concerns a patient has that the service can help with, such as benefit applications. 20
0 Sep Oct Nov Dec Jan Feb Mar Apr May Jun 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017
Subjects of PALS contacts Quarter 1 2017/18: Areas PALS contacts relate to Q1 2017/18:
60 25 50 20 40 15 30 10 20 10 5 0 0
22
Quarter 1 2017/18: Bereavement Service The Trust’s Bereavement Service co-ordinates matters following the death of an in-patient, this is part of the Patient Experience Team. After a patient has died the PALS / Bereavement Officer will contact the doctor involved in the patients care and arranged for the medical certificate of cause of death and other necessary documentation to be completed. The Bereavement Officers contact the deceased patient’s family and inform them of the formalities that they are required to take, and advice and support is given to the family to assist with this. At times the family want to visit their relative in the mortuary’s viewing room and the officers will liaise with the mortuary staff and escort them at the viewing. For Quarter 1 the Bereavement Service dealt with a total of 198 cases. This quarter we delivered training to the medical students about the tasks and paperwork a doctor is required to complete following a death, this training is popular with the students as it gives them an opportunity to see the paperwork and understand the reason for the documents and how to complete them before they experience this when they start working as FY1.
Number of days taken for doctors to write MCCD Referred to Coroner before issuing certificate
60 100
90 50 80
70 40 1 working day 60 Total Number 30 2 working days 50 3 working days 40 No. referred to Coroner 20 4 working days 30 before issuing 5 working days and over 20 10 10
0 0
23
Quarter 1 2017/18: Food satisfaction and cleaning standards Food satisfaction Cleaning standards • The scores have stayed consistently high against the target of 85%. Areas April May June • A total of 453 surveys were carried out in this quarter with a Warwick 94.7% 98% 97.4% total of 96.8 % of patients rating their food experience either Ellen Badger 100% 99% 98.5% excellent or good. Leamington and • We are continuing to receive very positive feedback from our Stratford patients who are enjoying the food served. • We have continued to jointly audit this food service with our • Patient Forum, Matrons/Heads of Nursing, Dietetics and Amey has continued to carry out technical audits • Amey team member. All shortfalls in standard were rectified within the timeframe set out in the National Cleaning standards. Below are the % results from the Patient Surveys for recent • The Hotel Services Monitoring Team has also been involved with months; the Patient Forum carrying out cleanliness audits together with our own programme of validation, spot checks and compliance. Areas April May June • Hotel Services has carried out an additional 35 spot check/ Warwick 97.2% 95% 96% management audits Ellen Badger 97.4% 96% 100% • We have carried out a programme of ‘Mini PLACE Assessments’ Leamington and through checking on work carried out that was raised in the main Stratford assessment earlier in the year. There have been 11 food service audits in this period as • Weekly walk-rounds on Fridays with the Director of Nursing, Heads follows; of Nursing/Matrons, Infection Prevention, Hotel Services, Maintenance and Amey have continued, this is proving to be very Food service April May June worthwhile as key people attend. Breakfast 1 1 0 • The Hotel Service Team is working with Amey to produce new Lunch 3 2 1 Supper 0 0 3 ward/department schedules for cleaning. This is to ensure that they • Issues regarding the actual food service to patients have are clear, easy to understand and combines the colour coding been greatly reduced as the food service is being constantly required. monitored and these spot checks continue to be carried out by the Hotel Services and Amey Management Teams. • Feedback on action taken is being received from Wards and Amey. • The tablet based menu ordering system, Saffron, is being trialled at present. 24
Quarter 1 2017/18: FFT
The Trust continues to promote and engage with patients through its FFT Survey. Whilst this commenced as a nationally mandated CQUIN, the Trust has continued with this valuable patient feedback tool. Whilst this is a resounding achievement, the Trust is constantly striving to engage with patients and make necessary improvements from their feedback. Feedback is reviewed by ward managers and is made available to all staff and improvement actions are monitored at the Patient Experience Group. Below are some examples of what our patients have stated in their surveys;
25
FFT Improving Response rates National benchmarking A decline in response rates has been noted across the April 2017 data is the latest dataset released by NHS England (NHS E) participating areas (A&E, Inpatients and Maternity). To date performance has been consistent and above Patients who recommend the ward/service (%) national average, with the exception of A&E. April 2017 (latest data released by NHSE) FFT surveys across all areas are being reviewed by the A&E Inpatients Community Maternity Outpatients Trust’s FFT Lead with ward managers and service leads to address the low response rates and to clarify if there National average 87% 96% 96% 96% 94% were any scanning or postage delays due to the lower Regional average 84% 95% 95% 96% 92% than usual response rates. Data will be refreshed once finalised data has been received. It is anticipated that SWFT 91% 96% 96% 96% 94% response rate volumes will improve and return to previous higher levels achieved.
Response rates (%) Despite the volatility in response rates, the Trust’s patient April 2017 (latest data released by NHSE) satisfaction remains notably high and significantly above the national average. A&E Inpatients Community Maternity Outpatients To address A&E response rates specifically, in July 2017 National average 12.5% 20.3% Data not 23.9% Data not the following actions were implemented by the Trust’s Regional average 11% 20.2% collated by 15.5% collated by FFT Lead;
SWFT Lowest: 2.2% 20.0% NHSE 26.0% NHSE • Patient friendly and focussed marketing (i.e. Highest: 25.7% posters, signage and access to survey) were designed and provided to the A&E Manager for . placement in the most suitable locations • A tablet device was sourced from IT and is placed on a locked stand to enable patients to provide feedback online
However due to the level of engagement from A&E staff not being as planned, a targeted action plan has been
developed in conjunction with IWGC with clear lines of accountability and delivery timescales. Progress against this will be reported in next month’s report with higher response rates to be the intended outcome.
26
FFT Lessons Learnt and Improvement Actions Taken
Emerging themes Feedback from the surveys has provided critical insight into patient experience and enabled the Trust to triangulate feedback with patient quality and safety indicators. This data is continuously reviewed and is included in the Nurse Staffing Report. The free text comments are analysed by the Trust’s FFT Lead and the emerging trends since implementation have been summarised below. These are monitored through the Patient Experience Group for improvement and implementation of appropriate remedial actions. The themes are consistent and have been categorised below;
Top 5 Positive themes: Top Negative themes:
• • Friendliness of staff A&E waiting time • Cleanliness of ward • Noise at night • Effectiveness of staff • Clear information form nursing staff • Attentive staff
The majority of patients and their families provide very positive feedback that is both complimentary and encouraging. Stating that the care they have received throughout the Trust has been delivered by kind; caring, friendly and knowledgeable staff in a clean and organised environment. One of the main negative themes throughout the entire acute trust is noise at night.
The following actions have been implemented to address dissatisfaction raised in surveys:
An evening tea round has started to place Ear defenders and eye masks have been Replacement of shower curtains and on Thomas ward, following feedback from tried Cleanliness improved in A&E shower heads and correction of loose toilet patietns. Timeliness of receiving medications seats Use of low lighting at night improved Replacement broken blinds in side rooms No mobile phone posters displayed in Replacement of worn blood pressure cuffs Expansion of food choice wards to help reduce noise and dirty oxygen saturation finger clips
.
27
NHS Choices star ratings Data refreshed 17th July 2017 Warwick Hospital
Ellen Badger Hospital
Royal Leamington Spa Rehabilitation Hospital
Stratford Hospital
28
NHS Choices comments
29
No formal complaint was received by the Trust
30
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Out of Hospital Care Collaborative Enclosure J Quarterly Update Report – Leg Ulcer Clinics
Nature of item For information For approval For decision
Decision The Board is asked to receive and note this report. required (if any)
General Report Author Debbie Martin, General Manager, Adult Information Community Services Lead Director Anne Coyle, Managing Director for Out of Hospital Care Collaborative
Received or Meeting approved by Date
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Out of Hospital Care Collaborative Quarterly Update Report – Leg Ulcer Clinics
Executive Opinion
This report provides a quarterly spotlight on a service within Out of Hospital Care Collaborative. This quarter Out of Hospital is providing the Board with an update on leg ulcer clinics (LUC).
Since 2012, LUC have delivered improved patient outcomes and increased productivity within Community Nursing Teams.
LUC healing rates have consistently performed above national best practice. As of February 2017, 70% healing rates were achieved within 12 weeks for venous ulcers and 18 weeks for mixed ulcers.
The service receives positive feedback from patients on the service received.
Anne Coyle Managing Director for Out of Hospital Care Collaborative
Introduction
The Trust provides LUC across Warwickshire, from 8 locations. In the North the clinics are delivered from Atherstone, Camphill and Bedworth. In Rugby LUC are delivered from the Orchard Centre and in the South they are delivered from Leamington, Southam, Stratford Hospital and Alcester.
A leg ulcer is a long lasting (chronic) wound that remains unhealed for more than 4-6 weeks. Patients with leg ulcers report a poor quality of life, restricted mobility and sleep disturbance due to pain and social isolation. This is reported by 68% of patients.
Research suggests that specialist Nurse led LUC can have a dramatic impact on healing rates and quality outcomes for patients as well as increasing productivity in Community Teams (Kings Fund 2010).
Development
In 2009, an audit was undertaken by Community Nursing Teams in respect to leg ulcer management. The audit identified that access to specialist advice and clinical intervention was not timely, this delay had a detrimental impact on healing rates.
In response, a pilot was established in North Warwickshire where 9 patients were directly referred to a LUC. The pilot demonstrated that there were improved healing rates, improvements in quality of life indicators for patients and improvement in productivity.
2 In 2012, 8 LUC were set up across the county as part of an ‘invest to save’ scheme. These clinics are for patients who have a wound on the lower leg that had not healed within six weeks. At the clinic these patients receive a specialist assessment.
By reconfiguring the workforce to provide LUC and standardising pathways, patients from the Community Nursing Team caseload were transferred into these clinics. This has generated a savings across the 11 Integrated Teams and supported permanent establishment of LUC.
In 2015, the Trust was awarded the contract in North Warwickshire to manage all of the GP patients presenting with leg ulceration. This additional investment enabled the service to expand to provide a service over 5 days in North Warwickshire. Detailed in the figure below are the leg ulcer pathway and service principles.
Outcomes
Leg ulcer prevalence in 2017 across the Trust has reduced by 9% in the last 3 years, contrary to national figures. 80% of these community patients are referred to LUC with Doppler’s. A Doppler assessment calculates an ankle brachial pressure index. An ankle brachial pressure index (ABPI) is a simple non-invasive method of identifying arterial insufficiency within a limb. It compares the ankle and brachial systolic blood pressures completed within one month of referral.
The LUC healing rates have consistently performed above national best practice. As of February 2017, 70% healing rates were achieved within 12 weeks for venous ulcers and 18 weeks for mixed ulcers. Nationally there are wide variations in practice and leg ulcer healing rates range from 45% to 70%.
3 Many improvements have been made to the leg ulcer clinics to improve patient outcomes. A Patient Group Directive (PGD) has been developed for antibiotics and steroid creams prescribed to patients, minimising delay by LUC staff and improving patient outcomes.
The service receives positive feedback from patients on the service received.
Conclusion
Leg ulcer care is complex. It is recognised nationally that leg ulceration requires a specialist assessment and that specialist clinics have far superior healing rates than care provided outside of the specialist clinic.
The Trust’s Leg Ulcer Service provides a high quality specialist service consistently achieving healing rates equivalent to the highest end of the national healing rates of 70%.
The LUC teams have an on-going programme of service development; in 2017/18 the teams are evaluating use of a portable scanner to improve hosiery measurement.
Anne Coyle Managing Director for Out of Hospital Care Collaborative
4 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Updated Register of Directors’ Interests Enclosure K
Nature of item For information For approval For decision
Decision The Board of Directors is invited to receive and note the updated required (if any) Register of Directors’ Interests.
General Report Author Sarah Collett, Acting Trust Secretary Information Lead Director Sarah Collett, Acting Trust Secretary
Received or Meeting approved by Date
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public
South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Updated Register of Directors’ Interests
1. Background
As a Foundation Trust the Trust is required to hold a number of registers and to make them available for public inspection.
2. The Constitution and Standing Orders
The Constitution (paragraph 34 refers) provides that:-
‘The Trust shall have:
34.4 a register of directors
34.5 a register of interests of the directors’
Paragraph 36 provides that:
’36.1 The Trust shall make the registers specified in paragraph 34 available for inspection by members of the public…….’
The Standing Orders for the Board of Directors (SO 7.8 refers) states that:
‘7.8.1 In accordance with the Constitution, the Secretary will ensure that a Register of Interests is established to record formally declarations of interests of Directors. In particular the register will include details of all directorships and other relevant and material interests (as detailed in SO 7.2) which have been declared by both executive and non-executive Board directors.’
7.8.2 These details will be kept up to date by means of an annual review of the register in which any changes to interests declared during the preceding 12 months will be incorporated.
7.8.3 The register will be available to the public and the Chief Executive will take reasonable steps to bring the existence of the register to the attention of local residents and to publicise the arrangements for viewing it.’
3. Registers
The Register of Directors’ Interests was subject to its annual review at the Board meeting on 5 April 2017, with an update received at the meeting on 5 July 2017. Further updates have been received from Alan Harrison, Non-Executive Director; Rosemary Hyde, Non-Executive Director, and Sue Whelan Tracy, Non-Executive Director.
2
The updated register is attached at Appendix A (updates in bold text and deletions crossed out) for the Board’s formal receipt and noting.
The updated register will be made available to the public via the Trust’s website and will be available for physical inspection through the Acting Trust Secretary.
Directors are reminded of their responsibility to advise the Acting Trust Secretary promptly of any changes to their register entries.
4. Recommendation
The Board of Directors is invited to receive and note the updated Register of Directors’ Interests.
Sarah Collett Acting Trust Secretary
3
Appendix A
The Trust is required to compile a Register of Directors’ Interests (as below), in accordance with the Constitution, and to make the register available for public inspection.
The register is maintained by the Trust Secretary who holds the original signed declaration forms. These are available for inspection by contacting the Trust Secretary on (01926) 495321 x8040. Register of Directors’ Interests (July 2017)
Voting Board Members Name Designation Declared Interest Charles Ashton Medical Director - Member of Solihull CCG Governing Body - Medical Director, Wye Valley NHS Trust
Jayne Blacklay Director of Development - Director of SWFT Clinical Services Ltd (a wholly owned subsidiary of South Warwickshire NHS FT)
Angela Brady Non-Executive Director - Member of the Conservative Party - Employed GP at Budbrooke Medical Centre - Part-owner of Lisle Court Medical Centre (premises only) - Spouse is a GP partner at Croft Medical Centre - Clinical Lead for mental health at Solihull CCG
Glen Burley Chief Executive - Chief Executive, Wye Valley NHS Trust - Spouse is the Chair of Governors at Myton School - Spouse is a Practice Nurse at Rother House Medical Centre
Russell Hardy Chairman - Chairman of Nuffield Health and Nuffield Health Pension Scheme - Chairman and majority owner of Maranatha I Ltd - Chairman of ‘Cherished’ - Chairman, Wye Valley NHS Trust
Alan Harrison Non-Executive Director - Chairman of the Fry Housing Trust - Director and Shareholder of Accord Housing Association - Justice of the Peace - Director of the Albatross Arts Project Ltd - Board member of the Accord Group Name Designation Declared Interest Treasury Ltd - Co-opted Board Member Accord Housing Association Rosemary Hyde Non-Executive Director - Director and Shareholder of RPR Consultants Ltd - Trustee of Stratford upon Avon Arts House Trust - Director of Stratford upon Avon Arts House (Trading) Ltd - Director of Fry Housing Trust - Spouse is Director and Shareholder of Brian Hyde Ltd - Spouse is Director of RPR Consultants Ltd Jane Ives Director of Operations - Managing Director, Wye Valley NHS Trust - Director and Company Secretary, Wiper Blades Ltd Helen Lancaster Director of Nursing - Board member of West Midlands Quality Review Service - Specialist Adviser for the Care Quality Commission Kim Li Director of Finance - Director of SWFT Clinical Services Ltd (a wholly owned subsidiary of South Warwickshire NHS FT) Simon Page Non-Executive Director - Owner and Director of Weathervane Consulting Bruce Paxton Non-Executive Director - Spouse is an employee of the Trust - Lay member on the Admissions Steering Group at Warwick Medical School Sue Whelan Tracy Non-Executive Director - Non-Executive Director of JDRF UK Ltd (Medical research charity for the cure, treatment and prevention of type I diabetes - Non-Executive Commissioner for the Independent Police Complaints Commission
Non-Voting Board Members Name Designation Declared Interest Tony Boorman Non-Executive Director - Director of SWFT Clinical Services Ltd (a wholly owned subsidiary of South Warwickshire NHS FT) - Spouse is trading as Thinkvivid ( a market research consultancy) and is on the advisory Board of Coventry Rape and Sexual Abuse Centre Ltd - Employed in a senior position by a subsidiary Company of IBM plc
5
Anne Coyle Managing Director Out of - Spouse is Director of Site Chooser Ltd Hospital Care Collaborative Ann Pope Director of Human - Director of SWFT Clinical Services Ltd (a Resources wholly owned subsidiary of South Warwickshire NHS FT)
Sarah Collett Acting Trust Secretary
6
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Summary of Ratified Policies Enclosure L
Nature of item For information For approval For decision
Decision The Board is asked to receive and note the summary of the following required (if any) policies: 1. SWH 01743 – Introducing New NICE Interventional Procedures and Other New Clinical Procedures, Methods, Techniques and Therapies Policy 2. SWH 01783 – Managing Conflicts of Interests Policy
General Report Author 1. Andy Butters, Head of Governance Information 2. Sarah Collett, Acting Trust Secretary Lead Director Glen Burley, Chief Executive
Received or Meeting Policy Review Group approved by Date 10 July 2017
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Summary of Ratified Policies
The following policies were ratified by the Policy Review Group on 10 July 2017:
SWH 01743 – Introducing New NICE Interventional Procedures and Other New Clinical Procedures, Methods, Techniques and Therapies Policy
This policy has been updated to take account of the development and changes to the Trust’s Governance structure.
The purpose of this policy is to assure the NHS and the Trust that all practitioners are competent in all of the activities that they undertake. It provides the steps required if a new NICE interventional procedure, or other new clinical procedure, technique or therapy is introduced to the Trust. This will safeguard patients and ensure they are involved in the decision to use any new or innovative procedures and that they are not exposed to unnecessary risk.
SWH 01783 – Managing Conflicts of Interests Policy
This is a new policy and its purpose is to help staff manage conflicts of interest risks effectively. It therefore:
• introduces consistent principles and rules; • provides simple advice about what to do in common situations, and • supports good judgement about how to approach and manage interests.
The policy reflects current legislation, national NHS guidance, including new guidance received from NHS England, and is based upon the model policy issued by NHS England.
This policy should be read and managed in conjunction with the SWH 01656 Gifts, Hospitality and Sponsorship Policy, which was ratified by the Policy Review Group in May 2017 and has been updated to include reference to SWH 01783 – Managing Conflicts of Interest Policy.
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Healthy Foods CQUIN 2016/17 Enclosure M
Nature of item For information For approval For decision
Decision The Board is asked to receive and note this report. required (if any)
General Report Author Ruth Breese, Community Dietitian Information Karen Newman, Hotel Services Operational Manager Lead Director Helen Lancaster, Director of Nursing
Received or Meeting approved by Date
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public South Warwickshire NHS Foundation Trust
Report to Board of Directors – 27 July 2017
Healthy Foods CQUIN 2016/17
Executive Opinion
The Trust has made significant in-roads into achieving the Healthy Foods CQUIN as part of the Food for Life project and as part of the continuous discussions with its service provider.
The Trust is committed to further improving the healthy food options available to its staff, patients and visitors and is on track to achieve to deliver the 2017/19 CQUIN requirements.
Targets
The 4 components of the CQUIN were as follows:
• the banning of price promotions on sugary drinks and foods high in fat, sugar or salt (HFSS); • the banning of advertisements on NHS premises of sugary drinks and HFSS; • the banning of sugary drinks and foods HFSS from checkouts, and • ensuring that healthy options are available at any point including for those staff working night shifts.
All necessary evidence has been submitted to the Clinical Commissioning Group (CCG) to demonstrate achievement of the CQUIN.
Introduction
In 2016/17, the ‘Improving Staff Health and Wellbeing’ CQUIN was nationally mandated for all NHS Trusts and included a healthy eating component. This CQUIN was managed by the Trust through its Food for Life Partnership Group.
The main catering provider on the Trust premises is Amey; however two volunteer organisations provide refreshments in the Outpatient Departments. All areas were required to meet the CQUIN.
Discussions Undertaken
At a meeting between the Trust and CCG representatives at the beginning of 2016/17, where the baseline audit was discussed that had been carried out by the CCG alongside a selection of recommendations that were also identified. A definition of healthy food and drink and a target to increase availability of healthy choices by at least 10%, aiming for 50% healthy items was agreed for the Food for Life project only.
Trust staff then met with suppliers to discuss the targets. Concern was expressed that introducing new items while stopping sales of others would reduce the income generated, this was of particular concern for the volunteer run coffee bars that pride themselves on the amount of money they raise. Agreements for change were agreed with Amey, Selecta
2 (vending supplier) the Red Cross Coffee Bar in Warwick Outpatients and the volunteer Coffee Bar in Stratford Outpatients. An action plan was devised.
The actions included removing signs identifying food manufacturers, changing the items for sale near the tills and increasing the amount of healthy food and drink on offer. See Appendix 1 for photos of changes made.
A table showing the changes in availability of healthy choices can be seen in Appendix 2.
Overview of Achievements
Trust staff worked with the suppliers to fulfill the CQUIN requirements and make the necessary changes that could be made.
Increasing the choice of healthier items proved difficult as there were limited healthy snacks available, especially from wholesalers used by the volunteer run coffee shops.
The CCG carried out a second audit in March 2017. They were satisfied the Trust and suppliers had worked hard to achieve the targets set by the CQUIN. A few items for further change were identified which the Trust is addressing.
CQUIN requirements Action taken by Trust The banning of price The Trust has not had any price promotions for promotions on sugary drinks sugary drinks and foods high in fat, sugar or salt and foods high in fat, sugar or (HFSS). salt (HFSS) The banning of The branding on fridges for Coke and Walls’ were advertisements on NHS changed. See photos in Appendix 1. premises of sugary drinks and HFSS The banning of sugary drinks This was completed easily for the restaurant at and foods HFSS from Warwick Hospital, but the coffee shop at Warwick checkouts and the restaurant and coffee bar at Leamington Spa Hospital had been designed with fridge for cake, drinks and confectionary next to tills, so a redesign of the area was needed. It was also difficult for the coffee bars to achieve this due to the limited space, so the CCG agreed that signposting the healthier choices would be acceptable. Ensuring that healthy options The Trust wanted to offer meals from vending are available at any point machines rather than just snacks. A tasting including for those staff session identified that while suggested items were working night shifts. tasty, they cost more than what people were willing to pay. Work continues to identify the best way to provide food 24/7 which includes the viability of a trolley service to the wards at night.
All necessary evidence has been submitted to the CCG to enable the year-end assessment of CQUIN achievement.
3 2017-19 Healthy Foods CQUIN Requirements
The CQUIN has been extended and updated for 2017-19. Providers are expected to build on the 2016/17 CQUIN by maintaining the four changes required in the 2016/17 and working towards three additional changes: a) Drinks • 2017/18: 70% of drinks lines stocked must be sugar free (less than 5 grams of sugar per 100ml). • 2018/19: 80% of drinks lines stocked must be less than 5 grams of sugar per 100ml. b) Confectionary and sweets • 2017/18: 60% of confectionery and sweets do not exceed 250 kcal. • 2018/19: 80% of confectionery and sweets do not exceed 250 kcal.
The Trust is however, looking for items with less than 150 calories as part of this. c) Pre-packed sandwiches and other savoury pre-packed meals • 2017/18: At least 60% of pre-packed sandwiches and other savoury pre-packed meals (wraps, salads, pasta salads) available contain 400kcal (1680kJ) or less per serving and do not exceed 5.0g saturated fat per 100g. • 2018/19: At least 75% of pre-packed sandwiches and other savoury pre-packed meals (wraps, salads, pasta salads) available contain 400kcal (1680kJ) or less per serving and do not exceed 5.0g saturated fat per 100g.
For 2017/18, Trusts also have a target set by NHS England to reduce the amount of sugary drinks sold. The Trust needs to reduce the total volume of monthly sugar- sweetened beverage sales per NHS outlet, reaching a target of 10% or less of the total volume of drinks sales for the whole month of March 2018 and continuing thereafter. This will need to be continued in all future contracts.
4 Appendix 1: Changes made across the Trust to meet the CQUIN
Branded fridges
Labeling healthy items
5 Appendix 2: changes made to the amount of healthy items offered as per food for life requirements
This shows that the targets were met by the majority of suppliers.
Venue Drinks Sweets & Crisps etc Cake & Biscuits % TOTAL Confectionary June 16 Jan 17 June Jan 17 June 16 Jan 17 June 16 Jan 17 June Jan 17 16 16 Warwick 21/43 22/40 1/58 2/52 7/14 8/15 7/20 8/17 31% 39%4 Coffee (49%) (52%) 1% (4%) (50%) (53%) (35%) (47%) Shop & restaurant Warwick 6/13 9/14 3/10 5/11 1/5 (20%) 2/5 5/12 7/14 34% 49% Outpatients (46%) (61%) (30%) (45%) (40%)3 (41%) (50%) Coffee Bar Warwick 10/16 14/17 1/5 0/4 4/8 (50%) 5/10 3/5 2/4 34% 46.5% Vending (62%) (82%) (20%) (0)1 (50%) (60%) 50% Leamington 9/14 11/15 1/11 3 /11 4/11 4/7 1/7 4/6 48% 55.75% Coffee Bar (64%) (73%) (9%) (27%) (36%) (57%) (14%) (66%) Stratford 11/13 11/13 4/13 5/11 2/6 (33%) 5/8 6/13 7/152 48% 60% Coffee Bar (85%) (85%) (31%) (45%) (62%) (46%) (47%)
6 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Meeting Board of Directors Date 27 July 2017
Subject Board Committee Minutes Enclosure N
Nature of item For information For approval For decision
Decision The Board is asked to receive and note the public Minutes of the Clinical required (if any) Governance Committee meeting held on 14 June 2017.
General Report Authors Lindsey Cotterill, Committee Administrator Information Lead Directors Helen Lancaster, Director of Nursing
Received or Meeting Clinical Governance Committee approved by Date 12 July 2017
Resource Revenue Implications Capital Workforce Use of Estate Funding Source
Applicable Integrated Care Normal Birth Rates Quality Patient Experience – End of Life Leg Ulcer Healing Rates Improvement Patient Experience – Dementia Electronic Observations Priorities Patient Experience – Booking Medicines Management Delayed Transfers of Care
Freedom of Confidential (Y/N) No Information (if yes, give reasons) Final/draft format Final
Ownership Trust
Intended for release Yes to the public
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
Minutes of the Clinical Governance Committee Meeting held on Wednesday 14 June 2017 at 12.30 hours in the Brooke Suite, Warwick Hospital
Present: Angela Brady (ABr) Non-Executive Director (NED) (Deputy Committee Chair) Charles Ashton (CA) Medical Director Richard Grimes (RG) Trust Governor Claire Hinds (CH) Associate Director of Operations (ADO) – Support Services and Chair of the Support Services Audit and Operational Governance Group (AOGG) (presentfrom Minute 17.127 until Minute 17.132) Simon Illingworth (SI) ADO Elective Care (Deputising for the Director of Operations) (present from Minute 17.125) Rosemary Hyde (RH) NED Sue Whelan Tracy (SWT) NED
In attendance: Madeleine Curran (MC) Deputy Director of Nursing Jennifer De Val (JDV) Principal Pharmacist (present from Minute 17.127 until Minute 17.129) Christine Gerogeu (CG) Matron for Infection Prevention and Control (present from Minute 17.125 until Minute 17.131) Ruth Gibson (RG) Patient Safety Manager Val Ross-Gilbertson (VRG) Hospital Based Coordinator – Cervical Screening Programme (present from Minute 17.130 until Minute 17.135) Martin Phillips (MP) Head of Pharmacy (present from Minute 17.127 until Minute 17.129) Sean Ramcharan (SR) Chair of the Elective Care AOGG (present until Minute 17.126) Katie Randall (KR) Consultant Haematologist (present from Minute 17.128 until Minute 17.134) Karun Thaper (KT) Trust Assurance Manager (present until Minute 17.127) Lindsey Cotterill (LC) Committee Administrator
MINUTE ACTION
17.121 APOLOGIES FOR ABSENCE
Apologies for absence were received from the Committee Chair, the Director of Operations, the Director of Nursing, The Associate Medical Director for Governance, the Matron for Community Hospitals, the Hospital Transfusion Practitioner and Dr Harrison (NED).
17.122 DECLARATIONS OF INTEREST
No Declarations of Interest were made.
17.123 MINUTES OF PREVIOUS MEETING HELD ON 10 MAY 2017
Cancer Services Annual Report (Minute 17.106 refers) Page 11, point (a), third sentence, this be amended to read: “However, there had not been an increase in diagnoses.”
Resolved – that subject to the above amendment, the Minutes of the meeting held on 10 May 2017 be confirmed as an accurate record of the meeting and signed by the Deputy Committee Chair.
SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Clinical Governance Committee Meeting Held on Wednesday 14 June 2017
17.124 MATTERS ARISING AND ACTIONS UPDATE REPORT
17.124.01 Actions Listed as Complete All Actions listed as Complete or On the Agenda on the Actions Update Report were noted and would now be removed from the report.
Resolved – that the position be noted
17.124.02 Elective Care AOGG Quarterly Report (Minute 17.075.02 refers) The Medical Director assured the Committee that a process was in place to reconcile patients seen in clinics with letters completed. The investigation revealed that there was not a problem with the system, but rather when the network went down letters were not transferred from the WinVoice system. The reconciliation process would then rectify this once the network was reinstated.
Resolved – that the position be noted.
17.124.03 Serious Incident (SI) Action Plan Tracker (Minute 17.101 refers) The Medical Directors had requested that the AOGGs tighten the process with regards to monitoring and updating the SI Action Plan Tracker. Compliance would be monitored through the SI Action Plan and the AOGG reports to the Committee.
Resolved – that the position be noted.
17.125 ELECTIVE CARE AOGG QUARTERLY REPORT
The Chair of the Elective Care AOGG presented this report to the Committee noting the following points:
(a) Nurse Led Indicators (NCI), Friends and Family Tests (FFTs) and the Safety Thermometer all performed well within the division throughout the last quarter with a good reporting culture present; (b) Local Safety Standards for Invasive Procedures (LocSSIPs) were on target. These were currently used within outpatients, with a plan for all departments to have these in place by July 2017. It was noted that the original document was quite large and departments had been encouraged to refine the process and only use relevant points, and (c) speciality reporting had revealed issues within dermatology. A locum had been employed to help with the service. The two-week target was now 82% rather than the national average of 95% and this was being monitored.
The main point of discussion revolved around the lack of orthopaedic geriatricians. These served the function of getting patients fit for theatre and looking after them following procedures. The lack of practitioners had severely affected the hip fracture numbers. An interim agreement had been reached with a rheumatologist, however there was not enough time to manage each patient. The main issue was the inability to retain staff, including junior doctors, within this speciality. Two locums were currently in post. The Medical Director explained that there was an ortho-geriatric ward Page 2 of 10 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Clinical Governance Committee Meeting Held on Wednesday 14 June 2017
with patients being treated efficiently, however daily ortho-geriatric input was missing. A piece of work had commenced to review the pathway flow, with the aim of re-engineering the pathway. Additionally, in a years’ time, 3 trainees would be available to take up elderly medicine posts within the Trust and further improvements would be seen following the implementation of a new junior doctors’ contract in August 2017. The Committee queried whether the lack of orthopaedic geriatricians was a patient safety risk. Patients could not be turned away or redirected as other local organisations were in the same position as the Trust. The Medical Director suggested a formal risk assessment be completed to quantify this issue. SI/SR
The ADO for the Elective division had previously raised concern regarding the number of endoscopy perforations. The Trust was now completing a higher number of endoscopies, so in ratio, the number of perforations remained the same. The Endoscopy Users Group (EUG) would monitor this closely and share any area of concerns with the AOGG.
A major concern was the IT issues, with staff struggling to work as the systems kept crashing. For departments that relied on several electronic systems, the frequent down time of one or more of the systems affected the efficient running of the department. The concern was that these issues were becoming part of an accepted culture, where the system was accepted to be unreliable without any resolution. The Committee queried though which platform these issues were monitored. The Chief Technology Officer would be invited to the July 2017 Committee meeting to explain how system DR downtime was monitored and what resolutions were planned. These issues would also be raised at the Board of Directors. The Chair of the Elective Care AOGG clarified that if a system went down and there was a lack of patient information, operations would be cancelled.
The issue of theatre staffing was discussed. It was thought that the situation would not improve before the opening of the Stratford Hospital. There was a plan to recruit overseas theatre nurses. This low staffing issue was currently on the risk register.
The Deputy Committee Chair queried the work of the Elective Care AOGG with regards to the SI Action Plan Tracker. The division was doing well and making progress. Teams were being pushed to finalise actions. Future SR AOGG reports would contain specific comment regarding the SI Action Plan Tracker.
The Controlled Drugs (CD) Audit had indicated 87% compliance within theatres. This would further improve over the coming months, with the aim to be at 90% or over within 3 months.
The Committee gave approval that patient safety alerts could be considered by the Endoscopy Users Group (EUG).
Resolved - that (A) the Elective Care AOGG Quarterly Report be received and noted; (B) a formal risk assessment be completed to quantify the issue of SI/SR a lack of orthopaedic geriatricians; Page 3 of 10 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Clinical Governance Committee Meeting Held on Wednesday 14 June 2017
(C) the Chief Technology Officer attend the July 2017 Committee DR meeting to explain how system downtime was monitored and what resolutions were planned, and (D) future AOGG reports would contain specific comment SR regarding the SI Action Plan Tracker.
17.126 PATIENT EXPERIENCE QUARTERLY REPORT
The Trust Assurance Manager presented this report to the Committee and highlighted the key issues:
(a) the data collection process was currently being reviewed. Datix would be updated to ensure that richer data was collected, improving data flow and allowing for stronger triangulation; (b) the number of complaints had been reduced from 24 to 11, with all being responded to within the agreed time frame and in line with the target of 90%; (c) the FFT A&E responses rates were the subject of an improvement plan with iWantGreatCare. This was documented within the report. The Trust would utilise a system that allowed for a high degree of demographic data. QR codes would be trialled that would take a patient directly to the survey, allowing this to be completed in private; (d) all targets for harm had been met apart from the safety thermometer, for which the Trust was above the national target but below the local target of 96%. This was measured monthly and would improve, and (e) discussion took place regarding complain 4012 which was dark amber. The stroke team was not contacted with regards to this patient, however incorrect information was given that the was no stroke cover at Warwick on a Sunday. The Medical Director clarified that there was no stroke physician cover over the weekend, however these cases were dealt with within acute medicine and stroke cases transferred to the University Hospitals Coventry and Warwickshire (UHCW). A piece of work had been instigated which would focus on stroke strategy and reorganisation.
Resolved – that the Patient Experience Quarterly Report be received and noted, and
17.127 PATIENT SAFETY MONTHLY REPORT
The Patient Safety Manager presented this report to the Committee. Discussion took place around the following key issues:
(a) with regards to a previous action requesting a verbal update on the changes to the Falls Steering Group (Minute 17.100 refers), assurance was given that a detailed piece of work was ongoing. Matrons had visited wards with a high number of falls and strong actions had been identified. The Falls Steering Group would consider how to direct this work in the future. A new data analyst had been recruited and would work with the team to help with the redesign of the report. A full report would be brought to the July
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2017 Committee meeting; (b) staffing data had been reviewed and would be finalised on the Monday before Committee meetings; as such the Patient Safety Report would always be “to follow” and distributed after the other papers. The Committee agreed to this as long as it was only this report; (c) the Medical Director provided an update on the changes in Acute Kidney Injury (AKI) figures. This was being monitored via that Deteriorating Patient Group and the Associate Medical Director FM (AMD) for Governance would provide an update on this at the July 2017 Committee meeting; (d) there had been a reduction in the number of falls with harm; (e) medication incidents were being reviewed by the Drugs and Therapeutics Committee for a 6-month period in order to attain Multidisciplinary Team (MDT) involvement and drive improvement in medication incidents; (f) the report now contained a section relating to reassessment of NCIs; (g) the Patient Safety Dashboard listed medication incidents with harm as 13.79%. The Patient Safety Manager assured the Committee that this figure would likely reduce once the incidents were reviewed; (h) the sepsis figures were discussed with regards to an increase in the Trust’s sepsis figures which it was believed was as a result of a RG change in national guidance on coding. It was queried whether this might have an effect on the comparison with the peer rami. This would be discussed further at the Deteriorating Patient Group and the July 2017 Committee report would contain further information; (i) the Committee expressed concern regarding the 7% gap in staffing levels. The Deputy Director of Nursing suggested that rosters had not been altered to reflect the bed reduction. Additionally some wards had an increased need for patient supervision. FM Resolved – that (A) the Patient Safety Monthly report be received and noted; RG (B) the AMD for Governance provide on AKI figures to the July 2017 Committee, and (C) the July 2017 Committee report contain further information on the Trust’s sepsis figures.
17.128 DRUGS AND THERAPEUTICS COMMITTEE QUARTERLY REPORT
This report was discussed confidentially and documented as minute 17.139.
17.129 SERIOUS INCIDENT (SI) ACTION PLAN TRACKER
The Patient Safety Manager presented this report, with discussion taking place around the following key points:
(a) the Committee had previously requested an update on IT actions within the tracker (Minute 17.101 refers) The Patient safety Manager had liaised with the Chief Technology officer and received assurance that there was a plan in place to manage the IT actions; Page 5 of 10 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Clinical Governance Committee Meeting Held on Wednesday 14 June 2017
(b) assurance was given that the relevant AOGG Chair now received a copy of the SI Action Plan prior to Committee meetings; (c) there were 29 open actions with 16 overdue due to a number of SIs being signed off; the Patient Safety Surveillance Committee would consider the action plan and assign actions to Matrons.
Resolved – that the SI Action Plan Tracker be received and noted.
17.130 INFECTION PREVENTION AND CONTROL MONTHLY REPORT
The Matron for Infection Prevention and Control presented this report to the Committee noting the following key points:
(A) there had been one1 C.diff toxin positive case and this was awaiting a Root Cause Analysis (RCA); (B) there had been 2 MRSA colonisation cases, with one occurring on the Special Care Baby unit (SCBU) which was very rare, it was felt that this was due to outside acquisition; (C) the E.coli numbers looked high, and the Committee was assured that the Department of Health was implementing a programme of work regarding this; (D) there had been one case of Klebsiella which counted as hospital attributed, however there were 7 cases in the community during the same period; (E) the hand hygiene audits continued. The Medical Director queried the secret shopper audits and noted that staff often knew when these were occurring. The Matron for Infection Prevention assured that this was not detrimental as the situation became a learning experience The Trust was considering the “nudge” theory to encourage people to wash their hands, such as spraying the scent of citrus into the air around sinks, and (F) the Committee would like to see surgical site infection data in orthopaedics within the report once more and a decision would be made as to whether this should be included quarterly.
Resolved – that (G) the Infection Prevention and Control Monthly Report be received and noted, and (H) the July 2017 report would contain surgical site infection data in orthopaedics and a decision would be made as to whether this should be included quarterly.
17.131 SUPPORT SERVICES AOGG REPORT
The ADO for Supports Services presented this report to the Committee.
The Committee had previously requested an update regarding the transfer of some dietetic services to Warwickshire County Council (Minute 17.060 refers). There was concern regarding the council commissioning and reducing the budget, however there was currently a stay of execution following communication with Public Health England and the budget would remain at £700k for the current financial and work would continue to change the criteria. A meeting had been had with the Clinical Commissioning Group Page 6 of 10 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Clinical Governance Committee Meeting Held on Wednesday 14 June 2017
(CCG) as they were not aware of the planned changes. The first quarter would be reviewed and its projected impact on the Trust would be considered. Audits were taking place and would be fed back within the next quarterly report.
The Committee noted the CD audits were not applicable to the Support Services division.
Podiatry services had an increased level of complex wound care. There was late referrals and higher than expected levels of amputation. Further work would be done with GP colleagues and community services regarding late presentation. The findings would be presented to the Finance and Performance Committee regarding the increased demand across the pathway.
There had been an increase in incident reporting regarding patients being aggressive to staff who were providing care in both clinics and at home. The Committee queried how staff could protect themselves whilst providing care and noted the link with the ability to put alerts on patient care systems to warn staff.
Dietetic staffing levels appeared higher and this was related to a number of staff returning to work following a high level of sickness.
Histopathology data had shown an improvement in cancer turnaround times. The next AOGG report due in September 2017 would include the turnaround times. A piece of service improvement work was taking place between the pathology network and histopathology to introduce KPIs for every element across the pathway to try and meet the maximum 5-day turnaround target. Data would be analysed regarding specialities and consultants with a commitment to meet the 5 day turnaround target.
All support services actions within the SI Action Plan Tracker were up to date and accounted for.
Assurance was given that all audits completed within the division added value to the organisation. Allied Health Professionals (AHPs) provided audits with particular purposes and were relevant to ensure that all case notes were accurate. This was also a beneficial part of the appraisal process.
Resolved – that the Support Services AOGG Quarterly Report be received and noted.
17.132 HAEMOSTASIS AND THROMBOSIS COMMITTEE (HTC) 6 MONTHLY REPORT The Consultant Haematologist presented this report to the Committee giving an overview of the work of the Committee.
Assurance was given that the Venous thromboembolism (VTE) risk assessments continued to meet the mandatory requirements. The new process for performing RCAs of hospital acquired VTE was now embedded into practice.
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During the previous 6 months, there had been one definite case of hospital acquired VTE, and a RCA had showed this to be non-preventable. A case from February 2017 was awaiting further review. The Committee was assured that the HTC had a robust system in place to review cases
The main area of concern was the anticoagulation service, with two experienced members of the team having left the service resulting in a skill gap. This had raised governance issues around the processed. Steps had been taken to mitigate the level of risk. The Consultant Haematologist had met with the ADO for the Elective Care Division to discuss and monitor these issues. Two new band 7 nurse posts had been advertised but had not attracted any applicants. Adverts would now go out for a band 7 nurse and a band 7 pharmacist.
Following a change in the RCA process, no major issues had been reported from the teams and doctors were now taking the lead with this.
Resolved – that the HTC 6 Monthly Report be received and noted.
17.133 HOSPITAL TRANSFUSION COMMITTEE 6 MONTHLY REPORT
The Consultant Haematologist presented this report to the Committee giving a high level of assurance.
A brief overview of the report was given. Reference was made to the service improvements regarding sample validity for blood transfusion. This had been delayed due to an IT update. The platform had continuously failed tests and consequently there was no date for implementation. The Trust was the only organisation within a network, with the current system being very labour intensive to retain 100% traceability. The team will go ahead without the IT update in implementing new processes in order that they become embedded within practice.
Resolved – that the Hospital Transfusion Committee 6 Monthly Report be received and noted.
17.134 CERVICAL SCREENING SERVICE – 6 MONTHLY REPORT
The Hospital Based Coordinator for the Cervical Screening Programme presented this report.
The Quality Assurance team had been contacted as no response had been received following the submission of recommendations. A response was yet to be received. Since the submission 2 outstanding actions had been updated; colposcopists now attended 50% of the MDTs and an additional administration post would be advertised for the colposcopy service. These updates would be sent to the QA team.
Within the annual report for Coventry and Warwickshire the were 49 recommendations, of which 21 related to Warwick.
The Committee was assured that every area of cervical screening was Page 8 of 10 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Clinical Governance Committee Meeting Held on Wednesday 14 June 2017
monitored for quality, with an impressive piece of work being completed by the histopathologists.
There was a national problem regarding cytology turnaround times, of the 57 labs in the country, 80% were failing to meet the turnaround times. The cytology department was struggling to retain staff as the cytology screening programme was coming to an end and would be replaced with HPV screening. Staff were therefore leaving as and when other suitable roles became available. The department had lost 10 screening staff within the last 4 years. Although the network would never achieve the turnaround standard, all other quality standards were being met. 82% of results were reported within 21 days, mainly due to the fact that work was being sent to the TDL lab in London, a NHS Partnership company. This was an expensive alternative. Public Health England and NHS England planned to make the switch from cytology testing to HPV testing by April 2019, however it was thought that this would be delayed due to the complex nature of the systems.
The Committee queried whether cytology screeners could be offered an incentive to stay with the Trust until the switch. Staff would not lose their jobs following the switch; however redeployment of band 4 screeners would be a challenge. The Hospital Based Coordinator for the Cervical Screening Programme was communicating with UHCW regarding payment of a retention premium to encourage staff to stay. A request was made that the Network be informed that the Committee had concerns that this could become a substantial problem if not dealt with swiftly.
Colposcopy was doing well. The high grade to treatment within 4 weeks standard was not being met, but no Trusts were meeting this and it was being monitored and audited every quarter.
Resolved – that the Cervical Screening Service 6 Monthly Report be received and noted.
17.135 COMBINED QUARTERLY SAFEGUARDING REPORT
The Lead Nurse for Safeguarding Children and the Director of Nursing were not available to present this report. The report was taken as read and the Deputy Director of Nursing agreed to relay the following questions to the MC safeguarding leads:
(a) Level 3 training was currently at 23%, was this on plan? (b) The Trust had previously agreed to host the Multi Agency Safeguarding Hub (MASH) Health Representative. An appointment had not yet taken place. Why had this not been filled and was there any impact on the service? Could further information regarding escalating be provided? (c) With the MASH representative in place, would this meet the suggested best practice? (d) How does MASH link with the Identification and Referral to Improve Safety (IRIS) scheme? Additionally, how do the domestic abuse resources such as the “talktosomeone” website work together from the provider’s perspective? Page 9 of 10 SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Clinical Governance Committee Meeting Held on Wednesday 14 June 2017
Resolved – that (A) the Combined Quarterly Safeguarding Report be received and noted, and (B) the above questions be presented to the Lead Nurse for MC Safeguarding Children and the Director of Nursing for an update at the July 2017 Committee.
17.136 ANY OTHER BUSINESS
17.136.01 Diabetics Clinical Network The Diabetic Clinical Network had recently been launched in the area. The team was optimistic regarding diabetic care in the area. The Trust was currently in the bottom quartile in terms of reporting and in the bottom half with regards to clinical results in this area. The development of the network would hopefully this will improve. The Medical Director had heard good reports regarding how the Network was progressing with good engagement from primary care.
Resolved – that the position be noted.
17.137 CONFIDENTIAL MINUTES FOR THE MEETING HELD 10 MAY 2017
17.138 MATTERS ARISING AND ACTION UPDATE REPORT
17.139 DRUGS AND THERAPEUTICS COMMITTEE (DTC) QUARTERLY REPORT
17.140 CYSTOSCOPY LOOK BACK EXERCISE
17.141 SERIOUS INCIDENT - SI/2017/6731/6386
17.142 SERIOUS INCIDENT - SI/2017/10103/6431
17.143 ANY OTHER CONFIDENTIAL BUSINESS
17.144 DATE AND TIME OF THE NEXT MEETING
The next meeting would be held on Wednesday 12 July 2017 at 12:30pm in the Brooke Suite, Warwick Hospital.
Signed Date 12 July 2017 (Chair of the Clinical Governance Committee)
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