Business Meeting of the Board of Directors
Thursday 6 September 2018
Session in public at 10.00
The Archibald McIndoe Board Room Queen Victoria Hospital Holtye Road East Grinstead West Sussex RH19 3DZ
MEETINGS OF THE BOARD OF DIRECTORS: 6 September 2018
Members (voting):
Chair - Beryl Hobson
Senior Independent Director - John Thornton (apols)
Non-Executive Directors: - Ginny Colwell - Kevin Gould - Gary Needle
Chief Executive: - Steve Jenkin
Medical Director - Ed Pickles
Director of Nursing - Jo Thomas
Director of Finance and Performance - Michelle Miles
In full attendance (non-voting):
Director of Operations - Abigail Jago
Director of Workforce & OD - Geraldine Opreshko
Director of Communications and Corporate Affairs - Clare Pirie
Deputy Company Secretary - Hilary Saunders
Lead Governor - John Belsey
Annual declarations by directors 2018/19
Declarations of interests
As established by section 40 of the Trust’s Constitution, a director of the Queen Victoria Hospital NHS Foundation Trust has a duty:
• to avoid a situation in which the director has (or can have) a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the foundation trust. • not to accept a benefit from a third party by reason of being a director or doing (or not doing) anything in that capacity. • to declare the nature and extent of any relevant and material interest or a direct or indirect interest in a proposed transaction or arrangement with the • foundation trust to the other directors.
To facilitate this duty, directors are asked on appointment to the Trust and thereafter at the beginning of each financial year, to complete a form to declare any interests or to confirm that the director has no interests to declare (a ‘nil return’). Directors must request to update any declaration if circumstances change materially. By completing and signing the declaration form directors confirm their awareness of any facts or circumstances which conflict or may conflict with the interests of QVH NHS Foundation Trust. All declarations of interest and nil returns are kept on file by the Trust and recorded in the following register of interests which is maintained by the Deputy Company Secretary.
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Register of declarations of interests Relevant and material interests Directorships, including Ownership, part ownership Significant or A position of authority Any connection with a voluntary or Any Any "family non-executive or directorship of private controlling share in in a charity or voluntary other organisation contracting for connection interest": an directorships, held in companies, businesses or organisations likely or organisation in the field NHS or QVH services or with an interest of a private companies or consultancies likely or possibly seeking to do of health or social care. commissioning NHS or QVH organisation, close family public limited possibly seeking to do business with the NHS services. entity or member which, companies (with the business with the NHS or or QVH. company if it were the exception of dormant QVH. considering interest of that companies). entering into or director, would having entered be a personal or into a financial pecuniary arrangement interest. with QVH, including but not limited to lenders of banks. Non-executive and executive members of the board (voting) Beryl Hobson Director: Professional Part owner of Nil PGS clients include health Not as far Nil Chair Governance Services Professional Governance charities, including a Royal as I am Ltd Services Ltd College and a health based aware livery company. PGS has also Director of recently undertaken work for a Longmeadow Views charity in East Grinstead Management Company Ginny Colwell Board advisor for Nil Nil Nil Nil Nil Nil Non-Executive Director Hounslow & Richmond Community Healthcare NHS Trust
Kevin Gould Director, Sharpthorne Nil Nil • Trustee and Nil Nil Nil Non-Executive Director Services Ltd; Director Deputy Chair for CIEH Ltd The Chartered Institute of Environmental Health • Independent member of the Board of Governors at Staffordshire University
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Gary Needle 1. Director, Gary Chair of Board of Nil Nil Nil Nil Nil Non-Executive Director Needle Ltd, Trustees at East (management Grinstead Sports Club Ltd consultancy) (registered sport and 2. Director, T& G lifestyle activities charity) Property Ltd (residential property development)
John Thornton 1. Non-Executive Nil Nil Nil Nil Nil Nil Senior Independent Director: Golden Director Charter Ltd 2. Director of Oakwell Consulting Ltd
Steve Jenkin Nil Nil Nil Nil I have known David Cowan (of Nil Nil Chief Executive Cowan Architects, East Grinstead) for 20 years Michelle Miles, Nil Nil Nil Nil Nil Nil Nil Director of Finance
Ed Pickles Nil Nil Nil Nil I am a member of EGAS (East Nil Nil Medical Director Grinstead Anaesthetic Services). A partnership of QVH anaesthetic consultants who, in addition to their NHS work, also provide some private perioperative and anaesthetic care to patients in several local independent hospitals. These patients may be privately insured, self-funded or as part of an NHS contract in the independent sector
Jo Thomas Nil Nil Nil Nil Nil Nil Nil Director of Nursing Other members of the board (non-voting) Abigail Jago Nil Nil Nil Nil Nil Nil Director of operations Geraldine Opreshko Nil Nil Nil Nil Nil Nil Nil Director of HR & OD
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Clare Pirie Nil Nil Nil Nil Nil Nil Nil Director of Communications & Corporate Affairs John Belsey Director of Golfguard Nil Nil Trustee of Age UK None anticipated Nil Nil Lead governor Ltd Ltd, East Grinstead & Director of Mead District Sport & Leisure Ltd Councillor, Mid Sussex District Council
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Fit and proper person declarations
As established by regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“the regulations”), QVH has a duty not to appoint a person or allow a person to continue to be an executive director or equivalent or a non-executive director of the trust under given circumstances known as the “fit and proper person test”.
By completing and signing an annual declaration form, QVH directors confirm their awareness of any facts or circumstances which prevent them from holding office as a director of QVH NHS Foundation Trust.
Register of fit and proper person declarations
Categories of person prevented from holding office The person is an The person is the The person is a person The person has made a The person is included The person is The person has been undischarged subject of a bankruptcy to whom a moratorium composition or in the children’s barred prohibited from holding responsible for, been bankrupt or a person restrictions order or an period under a debt arrangement with, or list or the adults’ barred the relevant office or privy to, contributed to, whose estate has interim bankruptcy relief order applies granted a trust deed list maintained under position, or in the case or facilitated any had a sequestration restrictions order or an under Part VIIA (debt for, creditors and not section 2 of the of an individual from serious misconduct or awarded in respect order to like effect relief orders) of the been discharged in Safeguarding carrying on the mismanagement of it and who has not made in Scotland or Insolvency Act respect of it. Vulnerable Groups Act regulated activity, by or (whether unlawful or been discharged. Northern Ireland. 1986(40). 2006, or in any under any enactment. not) in the course of corresponding list carrying on a regulated maintained under an activity, or discharging equivalent enactment in any functions relating to force in Scotland or any office or Northern Ireland. employment with a service provider. Non-executive and executive members of the board (voting) Beryl Hobson NA NA NA NA NA NA NA Chair Ginny Colwell NA NA NA NA NA NA NA Non-Executive Director Kevin Gould NA NA NA NA NA NA NA Non-Executive Director Gary Needle NA NA NA NA NA NA NA Non-Executive Director John Thornton NA NA NA NA NA NA NA Non-Executive Director Steve Jenkin NA NA NA NA NA NA NA Chief Executive
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Michelle Miles NA NA NA NA NA NA NA Director of Finance Ed Pickles NA NA NA NA NA NA NA Medical Director Jo Thomas NA NA NA NA NA NA NA Director of Nursing Other members of the board (non-voting) Abigail Jago NA NA NA NA NA NA NA Director of operations Geraldine Opreshko NA NA NA NA NA NA NA Director of HR & OD Clare Pirie NA NA NA NA NA NA NA Director of Communications & Corporate Affairs John Belsey NA NA NA NA NA NA NA Lead governor
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Business meeting of the Board of Directors Thursday 6 September 2018 10:00 – 13:00 The Archibald McIndoe board room, Queen Victoria Hospital RH19 3DZ
Agenda: session held in public
Welcome 125-18 Welcome, apologies and declarations of interest Beryl Hobson, Chair Standing items Purpose Page 126-18 Draft minutes of the meeting held in public on 5 July 2018 approval 1 Beryl Hobson, Chair 127-18 Matters arising and actions pending review 8 Beryl Hobson, Chair 128-18 Chief executive’s report (including BAF overview) assurance 10 Steve Jenkin, Chief executive Key strategic objectives 3 and 4: operational excellence and financial sustainability 129-18 Board Assurance Framework Abigail Jago, Director of operations and assurance 22 Michelle Miles, Director of finance 130-18 Financial, operational and workforce performance assurance assurance - Kevin Gould, non-executive director 131-18 Operational performance assurance 24 Abigail Jago, Director of operations 132-18 Financial performance assurance 35 Michelle Miles, Director of finance
Key strategic objective 5: organisational excellence 133-18 Board assurance framework assurance 54 Geraldine Opreshko, Director of workforce & OD 134-18 Workforce monthly report assurance 55 Geraldine Opreshko, Director of workforce & OD Key strategic objectives 1 and 2: outstanding patient experience and world-class clinical services 135-18 Board Assurance Framework Jo Thomas, Director of nursing assurance 67 Ed Pickles, Medical director 136-18 Quality and governance assurance assurance 69 Ginny Colwell, Non-executive director and committee chair 137-18 Corporate risk register (CRR) review 72 Jo Thomas, Director of nursing 138-18 Risk appetite approval 83 Jo Thomas, Director of nursing 139-18 Quality and safety report Jo Thomas, Director of nursing assurance 89 Ed Pickles, Medical director 140-18 Research and development annual report information 122 Ed Pickles, Medical director 141-18 Safeguarding annual report approval 149 Jo Thomas, Director of nursing 142-18 Infection prevention and control annual report approval 182 Jo Thomas, Director of nursing 143-18 Patient experience annual report information 214 Jo Thomas, Director of nursing 144-18 Emergency preparedness, resilience and response, and business continuity annual report information 233 Jo Thomas, Director of nursing 145-18 Consultant revalidation approval 242 Ed Pickles, Medical director Any other business (by application to the Chair) 146-18 Beryl Hobson, Chair Discussion -
Questions from members of the public 147-18 We welcome relevant, written questions on any agenda item from our staff, our members or the public. To ensure that we can give a considered and comprehensive response, written questions must be submitted in advance of the meeting (at least three clear working days). Please forward questions to [email protected] clearly marked "Questions for the board of discussion - directors". Members of the public may not take part in the Board discussion. Where appropriate, the response to written questions will be published with the minutes of the meeting. Beryl Hobson, Chair Motion to exclude the press and members of the public 148-18 Further to paragraph 39.1 and annex 6 of the Trust’s Constitution, it is proposed that members of the public and representatives of the press shall be excluded from the remainder of the meeting for the purposes of allowing the board to to note - discuss confidential information concerning the trust’s corporate governance Beryl Hobson, Chair 149-18 Observations and feedback discussion - Led by Michelle Miles, Director of finance Date of the next meetings Board of directors: Board committees Council of governors Public: 01 Nov 2018 at 10:00 Charity: 13 September 2018 Public: 15 October 2018 at 16:00 Audit: 19 September 2018 F&P: 24 September 2018 Q&G: 18 October 2018
Document: Minutes (draft and unconfirmed) Meeting: Board of Directors (session in public) Thursday 5 July 2018, 10:00 – 13:00, Archibald McIndoe board room, QVH site Present: Beryl Hobson, (BH) Trust chair (voting) Ginny Colwell (GC) Non-executive director (voting) Kevin Gould (KG) Non-executive director (voting) Abigail Jago (AJ) Director of operations (non-voting) Steve Jenkin (SJ) Chief executive (voting) Michelle Miles (MM) Director of finance (voting) Gary Needle (GN) Non-executive director (voting) Geraldine Opreshko (GO) Director of workforce and OD (non-voting) Ed Pickles (EP) Medical director (voting) Clare Pirie (CP) Director of communications and corporate affairs (non-voting) Jo Thomas (JMT) Director of nursing (voting) John Thornton (JT) Non-executive director (voting) In attendance: John Belsey (JEB) Lead governor Hilary Saunders (HS) Deputy company secretary (minutes) Public gallery: Four members of the Council of governors
Welcome
97-18 Welcome, apologies and declarations of interest The Chair opened the meeting and welcomed AJ as the new Director of operations, together with the four members of public in attendance today.
There were no apologies and no new declarations of interest.
Standing items 98-18 Patient story JMT read out a statement received from the relative of a patient with dementia. This described the lengths to which staff had gone to in ensuring this patient received excellent care throughout his treatment. She noted that despite the current staffing challenges which the Trust was experiencing, it was gratifying that staff were still able to make a difference. The Chair thanked JMT for her report which was NOTED by the Board.
99-18 Draft minutes of the meeting session held in public on 3 May 2018 The minutes of the meeting held in public on 3 May were APPROVED as a correct record.
100-18 Matters arising and actions pending The Board received and approved the current record of matters arising and actions pending.
101-18 Chief executive’s report, including Board Assurance Framework (BAF) overview SJ presented his report highlighting the following: • NHS 70th birthday; • That under the CQC adult inpatient survey QVH had been identified as one of only eight trusts with results ’much better than expected’; • As agreed by the Board in June, the Trust’s operating annual plan for 2018/19 had been resubmitted to NHSI.
Following recent reports of NHS England plans to address less effective procedures, the Board sought
QVH BOD September 2018: Session in public Page 1 of 260 and received assurance this was unlikely to impact QVH. The Trust had already been working with CCGs whose criteria was more stringent than that proposed by NHSE and it was felt that the current national review would have little impact on our activity.
The Board went on to consider the overall BAF, focusing in particular on workforce challenges. SJ reported that the Trust was partnering with Yeovil NHS Trust to recruit specialist clinical staff from overseas. Whilst welcoming this initiative, the Board noted that cultural challenges should not be underestimated. GO provided assurance that Yeovil had significant experience in this area, (one of the reasons why it had been selected as a partner), and described the ways in which an appropriate induction would be managed.
There were no further questions and the Board NOTED the contents of the update.
Key strategic objective 5: organisational excellence
102-18 Board assurance framework GO presented the BAF for KSO 5. The Board sought clarification regarding the target risk rating, asking for consistency across all BAFs.
There were no further questions and the Board NOTED the contents of the update.
103-18 Workforce monthly report GO presented the Workforce and organisational development report highlighting ongoing challenges with turnover and use of temporary staffing. She assured the Board that she is working with all directors to help understand the position. In the meantime, following resubmission of the operating plan, systems and process for agreeing to temporary staff were now more stringent. External pressure from the STP and NHSI was also being applied to reduce agency costs. In response to a query as to when the Trust might see results the Board was advised that whilst unit costs were reducing, it may not be possible to guarantee a reduction in overall agency costs at this stage as safety will always take priority. There was a short discussion which considered a range of options being introduced to manage this and updates will be given at the to the Finance and performance committee in October [Action: GO]
The Board went onto seek and receive assurance on the following: • That the profile of organisational development would be raised on the KSO5 BAF. GO stated that BAF headings were currently being revised and would support this.[Action: GO] • Support and training is provided to managers to carry out appraisals on an ongoing basis. Given current challenges and taking into account that figures included staff on maternity leave or long term sickness absence, management felt that both appraisal and mandatory and statutory percentages were good. Over the last 12 months, a dip had been noted in Eyes, but this had been picked up at the performance review meetings.
It was too early to say whether Agenda for Change pay reform would have a positive effect on recruitment. Whilst the percentage pay increases are funded, Trusts are still receiving guidance on the financial arrangements which are quite complex There were no further questions and the Board NOTED the contents of the update.
104-18 Staff survey 2017
The Chair reminded the Board that the results of the staff survey had initially been considered while under national embargo at the confidential session of its March meeting. Her intention had been for this report to be presented in May, but due to limited resources within the workforce team at the time, she had agreed for this to be deferred until now.
QVH BOD September 2018: Session in public Page 2 of 260 GO opened by asking the Board to note that despite the slight decline in staff engagement scores QVH had also shown a significant improvement in three key areas compared to the benchmark group. She reminded the Board of the main findings from the survey and described emerging themes; these were correlated with findings from the Staff Friends and Family Test, and stay/exit interviews.
Areas for improvement were highlighted including the recruitment and retention programme and ongoing well-being events. The Board noted that work continued at pace, but was constrained by resources.
The Board discussed areas where QVH results were below average, including effectiveness of procedures for reporting incidents and staff confidence in reporting unsafe clinical practice. It was noted that the comparator for these is other specialist trusts not the NHS as a whole but also that we should be seeking to improve QVH scores against those in the previous year’s survey.
GO also highlighted to the Board the positive improvement in relation to many of the leadership and management scores which had previously been highlighted in the evaluation report on Leading the Way.
The Board discussed the marked difference between turnover and the stability factor which suggests that the majority of leavers have not been with the Trust for long. The chief executive now invites all new staff to meet with him three months after induction; all those who have attended have been positive about working at QVH.
The Board sought assurance as to how progress would be monitored and assessed in relation to the recommendations. It was agreed that the Finance and performance committee would define what was required in terms of assurance and report back to the Board. [Action: GO]
The Board asked what was being done in terms of communications to demonstrate our commitment to staff before the next survey was launched in the Autumn. CP reminded the Board that, in addition to the launch of the Team Brief, all staff communications throughout the year, (including the CEO blog) had focused on changes which the Trust was implementing, reinforcing the message that staff comments were being listened to and acted upon. JMT reminded the Board that this was also triangulated by work undertaken towards meeting the Health and Wellbeing CQUIN.
There were no further comments and the Board NOTED the contents of the report.
Key strategic objectives 3 and 4: operational excellence and financial sustainability
105-18 Board assurance framework KSO3 Under Controls and assurance, AJ asked the board to note one change to the BAF relating to the data warehouse project which was now in place enabling impacts to be clearly seen and managed accordingly. More changes were likely to be made in the near future. There were no further comments.
KSO4 MM presented the BAF for KSO4, highlighting the most recent changes. She confirmed that the acronym POD stood for ‘point of delivery’. There were no further comments.
106-18 Financial and operational performance assurance report JT presented his F&PC assurance report, noting that issues affecting workforce, operations and finance were all interlinked. He stated that performance against access targets was still well below target, especially in RTT. However, he felt assured that the full picture of the total waiting list should be 80% available within a month - at which time new trajectory for recovery would be set. AJ added
QVH BOD September 2018: Session in public Page 3 of 260 that progress on the 80% estimate had been made since this report had been submitted, and the Trust was anticipating knowing the full position (with the exception of Dartford) this week.
JT also raised concerns that the Trust was now working more inefficiently and that less revenue was being generated at a higher cost than in previous periods. There was no shortage of demand for our services and so it was vital to ensure activity levels and processes were aligned to generate additional income.
The Board asked why the EDM project had been halted. AJ advised that an assessment of progress to date was underway, with a new plan to include learning so far being developed. After a brief discussion, the Board acknowledged that a slower pace was acceptable provided it enabled necessary cultural changes to be embedded alongside technological changes, and result in the anticipated efficiencies and benefits.
There were no further comments and the Board NOTED the contents of the update.
107-18 Operational performance AJ presented the operational performance report which focused on access standards, outpatients and theatres. The Board commended the new style format of the report, whilst noting this was still under development.
AJ went on to explain the current challenges which the Trust was facing regarding the electronic referral system (eRS) paper switch off. Whilst work continued at pace internally, local CCGs had some of the lowest eRS utilisation rates nationally. This would present an additional burden on our resources and increase the level of patients experiencing delays in obtaining first appointments. The Board expressed concern at the risk to patients, noting that whilst the situation was not within our control, accountability still remained with QVH. AJ assured the Board that the Trust would continue to track all patient data to ensure clarity and that the situation was being carefully monitored through EMT.
AJ went on to describe the workstreams in progress to improve overall theatre efficiency. The Board was assured that all working groups remained cognisant of the importance of the WHO check list.
The Board asked how the Trust was managing 104-day clinical harm reviews. JMT explained that a process had been introduced, but was still in its infancy; however, external guidance and support was being provided by the regulator and commissioners.
Despite the challenges highlighted within the operational performance report, SJ noted that the procurement process for the CT Scanner was proceeding. He also commended the work of the teams involved in the recent histopathology/radiology order comms project. The Chair concurred and assured AJ she had the full support of the Board.
108-18 Financial performance MM asked the Board to note that today’s finance report was based on the original plan, prior to re- submission in June. She reported that there had been a monthly overspend of £750k with the Trust delivering a deficit of £1,436k year to date, and highlighted in particular: • CIPP achievement was £2.3m behind plan, due to a number of targets not yet being developed into plans, and under delivery on existing plans. To address this, supplementary performance meetings had been introduced for all areas focusing on activity by speciality and POD. • RTT performance was well below target, but there was an awareness that whole activity needed to increase. Focus was on improving productivity and efficiencies in Eyes and within Theatres; • The YTD pay position was of particular concern. Whilst previously, whole time equivalent (WTE) posts had not been fully reported there was an urgency to ensure that electronic staff records (ESR) was clearly aligned to the ledger system to gain an understanding of areas of over and
QVH BOD September 2018: Session in public Page 4 of 260 under establishment.
The Board noted difficulties in recruiting to non-clinical as well as clinical areas and asked if there was more the organisation could be doing to address this. Whilst the Trust was constrained by pay budgets, AJ advised that work was underway to review current admin structures and review processes, and was confident that this would have a positive impact.
The Board noted that of all the challenges facing the Trust, CIPP achievement was entirely within the Trust’s control and expressed support for a rigorous and robust programme.
There were no further questions and the Board NOTED the contents of the update.
Key strategic objectives 1 and 2: outstanding patient experience and world-class clinical services
109-18 Board assurance framework KSO1 The Board NOTED the BAF for KSO1. There were no further comments.
KSO2 EP presented the latest BAF for KSO2, noting that although scores remained the same, concerns had been recorded in respect of medical staffing for the sleep disorder unit. These were being carefully monitored. There were no further comments and the Board NOTED the contents of the update.
110-18 Quality and governance assurance report As Chair of the Quality and governance committee, GC presented her latest assurance report, noting in particular that in Q4 the Trust had secured 99% of its CQUIN target, which was a significant achievement.
Board members sought clarification regarding changes made to the annual Q&GC work programme and were advised that proposed streamlining would in future enable the Committee to give more focus to the most important issues; however, any changes would be carefully monitored.
There were no further comments and the Board NOTED the contents of the report.
111-18 Corporate risk register JMT presented a revised version of the CRR noting a ‘heat map’ was now included with the report providing a visual summary of the risks. The Board commended this addition which facilitated a focus on the key issues.
The Board asked why the eRS risk (as discussed under item 107-18) was not included on this CRR. JMT confirmed it had already been incorporated into the register, but due to reporting time lags, it would not be visible until next month.
There were no further questions and the Board NOTED the contents of the update.
112-18 Quality and safety report The Board noted that in an effort to avoid duplication and provide a more integrated account, the Quality and safety report now combined both KSOs 1 and 2.
Whilst noting the Medical Director’s view that there was little detail in the STP clinical case for change relating to the configuration of secondary acute care, the Board were advised that progress could be made at the forthcoming North System Improvement meeting scheduled for later in the month.
Two meetings of the newly configured ‘programme board’ between Western Hospital, Brighton and
QVH BOD September 2018: Session in public Page 5 of 260 Sussex University Hospitals and QVH had recently taken place. EP noted that form and function was still being developed, and that terms of reference would be made circulated when available.
In response to a query JMT explained that despite an increase in the reported level of medication errors, QVH compared well with its peers. Very few incidents were moderate or above, and it was reassuring that increases related to ‘no harm’ or ‘near-miss’ categories.
When asked about the spike in safeguarding activity, JMT said it was too early to say whether this was as a result of enhanced reporting, or if this could be a new trend and would continue to be monitored.
Replying to a question about the nursing metrics, JMT advised that it was a requirement to present to the Board data showing a breakdown by individual wards. The Board discussed the benefits of adding in a report showing the overall nursing metric. It was agreed that board members would consider whether this was required for assurance in addition to data already provided in the Workforce report.
JMT reminded the Board that the current report on performance indicators was still a work in progress and data on theatres would be included in future. The Chair asked for this issue to be followed up through Q&GC, with the outcome fed back at the next Board meeting. [Action: JMT].
The Board sought assurance that the use of agency staff was ensuring safe staffing levels were being maintained. JMT felt there assured in wards and theatres, but only partially assured in critical care, where the situation continued to be carefully monitored.
The Board considered whether the inclusion in the executive summary of a statement of time since last Never Event would enhance the report, but after a short discussion agreed it would not add any particular value.
There were no further questions and the Board NOTED the contents of the report.
Board governance
113-18 Audit committee As Chair of Audit, KG presented an update following the recent meeting. He reported that additionally, a short discussion had taken place to consider options for the External Audit contract which was due for renewal next year. A short meeting would be convened immediately after today’s Board to agree a recommendation for the Council of Governors in July.
There were no further comments and the Board NOTED the contents of the update.
114-18 Annual review of corporate governance documentation MM and CP provided a joint update on proposed amendments to corporate governance documentation following an annual review by the Audit committee in June.
As highlighted under the KSO4 BAF, MM reminded the Board that Standing Financial Instructions had been revised with amended levels of delegation to reduce levels of authorisation. (A typo showing the level of delegation under item 2.1 was corrected to read £200k).
Whilst noting that use of terminology within the SFIs was regulated, MM confirmed that changes to the SFIs would be communicated to staff in more familiar language.
There were no further comments and the Board APPROVED the changes as recommended by the Audit committee.
QVH BOD September 2018: Session in public Page 6 of 260 115-18 Board level governance: engagement with governors CP reminded the Board that a recommendation of the Well Led review had been for the Trust to undertake a review of the function of the governor representative on board committees. It was felt that whilst the roles were established as an effective means of engagement between governors and the Board, the current agreement included areas of ambiguity. The Board considered a report recommending steps to remove these ambiguities and avoid any potential conflicts of interest. CP noted that this report had the support of lead governors.
After a brief discussion, the Board APPROVED the report and associated agreement, noting that this would be presented to Council of Governors for ratification at its meeting on 30 July.
The Chair expressed her gratitude to our Council of Governors for its support of the Trust.
Any other business
116-18 There was none.
Questions from members of the public
117-18 A member of the public asked why staff were not required to complete the annual staff survey. The Board explained that the survey was completely anonymous and that it was entirely up to the individual as to whether to respond or not. The Trust made every effort to encourage staff to participate each year, and the level of response rate enabled a meaningful analysis of results.
118-18 Motion to exclude the press and members of the public Further to paragraph 39.1 and annex 6 of the Trust’s constitution, the Board approved a motion by the Chair that members of the public and representatives of the press be excluded from the remainder of the meeting to enable the board to discuss confidential information concerning the Trust’s corporate governance.
119-18 Observations and feedback KG provided feedback on today’s meeting. He commended the concise nature of the reports and noted there had been greater challenge at this meeting that previously. During discussions, the Board was assured that finance and operational performance were reviewed at granular level at performance review meetings in addition to EMT, HMT and F&PC.
There were no further comments and the Chair closed the meeting.
Chair …………………………………………………. Date ………………………
QVH BOD September 2018: Session in public Page 7 of 260 Matters arising and actions pending from previous meetings of the Board of Directors ITEM MEETING REF. TOPIC CATEGORY AGREED ACTION OWNER DUE UPDATE STATUS Month 1 July 2018 103-18 Workforce report KSO5 Systems and processes have been GO Oct Pending enhanced to better manage the use of temporary staff. External pressure is also being applied to reduce costs. Whilst unit costs are reducing, the Board is also seeking a reduction in overall costs. It has therefore been agreed that an update will be provided to the October F&PC meeting. 2 July 2018 103-18 Workforce report KSO5 Profile of organisational development to GO Sept Pending be raised on KSO5 BAF
3 July 2018 104-18 Staff Survey KSO5 Sept F&PC to define what is required for GO Sept Pending assurance regarding levels of staff Nov engagement/satisfaction and report back to BoD in November.
4 July 2018 112-18 Quality and safety KSO1 Q&GC to oversee inclusion of Theatres JMT Sept Pending data into current report on performance indicators. Board to receive update.
5 May 2018 62-18 Chief Executive's Standing items STP governance arrangements to be SJ July Pending report presented to the board in July for Sept On Sept agenda pending local authority input approval Nov On November agenda pending local authority input
6 May 2018 64-18 BAF KSO1 Status update of estates strategy and MM July On July agenda (commercial in confidence) Closed development control plan to be brought to board. 7 May 2018 65-18 CRR KSO1 Review of definitions/development of JMT July 11 06 18 On Sept heat map for current and residual risk Sept Moved to September agenda to enable risk agenda ratings. management to be considered as a whole
8 May 2018 65-18 CRR KSO1 EMT to undertake refresh of BAF, JMT July 11 06 18 On Sept include risk appetite and return to Sept Moved to September agenda to enable risk agenda board for approval management to be considered as a whole BAF review due for completion August 2018
QVH BOD September 2018: Session in public Page 8 of 260 9 May 2018 67-18 Quality and safety KSO1 Evaluation of facebook recruitment GO Sept To be included as part of overall review of On Nov initiative to be undertaken and reported Nov recruitment and retention report agenda back to November BoD (via Sept F&PC)
10 May 2018 71-18 MD report KSO2 Outcome of forthcoming Deanery visit EP Jan 19 Feedback scheduled for January 2019 BoD On January to be reported back to board 2019 agenda
11 May 2018 71-18 MD report KSO2 Outstanding job plans to be followed up EP July All completed where possible. Wil be Closed monitored at future EMT meetings 12 March 2018 43-18 Quality and safety KSO1 New revised streamlined patient JMT Sept On Sept report experience report to be trialled from agenda May 2018, with board evaluation scheduled for September 2018
13 March 2018 45-18 Medical Director's KSO2 Members of Clinical Research EP July 05 07 18 On Oct report department to be invited to present at Confirmed as Oct board seminar agenda future Board seminar 14 March 2018 48-18 Operational KSO3 Revised trajectories to be prepared for SLJ July Pending July F&PC meeting On July performance F&PC, setting out worst case/good MH F&PC case/best case scenarios AJ agenda
15 January 2018 16-18 Q&GC assurance KSO1 Governance process for FTSU reporting GC Sept 13 08 18 Pending to be clarified KG/JMT Trust 'raising concerns (whistleblowing)' GO policy to go to September Audit committee for approval.
QVH BOD September 2018: Session in public Page 9 of 260 KSO 1 Outstanding Patient KSO 2 World Class KSO 3 Operational KSO 4 Financial KSO 5 Organisational ExperienceBoard AssuranceClinical Services Framework Excellence – Risks to achievementSustainability of KSOsExcellence Patients lose confidence in the Patients, clinicians & Patients & Regulators lose We seek to maintain a well led quality of our services and the commissioners lose Commissioners lose confidence in the long- organisation delivering safe, environment in which we confidence in our confidence in our term financial effective and compassionate provide them due to increasing services due to a ability to provide sustainability of the Trust care through an engaged and patient safety incidents, a decline in clinical timely and effective due to a failure to create motivated workforce decline in care standards and a outcomes, a reduction treatment due to an adequate surpluses to failure to maintain a modern in research output and increase in waiting fund operational and care environment fall in teaching times and a fall in strategic investments. standards. productivity. Current Risk Levels The entire BAF was reviewed at executive management team meeting in 29 August 2018 alongside the corporate risk register. KSO 1 and 2 were reviewed 16 August at the Quality and Governance Committee. KSO 3, 4 and 5 were reviewed 23 July at the Finance and Performance Committee. Changes since the last report are shown in underlined type on the individual KSO sheets. Whilst workforce remains a key risk to the trust, the RTT 52 week breach position ,the risk to patients and the trust reputation has required the a high degree of focus and assurance both internally and externally to regulators and stakeholders. Target Q 3 Q 4 Q 1 Q2 2017/8 2017/8 2018/9 2018/19 risk
KSO 1 15 15 15 15 9
KSO 2 12 12 12 12 8
KSO 3 20 20 20 20 15
KSO 4 20 20 20 20 16
KSO 5 16 20 20 20 15
QVH BOD September 2018: Session in public Page 10 of 260
Report cover-page References Meeting title: Board of Directors Meeting date: 05/09/2018 Agenda reference: 128-18 Report title: Chief Executive’s Report Sponsor: Steve Jenkin, Chief Executive Author: Steve Jenkin, Chief Executive Appendices: QVH media update June & July 2018
Executive summary Purpose of report: To update the Board on progress and to provide an update on external issues that may have an impact on the Trust’s ability to achieve its internal targets. Summary of key • Referral to Treatment Time issues • Capital spend • Developing the long-term plan for the NHS Recommendation: For the Board to NOTE the report Action required Information Discussion Link to key strategic KSO1: KSO2: KSO3: KSO4: KSO5: objectives (KSOs): Outstanding World-class Operational Financial Organisational patient clinical excellence sustainability excellence experience services Implications Board assurance framework: Included as part of report
Corporate risk register: None
Regulation: N/A
Legal: None
Resources: None
Assurance route Previously considered by: EMT Date: 29/08/18 Decision: Review BAF Next steps:
CHIEF EXECUTIVE’S REPORT SEPTEMBER 2018
QVH BOD September 2018: Session in public Page 11 of 260 TRUST ISSUES Our last Board meeting coincided with the nation’s celebrations to mark the 70th anniversary of the NHS. Three staff members led by Nicky Reeves, our Deputy Director of Nursing attended a special NHS70 service at Westminster Abbey. Locally, at the hospital the League of Friends generously supported afternoon NHS7T and biscuits in all areas. This important anniversary provides an opportunity to remember the vital role the NHS plays in so many people’s lives and to recognise and thank the extraordinary NHS staff and volunteers – the everyday heroes – who are there to guide, support and care for us, day in, day out.
QVH was also chosen by The Royal Mint as one of nine Trusts in England to circulate a new 10p coin as part of their official Great British Coin Hunt, quintessentially British A to Z coin collection celebrating everything British. Each of the 26 coins features a British design from the iconic Red Double-decker Bus and the famous prehistoric monument, Stonehenge to the elusive Loch Ness Monster. th The letter N commemorating the NHS 70 anniversary.
Referral to Treatment Time In March 2010, the NHS Constitution was updated to include a new right for patients to start consultant-led treatment within a maximum of 18 weeks of a GP referral. In 2012, it became a statutory requirement that at least 92% of patients should have a referral to treatment (RTT) time of less than 18 weeks, and since June 2015 this has been the sole measure of treatment waiting time performance. In 2013/14, NHS England set an operational standard to ensure that no-one waits more than 52 weeks for treatment.
QVH has rectified long-standing issues with systems used to report waiting list information; this has resulted in an increase in our reported waiting list. Our systems are now more reliable than they have been for several years. This will help with the smooth running of the hospital’s appointment systems.
I am very sorry that some patients have waited longer than they or we would want for treatment and are working to ensure there are no unnecessary delays for patients. We have undertaken a clinical harm review to establish if any patients have come to harm as a result of our data quality issues. To date no instances or moderate or severe harm have been identified.
New theatre scheduling As part of the work that the theatre scheduling task and finish group have been doing, on Monday 30 July we began implementing a new theatre scheduling processes called 6-4-2. This process will
QVH BOD September 2018: Session in public Page 12 of 260 ensure we make the best use of theatres and improve patient and staff experience by offering increased notice of to come in date and minimising short notice cancellations.
The 6-4-2 process has been successful in many hospitals as a way of effectively scheduling elective care and focuses on ensuring that all theatre sessions are used or reallocated for use. It improves:
• safety and reliability of care - communicating lists in advance, preventing last minute changes, ensuring specialist equipment is ordered and correct skill mix available • patient experience - reducing waiting times, avoiding cancellations, avoiding delays on the day. Providing information in a timely manner allowing patients and carers to plan.
Capital spend Through our cascade Team Brief sessions staff teams have recently been consulted on the opportunity to use the Sustainability and Transformation Fund (STF) we achieved for reaching our control total in 2017/18. NHS Improvement approved the capital funds could be used this financial year. Two improved staff areas on the basis of previous staff conversations have been agreed: a new modular building located behind theatres and an upgrading of the surgeon’s mess to meet a wider staff need.
The Hospital Management Team considered the remaining high number of bids received at their monthly meeting last month. In addition to a number of small schemes to be approved, a major project was approved to create separate entrances for the critical care unit and burns ward thus improving infection control and potentially creating the opportunity for more single bays thus providing an enhanced patient experience.
Staff Awards Nominations closed for the QVH Staff Awards 2018 on 20 August with more than 230 entries across the nine categories. The staff awards ceremony will be held on Thursday 4 October.
Board Assurance Framework (BAF) Attached is the BAF front sheet, the following points are worth noting:
Recruitment and retention remains one of the most significant challenges facing the NHS and in particular at QVH in theatres and critical care. Our recent overseas recruitment campaign has led to 36 acceptances of posts.
Our waiting list position in terms of referral to treatment times has deteriorated. The action taken to address this is set out in the operations paper.
Media Appendix 1 shows a summary of QVH media activity during June and July.
SECTOR ISSUES Sussex & East Surrey Sustainability & Transformation Partnership (STP) We are one of six STPs identified to take part in an annual study on financial sustainability within the NHS to be conducted later this month by the National Audit Office (NAO). Since 2012, the NAO has produced an annual report, the most recent in January of this year which examined the headline performance of the NHS and support provide by national bodies to STPs, CCGs and providers. Their visit to our STP will examine progress made by the STP and its current challenges; STP leadership, governance and decision-making processes; and, support from national bodies.
QVH BOD September 2018: Session in public Page 13 of 260
Radiology review – East Sussex Healthcare Trust East Sussex Healthcare Trust (ESHT) said it is to investigate X-rays taken between 2012 and 2017. In a report in a health journal, ESHT stated since 2014 X-rays taken for inpatients and those attending clinics at ESHT have only been reviewed by a radiologist if the doctor who asked for the film specifically requested it once they had reviewed the image themselves.
The trust is now revising that policy but concerns that something may have been missed has meant it needs to look at unreported X-rays. In a statement the trust said it had chosen to look at the 2012- 17 period “as this was felt to be a safe timeframe to review.”
QVH reviews all of its own X-rays on site by trained radiologists.
Chair role at two NHS Trusts The Council of Governors of South East Coast Ambulance Service NHS Foundation Trust has recently appointed David Astley as the Trust’s new substantive Chair. David has over 40 years’ management and leadership experience in the NHS and abroad. He was awarded an O.B.E in 2006 for services to the NHS and has held a number of very senior roles in the NHS including Chief Executive of East Kent University Hospitals NHS Trust between 1999 and 2006 and Chief Executive of St George’s Healthcare NHS Trust between 2006 and 2011. He also worked in Qatar for four years to 2015 and will stand down from a Non- Executive Director of Liverpool Women’s Hospital NHS Foundation Trust when he commences as Chair.
Alan McCarthy has been appointed as the new Chair of Western Sussex Hospitals NHS Foundation Trust and Brighton and Sussex University Hospitals NHS Trust (WSHFT/BSUH) and will take up this role shortly. Alan has been involved with Surrey and Sussex Healthcare NHS Trust (SASH) for eight years and has overseen significant improvements in patient care as Chair.
NATIONAL ISSUES Developing the long term plan for the NHS In March, the Prime Minister committed to a “sustainable long term plan” for the NHS backed by “a multi-year funding settlement”. She expanded on this in June, confirming a new funding settlement for the NHS of an average of 3.4% real terms increase over the next five years. Mrs May also tasked the NHS with producing a 10 year plan in return for the increase in funding, setting out how the service intends to deliver major improvements. The timing of the plan’s publication is expected to coincide with the autumn Budget, where the funding uplift, and how it will be funded, will be formally set out.
The NHS will start developing a delivery plan for the first few years of a new 10 year strategic plan and are keen to secure wide engagement by creating a number of working groups, covering the priorities set out by the Government.
Brexit guidance received The Secretary of State for Health and Social Care, Matt Hancock has written to all NHS trusts and commissioners to provide an update on the Government’s ongoing preparations for a March 2019 ‘no deal’ Brexit scenario, in particular focusing on the preparations required to be taken over the next seven months. In his letter of 23 August 2018, he says, “The Government has made significant progress in negotiations and remains confident we will leave with a good deal for both sides.” He stresses that the health and care system must however plan to ensure patients continue to get the supplies they need, in a timely way.
QVH BOD September 2018: Session in public Page 14 of 260 The letter confirmed reports that pharmaceutical suppliers will be asked to stockpile an “additional six weeks supply of medicines in the UK on top of their own normal stock levels”. It said this request is “subject to revision in light of future developments”. This will not cover over the counter medicine. Hospitals, GPs and community pharmacies throughout the UK are requested not to stockpile additional medicines, beyond their business as usual stock levels.
The Government is putting in place measures to manger other issues in health including future immigration rules, continuity of research funding, and future reciprocal healthcare arrangements. The letter was released at the same time as 25 papers on no-deal Brexit contingency plans were published.
NHS England consultation NHS England has launched a 12 week consultation on the contracting arrangements for Integrated Care Providers (ICPs). The consultation period runs from 3 August to 26 October 2018.
The consultation provides more detail about how the proposed ICP Contract would underpin integration between services, how it differs from existing NHS contracts, and how ICPs fit into the broader commissioning system. There is widespread support for ending the fragmented way that care has been provided to improve services for patients and the NHS has been working towards this in a number of ways.
ICPs are one of these ways, and are intended to allow health and care organisations to be funded to provide services for a local population in a coordinated way. Following two recent Judicial Reviews which were dismissed, the High Court has twice now ruled that this proposed contractual approach to developing integrated care is lawful; and in a recent report Parliament’s cross-party Health and Social Care Select Committee said ICPs were part of a ‘pragmatic response’ to pressures in the system.
The previous iteration of this contract was referred to as the draft Accountable Care Organisation Contract. The term Integrated Care Provider is in recognition that, as reported by the House of Commons Health and Social Care Committee, previous use of the term ‘accountable care’ has generated unwarranted misunderstanding about what is being proposed – which is a move to more integrated care.
Steve Jenkin Chief Executive
QVH BOD September 2018: Session in public Page 15 of 260 QVH media update – June and July 2018
Here’s a summary of the media activity secured for QVH…
The Daily Mail cataract guide Our consultant ophthalmic surgeon Damian Lake was interviewed for a four page health pull-out in the Daily Mail about cataracts. In the article, the first part in the paper’s Good Doctors Guide, Damian explained why, once diagnosed, surgery to replace a cataract with an artificial lens is the only real treatment. He also explained the importance of wearing sunglasses, advice which extends to children.
You can read the article on the Mail’s website.
CQC national inpatient survey Mid-month we received the latest national NHS inpatient survey results which showed Queen Victoria Hospital continuing to achieve some of the best feedback from patients in the country. We issued the highlights of the survey to the media and have so far received coverage on the Clinical Services Journal website and a photo-led piece in the East Grinstead Gazette. It was also featured in radio station Heart Sussex’s news bulletin the day the release was issued.
What drives you? Nursing Standard ran an article about our ‘What drives you?’ recruitment campaign which has been running for the last two months. Through the voices of our staff, the campaign gives an insight into what it's really like to work at Queen Victoria Hospital and hopefully encourage nurses to consider the hospital for their next career move. The link to the piece is here (you may need to sign up for free access to read it).
Accolades for QVH staff Peter Venn, clinical lead of our sleep disorder centre, achieving the College Medal from the Royal College of Anaesthetists, its highest accolade, received local media coverage on the Heathfield News website (his local area) and also in the East Grinstead Gazette.
QVH BOD September 2018: Session in public Page 16 of 260
This month the East Grinstead Gazette also ran a piece on Danny Favor, our ophthalmic clinical nurse specialist, whose role as new deputy mayor of East Grinstead hit the headlines in the Philippines (as mentioned in last month’s media update).
Children and sunburn Julie Baker our paediatric matron, was interviewed by radio station Heart Sussex about sunburn in children and sun safety advice. It comes after we have experienced a steady increase in children seen by our team since the warm weather began, including children as young as six months old. The key message was around ensuring all children if they are out in the sun, even babies, wear some kind of appropriate sun protection, not to cover buggies/pushchairs with blankets, and a reminder of burns first aid advice.
Local press The East Grinstead Gazette ran a photo led piece about us thanking our volunteers for the contribution they make to QVH, to tie in with volunteers’ week (pictured). This also mentioned some of the latest opportunities we have if people would like to get involved.
We were also named in the Mid Sussex Times regarding Dementia Awareness Week in relation to the East Grinstead Alliance supporting a coffee morning we had onsite.
Thanking our volunteers During volunteers’ week we did our own thank yous through our internal communications and social media channels. This included daily social media posts to our current volunteers and also offering the opportunity for people to get in touch if they’d like to join us.
Ad hoc media This month we also received ad hoc mentions in relation to patients who have received treatment at QVH.
Press releases During June we issued the following information to the public which you can read via these links:
• With a little help from our friends this volunteers’ week • National survey shows QVH is top for positive patient experience • Rebuilding lives and facing the future – your invite to the QVH AGM 2018
QVH BOD September 2018: Session in public Page 17 of 260 NHS70 and QVH BBC South East Today filmed a special piece about the NHS turning 70 here at QVH which aired on Wednesday 4 July. It looked at how our impressive heritage and how pioneering techniques in plastic surgery developed over the last 70+ years have informed what we do today.
Nora Nugent, consultant plastic surgeon explained how we're supporting patients in our burns unit and using treatments like Nexobrid, which is formed from an enzyme found in pineapples; spoke to a patient David who had received the nexobrid treatment; and also met Simon Booth, burns researcher to learn about the scar study we’re working on and how we're playing an important part in trying to make a scar free future a possibility for patients. It appeared in the 1.30pm, 6.30pm and late news bulletins.
The local BBC news and radio channels also posted a one minute snapshot of the piece on their Facebook and Twitter channels which was very popular, gaining further comments about QVH and people’s experience of the hospital.
NHS70 and LBC Continuing on the NHS70 theme, consultant plastic surgeon Martin Jones was interviewed by Global Radio for one of a series of special NHS70 pieces stations across their chain were running on Thursday 5 July – the NHS’ 70th birthday. Martin was asked about our pioneering plastic surgery, including breast reconstruction for patients who have had cancer. The piece, accompanied by comments from Martin’s patient Annette about how QVH and the NHS saved her life, aired on LBC (which has 2.2 million listeners) and Heart Sussex.
Sleep disorder centre on BBC Radio 4 Inside Health Peter Venn a consultant from our sleep disorder centre was interviewed for the first of two appearances QVH made on BBC Radio 4’s Inside Health this month. Peter spoke about insomnia and why sleeping tablets don’t help most people.
The piece which aired on Tuesday 10 July (repeated Wednesday 11 July), also included an interview with one of our patients, Imogen, regarding her experience of medication, insomnia and how her bed is no longer a place she fears to go to.
Feedback from our sleep disorder team says people have been contacting the service since the piece aired, interested in finding out more.
QVH BOD September 2018: Session in public Page 18 of 260 QVH and the Great British Coin Hunt Our participation in the Great British Coin Hunt was featured on the BBC South East regional breakfast news on Wednesday 11 July. QVH is the only hospital in the south east to have been chosen by the Royal Mint to help circulate its special NHS ‘N’ 10p coin, to coincide with NHS70. It was also mentioned as a photo- led story later this month in the East Grinstead Gazette (pictured). Clare Pirie, director of communications, was also interviewed about the coin hunt for BBC Radio Sussex, and The Sussex Newspaper’s website also ran a story.
BBC South East Today and black henna tattoos Baljit Dheansa, consultant plastic surgeon, was interviewed for BBC South East Today on Monday 16 July, providing advice regarding the danger of black Henna tattoos and the risk of burns/scarring (to accompany a case study the programme was also running). The interview was shown as part of the 6.30pm and late news.
Emergency Nurse journal and the management of burns The nursing journal, Emergency Nurse, ran an article entitled “Emergency management of burns: part 2” written by Kristina Stiles our burns care lead. The second of a two-part series, it gave an overview of the minimum standard of care in burns first aid, and highlighted the likely challenges in assessment of burn depth and size.
QVH in the Daily Mail Bav Shergill, consultant dermatologist, was quoted in a story in the Daily Mail and Mail Online regarding light therapy now being used to treat bed sores. He expressed his interest in the outcomes of the study that’s taking place. The piece was also carried on infosurhoy.com.
Artificial eyes on BBC Radio 4 Inside Health QVH’s second feature on BBC Radio 4’s Inside Health was talking about all things artificial eyes. Raman Malhotra, consultant oculoplastic surgeon and Emma Worrell, principal maxillofacial prosthetist, spoke about our treatment for people who unfortunately lose an eye due to accident or illness, the work of our prosthetics department in hand making artificial eyes, and the ongoing support QVH offers to patients like Sue who was also interviewed. It also featured the national study QVH is leading into comfort and outcomes for people with an artificial eye.
Since the programme aired on Tuesday 24 July (repeated the following day), people have already been in contact interested in signing up for the study.
QVH BOD September 2018: Session in public Page 19 of 260 OT Magazine explores our burns unit Louise Rodgers, our advanced occupational therapist in burns and plastics, was interviewed for a three page feature in the July/August issue of OT magazine.
She explained the role of an occupational therapist in our burns unit, talked about the sensitive process from referral to discharge, and the emotional journey it takes both the patient and our staff on.
Trainee nursing associates The Clinical Services Journal ran a story on its website about our first two trainee nursing associates completing the opening term of their apprenticeship. QVH will be expanding this opportunity in September, enabling another three members of staff to take part in this programme devised nationally to bridge a gap between health care assistants and registered nurses, to deliver additional hands-on care.
Mum shows her appreciation on television QVH was mentioned in a piece on BBC South East Today on Sunday 29 July about patient Jessie Symons, who came to our hospital after a fire pit accident. She received treatment on Peanut ward and also skin grafts. Her mum described QVH as their “second home for seven weeks” and sang the praises of the teams who helped get her daughter home. It was aired on the evening and late news, and the Kent Online website.
ITV London raises awareness of sun safety In our fifth and final TV appearance this month, QVH was featured on ITV London, the first time in the last couple of years. The piece highlighted the importance of sun safety to prevent burns and also skin cancer. Siva Kumar, consultant plastic surgeon, spoke about the importance of applying sun cream and also the types of moles he would be concerned about becoming melanoma. Julie Baker, paediatric matron, talked about children as young as six months the team have seen this year, and why you should keep children out of the sun. The mum of one year old Max, a patient with a burn to his hand, was also interviewed.
QVH BOD September 2018: Session in public Page 20 of 260 QVH Charity in the local press Our charity, QVH Charity, received its own local press coverage this month, including the July issue of East Grinstead Living magazine featuring an article on the East Grinstead branch of the Soroptimists which included a photo of Carol Lehan, a nurse from Peanut ward, receiving a cheque donation. The summer edition of The Line, the newsletter from East Grinstead Town Council, mentioned outgoing town mayor, Julie Mockford and her fundraising for three charities including QVH Charity.
As part of our NHS70 awareness raising, we enlisted the help of four celebrities to encourage people to have a big 7tea party and raise funds for QVH Charity at the same time. Our celebrities: Amanda Redman; Jack Ashton, Dr Mark Porter, and Fiona Dolman, were featured across our social media channels (QVH and QVH Charity) and also mentioned in the East Grinstead Gazette.
Our cycling surgeons, Andy Mellington and Ben Way, taking part in the Ride London in aid of QVH Charity, were front page of the East Grinstead Gazette in the issue that was printed two days before the event.
QVH in the local press QVH received its own local press coverage this month including our AGM featuring in the East Grinstead Gazette (sadly run with last year’s information); the July issue of RH Uncovered (East Grinstead edition) running a story about Danny Favor, our ophthalmic nurse practitioner, being named deputy mayor of East Grinstead (following the previous month’s local media); and The Sussex Newspaper featuring our ask for nominations for our outstanding patient experience award.
In other local news, a piece in the East Grinstead Gazette about the appointment of Lester Porter as trustee chairman of the East Grinstead Museum name-checked QVH (he was previously one of our non-executive directors). Also the East Grinstead Gazette ran a story about how the town welcomed the South and South East in Bloom committee which included them coming to visit our hospital.
Press releases During July we issued the following information to the public which you can read via these links:
• Celebs support Queen Victoria Hospital for the NHS’ 70th birthday • Queen Victoria Hospital selected to take part in The Great British Coin Hunt • Your chance to nominate outstanding staff for annual hospital awards • Surgeons get on their bikes for hospital charity • Staff complete first term of new nursing associate apprenticeship
For more information… Please contact Michelle Baillie, Communications Manager, at [email protected] or call x4508.
QVH BOD September 2018: Session in public Page 21 of 260 KSO3 – Operational Excellence Risk Owner – Director of Operations Date last reviewed 28 August 2018 Strategic Objective Risk Appetite The trust has a low appetite for risks that impact on operational Initial Risk 5 (c) x3 (L) =15, moderate We provide streamlined services delivery of services and is working with a range of stakeholders to redesign and Current Risk Rating 5 (C) x 4 (L) = 20, major that ensure our patients are offered improve effectiveness and efficiency to improve patient experience, safety and Target Risk Rating 3 (C) x 3 (L) = 9, low choice and are treated in a timely quality. manner.
Rationale for risk current score Future risks Risk • Vacancy levels in theatre nursing • National Policy changes to access targets Patients & Commissioners lose • Demand and capacity for challenged areas including MaxFax and Plastics e.g. Cancer & complexity of pathways, confidence in our ability to provide • Trust wide booking and scheduling processing QVH is reliant on other trusts timely timely and effective treatment due • Demand and Capacity issues in MaxFax alongside lack of PTL referrals onto the pathway; to an increase in waiting times and • Visibility of waiting list at Medway and understanding true waiting list baseline • NHS Tariff changes & volatility; a fall in productivity. with ongoing NHSI work • Future impact of Brexit on workforce Some spoke sites (Medway) have • Data capture from off site services is impacting upon demand and capacity • Reputation as a consequence of waiting capacity issues which can impact planning across cancer, 18RTT & 52 week breaches; times upon our services at that site • Capacity /system issues in referring trusts have a negative impact upon QVH as we receive late referrals to this site plus where we provide services at spoke sites • Current limitations re additional capacity at spoke sites and control over booking Future Opportunities processes • Spoke sites offer the opportunity for • eRS delivery further partnerships • Challenged theatre capacity • Closer working between providers in STP – networked care • Partnership with BSUH/WSHFT
Controls / assurance Gaps in controls / assurance • Weekly RTT and cancer PTL meetings established • Not all spoke sites on QVH PAS so access to timely information can • Revised PTL in place & ongoing work with NHSI to ensure comprehensive capture of data be limited plus some spoke sites have reporting issues – when visible • RTT action plan in place. With a focus on systems & processes, trajectories & performance, will impact negatively upon 18RTT & 52 week breaches sustainability, capacity & pathways. • Shared pathways for cancer cases with late referrals from other • Additional Validator funding approved & out to advert, interims in post ; trusts • New role of business manager for spokes and access in post • Demand and capacity modelling with benchmarking requires • Development of revised operational report underway to enhance assurance and grip continual development for each speciality • Outsourcing in place and more being sourced but more required; • Late referrals for 18RTT from neighbouring trusts, two of which are in • Monthly business unit performance review meetings & dashboard in place with a focus on special measures and others with severe pressures exceptions, actions and forward planning; • Increase in referrals greater than growth assumptions • Data warehouse project in place and beginning to give off site PTL visibility with associated • High vacancy rate in theatre nursing/OPD worsening and so limits validation being undertaken so the scale of the issue & impacts (particularly at Medway) can ability to put on extra lists in a sustainable manner be seen and managed accordingly QVH BOD September 2018: Session in• publicCapacity challenges for both admitted and non admitted pathways • Documentation of all booking and scheduling processes underway to inform Pageprocess 22 ofredesign 260 • Variable trust wide systems and processes
KSO 4 – Financial Sustainability Risk Owner: Director of Finance & Performance Committee: Finance & Performance Date last reviewed: 29th August 2018
Strategic Objective Risk Appetite The Trust has a moderate appetite for risks that impact on Initial Risk 3 (C) x 5(L) = 15, moderate We maximize existing the Trusts financial position. A higher level of rigor is being placed to fully Current Risk Rating 4 (C) x 5(L)= 20, major resources to offer cost- understand the implications of service developments and business cases Target Risk Rating 4(C) x 3(L) = 12, moderate effective and efficient care moving forward to ensure informed decision making can be undertaken. whilst looking for Rationale for current score (at Month 4) Future Risks opportunities to grow and • Deficit £1,907k deficit/ £1,649k deficit plan NHS Sector financial landscape Regulatory Intervention develop our services • CIP forecast delivery - (current material gap £90k YTD variance on • Autonomy plan, yet to be identified £1.9m) • Capped expenditure process • Finance & Use of resources – 3 (planned 3) • Single Oversight Framework • Capital Service cover - 4 • Commissioning intentions – Clinical effective commissioning Risk • Liquidity -1 • Sustainability and transformation footprint plans Loss of confidence in the long- • I&E Margin –4 • Planning timetables–Trust v STP term financial sustainability of • I&E Margin Var from plan – 3 the Trust due to a failure to • Agency Cap – 4 Future Opportunities create adequate surpluses to • CIP pipeline schemes to be identified to bridge the gap • New workforce model, strategic partnerships; increased trust fund operational and strategic • High risk factor – availability of staffing in particular nursing and non resilience / support wider health economy clinical posts investments • Using IT as a platform to support innovative solutions and • Commissioner challenge and scrutiny new ways of working Potential changes to commissioning agendas • • Improved vacancy levels and less reliance on agency staffing 2018/19 CIPP Gap and non delivery YTD • • Increase in efficiency and scheduling through whole of the • Contracting alignment agreement patient pathway Underperformance on activity plan • • Spoke site activity repatriation Significant overspend on agency staffing, however clinical safety is • • Strategic alliances \ franchise chains and networks requiring additional agency costs over and above ceiling Controls / Assurances Gaps in controls / assurances • Performance Management regime in place • Structure, systems and process redesign and enhanced cost • Standing Financial Instructions revised and ratified with amended levels of delegation in line with a control turnaround environment to reduce levels of authorisation (June 18) • Carter Report Review and implementation • Contract monitoring process • Costing Transformation Programme - Implementation Q4 • P erformance reports to the Trust Board 2017/18 – roll out of management information • Finance & Performance Committee in place • Enhanced pay and establishment controls including • Audit Committee and reports performance against the agency cap • Internal Audit Plan including main financial systems and budgetary control • Finance and procurement training to budget holders • Budget Setting and Business Planning Processes (including capital programme) • CIP Governance processes • Income / Activity capture and coding processes embedded and regularly audited • Weekly activity information per Business unit, specialty and POD QVH BOD September 2018: Session in public Page 23 of 260 • Refreshed Operating Plan submitted (June 18)
Report cover-page References Meeting title: Board of Directors Meeting date: 05/09/2018 Agenda reference: 131-18 Report title: Operational performance Sponsor: Abigail Jago, Director of Operations Author: Abigail Jago, Director of Operations Appendices: None
Executive summary Purpose of report: To update the Board regarding operational performance Summary of key • The Trust is now able to report consolidated waiting list figures; referral to issues treatment time has therefore deteriorated and 52 week waits have increased. • Planned implementation of eRS (electronic referral) hard paper switch off • Theatre improvement programme of work including the launch of 6-4-2 scheduling model for theatres Recommendation: The Board is asked to note the operational performance position and challenges. Action required Approval Information Discussion Assurance Review Link to key strategic KSO1: KSO2: KSO3: Y KSO4: KSO5: objectives (KSOs): Y/N Y/N Y/N Y/N Outstanding World-class Operational Financial Organisational patient clinical excellence sustainability excellence experience services Implications Board assurance framework: The BAF is updated in line with developments set out in the operational report. Corporate risk register: CRR is updated to reflect developments in operational delivery.
Regulation: N/A
Legal: None
Resources: None
Assurance route Previously considered by: EMT Date: 29/08/18 Decision: Review BAF Next steps:
QVH BOD September 2018: Session in public Page 24 of 260
www.qvh.nhs.uk 260 of 25 Page
public public in Session 2018: September BOD QVH
Operations of Director Jago, Abigail
Operational Performance Report Performance Operational
Summary
The key item to note in the operational update is the RTT position . The Trust has a revised and increased PTL waiting list size and increased number of patients waiting greater than 52 weeks following extensive validation work and a review of all spoke sites. This will be included in national publication of July performance data.
Also of note: • Delivery of MIU 4 hour wait standard • In month challenges in regard to delivery of diagnostic standards - performance of 98.4% against a target of 99%. • In month delivery of 2WW and 62 day standards and ongoing challenges with 31 day standard • Planned implementation of eRS (electronic referral) hard paper switch off • Theatre improvement programme of work including the launch of 6-4-2 scheduling model for theatres
2 QVH BOD September 2018: Session in public Page 26 of 260 Diagnostic Waits (DM01)
100.00%
99.50% (Last reporting period – June 18 ) (This reporting period – July 18 )
Modality / test Breaches Perf. Modality / test Breaches Perf. 99.00% CT 2 98.40% CT 10 93.46% 98.50% ECHOCARDIOG ECHOCARDIOG 0 100% 0 100% RAPHY RAPHY 98.00% MRI 1 100% MRI 1 99.52% NON- NON- 97.50% OBSTETRIC 0 100% OBSTETRIC 4 99.37% ULTRASOUND ULTRASOUND 97.00% SLEEP SLEEP 1 99% 3 97.35% STUDIES STUDIES
Performance Target
Performance commentary Forward look / performance risks
• Challenges with delivering DMO1 with performance of 98.4% against a • Outsource CT delays likely to continue until on-site CT delivered and target of 99%. operational – Aug/Sept 2018. • 15 breaches in radiology • Ongoing challenges in sleep due to staffing. Work ongoing to address • 3 breaches in sleep studies staffing issues.
3 QVH BOD September 2018: Session in public Page 27 of 260 RTT18 • A programme of work has been underway within the trust, with the support of the NHSI intensive support team (IST), to review RTT waiting list systems and processes following the identification of reporting anomalies.
• A cohort of patients have been identified that have not historically been included within the QVH reporting position. This includes activity at some of the trust spoke sites (Medway, Hastings, Eastbourne and Dartford) and also a cohort of patients that have previously been recorded outside of the trust Patient Tracking List. The Trust had been stating for some time that the reported PTL figures were incomplete; we are now able to report an accurate position.
• A programme of validation has been underway and a revised PTL report is now in place.
• The impact on Trust performance is as follows: • the total waiting list size has increased from 11101 to 14738 • 145 patients waiting 52 weeks or more • RTT performance of 74.48%
4 QVH BOD September 2018: Session in public Page 28 of 260 RTT18 System escalation • System partners, commissioners and NHSI have been fully engaged and supportive in addressing this issue.
Consolidated reporting • A consolidated PTL has been developed in collaboration with our spoke sites to enable the reporting of all patients and our reporting systems are now more reliable.
Validation • Considerable additional resource has been put in to an extensive validation programme of the patients outside of our previous reporting. The final stages of this work are underway. • Validation of an auto discharge system function will be completed over the next month.
Clinical Harm Reviews • A clinical harm review process is in place for all patients who have waited greater than 52 weeks. There have been no cases of clinical harm identified to date. The clinical harm review protocol includes duty of candour instruction should this be required.
Patient treatment plans • Work is underway to identify capacity to ensure the patients are now treated in a timely manner. Additional theatre capacity has been identified at a local NHS provider (ESHT) and in the independent sector. • The trust is working with commissioners to also identify further capacity outside of the Trust. • QVH no longer accepts referrals for low complexity dental work enabling us to focus on patients requiring the specialist skills of our staff. NHSE Dental have identified some capacity for low complexity patients already on the QVH waiting list. • QVH routinely review patient level plans on a weekly basis for all patients waiting greater than 38 weeks.
RTT Improvement plan • The programme of work to improve the trust reporting is a key strand of the overarching trust RTT improvement plan previously reported to Board.
Theatre Efficiency • 6-4-2 theatre scheduling is now in place • External expertise to support theatre utilisation programme has been identified
5 QVH BOD September 2018: Session in public Page 29 of 260
Cancer Performance – 2WW & 62 day
Two Week Wait Performance 2WW Performance – Target 93% 100.00% Overall performance 95.4% June-18 June-18 June-18 95.00% Total Breach Perf. 90.00% Performance Head & neck 143 4 93.7% 85.00% Linear (Performance) Skin 115 3 97.4% 80.00% Children’s 3 3 100%
62 Day Performance 90% 80% 62 Day Performance – Target 85% 70% Overall performance 85% 60% 50% June-18 June-18 June-18 40% Performance Total Breach Perf. 30% Linear (Performance) Head & neck 6 1.5 75% 20% 10% 0% Skin 12.5 0.5 96% Jul-17 Jan-18 Jun-18 Oct-17 Apr-18 Feb-18 Sep-17 Dec-17 Aug-17 Nov-17 Mar-18
May-18 Breast 1 0.5 50%
6 The trust has improved performance of 2WW and 62days. QVH BOD September 2018: Session in public Page 30 of 260 Cancer Performance – 31 day
31 Day Rolling Monthly Performance 31 day performance – Decision to first treatment (Target 96%) 100.00% Overall performance 88.1% 95.00% June-18 June-18 June-18 Total Breach Perf. 90.00% Head & 9 1 88.9% 85.00% Performance neck Linear (Performance) 80.00% Skin 46 5 89.1% 75.00% Breast 4 1 75% Jul-17 Jan-18 Jun-18 Oct-17 Apr-18 Sep-17 Feb-18 Dec-17 Aug-17 Nov-17 Mar-18 May-18
31 Day Subsequent Monthly Performance 31 day performance – decision to subsequent treatment (94%) 120.00% Overall performance 95.5%
100.00% June-18 June-18 June-18 Total Breach Perf. 80.00% Head & 1 0 100% 60.00% neck Performance 40.00% Linear (Performance) Skin 19 1 94.7% 20.00%
0.00% Breast 1 0 100% Jul-17 Jan-18 Jun-18 Oct-17 Apr-18 Sep-17 Feb-18 Dec-17 Aug-17 Nov-17 Mar-18 7 May-18 QVH BOD September 2018: Session in public Page 31 of 260 Cancer Performance - commentary
Breach Allocation – 62 Day Pathway The 38 day breach allocation has now commenced as of July. This requires patients to be transferred to the treating hospital by day 38 and treated within 24 days by the receiving hospital.
Cancer breaches Any cancer breach will have a breach report completed and sent to the managing consultant, service manager and clinical lead. Root cause analysis reviews are completed to improve pathways.
Central Oncology Hub Oncology hub now in place to ensure consistent management of oncology referrals. Process mapping taking place to improve the efficiency of booking oncology referrals.
Cancer Access Policy A new Cancer Access Policy is currently under development with support of NHSI.
Timed pathways Timed pathways are being developed for Skin and Head and Neck Work is underway for all 2WW skin patients to be seen in a See and Treat clinic.
Increased communication Improved communication with referring trusts – weekly conference calls in place with Medway and Conquest. This approach is being rolled out to other partners
Challenges and risks to delivery Capacity for follow-up appointments to achieve the new 28 day diagnosis target. To tackle this, specialties to develop notes review clinics or virtual clinics. Capacity challenges for diagnostic procedures for Head and Neck Capacity for Sentinel Lymph Node patients – additional capacity had been identified Challenges to treat tertiary referrals within 24 days of receiving the referral
QVH BOD September 2018: Session in public 8 Page 32 of 260 Minor Injuries Unit (MIU)
MIU Performance v Target
MIU attendence and Performance 1400 101%
1200 100% 99% 1000 98% 800 97% Attendances 600 96% Performance( target 95%) 95% Target 400 94% 200 93% 0 92% Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18
Performance commentary Forward look / performance risks
• Recent seasonal increase in MIU attendances • No specific risks identified
QVH BOD September 2018: Session in public 9 Page 33 of 260 eRS (electronic referral) utilisation – Outpatients - eRS CCG & Trust:
CCG Report 55% utilisation rate for July (up from 38% in June) ALL CCG 25-Jun-18 02-Jul-18 09-Jul-18 16-Jul-18 23-Jul-18 30-Jul-18 Ebookings Made 93 134 122 140 148 134 QVH report 46% utilisation (up from All Ref from GP and GPwSI 415 400 394 403 364 291 22% in June) % ref outside eRS 78% 67% 69% 65% 59% 54%
eRS paper switch off QVH moved to ‘soft paper switch off’ on 2 July and hard PSO on 31 August in line with SASH and BSUH, at request of the CCG Alliance. Weekly calls with NHSE, NHS Digital and CCGs continue throughout this period. August national stocktake rated QVH green.
Key risks to delivery include: Capacity – Appointment Slot Issues (ASIs) are being monitored and managed daily to identify capacity issues and action required.
GP utilisation - Local CCGs utilisation rates are improving across locality but levels of manual return remain higher than planned.
Operational readiness - Trust revised SOPs for Paper returns process have been agreed by NHSE/NHSD/CCGs.
QVH BOD September 2018: Session in public 10 Page 34 of 260
Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/2018 Agenda reference: 132-18 Report title: Finance Report M4 July 2018 Sponsor: Michelle Miles, Director of Finance and Performance Author: Jason McIntyre, Deputy Director of Finance Appendices: Finance Report M4
Executive summary Purpose of report: To highlight the Financial position of the Trust to Month 4 (July) Summary of key • The Trust delivered a deficit of £301k in month; £260k below plan. issues • For the Trust to meet the full year control total of £0.9m bottom line surplus the financial position has to improve by £2.8m in the last 8 months of the year. • The Trust is forecasting to meet plan by the end of the year. However there are significant risks to full year delivery especially given the clinical workforce and cost saving challenges.
Recommendation: To note the report Action required Approval Information Discussion Assurance Review
Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Organisational (KSOs): Financial patient clinical excellence sustainability excellence experience services Implications Board assurance framework: See KSO4 Financial Sustainability
Corporate risk register: Risks: Non achievement of the Trusts agreed control total and non achievement of STF.
Regulation: • Monthly reporting to NHSI on progress on all financial elements of the Trust including capital, cash, CIP delivery and the
financial income and expenditure position • The Finance Use of Resources rating is 3
Legal: The NHS Constitution to deliver financial balance
Resources: None Assurance route Previously considered by: Executive Management Team Date: 20 August (abridged) Decision Noted 29 August (full) Next steps:
QVH BOD September 2018: Session in public Page 35 of 260 Finance Report July 2018
Executive Director: Michelle Miles
QVH BOD September 2018: Session in public Page 36 of 260 Contents
3. Summary Position 4. Summary Trend Position 5. Activity Performance by POD 6. Activity Trends by POD 7. Financial Position by Business Unit 8. CIP – service line performance 9. CIP 10. Balance Sheet 11. Capital 12. Debtors 13. Cash 14. Creditors 15. A ppendices 16. Appendix 1: Use of resources metric score 17. Appendix 2: Agency Ceiling & Analysis 18. Appendix 3 : Historic trend analysis
QVH BOD September 2018: Session in public Page 37 of 260 Summary Position – M4 2018/19
Table 1 – Financial Performance Financial Performance In Month £'000 Year to Date £'000 Summary - Plan Performance
Annual Favourable/ Favourable/ Income and Expenditure Budget Actual Budget Actual Budget (Adverse) (Adverse) • The Trust delivered a deficit of £301k in month;£260k below plan. The YTD deficit has Income Patient Activity Income 67,086 5,481 5,577 96 21,307 21,532 225 increased to £1,907k; £258k below plan. The use of resources rating is 3 in line with Other Income 4,239 358 453 96 1,379 1,674 295 plan. Total Income 71,325 5,839 6,030 191 22,686 23,206 520 Pay Substantive (45,793) (3,905) (3,660) 245 (16,095) (14,404) 1,692 Bank (80) (7) (221) (214) (27) (835) (808) • For the Trust to meet the full year control total of £0.9m bottom line surplus the Agency (273) (23) (259) (236) (91) (1,135) (1,044) financial position has to improve by £2.8m in the last 8 months of the year - in effect Total Pay (46,146) (3,935) (4,140) (205) (16,213) (16,374) (161) Non Pay Clinical Services & Supplies (12,870) (924) (1,038) (114) (3,931) (4,251) (319) generate a monthly surplus of £0.35m for each of the remaining months. Drugs (1,553) (129) (150) (21) (518) (546) (29) Consultancy (79) (7) (28) (22) (26) (95) (69) • The Trust is forecasting to meet plan by the end of the year. However there are Other non pay (5,562) (513) (650) (137) (2,157) (2,454) (297) Total Non Pay (20,064) (1,573) (1,866) (293) (6,632) (7,346) (713) significant risks to full year delivery especially given the clinical workforce and cost Financing (4,469) (393) (343) 50 (1,571) (1,471) 100 saving challenges. Total Expenditure (70,680) (5,901) (6,349) (448) (24,417) (25,191) (775) Surplus / (Deficit) 645 (62) (318) (256) (1,730) (1,985) (255) In Month Performance Adjust for Donated Depn. 255 (20) (17) 3 (82) (78) 3 NHSI Control Total Excluding STF 900 (42) (301) (260) (1,649) (1,907) (258) • Patient activity income has over performed by £96k, this is mainly due to critical care bed days. Elective & daycases are below plan in month by £71k, 82 spells which is YTD Performance mainly within OMFS, Burns and Hands services, partially offset by over performance • The Trust is £258k adverse to plan YTD. Income is above plan by £520k YTD, which within plastics (breast and skin). Non Elective is above plan by £88k within OMFS & has been offset by overspends within expenditure of £775k. Plastics services.
• Income has over recovered by £328k YTD, which is due to patient activity income of • Other Income has slightly increased which is largely due to the increase provider £225k over recovery and other income over recovered by £295k. recharge income, education funding and additional £51k for AFC pay award funding • Patient activity income: Elective over performance is £384k favourable YTD and non elective below plan by £155k YTD. The main area of under performance is Oral partially offsetting pay expenditure. by £70k, Plastics has reduced its adverse position to £46k. Sleep services are over performing YTD £189k and eyes services is favourable YTD by £86k. There is a • Pay is £205k adverse in month, this is partially due unidentified saving of £33k reflected provision of £92k YTD for CQUIN and challenges. in month. There has been an increase in spend from the new pay awards of £55k for • Other income has over performed due to additional Trust recharge income, AFC which has been partially offset by additional income. Medical staffing is high in education and training and AFC award funding. month due to additional payments within plastics of c£40k currently being • The YTD pay position is £161k adverse YTD. £53k budget decrease within pay which investigated. Agency medical staffing will reduce in M5, with the increase in is due to unidentified CIP and slippage on schemes. Medical staffing and nursing substantive junior doctor in post. Agency expenditure has reduced in month whilst overspends have been offset by underspends within other staff categories. bank expenditure has had a similar value increase.
• Non pay is over spent by £713k YTD £319k within clinical supplies partially offset by • Non Pay is £293k adverse in month, this is partially due to unidentified CIP of £93k, pass-through income within patient activity £75k, £297k within other non pay Clinical supplies is overspend by £114k (including £12k pass through) and drugs £21k mainly unidentified CIP £245k . This has been partially offset by depreciationQVH BOD September 2018: dueSession to healthcare in public at home expenditure. Financing is £50k favourable in month, which charges underspend within financing of £100k. Page 38 of 260is mainly due to under spend within depreciation. Page 3
I&E Trend Position – M4 2018/19
Actual Actual Actual Actual Actual Actual Actual Plan Plan Plan Plan Plan Plan Plan Plan Plan 18/19 In Actuals 18/19 Board Line M10 M11 M12 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 Month In Month 17/18 17/18 17/18 Patient Activity Income 5,389 4,811 5,051 5,006 5,329 5,620 5,577 5,127 5,658 5,772 6,328 5,040 6,166 5,635 6,051 5,481 5,577 Other Income 429 496 898 361 337 523 453 357 857 358 358 356 359 358 358 358 453 Total Income 5,818 5,307 5,949 5,367 5,666 6,143 6,030 5,484 6,515 6,130 6,686 5,396 6,525 5,993 6,410 5,839 6,030 Substantive (3,468) (3,415) (3,497) (3,553) (3,654) (3,536) (3,660) (3,905) (3,905) (3,648) (3,648) (3,648) (3,648) (3,648) (3,648) (3,905) (3,660) Bank (122) (132) (139) (326) (140) (148) (221) (7) (7) (7) (7) (7) (7) (7) (7) (7) (221) Agency (205) (251) (289) (276) (295) (305) (259) (23) (23) (23) (23) (23) (23) (23) (23) (23) (259) Total Pay (3,794) (3,798) (3,925) (4,155) (4,090) (3,989) (4,140) (3,935) (3,935) (3,677) (3,677) (3,677) (3,677) (3,677) (3,677) (3,935) (4,140) Clinical Services & Supplies (1,054) (1,025) (301) (1,076) (944) (1,193) (1,038) (961) (933) (939) (1,071) (1,240) (1,231) (1,231) (1,334) (924) (1,038) Drugs (118) (105) (126) (116) (137) (143) (150) (129) (129) (129) (129) (129) (129) (129) (129) (129) (150) Consultancy (17) - (83) (8) (37) (22) (28) (7) (7) (7) (7) (7) (7) (7) (7) (7) (28) Other non pay (562) (595) (484) (607) (592) (605) (650) (504) (503) (400) (400) (400) (400) (400) (399) (513) (650) Total Non Pay (1,750) (1,726) (993) (1,807) (1,709) (1,963) (1,866) (1,601) (1,572) (1,475) (1,607) (1,776) (1,767) (1,767) (1,869) (1,573) (1,866) Non Operational Expenditure (114) (114) (181) (127) (127) (128) (142) (129) (129) (129) (129) (129) (129) (129) (129) (129) (142) Non Operating Income 333333311111111 1 3 Depreciation and amortisation (233) (233) (243) (249) (249) (257) (203) (265) (265) (265) (265) (265) (265) (265) (265) (265) (203) Financing (345) (345) (421) (373) (374) (381) (343) (393) (393) (393) (393) (393) (393) (393) (393) (393) (343) Total Expenditure (5,890) (5,869) (5,340) (6,336) (6,172) (6,334) (6,349) (5,929) (5,900) (5,545) (5,677) (5,846) (5,837) (5,837) (5,939) (5,901) (6,349) Surplus / (Deficit) (72) (561) 609 (969) (506) (191) (318) (445) 615 586 1,010 (449) 688 156 470 (62) (318) Donated Depreciation (19) (19) 124 (20) (20) (22) (17) (20) 480 (20) (20) (20) (20) (20) (20) (20) (17) NHSI Contol Total Excluding STF (52) (542) 485 (950) (486) (169) (301) (425) 136 606 1,030 (429) 708 177 491 (42) (301)
Summary The above table details in month actuals, including Q4 of 17/18 and compared to planned income and expenditure for the remainder of the year. It provides an analysis of income and expenditure relative to actual performance year to date.
The Income plan in Q1 and Q2 are relatively low in relation to the remainder of the year. The Income plan significantly ramps up in over the last 2 quarters of the year. Expenditure is anticipated to reduce in the final 2 quarters as productivity and saving initiatives gain traction.
QVH BOD September 2018: Session in public Page 4 Page 39 of 260 Activity Performance by POD – M4 2018/19
Table 1 - Performance by POD Summary Activity Performance In Month In Month Year To Date Year To Date
Acty Actual Plan Actual POD Currency Plan Acty Act Acty Plan £k Var £k Act Acty Acty Var Plan £k Var £k Minor injuries attendances are 237 and £17k better than plan. YTD Var £k Acty £k activity is 440 attendances and £32k above plan. Minor injuries Attendances 943 1,180 237 68 85 17 3,712 4,152 440 267 299 32 Elective (Daycase) Spells 1,012 941 (71) 1,106 1,013 (93) 3,950 3,858 (92) 4,322 4,257 (65) Daycase activity in month is 93 spells and £93k below plan with Elective Spells 304 293 (11) 710 733 22 1,186 1,271 85 2,774 3,158 384 under-performance in plastics (hands) £73k and eyes (corneoplastics) Non Elective Spells 497 460 (37) 1,175 1,264 89 1,954 1,825 (129) 4,625 4,471 (155) £29k partially offset by over-performance plastics (skin). YTD activity is XS bed days Days 57 46 (11) 16 13 (3) 221 297 76 61 79 18 92 spells and £65k under plan within Oral £82k, eyes (corneoplastics) Critical Care Days 78 44 (34) 80 89 9 305 321 16 315 485 170 £82k and plastics (hands) £69k. This has been partially offset by Outpatients - First Attendance Attendances 3,934 3,966 32 542 530 (12) 15,105 15,647 542 2,081 2,099 18 above plan performance within plastics (skin) £100k, sleep studies Outpatients - Follow up Attendances 11,416 10,598 (818) 814 770 (44) 43,863 41,415 (2,448) 3,127 3,094 (33) £48k and plastics (burns) £33k. Outpatient - procedures Attendances 2,625 1,806 (819) 347 235 (112) 10,056 9,057 (999) 1,328 1,184 (144) Other Other 3,922 3,085 (837) 590 610 19 15,100 15,125 25 2,272 2,442 170 Other clincial income inc. WIP/ coding 32 236 203 133 (37) (170) 5,481 5,577 96 21,307 21,532 225
Table 2 - Performance by Service Line Elective activity in the month is 11 spells below plan and over delivered income by £22k within plastics (breast) and eyes Activity Financial Performance In Month Year to Date (corneoplastics). The YTD activity is 85 spells and £384k above plan largely within Oral £105k, Eyes (corneoplastics ) £96k, Actual Service Line Plan £k Actual £k Var £k Plan £k Var £k Plastics (skins ) £87k & (Breast Surgery)£40k. £k
Perioperative Care 82 90 8 323 493 169 Clinical Support 585 577 (8) 2,262 2,322 59 Non-elective activity has under performed by 37 spells and over performed by £94k in month due to casemix of activity in Eyes 551 597 45 2,129 2,215 86 month primarily within Plastics service lines. The YTD position reports an under-performance of 129 spells and £155k Oral 1,190 1,066 (124) 4,596 4,526 (70) underperformance due to under performance within plastics services lines £205k partially offset by overperformance within Plastics 2,635 2,587 (47) 10,307 10,260 (46) eyes (corneoplastics). Sleep 401 418 18 1,539 1,729 190 Other clincial income inc. WIP/ coding 37 242 205 151 (12) (163) Critical care days have under -performed by 34 days in month and over performed by £9k. The YTD position is above plan by Grand Total 5,481 5,577 96 21,307 21,532 225 16 days and £170k YTD. There was a long stay high acuity patient discharged in month accounting for the casemix benefit.
Outpatient attendances (FA/FUs) are 785 attendances and £56k lower than plan in month and 1906 attendances and £177k NB below plan YTD. Outpatient procedures are £133k under plan in month by £112k and £144k YTD. There is a timing delay in * Other clinical income has been added to analysis (i.e RTA, Private patients) the completion of coding of outpatient procedures , the anticipated value of the coding gain is accrued into the in month to reconcile to total Clinical Income. position and reflected within prior period adjustments & WIP category as an estimate.
** Further activity trend analysis is included on the next page. Other overperformance due to diagnostic imaging for radiology £100k and PBR £86k due to overperformance within sleep
£76k and plastics £56k partially offset by underperformance within oral service lines £50k. *** Total in month and YTD service line performance does not reconcile to activity income analysis by business unit page 7 as non SLAM activity income has not been disaggregated to business unit. Within services lines over performance within perioperative care(critical care), sleep, eyes, and clinical support have offset QVHunder BOD recovery September within 2018: plastics Session and in oral public service lines. Page 40 of 260 Page 5 Activity Trends by Pod – M4 2018/19
Activity Trend Actual Actual Actual PLAN Actuals Actual Actual Plan Plan Plan POD M10 M11 M12 Actual M1 Actual M4 Plan M5 Plan M6 Plan M7 Plan M8 Plan M9 18/19 In 18/19 In M2 M3 M10 M11 M12 17/18 17/18 17/18 Month Month Minor injuries 798 745 863 924 1,005 1,040 1,180 943 913 943 913 943 943 852 943 943 1,040 Elective (Daycase) 1,107 992 905 958 962 957 941 993 1,098 1,117 1,356 1,079 1,387 1,276 1,381 1,012 957 Elective 284 297 317 319 337 321 293 290 342 336 420 313 420 384 413 304 321 Non Elective 418 399 386 452 444 467 460 497 481 497 481 497 497 449 497 497 467 XS bed days 33 52 98 72 160 35 46 53 57 58 60 50 56 52 56 57 35 Critical Care 126 81 49 97 93 35 44 78 75 78 75 78 78 70 78 78 35 Outpatients - First Attendance 3,763 3,153 3,644 3,618 3,874 4,651 3,966 3,349 4,065 4,111 4,423 2,907 3,878 3,576 3,809 3,934 4,651 Outpatients - Follow up 10,480 9,107 10,132 9,991 10,675 10,653 10,598 9,804 11,684 11,930 12,721 8,550 11,248 10,379 11,060 11,416 10,653 Outpatient - procedures 2,737 2,233 1,565 2,116 2,532 1,302 1,806 2,142 2,835 2,744 3,074 1,819 2,606 2,387 2,525 2,625 1,302 Other 4,288 3,826 3,142 3,940 4,062 3,964 3,085 3,481 3,865 4,098 4,221 3,086 3,921 3,565 3,742 3,922 3,964 24,034 20,885 21,101 22,487 24,144 23,425 22,419 21,628 25,416 25,912 27,743 19,321 25,036 22,989 24,503 24,787 23,425
£'000 Trend Actual Actual Actual PLAN Actuals Actual Actual Plan Plan Plan POD M10 M11 M12 Actual M1 Actual M4 Plan M5 Plan M6 Plan M7 Plan M8 Plan M9 18/19 In 18/19 In M2 M3 M10 M11 M12 17/18 17/18 17/18 Month Month Minor injuries 59 55 64 67 72 75 85 68 66 68 66 68 68 61 68 68 75 Elective (Daycase) 1,329 1,186 1,014 1,098 1,096 1,024 1,013 1,099 1,181 1,221 1,463 1,199 1,512 1,395 1,514 1,106 1,024 Elective 765 780 746 809 810 781 733 697 771 784 952 758 974 896 970 710 781 Non Elective 1,056 996 951 1,026 996 1,226 1,264 1,175 1,137 1,175 1,137 1,175 1,175 1,062 1,175 1,175 1,226 XS bed days 9 15 27 20 42 9 13 15 16 16 17 14 16 14 16 16 9 Critical Care 189 87 54 87 117 42 89 80 77 80 77 80 80 72 80 80 42 Outpatients - First Attendance 518 419 501 489 525 622 530 458 565 567 615 396 533 493 526 542 622 Outpatients - Follow up 799 691 768 756 796 778 770 694 840 851 914 603 800 740 791 814 778 Outpatient - procedures 363 300 210 279 328 171 235 283 374 362 406 241 344 315 333 347 171 Other 430 410 494 561 669 612 610 517 595 615 645 458 585 536 570 590 612 Work in progress and coding adjustment (186) (123) 279 236 32 236 5,518 4,939 4,829 5,006 5,329 5,620 5,577 5,087 5,623 5,740 6,292 4,991 6,088 5,585 6,043 5,481 5,576
QVH BOD September 2018: Session in public Page 6 Page 41 of 260 Financial Position by Business Unit – M4 2018/19
Patient Activity Variance by type: in £ks Other Income Pay Non Pay Position In Month Year to Date Income Annual % performance against financial plan CMV YTDV CMV YTDV CMV YTDV CMV YTDV Budget Actual Variance Budget Actual Variance Contribution Budget Contribution Operations 1.1 Plastics 50 (20) 12 55 (103) (340) (9) (139) 23,280 1,873 1,823 (50) 67% 7,267 6,823 (444) 66% 1.2 Oral (95) (21) (39) 75 (3) (67) (11) (32) 7,227 575 427 (148) 40% 2,133 2,088 (45) 45% 1.3 Eyes 98 106 6 61 (21) (23) (1) (38) 3,728 281 364 83 54% 1,034 1,140 106 48% 1.4 Sleep (9) 134 1 1 7 9 (24) (88) 2,389 194 167 (27) 42% 712 769 57 45% 1.5 Clinical Support 93 133 1 (63) 23 198 8 29 (2,255) (168) (42) 125 -6% (761) (464) 297 -18% 1.6 Perioperative Care 139 214 20 15 (140) (364) (13) (72) (11,562) (942) (936) 5 -359% (4,014) (4,221) (207) -673% 1.7 Operational Nursing 1 7 (2) (8) (8) (107) 10 9 (3,681) (307) (306) 1 -3030% (1,228) (1,328) (100) -3250% Operations Total 277 553 (2) 135 (244) (694) (41) (331) 19,126 1,507 1,497 (10) 5,143 4,806 (337) Nursing & Clinical Infrastructure 2.1 Clinical Infrastructure ---- (2) (19) (0) 7 (1,107) (92) (94) (2) #DIV/0! (369) (381) (12) #DIV/0! 2.5 Director Of Nursing -- (13) (32) (17) (52) (78) (87) (2,856) (238) (347) (109) -2421% (953) (1,123) (170) -1446% Nursing & Clinical Infrastructure -- (13) (32) (19) (71) (78) (80) (3,963) (330) (441) (111) (1,322) (1,504) (182) Corporate Departments 3.1 Non Clinical Infrastructure (3) (11) 7 27 (6) (3) (57) (38) (4,360) (365) (423) (59) -754% (1,469) (1,494) (25) -689% 3.2 Commerce & Finance -- (2) 15 (21) (28) 13 (6) (2,771) (231) (241) (11) -362027% (925) (944) (19) -4108% 3.4 Finance Other (178) (319) 70 84 65 566 (22) (84) (4,483) (402) (465) (63) -1367% (2,190) (1,942) 247 -1615% 4.1 Human Resources -- 40 81 4 22 (34) (39) (1,007) (84) (74) 10 -134% (336) (272) 64 -193% 5.4 Corporate -- (4) (14) 16 47 (23) (36) (1,897) (158) (168) (10) #DIV/0! (632) (636) (4) #DIV/0! Corporate Total (181) (330) 111 192 59 603 (123) (203) (14,518) (1,239) (1,372) (133) (5,552) (5,288) 264
Surplus / (Deficit) 96 223 96 295 (205) (161) (243) (613) 645 (62) (318) (254) (1,730) (1,986) (256) Summary Patient Activity Income: The main areas of over performance in month of £96k is within perioperative care (critical care days), clinical support(MIU/ direct access activity) eyes (elective, emergency activity) partially offset by the oral (inpatients, outpatients and PBR exclusions) and finance other due to technical adjustment and increase of provisions for fines and challenges. YTD overperformance of £223k is mainly within perioperative care (critical care beddays), sleep (inpatient, outpatients , PBR exclusions activities), clinical support (support(MIU/ direct access activities), eyes (emergency and PBR exclusion activities) offset by underperformance within plastics, oral and finance other. Other income: In month is above plan by £96k, YTD £295K. The in month and YTD is due to increase in clinical excellence awards, partially offsetting pay overspend within medical budgets. Plastics is mainly due to BSUH recharge , which is partially offsetting over spend within Medical spend in pay. Oral above plan is mainly due to additional income from NHS England Education and cleft lip services from Guy’s & St Thomas’s. Eyes is mainly due to increase in our supply of pre-cut corneal tissue to various providers. Additional AFC funding of £55k is offsetting some of the pressures due to the AFC pay award across the Trust. Pay: In month is over spent by £205k in month ; £161k YTD. The main driver of overspend are within plastics and perioperative care. Plastic service is above plan by £103k in month and £340k YTD due largely to medical pay for additional BSUH recharge costs (offset by other recharge income), agency usage and additional medical payments. Perioperative is above plan by £140k in month and £224k YTD which is due to high agency usage to cover vacancies and additional payments for weekend work. The Trust is above the NHSI agency cap by £591k YTD. Cost pressures as a result of medical job planning of circa £20k / month have not been reflected in positon due to timing issues but will be included from next month. Non Pay: In month is over spent by £436k; £613k below plan YTD. There was unidentified saving of £245k shown within the position. Plastics is above plan which is mainly due to outsourcing of activity to McIndoe which is being recovered through Patient Activity Income. Oral is mainly due to an increase spend in Implants & Prosthesis Appliances offset by income overperformance. Depreciation costs within Finance other are less than anticipated in month £50k and YTD £100k which is not expected to continue over the remainder of the year.
QVH BOD September 2018: Session in public Page 7 Page 42 of 260 Cost Improvement Plan (CIP) – M4 2018/19
Change (+ve Estimated means Financial identification of Sum of NHSI Sum of YTD Sum of YTD Over / CIPP Target Delivery based Business Unit Lead 18/19 Gap further CIPPs Planned Savings Actual Savings (Under) £ on RAG rating compared to YTD £ by BU Total £ Achievement £ as reported at reported at Month 3 Month 3)
1.1 Plastics Paul Gable (461,621) (343,185) (118,436) 0 (27,624) (37,600) 9,976 1.2 Oral (365,162) (355,162) (10,000) 0 (3,333) (8,138) 4,805 1.3 Eyes (170,687) (164,075) 0 6,612 0 (7,158) 7,158 1.4 Sleep (48,272) 26,958 (97,433) (22,203) (27,438) (7,438) (20,001) 1.5 Clinical Support Services Paul Gable (429,084) (142,506) (289,622) (3,044) (57,353) (42,706) (14,647) 1.6 Perioperative Care (646,490) (559,314) (87,176) 0 (58,117) (41,126) (16,991) 1.7 Operational Nursing Nicky Reeves (182,391) (180,891) (1,500) 0 (1,667) (1,667) 0 2.1 Performance & Access Phil Kennedy (50,977) (27,225) (1,000) 22,752 (3,333) 0 (3,333) 2.5 Director of Nursing Nicky Reeves (172,735) (74,333) (98,403) 0 (30,335) (27,002) (3,333) 3.1 Non Clinical Infrastructure Steve Davies (240,528) (66,415) (174,113) 0 (3,000) (42,000) 39,000 3.2 Commerce & Finance Jason McIntyre (136,847) 70,473 (207,320) 0 (98,373) (23,625) (74,749) 4.1 Human Resources Dave Hurrell (55,100) (49,740) (5,360) 0 (17,866) (447) (17,419) 5.4 Corporate Clare Pirie (89,106) (89,106) 0 Targets in Op Plan 20,000 (20,000) 0 0 0 0 Grand Total (3,049,000) (1,934,521) (1,110,363) 4,116 (328,441) (238,906) (89,535)
Summary
• In M4 the Trust achieved savings of £66k; £35k below plan. The YTD savings have increased to £239k, £89k below plan.
• The YTD underperformance is due to slippage in resmed contract (Sleep) and Community ENT (clinical Services) as well as delays due to staffing issues within Rheumatology and MSK Physio (Clinical Support). Perioperative Care is under delivered on clinical supplies and Surgical Instrument Management contract (SIMS) and finance adverse variance is due to slippage on procurement schemes although this is expected to recover later in the year. Procurement has a stretch target of £0.6m and £0.3m has been currently identified.
• The Trust has identified saving so £1.1m; a significant gap (£1.9m) compared to target. There have been additional meetings for in-depth CIP and activity reviews with all business units which have been scheduled monthly. This is in addition to the monthly performance reviews. Therefore the Trust is focusing on CIP and activity achievement on a two weekly basis to aid focus and delivery to reduce the gap. QVH BOD September 2018: Session in public Page 8 Page 43 of 260 Cost Improvement Plan (CIP) – M4 2018/19
QVH BOD September 2018: Session in public Page 9 Page 44 of 260 Balance Sheet – M04 2018/19
Balance Sheet 2017/18 Current Previous Summary as at the end of July 2018 Outturn Month Month £000s £000s £000s • Capital asset value has decreased in month by £0.17m due to the capital spend profile. Non-Current Assets • Net current assets have decreased in month by £0.32m. 47,588 47,021 47,193 Fixed Assets • Inventories are planned to be monitored on a regular basis. Other Receivables - - -
Sub Total Non-Current Assets 47,588 47,021 47,193 • Trade and other receivables have decreased by £0.865m due to invoice payment. Current Assets Inventories 1,178 1,168 1,178 • Cash has increased by £1.2m primarily due payment of outstanding Trade and Other Receivables 8,217 6,878 7,743 invoices and STF, receipt of additional receipts Cash and Cash Equivalents 8,914 8,528 7,306 • Current liabilities have increased by £0.49m. (8,933) (8,806) (8,313) Current Liabilities • Non current liabilities have remained stable Sub Total Net Current Assets 9,376 7,768 7,915 Total Assets less Current Liabilities 56,965 54,789 55,108 Issues Non-Current Liabilities Provisions for Liabilities and Charges (625) (625) (625) • Sufficient cash balances need to be generated by the Trust to provide Non-Current Liabilities >1 Year (5,823) (5,434) (5,434) liquidity, service the capital plan and to meet future loan principal repayment obligations. Total Assets Employed 50,517 48,730 49,049
Tax Payers' Equity Actions Public Dividend Capital 12,237 12,236 12,237 Retained Earnings 26,100 24,314 24,632 • Further details of actions taken to ensure robust cash management Revaluation Reserve 12,180 12,180 12,180 processes are outlined on the debtor and cash slides Total Tax Payers' Equity 50,517 48,730 49,049
NB Analysis is subject to rounding differences
QVH BOD September 2018: Session in public Page 10 Page 45 of 260 Capital – M3 2018/19
Annual YTD YTD YTD Full Year Full Year Month 4 - July 2018 Plan Plan Actual Variance Forecast Variance Summary £000s £000s £000s £000s £000s £000s Estates projects • The original Capital plan for 2018/19 was £3,850k including the Backlog maintenance - Energy Management 216 - - - 216 (0) Backlog maintenance - Health & Safety 105 - 18 (18) 105 - CT scanner project for which a donation of £400k has been Backlog maintenance - Fire Safety 145 - 11 (11) 145 - Backlog maintenance - Internal Accommodation 234 10 64 (54) 234 - agreed. A further £1,000k has now been added following the Backlog maintenance - External Works 180 - 0 (0) 180 - decision to invest part of the Trust's STF funding in capital projects. Other projects 384 157 107 51 384 (0) Estates projects 1,264 167 200 (32) 1,264 - This has been added to the annual total in this report but has not yet been phased across the remainder of the year until detailed Medical Equipment 1,033 200 99 101 1,033 (0) agreed. Information Management & Technology (IM&T) Ordercomms 120 80 80 - 120 - • The capital programme has been developed through the 2018/19 Infrastructure strategy - hardware 170 - - - 170 - business planning process via the Capital Planning Group and with Infrastructure strategy - end user reconfiguration 150 - - - 150 - Infrastructure strategy - desktop/mobile 100 - - - 100 - EMT and Board approval. The use to which the STF funding will be Health & Social Care Network 150 - 21 (21) 150 - used is being determined and agreed at HMT. Vital Sign implementation (eObservations) 108 - - - 108 - EDM 108 10 - 10 108 - • The largest element of the Estates programme is backlog Other projects 534 170 34 136 534 - Information Management & Technology (IM&T) 1,440 260 135 125 1,440 - maintenance. The Trust is in year 3 of a 5 year programme. Works STF funding allocated to capital 1,000 - - - 1,000 - associated with the installation of the cone beam scanner have Back-dated VAT recoveries - - (37) 37 (37) 37 Contingency 113 - - - 150 (37) been completed and the scanner is now in service. Enabling Total 4,850 627 396 231 4,850 - works for the CT scanner have been initiated. • The CT scanner itself has been ordered. • The IT programme is largely based on the IM&T Strategy and work is expected to gain momentum form next month onwards. The implementation of Ordercomms, the electronic ordering of diagnostic tests and images, is progressing. The EDM project continues and is approximately half-way through implementation. • YTD expenditure is 37% below plan. Full year expenditure is forecast to be in line with plan. Additional meeting have been agreed with key areas to ensure delivery of forecast. • The back-dated recovery of VAT relating to projects that started in 2017/18 and have continued into 2018/19 has been shown QVH BOD September 2018: Session in publicseparately to avoid distorting the presentation of the 2018/19 Page 11 Page 46 of 260 spend. Debtors – M04 2018/19
Debtor Trend 10,000 8,000
6,000 £k 4,000 2,000 - Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total 2018/19 8,147 7,492 7,743 6,878 Total 2017/18 7,679 7,330 7,639 8,168 8,172 8,901 8,756 9,233 8,206 8,419 7,778 8,217 Total 2016/17 7,593 6,194 6,722 6,322 4,811 5,196 5,764 7,742 7,347 6,207 7,049 7,068
Summary Debtors 2018/19 • The debtor balance decreased by £0.8m (11%) from month 3. 4,000 This is due largely to recovery of aged debt relating to prior 3,000 months over performance invoices. 2,000 • At M04 there is £1.4m of accrued income for activity over-performance and NCAs. which is an decrease of £1.4m 1,000 £m compared to the previous month due to payment of STF income. 0 Next Steps NHS Debtors Non NHS Debtors Prepayment & Other Provision for Bad (1,000) Accrued income Debt (Inc RTA) • Financial services continue to work with the business development team to ensure billing is accurate, timely and resolutions to queries are being actively pursued. Aged Debtors POD 30 Days 60 Days 90 Days 90+ Days NHS 1,331,807 346,092 231,115 1,378,958 Non NHS 53,783 18,338 1,713 64,506 QVH BOD SeptemberTotal 2018: Session in public 1,385,590 364,430 232,828 1,443,465 Page 12 Page 47 of 260 Cash – M04 2018/19
Cash Balances Summary 11.000 10.000 9.000 8.000 7.000 6.000 5.000 4.000 3.000 2.000 1.000 0.000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 18/19 Actual 7.948 7.890 7.304 8.525 18/19 NHSI Plan 8.110 8.230 7.210 7.320 7.040 6.710 7.550 8.820 8.150 9.110 9.540 9.668 17/18 Actual 6.657 7.124 7.048 7.561 7.387 7.029 7.846 7.490 8.060 8.367 8.817 8.895
Cash Balance 2018/19 Actual (£m) Forecast: Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Summary Opening Balance 8.89 7.95 7.89 7.30 8.53 9.19 9.42 9.96 10.92 9.94 10.31 10.15 • The in month cash position is favourable on the basis of current Receipts from invoiced income 5.77 6.42 5.54 5.62 5.42 6.45 6.11 6.67 5.38 6.53 6.00 6.42 Receipts from non-invoiced income 0.16 0.15 0.26 1.73 1.35 0.65 0.15 0.15 0.15 0.15 0.15 0.15 liquidity and debt service ratios. Total Receipts 5.93 6.57 5.80 7.35 6.77 7.10 6.26 6.82 5.53 6.68 6.15 6.57 • The cash balance at the end of M04 has a favourable variance of £1.2m against the plan submitted to NHSI. This is due to higher Payments to NHS Bodies (0.62) (0.52) (0.42) (0.60) (0.60) (0.60) (0.60) (0.60) (0.60) (0.60) (0.60) (0.60) Payments to non-NHS bodies (2.55) (2.41) (1.90) (1.91) (1.37) (1.72) (1.24) (1.37) (1.54) (1.83) (1.82) (1.89) than anticipated receipts relating to aged debt and the payment of Net payroll payment (2.08) (2.08) (2.01) (2.07) (2.39) (2.14) (2.14) (2.14) (2.14) (2.14) (2.14) (2.14) £0.2m to Brighton and Sussex University Hospital NHS Trust in PAYE, NI & Levy pa yment (1.03) (1.03) (1.01) (0.97) (1.06) (1.06) (1.06) (1.06) (1.06) (1.06) (1.06) (1.06) month. Pensions Payment (0.60) (0.59) (0.57) (0.57) (0.69) (0.69) (0.69) (0.69) (0.69) (0.69) (0.69) (0.69) PDC Dividends Payment -- - - - (0.67) - - - - - (0.67) • Cash balances are forecast to remain above or in line with plan for Theatre Loan Repayment - - (0.48) - - - - - (0.48) - - - the remainder of 2018/19. Total Payments (6.88) (6.63) (6.39) (6.13) (6.10) (6.88) (5.73) (5.86) (6.50) (6.32) (6.31) (7.04) Actual Closing Balance 7.95 7.89 7.30 8.53 Next Steps Forecast Closing Balance 9.19 9.42 9.96 10.92 9.94 10.31 10.15 9.67 • The Trust will continue to review short term cash flow on a daily NHSI Plan 8.11 8.23 7.21 7.32 7.04 6.71 7.55 8.82 8.15 9.11 9.54 9.67 basis to manage liquidity and inform decision making. Variance to NHSi plan (0.16) (0.34) 0.09 1.21 2.15 2.71 2.41 2.10 1.80 1.20 0.61 0.01 QVH BOD September 2018: Session• in publicFinancial services will work with commissioners to ensure Page 48 of 260 Page 13 payments are made in a timely manner.
Creditors – M04 2018/19
Trade Creditors 4,000 3,000 £k 2,000 1,000 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2018/19 3,377 3,033 2,967 2,825 2017/18 2,175 2,140 2,543 2,810 2,022 2,129 2,422 2,283 2,318 2,882 3,157 3,598 2016/17 2,144 2,283 1,549 1,580 1,838 1,971 2,003 1,964 2,040 2,721 2,623 2,503
2017/18 Current Current Better Payment Practice Code (18/19) 2017/18 YTD No Outturn Month Month YTD £k July Outturn £k Invs Summary No Invs No Invs £k
• The trade creditors balance at M4 is £2.8m compared to an average of £2.5m during 2017-18. There was a reduction of Total Non-NHS trade invoices paid 20,090 21,583 1,894 3,046 7,303 13,516 £0.1m compared to previous month; a continuation of the Total Non NHS trade invoices paid within target 17,585 18,501 1,596 2,762 6,172 12,155 reducing trend since April. • Reviews will continue to target older NHS SLA balances with our Percentage of Non-NHS trade invoices paid within target 88% 86% 84% 91% 85% 90% key partner Trusts. Total NHS trade invoices paid 884 4,181 96 444 339 1,452 • The Trust’s BPPC percentage has increased in month by 1% and Total NHS trade invoices paid within target 521 2,020 40 169 176 536 the average days to payment increased to 28 days. • Savings from prompt payment discounts taken in month Percentage of NHS trade invoices paid within target 59% 48% 42% 38% 52% 37% amounted to £2k, in line with plan. Next Steps Aged Creditors POD 30 Days 60 Days 90 Days 90+ Days • Financial services are continuing to review areas where NHS 150,204 181,227 89,166 1,426,220 invoice authorisation is delayed in order to target support and training. Non NHS 720,625 258,786 33,823 173,221 Total 870,829 440,013 122,988 1,599,441 QVH BOD September 2018: Session in public Page 14 Page 49 of 260
Appendices
QVH BOD September 2018: Session in public Page 15 Page 50 of 260 Appendix 1: Finance Score (Single Oversight Framework)
Table 1 Table 2
Finance Score: July2018 Metrics £k Measure Rating Weight Score Plan Continuity of Services: Capital Service Cover Operating surplus (Adj YTD) (303) -0.33 4 20% 0.80 4 Capital Servicing Obligation YTD 913 Liquidity Working Capital 6,600 33.9 1 20% 0.20 1 Operating Costs (per day) 195 Financial Efficiency: Control Total Margin (%) Adj. Surplus (deficit) YTD (1,707) -7.29% 4 20% 0.80 4 Adj. Income year to date 23,405 Margin Variance From Plan Adj. Actual surplus margin -7.30% -1.30% 3 20% 0.60 1 Adj. Plan surplus margin -6.00% Agency Cap Agency Spend 1,130 107.72% 4 20% 0.80 4 Agency Cap 544
Finance Score: July2018 3 Plan: 3
Summary • The use of resources score is a 3 due to the current deficit impact on control total margin and capital service cover and breach of agency cap.
• Table 2 details a definition of each of the metrics and the scoring mechanism.
QVH BOD September 2018: Session in public Page 16 Page 51 of 260
Appendix 2 - Agency Ceiling & Analysis
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total YTD £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Agency Ceiling 136 136 136 136 136 136 136 136 136 135 135 135 1,628 544 Agency Actuals 276 295 305 259 1,135 Variance (140) (159) (169) (123) (591)
Medical Nursing & Allied HeaAdmin & CSupport StGrand Tot Medical Nursing & Allied HeaAdmin & CSupport StGrand Total Agency Spend by Business Unit In Month Year to Date Nursing & AHP & Nursing & AHP & Admin & Support Admin & Support Staff Group Medical Healthcare Healthcare Grand Total Medical Healthcare Healthcare Grand Total Clerical Staff Clerical Staff Asstistant Scientists Assistant Scientists 1.1 PLASTICS 18 15 0 0 0 33 72 96 0 0 0 168 1.2 ORAL 000000000000 1.3 EYES 000000000000 1.4 SLEEP 0 0 0 0 0 0 (0) 0 0 0 0 (0) 1.5 CLINICAL SUPPORT 18 6 0 1 0 25 54 7 0 2 0 64 1.6 PERIOPERATIVE CARE 0 114 0 0 0 114 0 517 0 0 0 517 1.7 OPERATIONAL NURSING 0 33 0 0 0 33 0 173 0 0 0 173 2.1 CLINICAL INFRASTRUCTURE 0 0 0 7 0 7 0 0 0 42 0 42 2.5 DIRECTOR OF NURSING 000000000101 3.1 NON CLINICAL INFRASTRUCTURE 0 0 0 4 4 7 0 0 0 14 3 17 3.2 COMMERCE & FINANCE 0 0 0 40 0 40 0 0 0 152 0 152 3.4 FINANCE OTHER 000000000000 4.1 HUMAN RESOURCES 000000000000 5.4 CORPORATE 000000000000 Total 36 168 0 51 4 259 126 793 0 213 3 1,135 Summary NHSI has allocated each NHS provider an agency cap as a mechanism to reduce agency expenditure across the provider sector. QVH has been allocated an agency cap of £1.628m for the year. The cap is monitored on a monthly basis via the monthly financial monitoring returns.
The in month agency expenditure of £259k is £123k more than the QVH NHSI ceiling and a reduction of £46k compared to the previous period. The year to date agency expenditure is £591k above the agency ceiling.
Performance on the agency ceiling is one of the 5 metrics included within the Use of Resources measure in the single oversight framework.
The year to date Agency expenditure on Clinical Operations is £212k in month, £966k YTD. Corporate £47k in month, £169k YTD. Nursing is the largest area of agency spend £168k in month; £793k YTD - largely within nursing with Theatres and operationalQVH nursing BOD andSeptember plastics 2018: are mainSession areas. in public Page 17 Page 52 of 260
Appendix 3- Historic monthly trend analysis
QVH BOD September 2018: Session in public Page 18 Page 53 of 260
KSO5 – Organisational Excellence Risk Owner: Director of Workforce & OD Date: 29th August 2018 Strategic Objective Risk Appetite The Trust has a moderate appetite for risks that impact on Initial Risk 3(C)x 5(L)=15, moderate We seek to maintain a well led Organisational Excellence . The engagement and motivation of the workforce, Current Risk Rating 4(C)x 5(L)=20, major organisation delivering safe, Target Risk Rating 3(C)x 5(L) = 15 moderate supported by evidence based research, will impact on patient experience effective and compassionate care through an engaged and motivated workforce Rationale for risk current score Future risks Risk • National workforce shortages in key nursing areas particularly theatres, CCU • An ageing workforce highlighting a • Staff lose confidence in the • Generational changes in workforce shows high turnover in newly qualified Band significant risk of retirement in Trust as place to work due to a 5 nurses in first year of employment workforce failure to offer: a good working • 2-3 years to train registered practitioners to join the workforce • Many services single staff/small teams environment; fairness and • Around 36,000 nursing vacancies in England that lack capacity and agility. equality; training and • managers skill set in triangulating workforce skills mix against activity and • Developing new health care roles -will development opportunities ; financial planning change skill mix and a failure to act on feedback • unknown impact of STP case for change/clinical strategy • Consultant contract negotiations to managers and the findings • Staff survey results and SFFT show staff engagement is lower than previous resume in 2018 unknown financial of the annual staff survey. years impact • Insufficient focus on • impact on adequate substantive staffing resource in theatres to support Future Opportunities recruitment and retention productivity/meet RTT • Closer partnership working with STP and across the Trust leading to an • Agenda for Change 2018 reform impact as yet untested through LWAB increase in bank and agency • Addressing the reasons for retention is challenging as pressures on
costs and having longer term managers/leaders can lead to a reluctance to adopt new ways of working and issues for the quality of patient support significant change care Controls / assurance Gaps in controls / assurance • Developing long term workforce plan (3 years) for FY17/18 and linking to business planning • Current level of management competency in workforce planning process – includes skills mix/safe staffing reviews • Continuing resources to support the development of staff – optimal • Leadership programme launched Jan 2017, refreshed in 2018 with encouraging on going use of imposed apprenticeship levy budget high demand • Continuing attraction and retention problems in theatres , critical • Engaged in NHS Employers workforce retention programme nationally and part of NHSI care and paediatrics and C Wing Retention Support Programme • Theatre productivity group relaunched • monthly challenge to Business Units at Performance review • Capacity of workforce team to support the required initiatives to • Investment made in key workforce e-solutions, TRAC delivered on time, E-job plan ongoing, address recruitment and retention challenges including pay and HealthRoster implemented agency controls • Engagement and Retention paper presented to Board Sept 2017 actions ongoing, launched • Further expertise required in use of social media as a tool social media campaign February • Reconciliation required between ledger and ESR to enable full • Overseas recruitment now underway first offers made and firstQVH arrivals BOD Septemberin Q3 2018 2018: Session in publicestablishment control Page 54 of 260
Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/2018 Agenda reference: 134-18 Report title: Workforce Report – August Report, July Data Sponsor: Geraldine Opreshko, Director of Workforce and OD Author: David Hurrell, Deputy Director of Workforce Appendices: Workforce Report
Executive summary Purpose of report: The Workforce and OD report for August 2018 (July data) provides the Trust Board with a breakdown of key workforce indicators and information linked to performance. Summary of key Ongoing challenges related to turnover and use of temporary staffing issues Recommendation: The Board is asked to note the contents of the report Action required Approval Information Discussion Assurance Review [highlight one only] Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence [Tick which KSO(s) this experience services recommendation aims to support] Implications Board assurance framework: The challenges are reflected in KSO 5 Organisational Excellence
Corporate risk register: A number of risks on the Corporate risk register are specific to workforce challenges and in particular the level of vacancies and
use of temporary staffing Regulation: Workforce challenges will be implicit in all 5 domains of the CQC and in particular – Are they well Led?
Legal: No implications
Resources: The Workforce and OD team are trying to keep pace with demand and the need to support managers within existing resources
Assurance route Previously considered by: EMT Date: 29/8/18 Decision: For information Next steps:
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Human Resources & Organisational Development
Workforce Report – August 2018
Reporting Period: July 2018
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1.1 Current Month Picture
KPI Narrative ‘Staff in Post’ numbers increased again for the third consecutive month, by 5.42wte, finishing at an in month position of 835.19wte. Vacancies Small reductions in vacancy levels were seen in all directorates with the exception of Sleep,Plastics,Oral, Clinical Infrastructure and Operational Section 2 Nursing. New starters in month were 12.81wte, including 2wte healthcare assistants and 1wte registered nurse. The establishment is yet to be updated for the 2018/19 financial year, and this is expected to change ‘vacancy’ rates in some areas. Trust rolling annual turnover decreased for the second consecutive month, from 19.2% to 18.17%, putting the Trust back on its planned trajectory. Turnover This was prompted by continued decreases in turnover across all services with the exception of Sleep, where annualised turnover increased from Section 3 14.25% to 21.46%, Oral from 18.05% to 20.88% and operational nursing from 13.29% 14.92%. Clinical Infrastructure continues its significant improvement (now at 31.56%). There was a total of 8.62wte leavers; including 1.97wte qualified nurses. Total temporary staffing usage across the Trust increased by 3.02wte in month, to a total usage of 110.21wte. Temporary Agency use increased by 4wte, driven by an increased demand for registered nurses (+3.55wte) and non-clinical staff (+2.57wte); compensated by Staffing use of agency healthcare assistants ceasing in month and a reduction in clinical support staff. Section 4 Bank usage remains at record high levels, at 63.37wte, stopping agency use from increasing further. The recent healthcare assistant bank recruitment campaign has doubled the capacity to supply demand over the last three months, with 10.7wte used in month. Minor increases continue to be seen in non clinical bank usage, now at 33.18wte. Confirmed June sickness information shows an in month absence rate of 3.53%, an increase on last month’s position of 3.04%. Although there was an increase of 0.14% in short term absence, the increase in long term absence was more significant, up from 1.72% in May to 2.07%. The trust position is predominantly affected by increased sickness within Perioperative Care (+1.14% to new total 6.54%) and Sleep (+2.04% to new total 6.86%), where correlations can be made with comparatively high turnover rates. Clinical Infrastructure remains high at 6.95%, although this is Sickness reduced by 0.85% compared to prior month position of 7.8%. Section 5 Days lost due to reasons of anxiety/stress/depression/other psychiatric illnesses has increased to 286 days, up from last month’s high of 225 days, accounting for 27.4% of all absences (from 24.1%). ‘Other (non-back related) musculoskeletal conditions’ accounted for 194 days lost (18.6% of all sickness absence) compared to 156 days last month, and ‘Benign and malignant tumours, cancers’ accounted for 90 days lost (8.6% of absences), replacing ‘gastrointestinal problems’ as the third most cited cause of absence. Appraisal compliance figures dipped to 79.55% from last month’s 80.4%, the lowest position in 6 months. Clinical Support improved its position from Appraisals 88.16% to 92.05%, with other small increases seen in Corporate Services and Eyes. Perioperative retained last month’s position, and reductions were Section 6 seen in all other areas. Most significantly is the continued deterioration in Clinical Infrastructure, now at 61.54% compared to last month’s low of 70.27%. Mandatory and Statutory Training compliance figures continued their fluctuation in the 88-91% range, increasing marginally from 89.56% to 89.7%. MAST Trust-wide rates have remained relatively constant since June 2017. Section 6 A cancellation report shows continued high levels of staff withdrawing, cancelling or ‘do not attend’ bookings which will be addressed operationally.
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1.2 KPI Summary
Workforce KPIs (RAG Rating) Compared to Trust Workforce KPIs Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Previous 2018-19 Month
Establishment WTE 969.76 980.46 980.46 955.65 955.65 955.65 955.65 955.65 955.65 955.65 955.65 955.65 955.65 *Note 1 ◄►
Staff In Post WTE 831.88 840.54 843.26 859.91 856.13 845.60 841.32 838.58 845.26 831.41 827.24 829.77 835.19 ▲
Vacancies WTE 137.88 139.92 137.20 95.74 99.52 110.05 114.33 117.07 110.39 124.24 128.41 125.88 120.46 ▼
Vacancies % >12% 8%<>12% <8% 14.22% 14.27% 13.99% 10.02% 10.41% 11.52% 11.96% 12.25% 11.55% 13.00% 13.44% 13.17% 12.61% ▼
Agency WTE 25.64 28.60 28.53 28.12 30.96 26.95 33.76 38.28 42.51 45.58 50.61 42.85 46.85 ▲
Bank WTE 47.60 47.05 42.01 40.40 47.11 40.40 58.13 58.16 65.26 52.24 59.82 64.34 63.37 *Note 2 ▼
Trust rolling Annual Turnover % (Excluding Trainee Doctors) >=12% 10%<>12% <10% 18.98% 18.58% 18.92% 18.22% 18.41% 18.67% 18.87% 19.30% 19.57% 20.38% 20.43% 19.20% 18.17% ▼
Monthly Turnover 2.24% 1.02% 1.74% 1.00% 1.56% 1.80% 1.75% 1.47% 1.91% 2.24% 1.00% 0.68% 1.10% ▲
Stability % <70% 70%<>85% >=85% 98.5% 97.64% 98.77% 98.58% 98.61% 98.90% 98.68% 97.17% 98.78% 98.18% 99.18% 99.28% 98.66% ▼
July-18 = 3.52% 3.50% Sickness Absence % >=4% 4%<>3% <3% 2.06% 2.61% 3.15% 3.59% 3.46% 2.66% 3.59% 3.73% 3.73% 2.74% 3.04% Trend figure
% staff appraisal compliant <80% 80%<>95% >=95% 84.1% 86.27% 83.86% 81.24% 81.38% 81.00% 81.22% 78.58% 81.89% 81.64% 82.20% 80.40% 79.55% (Permanent & Fixed Term staff) ▼
Statutory & Mandatory Training (Permanent & Fixed Term staff) <80% 80%<>95% >=95% 89.2% 89.57% 89.94% 89.60% 88.81% 88.48% 89.97% 90.72% 89.59% 90.12% 89.07% 89.56% 89.70% ▲ *Note 3
Friends & Family Test - 2017-18 Treatment Measure Quarter 1: 2017-18 2017-18 2018-19 Extremely likely / Qtr 1 & Qtr 1 Quarterly staff survery to indicate Of 273 Quarter 2: Quarter 4: Quarter 1: likely % : ▼Responses responses: Of 212 responses: Of 306 responses: Of 205 responses: likelihood of recommending QVH to Extremely ▼ Likely 95.2% : 92% : 2.4% 90% : 5.23% 89.27% : 0.49% friends & family to receive care or unlikely / ▼Unlikely treatment unlikely% 2.6% National Staff Survey 2017 : 55% 2017-18 2018-19 Friends & Family Test - Work Measure Quarter 1: 2017-18 2017-18 Quarter 1: Extremely likely / Qtr 2 & Qtr 2 Quarterly staff survery to indicate Of 273 Quarter 2: Quarter 4: Of 205 responses: likely % : ▼Responses responses: Of 212 responses: Of 306 responses: 51.22% : 20.48%** likelihood of recommending QVH to Extremely ▼ Likely 57.5% : 66% : 19.8% 57.19% : 26.47% (**data inaccuracy up to 8% due friends & family as a place of work unlikely / ▼ Unlikely unlikely% 24.2% to survey error)
*Note 1 - 2018/19 Establishment not available in May 18 data reporting period . Establishment updated in August 2017 with nursing update in October 2017 *Note 2 - Bank WTE does not include extra hours worked by medical staff within establishment or overtime worked by all staff groups. *Note 3 - New RAG ratings for 2017/18 for Appraisals and for Statutory & Mandatory Training plus 2 new Board Reportable competences introduced - Fire Safety and Safeguarding Adults Level 2. 3
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2. Vacancies and Recruitment Posts Compared to Recruits in VACANCY PERCENTAGES May-18 Jun-18 Jul-18 MEDICAL RECRUITMENT (WTE) advertised Previous Month Pipeline this month Corporate 13.06% 12.20% 10.61% ▼ Clinical Support 0.00 3.00 Eyes 9.13% 11.44% 9.52% ▼ of which are Deanery Trainees, Trust Registrars or Fellows 0.00 3.00 Sleep -12.06% -14.38% -8.24% ▲ of which are SAS doctors 0.00 0.00 Plastics 5.26% 7.36% 8.65% ▲ of which are Consultants (including locums) 0.00 0.00 Oral 12.63% 12.51% 13.44% ▲ Plastics 0.00 11.00 Periop 24.36% 23.28% 21.48% ▼ of which are Deanery Trainees, Trust Registrars or Fellows 0.00 11.00 Clinical Support 7.19% 6.07% 4.02% ▼ of which are SAS doctors 0.00 0.00 Clinical Infrastructure 14.85% 15.39% 15.93% ▲ of which are Consultants (including locums) 0.00 1.00 Director of Nursing 16.48% 15.95% 12.96% ▼ Eyes 0.00 1.00 Operational Nursing 14.59% 14.40% 16.16% ▲ Plastics from 5.26% to 7.36% 0.00 1.00 QVH Trust Total 13.44% 13.17% 12.53% ▼ of which are SAS doctors 0.00 0.00 of which are Consultants (including locums) 0.00 0.00 Posts advertised NON-MEDICAL RECRUITMENT(WTE) Recruits in Pipeline Sleep 0.00 0.00 this month Corporate 0.00 9.60 Oral 1.40 7.00 Eyes 2.00 3.00 of which are Deanery Trainees, Trust Registrars or Fellows 1.00 7.00 Sleep 0.60 1.40 of which are SAS doctors 0.00 0.00 Plastics 6.00 7.86 of which are Consultants (including locums) 0.00 0.00 Oral 4.20 2.90 Periop 0.00 8.00 Periop 30.61 9.79 of which are Deanery Trainees, Trust Registrars or Fellows 0.00 8.00 Clinical Support 2.60 4.20 of which are SAS doctors 0.00 0.00 Clinical Infrastructure 0.00 3.00 of which are Consultants (including locums) 0.00 0.00 Director of Nursing 0.00 1.32 QVH Trust Total 1.00 30.00 Operational Nursing 11.12 5.14 of which are Deanery Trainees, Trust Registrars or Fellows 1.00 30.00 QVH Trust Total 57.13 48.21 of which are SAS doctors 0.00 0.00 of which Qual Nurses / Theatre Practs (external) 39.38 14.76 of which are Consultants (including locums) 0.00 0.00 of which HCA’s & Student/Asst Practs (external) 5.74 2.61
Trust Vacant WTEs for years 2016-17, 2017-18 and 2018-19 160 140 120 W T 100 E 80 60 40 20 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Vacancy WTE 2016-17 Vacancy WTE 2017-18 Vacancy WTE 2018-19
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3. Turnover, New Hires and Leavers
Compared to Compared to ANNUAL TURNOVER ROLLING 12 MTHS excl. Trainee Doctors May-18 Jun-18 Jul-18 MONTHLY TURNOVER excl. Trainee Doctors May-18 Jun-18 Jul-18 Previous Previous Month Month Corporate % 21.85% 20.61% 17.62% ▼ Corporate % 1.75% 0.66% 0.65% ▼ Eyes % 21.47% 23.83% 21.62% ▼ Eyes % 0.00% 0.00% 2.13% ▲ Sleep % 11.90% 14.25% 21.46% ▲ Sleep % 0.00% 2.40% 7.44% ▲ Plastics % 19.66% 18.35% 16.84% ▼ Plastics % 1.84% 3.62% 0.68% ▼ Oral % 19.30% 18.05% 20.88% ▲ Oral % 2.54% 0.86% 2.88% ▲ Peri Op % 24.98% 24.66% 22.89% ▼ Peri Op % 0.88% 0.00% 0.48% ▲ Clinical Support % 13.34% 11.76% 10.71% ▼ Clinical Support % 0.00% 0.40% 0.47% ▲ Clinical Infrastructure % 44.08% 34.72% 31.56% ▼ Clinical Infrastructure % 2.55% 0.00% 0.00% ◄► Director of Nursing % 12.18% 12.40% 8.88% ▼ Director of Nursing % 0.00% 0.00% 0.00% ◄► Operational Nursing % 16.14% 13.29% 14.92% ▲ Operational Nursing % 0.00% 0.00% 1.62% ▲ QVH Trust Total % 20.43% 19.20% 18.17% ▼ QVH Trust Total % 1.00% 0.68% 1.10% ▲
Trust Annual Turnover (Rolling 12 Months) Trust Monthly Turnover Percentage Rate 2016-17, Percentage Rate 2016-17, 2017-18 and 2018-19 2017-18 and 2018-19 (percentage rates in RAG colours) 3.00% 25.00% 2.50% 20.00% 15.00% 2.00% 10.00% 1.50% 5.00% 1.00% 0.00%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0.50%
0.00% Rolling 12 Mth Turnover % Rate 2016-17 Rolling 12 Mth Turnover % Rate 2017-18 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Rolling 12 Mth Turnover % Rate 2018-19 Green RAG Rating Upper Threshold Monthly Turnover % Rate 2016-17 Monthly Turnover % Rate 2017-18 Monthly Turnover % Rate 2018-19 Amber RAG Rating Upper Threshold
Trust Monthly New Hires and Leavers in 2017-18 and 2018-19 (excluding Trainee Rotational medical staff)
25.00
20.00
W 15.00 T E 10.00 5.00
0.00 Apr May Jun Jul Aug Oct Nov Dec Jan Mar Starters 2017-18 Leavers 2017-18 Starters 2018-2019 Leavers 2018-2019
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4. Temporary Workforce Agency Bank Compared Compared to BUSINESS UNIT (WTE) May-18 Jun-18 Jul-18 to Previous BUSINESS UNIT (WTE) May-18 Jun-18 Jul-18 Previous Month Month Corporate 3.04 2.49 5.03 ▲ Corporate 6.76 6.30 7.03 ▲ Eyes 0.00 0.00 0.00 ◄► Eyes 3.90 4.67 5.33 ▲ Sleep 0.00 0.00 0.00 ◄► Sleep 3.44 4.03 4.38 ▲ Plastics 8.53 4.89 6.24 ▲ Plastics 4.32 4.82 6.72 ▲ Oral 0.00 0.00 0.00 ◄► Oral 3.24 3.61 3.14 ▼ Periop 25.26 24.33 24.83 ▲ Periop 13.16 15.28 13.66 ▼ Clinical Support 2.76 2.98 2.44 ▼ Clinical Support 5.97 5.62 5.75 ▲ Clinical Infrastructure 1.20 0.00 0.00 ◄► Clinical Infrastructure 6.74 7.53 6.51 ▼ Director of Nursing 0.00 0.00 0.00 ◄► Director of Nursing 1.98 2.11 1.29 ▼ Operational Nursing 9.82 8.16 8.28 ▲ Operational Nursing 10.32 10.37 9.54 ▼ QVH Trust Total 50.61 42.85 46.85 ▲ QVH Trust Total 59.82 64.34 63.37 ▼
Agency Bank
Compared Compared to STAFF GROUP (WTE) May-18 Jun-18 Jul-18 to Previous STAFF GROUP (WTE) May-18 Jun-18 Jul-18 Previous Month Month Qualified Nursing 34.20 31.54 35.09 ▲ Qualified Nursing 19.64 21.09 17.23 ▼ HCAs 3.57 1.76 0.00 ▼ HCAs 6.51 7.96 10.70 ▲ Medical and Dental 5.85 4.23 5.06 ▲ Medical and Dental 0.00 0.00 0.00 ◄► Other AHP's & ST&T 2.76 2.83 1.63 ▼ Other AHP's & ST&T 3.05 3.14 2.89 ▼ Non-Clinical 4.23 2.49 5.06 ▲ Non-Clinical 30.63 32.15 33.18 ▲ QVH Trust Total 50.61 42.85 46.84 ▲ QVH Trust Total 59.82 64.34 63.37 ▼
Trust Agency Usage in WTEs for years 2016-17, 2017-18 and Trust Bank Usage in WTEs for years 2016-17, 2017-18 and 2018-2019 2018-19 60 50 70 60 40 50 30 40 20 30 20 10 10 0 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Bank WTE 2016-17 Bank WTE 2017-18 Bank WTE 2018-19 Agency WTE 2016-17 Agency WTE 2017-18 Agency WTE 2018-19
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5. Sickness Absence Compared to Apr-18 May-18 Jun-18 SHORT TERM SICKNESS Previous Month Short Term Sickness Absence Reasons Corporate 0.43% 1.14% 0.52% ▼ Number of Occurrences (Feb 17- Mar 18) 200 Clinical Support 1.34% 0.80% 1.08% ▲ O c 180 Plastics 0.65% 0.25% 1.64% ▲ c 160 u 140 Eyes 1.50% 0.88% 1.82% ▲ r 120 Sleep 0.10% 1.80% 3.05% ▲ r e 100 Oral 1.13% 1.34% 1.27% ▼ n 80 Periop 1.76% 2.22% 1.86% ▼ c 60 e 40 Clinical Infrastructure 2.41% 2.33% 1.41% ▼ s 20 Director of Nursing 1.13% 0.31% 0.13% ▼ 0 Operational Nursing 0.88% 2.10% 2.81% ▲ QVH Trust Total 1.11% 1.32% 1.46% ▲ Cold, Cough, Flu - Influenza Gastrointestinal problems Headache / migraine Chest and Respiratory Back Problems All Other Reasons Compared to Apr-18 May-18 Jun-18 LONG TERM SICKNESS Previous Month Corporate 0.52% 0.07% 0.29% ▲ Long Term Sickness Absence Reasons Clinical Support 1.25% 1.27% 1.89% ▲ Number of Occurrences (Feb 17- Mar 18) Plastics 2.06% 0.90% 0.06% ▼ 35 O Eyes 0.00% 1.87% 1.09% ▼ c 30 c Sleep 3.88% 3.02% 3.81% ▲ u 25 Oral 1.06% 1.09% 1.11% ▲ r r 20 Periop 2.16% 3.18% 4.68% ▲ e 15 n Clinical Infrastructure 3.67% 5.47% 5.54% ▲ c 10 Director of Nursing 0.00% 2.47% 3.47% ▲ e s 5 Operational Nursing 3.32% 1.91% 1.75% ▼ 0 QVH Trust Total 1.62% 1.72% 2.07% ▲
Compared to Apr-18 May-18 Jun-18 Anxiety/stress/depression/other psychiatric illnesses Other musculoskeletal problems ALL SICKNESS (with RAG) Previous Month Back Problems Benign and malignant tumours, cancers QVH Trust Total 2.74% 3.04% 3.53% ▲ Injury, fracture All Other Reasons
Trust Sickness AbsenceRates 2015-2019 by month Trust Sickness Absence Rates 2016/17, 2017/18 & 2018/19 by Long term & Short term sickness 4.25% 4.00%
3.50% 3.75% 3.00%
3.25% 2.50%
2.00% 2.75% 1.50%
2.25% 1.00%
0.50% 1.75% April May June July Aug Sept Oct Nov Dec Jan Feb Mar 0.00% 2015/16 3.25% 2.36% 2.32% 2.70% 3.23% 3.10% 3.24% 3.91% 3.70% 3.17% 3.72% 3.58% 2016/17 3.19% 2.14% 2.61% 2.57% 2.47% 2.00% 2.69% 2.69% 2.90% 3.20% 3.01% 2.43% Jul-16 Jul-17 Jan-17 Jan-18 Jun-16 Jun-17 Jun-18 Oct-16 Oct-17 Apr-16 Apr-17 Apr-18 Sep-16 Feb-17 Sep-17 Feb-18 Dec-16 Dec-17 Aug-16 Aug-17 Nov-16 Nov-17 Mar-17 Mar-18 2017/18 2.06% 2.75% 2.04% 2.06% 2.61% 3.15% 3.59% 3.46% 2.66% 3.59% 3.73% 3.73% May-16 May-17 May-18 2018/2019 2.74% 3.04% 3.53% 2016-17 Short Term Sickness 2016-17 Long Term Sickness 2017-18 Short Term Sickness 2017-18 Long Term Sickness 2018-19 Short Term Sickness 2018-19 Long Term Sickness 7
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6. Training, Education and Development
Compared to APPRAISALS May-18 Jun-18 Jul-18 Previous Trust Appraisal Compliance % for years Month 2016-17 and 2017-18 Corporate 81.94% 79.38% 80.00% ▲ 100% Clinical Support 91.45% 88.16% 92.05% ▲ 95% 90% Plastics 79.44% 81.55% 77.23% ▼ 85% Eyes 64.15% 62.26% 65.38% ▲ 80% Sleep 75.00% 80.00% 75.00% ▼ 75% 70% Oral 82.98% 77.89% 72.53% ▼ 65% Periop 77.42% 75.81% 75.82% ▲ 60% 55% Clinical Infrastructure 73.68% 70.27% 61.54% ▼ 50% Director of Nursing 96.97% 94.12% 88.57% ▼ Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Operational Nursing 90.91% 89.89% 89.41% ▼ Trust Appraisal Compliance % 2016-17 Trust Appraisal Compliance % 2017-18 QVH Trust Total 82.20% 80.40% 79.55% ▼ Trust Appraisal Compliance % 2018-19
Compared to MANDATORY AND STATUTORY TRAINING May-18 Jun-18 Jul-18 Previous Month Trust Statutory & Mandatory Training Compliance % Corporate 94.75% 95.26% 95.26% ◄► for years 2016-17 and 2017-18 Clinical Support 92.56% 93.64% 94.45% ▲ 100% 95% Plastics 87.02% 86.80% 86.64% ▼ 90% Eyes 88.66% 88.84% 88.75% ▼ 85% 80% Sleep 92.17% 96.01% 96.55% ▲ 75% Oral 83.44% 84.27% 84.06% ▼ 70% Periop 85.10% 84.87% 85.26% ▲ 65% 60% Clinical Infrastructure 85.84% 90.70% 89.56% ▼ 55% Director of Nursing 90.65% 87.12% 89.13% ▲ 50% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Operational Nursing 92.90% 93.54% 92.52% ▼ Trust Stat & Mand Compliance % 2016-17 Trust Stat & Mand Compliance % 2017-18 QVH Trust Total 89.07% 89.56% 89.70% ▲ Trust Stat & Mand Compliance % 2018-19
Org L1 Years Yearly 1 Year 1 Year annual 3 Years 3 Years Information Information NHS Conflict Conflict NHS Safeguarding Safeguarding Safeguarding Safeguarding Non-Clinical - 3 Non-Clinical Level 2 - 1 Year Level 1 - 3 Years Support - 1 Year Level 1 - 3 Years Level 2 - 3 Years Level 1 - 3 Years Level 2 - 3 Years Level 3 - 3 Years Welfare - 3 Years Equality, Diversity Diversity Equality, Health, Safety and and Safety Health, 2 - Adult Basic Life 2 - Adult Basic 2 - Paediatric Basic Basic 2 - Paediatric Fire - 2 Safety Years Governance - 1Governance Year Resuscitation - Level Resuscitation - Level Resuscitation Infection PreventionInfection PreventionInfection PreventionInfection Life Support - 1 Year Emergency Planning: Emergency Planning: Resolution (England) - (England) Resolution and Human Rights - 3 Rights Human and Adults - Safeguarding Adults - Safeguarding Emergency Planning - Emergency Planning Controland - Level 1 - Controland - Level 1 - Controland - Level 2 - - Handling and Moving - Handling and Moving Children (Version 2) - Children (Version 2) - Children (Version 2) - QVH 94.62% 86.16% 89.94% 91.88% 87.99% 91.18% 94.27% 86.46% 81.71% 95.49% 80.31% 90.53% 87.59% 87.57% 96.32% 94.84% 91.99% 88.44% 81.82%
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7. Medical and Dental Workforce
Medical Workforce
August Changeover: 22 doctors started in August in Anaesthetics, Plastic Surgery and Radiology. 13 more doctors due to start in September. Honorary Contracts: the number of requests from individuals requesting honorary contracts has continued to increase, creating pressure on medical workforce and the recruitment team. A revision of current policy is being proposed to manage demand. Locum Agencies: junior doctor usage reduced following the August changeover but usage continues due to difficulties with HEEKSS recruiting Plastics Job Planning: E Job Planning is still ongoing, delayed by annual leave and the absence of business managers in some of the specialties. Medic on Line and Medic on Duty: The implementation of a new electronic system to record leave and availability for medical and dental staff is continuing, Anaesthetics and Plastic Surgery are now using the sytem with roll out to the remaining specialties by end December 2018. Policies: Medical policies are being streamlined and incorporated into one policy along with AfC staff, starting with Annual Leave and Special Leave. Medical and Dental Locum Bank Rates: Rates have been increased from 1 August 2018 in order that the rates are competitive to help reduce locum agency spend Medical appraisal: Row Labels Sum of Required Sum of Achieved Compliance Clinical Support 8 8 100.00% Eyes 11 10 90.91% Oral 42 32 76.19% Peri-Op Services 24 17 70.83% Plastics 49 44 89.80% Sleep 3 1 33.33% Grand Total 137 112 81.75%
Medical Education
Monthly update The results of the GMC survey of doctors in training came out in July: o 2018 results show improvement on 2017 results, with 1 more green flag than last year (5), 3 less red flags (2), 2 light green flags and 14 pink flags. o The 8 pink flags in core surgical training (CST) show there is still work to be done in this area, but the majority of highlighted areas for both CST and Higher Plastic Surgery are already being addressed. July Local Academic Board was well attended. However, attendance at Junior Doctors’ Forum’s need to be re-invigorated.
Upcoming developments An OMFS interview preparation course was planned for 24 August. Preparations are underway for a School of Surgery visit to the Plastic Surgery department which will take place in September.
Statutory and mandatory training compliance Permanent/fixed term medical and dental employees are currently showing 83.9% compliant, which is a small improvement on the previous month. Medical and dental bank workers are showing as 68.75% compliant, which is a small drop on the previous month.
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8. Trajectories
Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Staff Turnover % trajectory 19.51% 19.62% 18.91% 18.46% 18.67% 18.24% 18.32% 18.18% 18.00% 18.41% 18.20% 17.84% 17.87% Actual Rolling Turnover % 19.57% 20.38% 20.43% 19.20% 18.17% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% Total Sickness % trajectory 2.99% 2.83% 2.42% 2.32% 2.44% 2.77% 2.75% 3.17% 3.35% 3.09% 3.11% 3.19% 3.05% Actual In Month Sickness % 3.73% 2.74% 3.04% 3.53% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% Vacancy Rate % trajectory 12.73% 13.17% 12.67% 12.46% 12.39% 12.23% 12.23% 12.68% 12.34% 12.97% 13.08% 12.88% 12.54% Actual In Month Vacancy Rate % 11.55% 13.00% 13.44% 13.17% 12.53% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% Non-Medical Appraisal Rate % trajectory 81.16% 80.33% 82.37% 81.18% 81.99% 81.99% 78.22% 75.39% 79.50% 80.70% 80.39% 78.54% 80.77% Actual In Month Non-Medical Appraisal % 81.81% 80.96% 80.96% 88.08% 79.55% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% Medical Appraisal Rate % trajectory 72.68% 74.29% 76.33% 79.86% 82.39% 80.63% 81.74% 85.28% 87.69% 86.52% 89.56% 92.37% 95.61% Actual In Month Medical Appraisal % 82.35% 85.42% 91.28% 78.93% 81.75% Mandatory Training % trajectory 90.23% 89.76% 88.81% 89.24% 88.49% 88.52% 89.83% 89.32% 88.73% 88.34% 89.08% 91.09% 90.86% Actual In Month Mandatory Training % 89.59% 90.12% 89.07% 89.56% 89.70% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
21.00% 4.00% 14.00% Turnover plan vs. in month Sickness plan vs. in month Vacancy plan vs. in month 20.00% 3.50% 13.00% 19.00% 3.00% 12.00% 18.00% 2.50% 17.00% 11.00% 2.00% 16.00% 10.00% 1.50% 15.00% 1.00% 9.00% 14.00% 8.00% 13.00% 0.50% 12.00% 0.00% 7.00%
Actual Rolling Turnover % Staff Turnover % trajectory Actual In Month Sickness % Total Sickness % trajectory Actual In Month Vacancy Rate % Vacancy Rate % trajectory
100.00% 100.00% 95.00% Medical appraisal plan vs. in month Non-Medical appraisal plan vs. in month Mandatory training plan vs. in month 95.00% 95.00% 90.00% 90.00% 90.00% 85.00% 85.00% 85.00% 80.00% 80.00% 80.00% 75.00% 75.00% 75.00% 70.00% 70.00% 70.00% 65.00% 65.00% 65.00%
Actual In Month Medical Appraisal % Actual In Month Non-Medical Appraisal % Actual In Month Mandatory Training % Medical Appraisal Rate % trajectory Non-Medical Appraisal Rate % trajectory Mandatory Training % trajectory
10
QVH BOD September 2018: Session in public Page 65 of 260
9. Organisational Development
Confirmation has been received that the Trust has been awarded the first quarter payment for the 2018/19 Health & Wellbeing CQUIN Wellbeing events and campaigns continue to run and over the next few months there will be a focus on back care awareness, organ donation and mental health with supportive links to professionals within the Trust. Our overseas nurse recruitment campaign is showing initial successes, with 75% of offers made accepted and some candidates at the certificate of sponsorship stage, meaning they are expected before the end of this calendar year Leading the Way Phase 2 sessions are underway including MBTI workshops and a range of leadership courses through NHS Elect The Trust is offering an MBA opportunity utilising Apprenticeship Levy funds A significant piece of work is underway to improve bank staff statutory and mandatory training compliance rates The Trust is proactively engaged with a range of cross STP OD initiatives Preparation is underway for the 2018 NHS Staff Survey which will go out in hard copy version to all staff the first week in October
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QVH BOD September 2018: Session in public Page 66 of 260 KSO1 – Outstanding Patient Experience Risk Owner: Director of Nursing and Quality Committee: Quality & Governance Date last reviewed: 23 August 2018 Strategic Objective Risk Appetite The Trust has a moderate appetite for risks that impact on Initial Risk 4(C) x 2(L) = 8 low patient experience but it is higher than the appetite for those that impact on Current Risk Rating 3(C) x 5(L) = 15 mod We put the patient at the heart of patient safety. This recognises that when patient experience is in conflict Target Risk Rating 3(C) x 3(L) = 9 low safe, compassionate and with providing a safe service that safety will always be then highest priority competent care that is provided by well led teams in an environment Rationale for risk current score Future risks that meets the needs of the . Compliance with regulatory standards • Unknown impact on patients waiting patient and their families. . Meeting national quality standards/bench marks longer than 52 weeks, CHR in progress . Very strong FFT recommendations • Future impact of Brexit on workforce . Excellent performance in CQC 2017 inpatient surveys, sustained better than Generational workforce : analysis shows Risk • national average. significant risk of retirement in workforce • Patient safety incidents triangulated with complaints and outcomes • Many services single staff/small teams that 1) Trust is not able to recruit monthly no early warning triggers lack capacity and agility. and retain workforce with • International recruitment- 36 posts offered • Developing new health care roles -will right skills at the right time. • National staff shortages of nurses and practitioners in theatres, critical care change skill mix 2) Patients lose confidence in impacting on service provision • STP strategic plans not fully developed the quality of our services and • Not meeting RTT18 and 52 week Performance and access standards the environment in which we Future Opportunities provide them , due to the • Further international recruitment condition and fabric of the estate. Controls / assurance Gaps in controls / assurance . Estates plan and maintenance programme . Vacancies in theatres, critical care and C-Wing, national and south . Robust Governance and clinical quality standards managed and monitored at the Q&GC, east shortage of nurses in theatres and critical care. Controls CGG and the JHGM, safer nursing care metrics, FFT and annual CQC audits , 6/12 CIP implemented have not yet improved the position Links to CRR . External assurance and assessment undertaken by regulator and commissioners 1094,1093,1077,1035,1097 . Quality Strategy, Quality Report, CQUINS, low complaint numbers . Increase in negative FFT comments re appointments/waiting times . Benchmarking of services against NICE guidance, and priority audits undertaken Links to CRR1097,1083,1081,949 . Sub group for theatre workforce/recruitment, proposals approved at HMT June 2017, new . More evidence of embedded learning from serious incidents being theatres safety lead in post Feb 2017 shared throughout the trust. . Trust recruitment and retention strategy mobilised, NHSI nursing retention initiative . Burns and Paediatric services not currently meeting all national guidance. CCG and Regulators fully aware of this, mitigation in place. SOC for inpatient paed burns being taken forward by Darzi Fellow who starts in post April 2018 MOU with BSUH . Developing QVH simulation faculty to enhance safety and learning culture . Clear written guidance for safe staffing levels in theatres and critical care QVH BOD September 2018: Session in public Page 67 of 260 KSO2 – World Class Clinical Services Risk Owner: Medical Director Date last reviewed: 13th June 2018
Initial Risk Rating 5(C)x3(L) =15, moderate HORIZON SCANNING – MODIFIED PEST ANALYSIS Strategic Objective Current Risk Rating 4(C)x3(L)=12, moderate We provide world class Target Risk Rating 4(C)x2 L) = 8, low services, evidenced by clinical and patient Rationale for current score POLICY COMPETITION outcomes. Our clinical ITU compliance and burns derogation. National Standards: Positive: services are underpinned by Paediatric inpatient standards compliance. ITU (ICS, SECCAN, ODN Burns) BSUH MoU and clinical partnership our high standards of Seven Day Standards for urgent care. Paediatrics (ODN burns and development. governance, education Junior doctor recruitment, conflict between RCPCH) Private patients research and innovation. education vrs service delivery, and GMC NTS survey General eg NICE, CQC STP collaboration results. Junior Doctor contract Negative: Internal and spoke governance resources. Seven Day Services NHS, NHS funded & private providers External and internal research funding and Learning, Candour and Consultant workforce changes: Part time/ organisation. Accountability. retiring early/LLPs Risk Job planning. (RR955) STP competition Patients, clinicians & Coroner’s PFD report and never event reporting. commissioners lose Induction and training processes for dual site junior INNOVATION RESILIENCE confidence in services due to doctors and dentists. (CRR1079) Efficient electronic job planning Engagement of workforce inability to show external Culture of safe and collaborative practice. Efficient theatre/OPD use Shared care, local and STP networks assurance by outcome Sleep disorder centre medical staffing and Optimum OOH care/training Leaders: CDs and governance leads measurement, reduction in succession planning. Multi-professional education, Demand in many services with research output, fall in Human factors and simulation opportunities in STP. teaching standards., or lack Research strategy CEA incentives of effective clinical Outcomes publication Management support for operational governance. New services initiatives Controls and assurances: Gaps in controls and assurances: Clinical governance group and leads and governance structure. Limited extent of reporting /evidence on internal and external standards Revising clinical indicators NICE refresh and implementation Limited data from spokes/lack of service specifications CQC action plan; ITU actions including ODN/ICS Scope delivering and monitoring seven day services (OOH) (RR845) Spoke visits service specification EKBI data management Plan for sustainable ITU on QVH site (CRR1059) Relevant staff engaged in risks OOH and management Recruitment challenges Networks for QVH cover-e.g. burns, surgery, imaging Achieving sustainable research investment Training and supervision of all trainees with deanery model Balance service delivery with medical training cost (CRR789) Creation of QVH Clinical Research strategy Job planning (RR955) Fully addressing GMC National Training Survey results (CRR789) QVH BOD September 2018:Detailed Session in partnership public agreement with acute hospital (CRR1059) Page 68 of 260Sleep disorder centre sustainable medical staffing model
Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/2018 Agenda reference: 136-18 Report title: Quality and governance assurance report Sponsor: Ginny Colwell, committee chair Author: Ginny Colwell Appendices: NA
Executive summary Purpose of report: To provide assurance to the Board in relation to matters discussed at the QGC meetings on the 19th July and 16th August 2018 Summary of key One general meeting and one planned extraordinary meeting took place. Good issues assurance was received on all areas Recommendation: The Board is asked to NOTE the contents of the report Action required Assurance Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence experience services Implications Board assurance framework: No additional areas identified
Corporate risk register: No additional risks identified
Regulation:
Legal:
Resources:
Assurance route Previously considered by: N/A Date: Decision: Next steps:
QVH BOD September 2018: Session in public Page 69 of 260
Report to: Board of Directors Meeting date: 06 September 2018 Reference number: 136-18 Report from: Ginny Colwell, committee chair and NED Author: Ginny Colwell, committee chair and NED Appendices: None Report date: 29 August 2018
Quality and Governance Assurance Report Meetings held on 19th July and 16th August 2018 Areas of particular note for assurance
1. The planned extraordinary meeting to receive the annual reports took place in July.
2. Annual reports received; no significant concerns highlighted; • Patient Safety- a short report due to staffing issues • Infection prevention and control- a brief audit has shown an improvement in the use of sharp boxes • Clinical Audit- shows good progress with the strategy • Research and Development- Shows an increase in activity, to Board • Safeguarding – to Board • Patient experience- noted that 2 complaints went to the PHSO, but no actions were required • Information governance- noted the increase in activity in this area • Medical devices • Medicines management- postponed • Responsible officer and revalidation
3. The general committee took place in August.
4. Risk exception- no Sis in this period, however 3 formal investigations were commenced. An updated CRR heat map was included for the first time.
5. A rise in paediatric safeguarding incidents was noted- no common theme identified.
6. Corporate Risk Register- continues to show movement and assures the committee of it’s on going management.
7. The new style BAFs were noted. The Exec team were asked to agree how the – Rationale for current score- section will be used.
QVH BOD September 2018: Session in public Page 70 of 260
8. CQC post never event visit noted the significant work that has taken place and that there has been no never events since October.
9. CQC quarterly provider visit report showed progress in critical care issues and provided an update on actions around staffing issues and RTT.
10. CQUIN- shows good progress on the 13 CQUINS. Full year money attached to these schemes is £1.130m; with 100% built into budgets.
11. GMC national Training survey results- Showed an improvement but some pink flags- that demonstrate that more work needs to be done.
12. Attendance of local governance meetings was noted to be behind schedule and all members were asked to book their visits.
13. Quality report priorities- it was noted that elective lists starting within 15 minutes was at 13%- target 60%. The targets may need to be changed to make them challenging, but realistic.
14. Infection control- progress with the MRSA outbreak in the critical care and burns unit was noted. No further cases since July 18th.
15. Other reports received and are either covered by the executive report or had no significant assurance issues; • Patient experience • NICE Assessment and escalation review • Quarterly report on safe doctors working- thanks to John Boorman who has now stepped down • Clinical governance group minutes • Strategic safeguarding group • Health and safety group • Nursing quality forum • Infection and prevention control group • Medicines and management group- pharmacy staffing issues noted
QVH BOD September 2018: Session in public Page 71 of 260
Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/18 Agenda reference: 137-18 Report title: Corporate risk register Sponsor: Jo Thomas, Director of Nursing Author: Karen Carter-Woods, Head of Risk and Patient Safety Appendices: None
Executive summary Purpose of report: For assurance that the trusts risk management process is being followed with new risks are being identified and current risks are being reviewed and updated in a timely way. Summary of key The Committee is requested to note the Corporate Risk Register information issues and the progress from the previous report.
The key changes are three new corporate risks added, five corporate risks closed and four re-scored.
Recommendation: The Board is asked to note the assurance level regarding the management of the corporate risks within the trust. Action required Assurance
Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence experience services Implications Board assurance framework: The entire BAF has been reviewed by EMT alongside the CRR; the corresponding KSOs have been linked to the corporate risks.
Corporate risk register: This document Regulation: All NHS trust are required to have a corporate risk register and systems in place to identify & manage risk effectively.
Legal: Compliance with regulated activities and requirements in Health and Social Care Act 2008.
Resources: Actions required are currently being delivered within existing trust resources
Assurance route Previously considered by: The Corporate Risk Register is considered monthly by the Executive Management Team. Date: 29/08/18 Decision: Reviewed Previously considered by: Quality & Governance Committee Date: 05 07 18 Decision: Reviewed and recommended for board assurance. Next steps:
QVH BOD September 2018: Session in public Page 72 of 260
Corporate Risk Register Report June and July 2018 Data
Key updates:
Three new risks were added to the Corporate Risk Register between 01/06/2018 and 31/07/2018
Risk Risk Risk Description Rationale and/or Score ID Where identified/discussed (CxL)
3x4=12 1116 Inability to provide sufficient medical provision to the Medical Director Sleep Disorder Centre
4x3=12 1119 Implementation of eRS (1st Oct 2018) Director of Operations
3x4=12 1117 Inability to meet legislative requirements of the Falsified Head of Pharmacy Medicines Directive
Corporate Risks closed during June and July: 5
Risk Risk Description Risk Rationale for Rescore Committee where ID Score change(s) agreed/ proposed
792 Unable to recruit 3x4=12 Reviewed and discussed: 5/6/18: adequate dental staff No longer a risk, effective controls in place OMFS BU Meeting for off-site clinics and and x4 doctors appointed theatres 1004 IT server software 4x3=12 The ARC servers operating system upgraded 12/6/18: operating system to 2008 R2 IM&T
1102 BSUH Out-sourced CT 4x3=12 3 months’ notice SLA: CT will be on site 19/6/18: CSS Business service Unit Meeting 1081 Longstanding demand 4x5=20 To be replaced with updated risk (Local R/V with new Director of & capacity mismatch in register) Operations the appointments team, exacerbated by poor systems & processes within the team 1003 Information 4x3=12 new UPS' now installed Reviewed at IM&T - Technology Network Outage
QVH BOD September 2018: Session in public Page 73 of 260 Corporate risks reviewed and re-scored: 4
Risk Risk Description Previous Update Rationale for Rescore Committee where ID Risk d Risk change(s) agreed/ Score Score proposed
1035 Inability to recruit adequate 3x4=12 4x4=16 Staff are being required to R/V with DoN numbers of skilled critical change / cover shifts at care nurses across a range short notice resulting in of Bands challenges to health & wellbeing 1077 Recruitment and retention 3x4=12 4x4=16 Loss of theatre lists due to R/V with DoN in theatres staff vacancies
1079 Inappropriate prescribing by 3x4=12 2x4=8 Reflects agreement they will R/V by Chief Pharmacist Eastbourne DCTs due to complete induction at same inexperience time as QCH DCTs
1117 Inability to meet legislative 3x4=12 3x3=9 Software unavailable at MMOG: initial grading requirements of the present; National issue for too high Falsified Medicines Directive all Trusts
The Corporate Risk Register is reviewed monthly at Executive Management Team meetings (EMT), quarterly at Hospital Management Team meetings (HMT) and presented at Quality & Governance Committee meetings for assurance. It is also scheduled bimonthly in the public section of the Trust Board.
Implications of results reported 1. The register demonstrates that the trust is aware of key risks that affect the organisation and that these are reviewed and updated accordingly.
2. No specific group/individual with protected characteristics is identified within the risk register.
3. Failure to address risks or to recognise the action required to mitigate them would be key concerns to our commissioners, the Care Quality Commission and NHSI.
Action required Continuous review of existing risks and identification of new or altering risks through improving existing processes.
Link to Key Strategic Objectives • Outstanding patient experience • Financial sustainability • World class clinical services • Organisational excellence • Operational excellence
The attached risks can be seen to impact on all the Trust’s KSOs.
Implications for BAF or Corporate Risk Register Significant corporate risks have been cross referenced with the Trust’s Board Assurance Framework.
Regulatory impacts The attached risk register would inform the CQC but does not have any impact on our ability to comply with CQC authorisation and does not indicate that the Trust is not: • Safe • Well led • Effective • Responsive • Caring
QVH BOD September 2018: Session in public Page 74 of 260 ID Opened Title Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress / Updates KSO Lead Rating Rating 1119 12/07/2018 Implementation of eRS (1st Oct From 1st October 2018, all GP referrals QVH working to project plan with NHSE, NHSD and CCGs to Abigail Jago Philip Compliance 12 8 KSO2 KSO3 KSO4 2018) to Consultant led clinics must be made ensure system readiness and to increase GP utilisation of the eRS Kennedy (Targets / via the eRS system. system before deadline. Assessment * Income risk - no payment s / * Quality risk - delays and RTT Standards)
1116 26/06/2018 Inability to provide sufficient Potential loss of medical outpatient 1) Forthcoming AAC appointment process to substantiate 1 WTE Dr Edward Dr Edward Patient 12 4 Discussions with other potential KSO1 KSO2 KSO3 medical provision to the Sleep capacity within the Sleep Disorder post (currently locum basis) Pickles Pickles Safety candidates KSO4 KSO5 Disorder Centre Centre, with associated effects on 2) Approval of funding for clinical fellow post Medical management structure waiting list and income. Possible under review. detriment to follow up of existing patients, particularly those requiring non-invasive ventilation for sleep disorders with a respiratory background.
1112 25/05/2018 Copying of CT images for MaxFax Third party companies contact QVH None generally Abigail Jago Dominic Information 15 6 12/07/18: Meeting to discuss KSO1 KSO2 KSO3 & Orthognathic patients radiology requesting patient images / Minimal controls for one company who has agreed to get CDs Bailey Governance processing agreement set up for data to be shared directly with them for encrypted by QVH IT - however there is still no agreed process in 13/07/18 with one of the two surgery planning (prosthetics / place outstanding suppliers. Awaiting implants) For one company images are encrypted by IT upon request, but response to meet with the other requests are always made last minute and there is also no data outstanding supplier. Pressures on radiology staff to provide sharing agreement in place for this company. 04/07/18:Satisfactory Data images to avoid surgery cancellations / Processing agreement put in delays place with one supplier. No progress made with the other There is no agreed process and no data outstanding suppliers. IG Lead to sharing agreement in place at QVH for deal directly with suppliers to radiology to copy secure images for 3rd expedite. party independent companies. 03/06/18: Service suspended Images have left QVH in unencrypted pending satisfactory technical and CDs that are holding patient data. organisational measures being put in place with third party suppliers, (encryption of mobile media and evidenced data processing agreements in place). Clinical lead for the service is now Jag Dhanda who will coordinate directly with IG/IT/Radiology and Business Manager.
QVH BOD September 2018: Session in public Page 75 of 260 ID Opened Title Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress / Updates KSO Lead Rating Rating 1111 11/05/2018 Loss of resilience in reporting from Inability to produce stable reliable Engaged Integris as Technical partners to provide initial Michelle Rob Lock Information 16 8 04/07/2018 Paper being KSO3 KSO4 BIU reports to internal and external stabilisation around Monthly RTT and other mandatory reports . Miles Managemen prepared for EMT.For on-going customers t and support and permanent solution Seeking authority to extend this relationship for 3 days per week Technology Support to date from partners Risk of not meeting mandatory to end of june to embed and improve reporting structure to has enabled action to begin to requirements for reporting timeliness , reduce instability and Maintenance overhead. Then to address address NHSI recommendations completeness or quality larger new work requests as defined and costed work packages as and build under-pinning stability part of a long term and stable solution for the Trust. to data warehouse whilst up- skilling existing staff 31/05/2018 SJJ joined team permanently from work trial(redeployment) experience matches with IST and ESR burden 06/06/2018 RL expecting and provides resilience with RTT gaps. Warehouse Developer gap response today from service remains partners to address skills provision , which will support 06/06/2018 awaiting proposal from BI(EK) and Integris to frame business proposal for longer term business case solution.
31/05/2018 SJJ joins team permanently
17/04/2018 SJJ offered on work trial from Operations directorate
1110 11/05/2018 Some Patient pathways not visible NHSI have observed risks in process and 1. Daily reporting of all patients on RTT pathway Michelle Rob Lock Patient 15 4 Reconciliation of PAS vs 04/07/2018 Planned PTL now KSO1 KSO2 KSO3 in reports, patient care may reporting that present risk to patients 2. New reports being developed to identify planned patients not Miles Safety springtime reviewed , additional fields become 'lost' being lost in the system or left on RTT pathway build planned patient report requested being scoped for untreated beyond target . 3. propose additional resource to develop new reports and development effort before reconcile process flows. publication . May lead to patient harm and 4. linked with risk 1111, awaiting proposal form service providers Auto discharge rule suspended reputational damage if a referral is not on NHSI advice. tracked or not visible in routine review instigated of spoke sites monitoring and reporting provision and extraction criteria for the data supplied to QVH.
External support engaged to provide skills to address 06/06/18 Build reports to provide visibilty of planned patient currently not shown in daily PTL
"Planned PTL" is built
Currently addressing issues in RTT standard reports : RL to arrange resource with Dir Ops and RTT teams to validate 'planned patients without an RTT pathway'
QVH BOD September 2018: Session in public Page 76 of 260 ID Opened Title Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress / Updates KSO Lead Rating Rating 1105 11/04/2018 Ventilation within Burns, EBAC and There is a high risk to patients having 1. Ventilation system currently in place in Burns is being Michelle Miss Sarah Estates 16 8 Install a new ventilation 14/6/18: r/v at E&FSG - paper KSO1 KSO4 CCU surgery, dressing changes and invasive maintained and monitored by the estates department. Miles Prevett Infrastructur system as part of the EBAC with 7 options submitted to DoN procedures undertaken in areas that 2. Daily checks of all ventilation alarms e & refurbishment 14/5: DoN to escalate to DoF re: the air has not been filtered and is not 3. All duct are to be cleaned in 2018 Environmen Upgrade the current system delays & request confirmation of being moved around. 4. All staff in the operating theatre wear clean scrubs, hats, t within the Burns unit and CCU project proceeding masks, gowns and gloves minimising the amount of exposed 11/04/2018 - No funding This potentially can lead infection being 31.05.18 - Report sent to Director of Nursing identifying a number allocated for either of the current spread or given to patients. of options with indicative costs associated to them. two actions 04.07.18 - Awaiting outcome of report with what action to take. Infection can cause increased length of 27.07.2018- Estates have been asked to re risk assess this risk stay in a hospital environment, or a needs to be re-assessed by the clinical/ IPC teams from a clinical new admission, slow healing wounds, operational view. the need for antibiotic therapy, surgery, increased pain, patient becoming acutely un well and potentially death.
1097 07/02/2018 Concern that there may be missing Concern has been raised by NHSI at Further details being sought from all parties to identify these Abigail Jago Victoria Patient 12 4 13/7/18: r/v with Exec Lead - KSO1 cancer patients on the cancer PTL their 'critical friend' visit that there may patients. Cancer PTL in place but it hasn't been able to identify Worrell Safety now confident re: internal be patients missing from the cancer the patients from the information given to date. Head of risk patients, spoke sites to be PTL. Two incomplete patient details informed and involved. New substantive cancer data manager in reviewed were given which did not give enough post after this post being vacant for a year plus and although Weekly conference calls detail to track so further detail is being covered by interims this was not ideal as there were three over implemented sought from Medway. The interim this period which led to a fragmented service. New Performance 14/5/18 (CGG): CEO and Head of service review manager in appts raised & Access Manager joins the trust in March 18 and she has a Patient Safety meeting with a similar issue but further detail is robust cancer background and so will be asked to undertake a Medway CEO & Director Elective required. All breast cancer patients review. NHSI asked if they can also provide IMAS/IST support Services June 18th also need to clearly visible on the PTL 9/4/18: Update - Info flex system had not been maintained QVH side; fully updated for 46 identified patients. 15/3/18 Being investigated independently and part of the Access & Appts action plan. Advised that all breast patients need to be on PTL, new Performance & Access Manager will oversee
1096 19/01/2018 Inappropriate storage facilities for Non compliance with national guidance 1. Storage is locked and alarmed. Michelle Steve Compliance 12 6 04.07.18 - HOE has identified special gases on storage of special gases 2. Restricted staff allowed access Miles Davies (Targets / suitable storage options for Assessment cylinders and arranged meeting s / on 13/07/18 with all Standards) stakeholders to approve and sign off. new units will be 6 weeks delivery.
Exec lead changed to Michelle Miles: confirmation of risk grading requested again 25/1/18:Exec lead & handler e- mailed for confirmation of risk grading
QVH BOD September 2018: Session in public Page 77 of 260 ID Opened Title Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress / Updates KSO Lead Rating Rating 1095 19/01/2018 Inability to provide full pharmacy Delays to indirect clinical services (eg. 1. Recruitment for newly funded post in process (only one Abigail Jago Judy Busby Patient 12 4 1. Start recruitment for 12/7/18: reviewed at MMOG - KSO3 services due to vacancies updating policies / guidelines / audit / applicant)Update 12/4/18 - starting 16/4/18 Safety remaining vacancies - all interviews planned w/c 16th July training 2. Recruitment for part-time assistant underway - interviewed. recruitment in progress 26/6/18 Band 8A pharmacist Pharmacy vacancy rate is increasing. Update 12/4/18 started 5/2/18 started in post. Band 7 Lack of trained bank staff to cover 3. Recruitment for band 8a pharmacist underway. Update pharmacist post in shortlisting (1 12/4/18 appointed, waiting HR clearance. Update 26/6/18 started suitable applicant). Band 3 29/5/18 assistant to start 23/7/18. 2 4. Some part-time staff willing to work more paid hours. members of staff on restricted 5. Locum pharmacist agreed Update 12/4/18 - locum in place. duties back to normal. 2 members Update 26/6/18 locum left but part-time bank pharmacist for staff on long term sick leave. covering short-term Locum and bank assistants being 6. Direct clinical work is the priority. Regular review of used. Bank pharmacists being outstanding work used. Locum pharmacist left and 7. Locum pharmacy assistant in post part-time not replaced. 8. Forward planning for summer holiday period 14/5 (CGG): currently worsening situation; one new long term sick & locum has given notice. HR to be requested to prioritise and expedite pharmacy recruitment processes. 12/4/18. recruitment underway for all vacancies.
1094 15/12/2017 Canadian Wing Staffing Current vacancy 7.79 wte in total 1. Use of agency and bank as available and movement of QVH Jo Thomas Nicola Patient 12 12 Discussion with Director of 4/7/18 - some further leavers KSO1 KSO2 registered and unregistered workforce staff to cover shortfall Reeves Safety Nursing wc 18th December but some recruited staff starting. Unable to cover shifts with qualified 2. Review of rota to identify new ways of working to address the Proactive management of bed nurses leading to constant micro shortfall in the short term & on-going rota scrutiny booking 14/5 (CGG): some success with management of off duty rotas. 3. Line-booked agency if available Line booking agency staff international recruitment, Unable to recruit staff to fill existing 4. Redeploying staff from other areas of the hospital to cover Planning further in advance to minimal success with social media vacancy 5. Cancelling or holding trauma and electives get increased choice of agency. campaign Occasionally unable to book sufficient 9/4/18: Update - interest from agency staff to cover the shortfall campaign, small number of On occasions trauma or elective activity applications received is cancelled or delayed to manage the 12/2/18: Update - Social media shortfall recruitment campaign underway Pegasus) January 2018 update: - enhanced bank rates to include C-Wing - new ward matron in post 1093 18/12/2017 Site Practitioner Staffing Current vacancy 2.0 out of 10 WTE of 1. Use of existing staff to do bank. Jo Thomas Nicola Patient 12 9 Proactive management rota 9/7/18: two new staff completed KSO1 total registered workforce 2. Review of rota to identify new ways of working to address the Reeves Safety Substantive recruitment once orientation. One further post Unable to cover shifts with suitably shortfall in the short term & on-going rota scrutiny the secondments completed offered which will result in team qualified nurses leading to constant 3. night shifts prioritised over day shifts (x2 on duty) Unable to support any further being fully established once in micro management of off duty rotas 4. Outreach bleep held by Critical Care flexible working or post and leaving the organisation vulnerable 5. Site Practitioner phone with DDoN / HoN secondment requests at this 12/6/18: Update - R&R ongoing due to lack of senior support. time. 9/4/18: Update - 1 staff member Unable to recruit staff to fill existing commenced, other to start end of vacancy as two staff on temporary April secondment. 12/2/18: 1wte post recruited to Unable to book agency staff to cover (= x2 part-time staff) To start in the shortfall due to the speciality of the role March / April 2018 role On occasions there are insufficient staff to maintain safety and trauma or elective activity
QVH BOD September 2018: Session in public Page 78 of 260 ID Opened Title Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress / Updates KSO Lead Rating Rating 1083 22/09/2017 Deterioration in 18RTT The trust's 18RTT position has June 2018: Abigail Jago Victoria Compliance 20 15 Outsourcing Routine Hand June 2018: access policy updated KSO1 KSO2 KSO3 performance deteriorated and is not meeting the *weekly PTL meeting in place (Chair: DOO) Worrell (Targets / Surgey with CCG's: currently ahead of target of 95%. This will mean that *NHSI supporting capacity & demand Assessment Design and implenent different planned sign-off June F&P patients will wait longer, regulators are *additional capacity identified for MF/plastics s / models of service provision 9/4/18: QVH more attention and our reputation *recovery plan under development Standards) Review Spoke Sites activity Theatre nursing vacancies will suffer. *review of PTL baseline underway with NHSI continue to increase Anaesthetic June 2018: on-going challenges with Additional validators in post appointments in post x3, 4th to theatre access Cancer data manager and Performance and Access Manager start in May appointed & in post. IST working with Trust to review capacity and demand
1077 22/08/2017 Recruitment and retention in * Theatres vacancy rate is increasing 1. HR Team review difficult to fill vacancies with operational Jo Thomas Nicola Patient 16 6 Actions to date 9/7/18: TUG agreed to pilot KSO1 KSO2 theatres * Pre-assessment vacancy rate is managers Reeves Safety different minor procedure increasing 2. Targeted recruitment continues: Business Case progressing via staffing model from July '18 * Age demographic of QVH nursing EMT to utilise recruitment & retention via social media Practice Educator in Dubai to workforce: 20% of staff are at 3. Specialist Agency used to supply cover: approval over cap to interview potential staff retirement age sustain safe provision of service / capacity * Impact on waiting lists as staff are 4. Trust is signed up to the NHSI nursing retention initiative 12/6/18: further work on theatre covering gaps in normal week & 5. Trust incorporated best practice examples from other establishment & budget. Testing therefore not available to cover providers into QVH initiatives feedback from staff re: skill mix additional activity at weekends 6. Assessment of agency nurse skills to improve safe transition for 14/5 (CGG): Pre-assessment June 2018: working in QVH theatres almost at full establishment * loss of theatre lists due to staff 7. Management of activity in the event that staffing falls below 12/2/18: recruitment to pre-op vacancies safe levels. assessment plus social media recruitment drive January 2018 update:all HCA's now in post
1059 22/06/2017 Remote site: Lack of co-location Lack of co-location with clinical SLA with BSUH re: CT scanning, acute medical care, paediatric Dr Edward Dr Edward Patient 12 10 Actions to date 14/5/2018 (CGG): some progress KSO1 KSO2 KSO4 with support services for specific specialities & facilities which may be care and advice Pickles Pickles Safety PEG service review re: discussions between sites - services required to manage complications of Guidelines re: pre-assessment & admission criteria, to QVH joint (BSUH & QVH)programme procdures undertaken at QVH Skilled and competent medical and nursing staff with mandatory board established and CT training focused on QVH specific risks procurement process underway Clinical governance oversight of scope of practice at QVH
QVH BOD September 2018: Session in public Page 79 of 260 ID Opened Title Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress / Updates KSO Lead Rating Rating 1040 13/02/2017 Age of X-ray equipment in All X-Ray equipment is reaching end of All equipment is under a maintenance contract, and is subject to Abigail Jago Sheila Black Patient 12 2 17/7/18: reviewed at CSS KSO1 KSO2 KSO3 radiology life. QA checks by the maintenance company and by Medical Physics. Safety meeting - new capital now No Capital Replacement Plan in place at available for this QVH for radiology equipment Plain Film-Radiology has 3 CR x-ray rooms and therefore patients 14/5 (CGG): procurement process capacity can be flexed should 1 room breakdown. continues 13.12.2017- Cone Bean CT Fluoroscopy- was leased by the trust in 2006 and is included in 1 scanner in procurement phase of these general rooms. Control would be to outsource all 1 Ultrasound machine in Fluoroscopy work to suitable hospitals during periods of procurement phase extended downtime. Business planning 2018-2019 has plan for rolling capital Ultrasound- 3 US units are over the Royal College of Radiologists replacement of radiology (RCR)5 year's recommended life cycle for clinical use. Plan is to equipment replace 1 US machine in 2017-2018. Should machines fail, then 06/09/2017- business planning clinical service will be compromised. for 2017-2018 agreed for the CBCT and 1 US machine imaging Cone Beam CT installed in 2008- RCR recommends that all CT equipment to be replaced. machines are on a replacement programme every 7 years. The 14/03/2017: Replacement items CBCT machine at QVH is showing end of life tendencies, and had to be included in Business Plan significant down-time in Sept 2016. All CBCT services had to be for 2018/19 suspended, and patients breaching the 6 week diagnostic target were out-sourced to other hospitals and modalities where possible - plan to replace in the financial year 2017-2018
1035 09/01/2017 Inability to recruit adequate * Failure to recruit adequate numbers 1. Burns ITU has a good relationship with 3 nursing agencies. Via Jo Thomas Nicola Patient 16 9 Actions update 16/7/18: Paper to HMT to agree KSO1 KSO2 numbers of skilled critical care of skilled critical care nurses across a these agencies we have a bank of 8 - 10 nurses who regularly Reeves Safety Risk Appetite for agency usage in nurses across a range of Bands range of Bands work on our unit,and are considered part of our team. Critical Care * Intensive Care Society recommends temporary staff are formally orientated to the unit with a 9/7/18: Update - Practice 50% of qualified nurses working on CCU document completed and kept on file. Educator in Dubai to interview team should have ITU course: this is 2. A register is kept of all agency nurses working in CCU:they all potential staff currently complied with due to existing have ITU Course or extensive experience 12/6/18: necessity for substantive workforce, new staff joining from C- 3. Concerns are raised and escalated to the relevant agencies staff to change / cover shifts at Wing and transfer of vacancy rates where necessary and any new agency staff are fully vetted and short notice resulting in impact * move of step-down beds to CCU has confirmed as fully competent to required standards upon health & wellbeing. increased the vacancy rate 4. Recruitment drive continues & review of skill mix throughout February 2018: social media *potential for cases to be cancelled the day and appropriate changes made recruitment drive launched 5. Review of patient pathway undertaken following move of step- January 2018 update: down patients to CCU: for review October 2017 - Increased Bank rates 6. International recruitment undertaken, appropriate staff moving implemented through required checks. Continue to advertise registered staff -'recommend a friend' staff positions. incentive scheme 7. Paper agreed at HMT to support current staffing issues in CCU. Dec vacancy rate = 6.01wte Vacancy remain high with long term sickness and maternity leave. Must ensure 50:50 split between CCU substantive staff and agency. Staff aware of the action.
QVH BOD September 2018: Session in public Page 80 of 260 ID Opened Title Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress / Updates KSO Lead Rating Rating 968 20/06/2016 Delivery of commissioned services -Potential increase in the risk to patient *Paeds review group in place Jo Thomas Nicola Compliance 12 4 To be reviewed in July 12/7/18: meeting held with whilst not meeting all national safety *Mitigation protocol in place surrounding transfer in and off site Reeves (Targets / following Clinical Cabinet Brighton to progress pathway standards/criteria for Burns and -on-call paediatrition is 1 hour away in of Paeds patients Assessment discussions 12/6 update: Darzi fellow in post Paeds Brighton *Established safeguarding processes in place to ensure children s / Paper to be presented at (1yr), reviewing paediatric -Potential loss of income if burns are triaged appropriately, managed safely Standards) Clinical Cabinet in June 2016 inpatient burns derogation lost *Robust clinical support for Paeds by specialist consultants within Paediatric review group met in 14/5 update: position paper -no dedicated paediatric anaesthetic the Trust August, paper to private board presented at March HMT - nil lists *All registered nursing staff working within paediatrics hold an in September 2016. new changes appropriate NMC registration *Robust incident reporting in place *Named Paeds safeguarding consultant in post *Strict admittance criteria based on pre-existing and presenting medical problems, including extent of burn scaled to age. *Surgery only offered at selected times based on age group (no under 3 years OOH) *Paediatric anaesthetic oversight of all children having general anaesthesia under 3 years of age. *SLA with BSUH for paediatrician cover: 24/7 telephone advice & 3 sessions per week on site at QVH
949 08/04/2016 Threat to scheduling and reporting Improved stability and detail of data 1.Business unit managers are aware and working to gather data Abigail Jago Victoria Compliance 15 6 22/06/2016 Risk reviewed with 13/07/2018 KSO1 KSO2 KSO4 of patient waits and performance from off-site locations will improve via manual and paper systems to assess risk as much as possible; Worrell (Targets / IHoR and IM Progress been All QVH RTT data except DVH (RTT18) through system visibility of underperformance against Assessment made with East Kent to now visible . DVH developing enhancement national standards e.g. waiting time 2.Accuracy of Onsite performance is validated and assured s / provide a data warehouse extract for end July 2018 which RTT18 & 52 week breaches but this will Standards) 3.A recovery plan will be will be the last piece to provide impact adversely upon reported commenced as soon as there is whole Trust RTT picture. performance. The lack of good data, enough data and a trajectory Resilient SSRS RTT PTL to go live along with access to their patient agreed, this will be revised on 01/08/2018 to replace legacy administration systems and so inability once there is more accurate Excel publication to include these patients on the QVH data via the warehouse Validation effort continues on patient tracking list, is a long standing functionality waiting list data and work with issue which is now being addressed. To gain access to offsite PAS NHSI to provide supplementary Medway is the main risk area as apart systems reports to ensure all patients are from a three month period in the visible summer of 2015, they have not been able to report their 18 RTT position June 2018: NHSI review of PTL to since November 2014 and this has include spoke sites impacted upon QVH. When Medway 15/3/18 was reporting, it was one of the worst New Performance & Access performers in England. manager in post but vacancies in the BI team. NHSI working with the trust and this will be picked up as part of their work
898 04/11/2015 Ageing specialist Histopathology The increasing age of the very specialist -Hand coverslip all slides if the coverslipper breaks Abigail Jago Fiona Estates 12 6 Ensure equipment to be 17/7/18: reviewed at CSS KSO1 KSO2 laboratory equipment laboratory equipment. -Leica to loan a cryostat to cover the period of time between Lawson Infrastructur replaced is part of business meeting - replaced approved for breakage and purchasing a replacement e & planning and capital bids for 2018/19 Environmen 2016-17 Update 9/1/18: Capital funding Items will be included in the capital business planning as required t application submitted and will also be put on rolling program over the next 3 years.
Where available, specialist maintenance contracts in place to ensure rapid response to repair essential equipment. However, this is not possible for some machines as they are too old and parts are no longer manufactured.
QVH BOD September 2018: Session in public Page 81 of 260 ID Opened Title Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress / Updates KSO Lead Rating Rating 877 21/10/2015 Financial sustainability 1) Failure to achieve key financial 1) Annual financial and activity plan Michelle Jason Finance 20 16 22/06/2016 Risk reviewed by 05/06/18: Reviewed; updated KSO4 targets would adversely impact the 2) Standing financial Instructions Miles Mcintyre IHoR need an update target risk to reflect BAF NHSI "Financial Sustainability Risk 3) Contract Management framework regarding current controls and rating and breach the Trust's continuity 4) Monthly monitoring of financial performance to Board and any additional actions. Email 3/10/17: reviewed at senior team of service licence. Finance and Performance committee sent ro risk owner requesting meeting = no change 2)Failure to generate surpluses to fund 5) Performance Management framework including monthly an update, sent 22nd June 06/12/2016: Reviewed by Senior future operational and strategic service Performance review meetings 2016 Management Team. DoF to investment 6) Audit Committee reports on internal controls 1) Development and review further to ensure score 7) Internal audit plan implementation of delivery accurately reflects current status. plan to address forecast underformance. Review of performance against delivery plan through PR framework with appropriate escalation policies. 2) Development of multi-year CIP/ transformational programme which complies with best practice guidelines. 3)Development and embedding of integrated business planning framework and pro
789 12/03/2015 Failure to meet Trusts Medical Inability to meet Trusts Medical 1. Funding of the non deanery clinical lead Dr Edward Chetan Compliance 15 12 Recruitment drive commenced 26/6/18: Action plan in place. Education Strategy Education Strategy: limited pool of non- 2. Temporary education centre in place Pickles Patel (Targets / Permanent Education Centre 2018 GMC results expected July. deanery trainees 3. Manage non LETB similar to LETB Assessment has had outline Board approval HEE visit 10th September 2018. 4. Quality reviews from colleagues received s / and funding TBA Recruitment remains 5. GMC feedback provided Standards) Reduced activity in some areas challenging. 6. Exit interviews undertaken with colleagues 03/06/2016 Risk Reviewed 22/1/18: Plastics currently fully 7. Action Plan being developed in response to GMC survey: with IHoR and MD: continued recruited, OMFS vacancies until developed & submitted to HEE & LaSE recruitment drive in place with April 2018. GMC survey results 8. Deanery visit planned Nov 2017 focus upon plastics new disappointing; Deanery visit contolrs added but scores awaited remain unchanged as still a risk to the Trust review in one month
QVH BOD September 2018: Session in public Page 82 of 260
Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/18 Agenda reference: 138-18 Report title: QVH risk appetite statement Sponsor: Jo Thomas, Director of nursing Author: Jo Thomas, Director of nursing Appendices: (1) Executive summary Purpose of report: To state the risk appetite of the organisation. Summary of key This paper details the current risk profile of the organisation and the amount of risk it issues is currently exposed to. It states the risk appetite- how much risk we are prepared to accept to achieve the strategic objectives It provides a platform for assessing future risk tolerance and should be used as part of our horizon scanning to identify emerging risks that are both within our control and external to our control. Recommendation: The Board is asked to approve the risk appetite statement Action required Approval [highlight one only] Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence experience services Implications Board assurance framework: The risk appetite forms part of the board assurance, the BAF was reviewed and key strategic risks form part of the risk appetite
assessment Corporate risk register: The CRR was also reviewed and the key risks are included in the risk appetite assessment
Regulation: Compliance with regulated activities and requirements in Health and Social Care Act 2008.
Legal: As above
Resources: Additional resources have been provided from commissioners to support the RTT/organisational performance challenges
Assurance route Previously considered by: EMT and circulated to the all board members for comments Date: August Decision: 2018 Next steps:
QVH BOD September 2018: Session in public Page 83 of 260 Queen Victoria Hospital Risk Appetite Statement 2018-2019
Risk appetite can be defined as the amount of risk, on a broad level, that an organisation is willing to accept in the pursuit of its strategic objectives.
Risk appetite is a core consideration in any corporate risk management approach. No organisation, whether in the private, public or third sector can achieve its objectives without taking a risk. The question for the decision-makers is how much risk do they need to or are prepared to take?
The UK Corporate Governance Code states that “the board is responsible for determining the nature and extent of the significant risks it is willing to take in achieving its strategic decisions”. As well as meeting the requirements imposed by corporate governance standards, organisations are increasingly being asked to express clearly the extent of their willingness to take risk to meet their strategic objectives.
Risk appetite, correctly defined, approached and implemented, should be a fundamental business concept that makes a difference to how organisations are run. The strategy will be to develop an approach to risk appetite that is practical and pragmatic, and that makes a difference to the quality of decision-making, so that decision-makers understand the risks in any proposal and the degree of risk to which they are permitted to expose the organisation while encouraging enterprise and innovation. (QVH Risk Management Strategy 2016-2020)
Introduction The Queen Victoria Hospital (QVH) risk strategy was written in 2016 and provided a 4 year plan of the key risks within the trust (appendix 1). It should be used as a reference point for trust staff and the Board in identifying, reporting and managing organisational risks. It set out the principles and core processes, responsibilities and accountabilities for this aspect of our corporate governance.
The Board of Directors is accountable for ensuring a system of internal control which supports the achievement of the organisation’s objectives is in place. The system of internal control ensures that:
• How much and what type of risk is acceptable for the organization: its risk appetite • The Trust’s Key Strategic Objectives are agreed. • Principal risks to those objectives are identified • Controls which eliminate or reduce these risks are implemented. • The effectiveness of these controls is independently assured. • Reports on unacceptable or serious risks and the effectiveness of control mechanisms are received from the Executive Directors and independent assurors. • Action plans are agreed to improve control over serious or unacceptable risks. • Policies are in place to determine what level of risks should be retained or accepted.
The current and emerging challenges facing the trust require a more detailed description of the trust’s risk appetite and the level of assurance across the risks to achieving the key strategic objectives. These challenges include greater financial pressures, access and performance issues and workforce sustainability.
Decision makers and leaders must understand the full current risks and give consideration to future risks when proposing change or new business ventures. The degree of risk the organization is exposed to must be articulated as well as the details of how the outcome / innovation will be realized.
QVH key strategic objectives
The 5 key strategic objectives were agreed as part of the QVH 2020 strategy work, which was widely consulted on with staff throughout the trust. The KSOs are reviewed at the committees of the Board, KSO1 and 2 at the Quality and Governance Committee (Q&GC) and KSO3, 4 and 5 at the Finance and
QVH BOD September 2018: Session in public Page 84 of 260 Performance Committee (F&PC) and all periodically at the Audit Committee (KSOs in Appendix 1).
Risk appetite
The purpose of the risk appetite statement is to give guidance to the decision maker on the Board appetite for risk taking to achieve the KSOs. The nature and business of healthcare organisations make them risk averse, the intention of having a risk appetite statement is to make the trust more risk aware.
The risk appetite statement should also be used to drive action in areas where the risk assessment in a particular area is greater than the risk appetite stated. The table below provides suggested definitions for grading risk appetite.
Appetite Approach to Described as risk None Avoid The avoidance of risk and uncertainty is a key organizational objective Low Minimal Preference for ultra-safe delivery options that have a low degree of inherent risk. The balance of risk has to be weighed up against the potential reward even with a low risk appetite Moderate Cautious Preference for safe delivery options that have a low degree of inherent risk. The balance of risk has to be weighed up against the potential reward even with a moderate risk appetite High Open Willing to consider all potential delivery options and choose while also providing an acceptable level of reward and value for money Significant Seek Eager to be innovative and to choose options offering potentially higher rewards despite greater inherent risk
The 2018/19 QVH risk appetite statement
This statement has been reached by considering the QVH risk strategy, the KSOs, Board Assurance Framework, Corporate Risk Registers and emerging challenges facing the trust. The key themes from these documents are detailed later in this paper.
The Trust will not accept risks that materially impact on patient safety.
The Trust is keen to pursue innovation and research opportunities and this is our area of highest risk appetite.
At QVH we recognise that the trust’s longer term sustainability will depend upon the delivery of our strategic objectives and our positive and constructive relationships with our patients, the public and partners in the local health economy. In this, we are willing to challenge working practices and take potential moderate reputational risk where positive gains can be achieved. This will always be within the constraints of our regulatory environment
This risk appetite assessment reflects our current understanding and may change if the risk assessment is undertaken again at a later date. The risk appetite statement will be reviewed annually.
QVH BOD September 2018: Session in public Page 85 of 260 Themes Link to Issue Risk KSO appetite Patient KSO1, We do not develop an effective short-term strategy to retain and
Experience 2,3,4,5 recruit staff for the next 12 months to sustain the high quality care Moderate and patient experience and deliver planned trust activity. We do not achieve our medium to long-term strategy are unable retain staff and recruiting internationally the required number of staff, particularly theatre and critical care staff to provide high quality care and patient experience. New health care roles are not recruited to or don’t meet the gap in care skills require to provide high quality care and patient experience plan.
We do not achieve the short to medium term plans to improve booking and scheduling of appointments and theatres and patients continue to have longer than necessary delays in treatments Low pathways.
Patients lose confidence in the quality of our services and the environment in which we provide them, due to the condition and fabric of the estate. We do not undertake backlog maintenance and approved capital and Moderate estates projects outlined in estates strategy which could result in patients choosing other providers for their care or impact on satisfaction. Safety and KSO Patients, clinicians and commissioners lose confidence in services Low Quality 1,2,3,4 due to inability to show external assurance by outcome measurement.
Patients lose confidence in the trust due to serious incidents and Low negative press about the safety and quality of our services.
Regulators and commissioners lose confidence in trust due to lack of Low embedded learning from serious incidents. Patients, clinicians and commissioners lose confidence in services regarding patient safety by failing to treat patients within national treatment pathways due to lack of effective governance in the Low management of these processes. Re inspection by CQC, which is due by November 2018 fails to Low achieve good or better in each of the 5 domains and an overall rating of good. Innovation KSO1,2, Patients, clinicians and commissioners lose confidence in services and research 3, 4,5 due to inability to show external assurance by reduction in research High output Research/Innovation potential – are we implementing research High evidence and promoting our endeavors sufficiently. Trust is unable to support innovation due to investment financially Moderate being greater than the return Access and KSO1,2, Regulators and commissioners lose confidence in our ability to
provide timely and effective treatment due to breach in the conditions Performance 3,4,5 Low of our foundation trust license for RTT18, cancer 62 and 52 week breaches.
Spoke site service provision is not fully understood within the agreed Moderate time frame of review which impacts negatively on the ability to efficiently and effectively deliver services on QVH site.
Staff and commissioners lose confidence in our ability to provide Low timely and effective treatment due to lower than expected theatre productivity.
QVH BOD September 2018: Session in public Page 86 of 260
Reputation/ KSI Occurrence of avoidable incidents or harms do not continue to Low stakeholder 1,2,3,4 decrease. relationships Trust doesn’t achieve its recovery trajectory for access and Low performance within agreed timescales or doesn’t sustain the confidence of the NHSI intensivist support team or control total agreed with NHSI.
Financial KSO3,4, Loss of confidence in the long term financial sustainability of the trust Moderate sustainability5 if it fails to achieve NHSI control total and create adequate surpluses to fund operational and strategic investments.
The trust is unable to achieve plan in year due to lack of safe staffing Low levels resulting in theatre cancellations or declined admissions or ward closures
We do not understand our business sufficiently, particularly the service Moderate line costs to identify and implement all improvement and efficiency opportunities.
The business planning cycle process is not fully developed to include business planning with workforce planning and financial planning. This Low has resulted in the past with a lack of clarity with regards to funding streams and budget sign off. This results in the Trust having incomplete plans confusion about what has been funded; and management action can become reactive
Culture KSO The values of the trust are not upheld throughout the organization and Moderate 1,2,3,4,5 errors, discrimination and loss of staff occur as a result of this Establishing a positive, supportive culture which is allied to accountability for safe care and delivery of service is not seen as a priority, and does not foster accountability amongst workforce.
Staff lose confidence in the trust as a place to work due to Low perceived failure of line managers to act on staff feedback
Staff lose confidence in the trust as a place to work due to variation Moderate in fairness and equality.
Workforce KSO Patients, clinicians, deanery and commissioners lose confidence in Low 1,2,3,4, services due to fall in teaching standards 5 Staff lose confidence in the trust as a place to work due to insufficient Low training and development opportunities. Insufficient focus on recruitment and retention at all levels within the Low Trust. Improvements to bank pay, and recruitment and retention initiatives don’t have the desired effect of attracting staff to join QVH and retaining existing workforce staff retention Moderate Staff lose confidence in the trust as a place to work due to working Low environment.
Perception amongst staff that the trust has not articulated how we will Low deliver our strategy underpinned by widely communicated and owned supporting delivery plans, resulting in an inability to take strategic decisions as an organisation, leading to difficulty in identifying clinical service priorities and consequently a lack of engagement in the future success of the Trust amongst our workforce.
RECOMMENDATION
The Board is asked to approve the risk appetite statement for 2018/19 and risk descriptor table.
QVH BOD September 2018: Session in public Page 87 of 260 Appendix 1
Key Strategic Objectives
Director of Nursing Medical Director Director of Director of Finance Director of HR & Operations OD KSO 1 Outstanding KSO 2 World KSO 3 KSO 4 Financial KSO 5 Patient Experience Class Operational Sustainability Organisational Clinical Services Excellence Excellen We put the patient We provide world We provide We maximize existing We seek to maintain at the heart of safe, class services that are streamlined services resources to offer a well led compassionate and evidenced by clinical that ensure our cost- effective and organisation competent care that is and patient outcomes patients are offered efficient care whilst delivering safe, provided by well led and underpinned by choice and are treated looking for effective and teams in an our reputation for high in a timely manner. opportunities to grow compassionate care environment that quality education and and develop our through an engaged meets the needs of training and innovative services. and motivated the patient and their R&D. workforce families.
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Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/2018 Agenda reference: 139-18 Report title: Quality and Safety Report, September 2018 Board Sponsor: Jo Thomas, Director of Nursing and Quality and Ed Pickles Author: Kelly Stevens, Head of Quality and Compliance Appendices: None Executive summary Purpose of report: To provide updated quality information and assurance that the quality of care at QVH is safe, effective, responsive, caring and well led. Summary of key The Committee’s attention should be drawn to the following key areas detailed in the issues report: • An outbreak was declared on the 19/06/18 of MRSA in the critical care and burns units • Burns Derogation work being taken forward and links made with BSUH • Improvement in the GMC National Training Survey published in July 2018 The Board should also note the changing structure of the repot and the move to a more assurance based focus. Recommendation: The Board is asked to review and seek assurance that the contents of the report reflect the quality and safety of care provided by QVH Action required Assurance
Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence experience services Implications Board assurance framework: The Quality and Safety Report contributes directly to the delivery of KSO 1 and 2, elements of KSO 3 and 5 also impact on this. Corporate risk register: CRR reviewed as part of the report compilation –and the workforce and RTT18 risk impact the most on quality, safety and patient experience. Regulation: The Quality and Safety Report contributes and provides evidence of compliance with the regulated activities in Health and Social Care
Act 2008 and the CQC’s Essential Standards of Quality and Safety. Legal: The Quality and Safety Report uphold the principles and values of The NHS Constitution for England and the communities and people
it serves – patients and public – and staff. Resources: The Quality and Safety Report was produced using existing resources. Assurance route Previously considered by: Quality & Governance Committee Date: 16/08/18 Decision: Reviewed and recommended for approval at board with addition of whistleblowing update Next steps:
QVH BOD September 2018: Session in public Page 89 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Executive Summary - Quality and Safety Report, September 2018
Domain Highlights
Workforce remains the key risk factor to safety and quality of care. There have been no direct links to unsafe care or avoidable harm, however working with non substantive staff over a period of time does reduce efficiency and impacts on patient and staff experience. There are no significant changes in trained short term recruitment and retention of trained nurses with vacancies static at 21.21%. There has been an improvement in untrained vacancies which is currently at 14.71% from 16.15%. The Trust continues to work in partnership with another trust on international recruitment and has offered circa 45 posts; a number of which may be in post by January 2019. These offers have been made to nurses with theatres, critical care and surgical ward experience.
The Senior Nursing Team and the Operations Team continue to work closely together and have been working on reducing cancellations on the day for patients and a model of care that will embed this way of working. We have already seen some improvements in patient and staff experience using this approach. Director of Nursing and Quality An outbreak was declared on the 19/06/18 of MRSA in the Critical Care and Burns units. The specific type of the organism is PVL MRSA which was notifiable to Public Health England. The index case has been identified and there have been seven cases of patients being colonised with this organism - this is due to transmission whilst an inpatient or in the burns dressing clinic.
Regular meetings with Public Health England (PHE) The Health Protection Agency (HPA) and our commissioners continue to take place during this outbreak. The London and South East Burns Network, NHSI, NHSE and Specialist Commissioning have also been informed.
Despite enhanced infection prevention and control measures we have been unable to break the chain of transmission. Both the critical care and burns units were closed to admissions on the 23 July and staff screening was commenced. The unit was reopened on 7th August once all existing patients had been discharged and double deep clean and environmental swabbing had taken place. Enhanced infection prevention and control measures remain in situ. We have had no further cases since 18th July.
QVH BOD September 2018: Session in public Page 90 of 260 The development of collaboration between QVH and BSUH and WSHT continues. A programme board manager, Dr Amanda Harrison has been appointed. Her first meeting with the Programme Board will be in early September. Emer Keating the Darzi fellow continues to lead the paediatric burns stream, and is now leading the writing of the service specification. Initial meetings have been held regarding the potential for networking of Sleep Disorder Services between QVH and BSUH.
The 2018 GMC National Training Survey was published in July. It demonstrates good results in anaesthetics and OMFS. Results for plastics higher training are much improved. Results for core training in plastic surgery are slightly improved on 2017, but remain disappointing. Actions will be led by the Local Academic Board (LAB) and our training will be further assessed by a Health Education Medical Director England visit on 10th September.
Data analysis has identified 177 patients on 18 week pathways who have waited longer than 52 weeks for treatment. A significant increase in the number of patients waiting in excess of 52 weeks for treatment. Approximately half of these patients are on Medway or Dartford waiting lists. Clinical harm reviews are underway to identify whether any patient has suffered significant harm as a result of their waiting time. No harm has been identified following 44 reviews so far.
Electronic job planning has now been completed.
QVH BOD September 2018: Session in public Page 91 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce
Report by ExceptionThe Trust is exploring - Key Messages
Domain Issue raised Action taken The CQC attended site for a planned engagement visit in June 2018 for planned provider engagement meeting with a planned focus on workforce and critical care. They also held a meeting with come Trust consultants. Feedback received was positive and no new causes for concern were raised by the regulatory body.
CQC Provider Engagement Meeting and Feedback received from the Post Never Event Review acknowledged that significant work CQC Post Never Event Review Feedback has been undertaken to improve the safety culture in theatres and referenced this as an (meeting held 25th April 2018) area of good practice, including: - Engagement of theatre staff in improving the safety culture - Simulation training, - Work to embed the WHO Surgical Safety Checklist - Named theatre caps - Empowering of staff at all levels to challenge each other.
Capsticks external investigation following The initial investigation has now been completed and a number of recommendations External whistleblowing report relating to access were made which included additional investigation, and changes to service provision, investigation and performance systems and process.
QVH BOD September 2018: Session in public Page 92 of 260 The Trust has followed guidance and issued to heads of department the national Met Office Hot Weather alerts (level two and three). These alerts trigger actions to ensure all necessary safety precautions have been taken to ensure that patients, staff and visitors are as comfortable as possible during this difficult period. - this was particularly the case when the Level 3 alert was issues. These include: - Encouraging staff members to keep their windows closed during full sun and use of blinds Hot Weather Response to national heatwave - Drinking cool drinks throughout the day Alert - Moving to cool offices and spaces - being mindful and recognising colleagues who are suffering and feeling unwell - Use of fans - Review of air conditioning in specific clinical areas.
Changes in the weather will continue to be monitored and advice provided as appropriate.
International recruitment of theatre QVH had offered circa 45 posts to theatre, critical care and surgical ward staff. We Nursing practitioners, critical care and ward anticipate an interim report from Yeovil District Hospital NHS Foundation Trust and the recruitment nurses acceptance and breakdown of post by specialty week beginning 13 August.
QVH BOD September 2018: Session in public Page 93 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Safe - Performance Indicators
2015/16 12 month Description (Activity per 1000 spells is based on HES Data: the number of inpatients Quarter 2 Quarter 1 total / Target Quarter 3 Quarter 4 total/ discharged per month including ordinary, day case and emergency - figure /HES x 1000) 2017/18 2018/19 average rolling Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July average Infection Control
MRSA Bacteraemia acquired at QVH post 48 hrs after admission 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1
Clostridium Difficile acquired at QVH post 72 hours after admission 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gram negative bloodstream infections (including E.coli) 00000000000000
MRSA screening - elective 98% >95% 99% 99% 97% 98% 96% 97% 97% 98% 98% 98% 98% 97% 98% MRSA screening - trauma 97% >95% 97% 95% 96% 96% 96% 97% 96% 98% 97% 95% 97% 96% 96% Incidents Never Events 001010000000002 Serious Incidents 300100000000001 OOH inductions: All patients: Number of patients operated on out of hours 5 2 5 3 4 3 4 2 5 6 5 5 5 49 22:00 - 08:00 Paediatrics under 3 years: : Induction of anaesthetic was between 0 0 0 0 2 0 0 0 0 0 0 0 0 2 18:00 and 08:00 Paediatric transfers out (<18 years) 200200000000 4 Medication errors
Total number of incidents involving drug / prescribing errors 191 8 9 20 16 16 10 9 13 6 12 7 8 134 No & Low harm incidents involving drug / prescribing errors 191 8 9 20 16 16 10 9 13 6 12 7 8 134 Moderate, Severe or Fatal incidents involving drug / prescribing 0 00000000000 0 0 errors Medication administration errors per 1000 spells 2.5 0.5 2.2 2.4 1.2 0.6 1.1 3 1.2 1.8 0.6 0.6 1.2 1.4 Harm free care rate (QVH) 97% >95% 97% 100% 100% 97% 100% 100% 97% 96% 98% 100% 97% 98% 98.4% Harm free care rate (NATIONAL benchmark) - one month delay 94% >95% 94.1% 94.3% 94.3% 94.2% 94.4% 94.2% 94.2% 94.0% 93.9% 94.0% 94.1% Pressure Ulcers Hospital acquired - category 2 or above 11 15 0300100011028 VTE initial assessment (Safety Thermometer) 98% >95% 100% 100% 100% 100% 94.7% 95.1% 97.3% 96.4% 100.0% 97.4% 97.1% 88.1% 97.2% Patient Falls Patient Falls assessment completed within 24 hrs of admission 94% >95% 100% 100% 100% 97% 87% 98% 92% 96% 95% 100% 100% 95% 96.31% Patient Falls resulting in no or low harm (inpatients) 40 412847823342 48 Patient Falls resulting in moderate or severe harm or death 0 0 0 0 0 0 0 0 0 0 1 0 0 1 (inpatients)
Patient falls per 1000 bed days 3.19 0.79 1.75 5.84 3.42 5.67 6.67 1.66 2.22 2.08 2.32 1.16 3.06
QVH BOD September 2018: Session in public Page 94 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Safe - Infection Outbreak
Background We currently have an outbreak of MRSA in the critical care and burns units. The index case has been identified and there have been 7 cases of patients being colonised with this organism due to transmission whilst an inpatient or in the burns dressing clinic. The outbreak was declared on the 19/06/18. We have had regular meeting with Public Health England (PHE) The Health Protection Agency (HPA) and our commissioners and NHSI, NHSE and Specialist Commissioning have also been informed.
Initial actions and assurances - All patients discussed with the Consultant Microbiologist; assessed and treated on an individual basis. - Nursing staff informed by the Infection Prevention and Control Team (IPACT) as each positive result known - staff advised to isolate the patient and implement full infection control precautions and start the patient on decolonization protocol. Where patients were discharged before the result known, either EBAC informed or the area the patient was currently being cared for. - Root cause analysis (RCA) form being undertaken for each patient - Outbreak meetings held to discuss possible causes and to advise on actions required - Samples sent to the reference laboratory for ribotyping to determine if there was cross-infection - may be due to the resistance pattern of the strain of MRSA each patient was found to have acquired - Timeline devised to review any identifiable links - All patients in CCU screened twice weekly from nose groin and all wounds for MRSA and screened on days of admission and discharge/transfer - CCU fully deep cleaned - All staff advised to wear full PPE when seeing any patient within CCU.
Further actions - CCU and Burns Unit closed to all new admission 23 July due to continued transmission, plan to remain closed till all current inpatients had been discharged. Double deep clean and environmental swabbing prior to reopening. -Staff screening commenced, any staff with positive screens will be decolonised and re screened ( not working clinically during this period) - Provision of CCU from recovery area from 30 August The Burns unit was reopened on 8 August. Enhanced infection prevention and control measures remain in situ. as we are still in outbreak mode. We have had no further cases since 18 July. Further outbreak meeting planned 9 August. No patients experienced any physical harm or increased length of stay as a result of the outbreak. However, the Trust does not underestimate the psychological impact on patients, families and staff during this time.
QVH BOD September 2018: Session in public Page 95 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Safe - Burns Derogation
Purpose / background Since 2013 QVH has been at derogation to the National Burns Care standards and Service specification principally due to lack of access to the following: - Trauma unit status and an Emergency Department - On-site 24/7 Paediatric High Dependency care - Access to a 24/7 Consultant Paediatrician who can attend within 30 minutes - 24/7 pathology and transfusion services - Access to Microbiology without delay.
In 2014 NHS England asked QVH to consider an alternative service model working with partners to ensure future compliance. A Strategic Outline Case for the development of Paediatric Burns and Lower Limb Trauma care was developed in 2016 between QVH and Brighton and Sussex University Hospitals (BSUH) - however, the required funding was not obtained and progress ceased.
Current position Challenges The first meeting was held in Brighton in July to revisit talks on The biggest challenge faced by the project is ensuring that the new Paediatric Burns and gain agreement towards the appropriate model is affordable whilst also providing high quality care. During the direction of travel. It was a positive meeting with lots of enthusiasm planning phase option appraisals for service delivery will be used to and engagement from all parties. obtain the best provision at the most appropriate cost.
Agreement was gained and the decision was taken to work towards a Providing the necessary skills and expertise at BSUH will also be a joint business case (to be developed in Q3 2018/19) with plastics challenge in terms of Nursing and Therapies. Work has already started provision to the Major Trauma Centre. with training via a skills exchange model with nursing staff from BSUH visiting QVH and plans for QVH staff to visit BSUH to administer more Work has now begun to design the new model of care to ensure it is formal lecture type training. safe, effective and will provide good patient experience.
Next steps. Work streams have been established to define the service model, activity, staffing and resource requirements along with a comprehensive training plan. This will ultimately lead to a business case being produced.
QVH BOD September 2018: Session in public Page 96 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Effective - Performance Indicators
Quarter 3 Quarter 1 Quarter 4 Quarter 2 2017/18 2018/19
Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Number of QVH patient deaths 0 0 0 0 2 1 1 0 0 0 Number of off-site deaths (within 30 days) 1 0 1 3 1 1 0 0 0 0 Preliminary review completed 1 0 1 3 3 2 1 0 0 0 Structured judgement review 0 0 0 0 2 1 Undertaking 0 0 0 Number of patients with a learning disability 0 0 0 0 0 0 0 0 0 0
All off site deaths are subject to preliminary review, and all deaths on-site, or where a concern has been raised, are subject to Learning from structured judgement review. The opinions of families and general practitioners are sought to check for concerns. The most recent deaths QVH death is the subject of an root cause analysis, which will report to the Clinical Governance Group in August. An annual report of ‘Learning from Deaths’ will be presented to the Quality and Governance Committee and the Joint Hospital Governance Meeting.
QVH BOD September 2018: Session in public Page 97 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Caring - Current Compliance - Complaints and Claims
Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18
Contacts (IP+OP+MIU, all sites) 19485 18613 20142 20402 16412 19319 16797 17670 18283 19641 19299 18080 Complaints 3 7 1 4 3 8 5 4 1 6 8 8 Complaints per 100 contacts 0.015 0.038 0.005 0.02 0.018 0.041 0.03 0.023 0.027 0.031 0.043 0.033 Number of complaints referred to 0 1 0 0 0 0 0 0 1 0 0 0 the Ombudsman for 2nd stage Number of complaints re-opened 1 0 0 0 0 0 0 0 1 0 0 1
QVH BOD September 2018: Session in public Page 98 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce
Caring - Current Compliance - FFT
QVH BOD September 2018: Session in public Page 99 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Nursing Workforce - Current Compliance
Domain Compliance Actions Staffing according to bed occupancy and acuity with additional staff deployed on high acuity days and resources redeployed from other During June and July there were 6/122 occasions where staffing areas. Below template shift dates have been triangulated with Datix Ross Tilley numbers did not meet planned levels (9/122 in April and May). safety incidents, ward FFT scores and complaints information. No All escalated to site practitioner as per trust protocol. falls , pressure ulcers or nursing medication errors occurred on these shifts.
Staffing according to bed occupancy and acuity with additional staff deployed on high acuity days and resources redeployed from other During June and July there was 1/122 occasion where staffing areas. One shift, due to short notice sickness was led by an agency Margaret numbers did not meet planned levels (5/122 in April and May). nurse with support from the site practitioner. Below template shift Duncombe All escalated to the site practitioner as per trust protocol. dates have been triangulated with Datix safety incidents, ward FFT scores and complaints information. No falls, pressure ulcers or nursing medication errors occurred on these shifts.
Staffing according to bed occupancy and acuity resources redeployed from other areas where template was below planned and additional During June and July there were 8/122 occasions where staffing staff required. Below template shift dates have been triangulated numbers did not meet planned levels (4/122 in April and May). Burns with Datix safety incidents, ward FFT scores and complaints All escalated to site practitioner as per trust protocol. This was information. No falls , pressure ulcers or nursing medication errors due to short term sickness and no show of agency staff. occurred on these shifts. The CCU and burns unit was closed on 24 July due to IC issue and reopened on 7/8/18.
QVH BOD September 2018: Session in public Page 100 of 260 During June and July there were 4/122 occasions where planned numbers did not meet planned levels (3/122 in April and May). All escalated to site practitioner as per trust protocol. In June there was one night when the ward closed at 19:30 due Staffing according to bed occupancy and acuity. Below template shift to staffing levels. There were 18 nights with inpatients and 11 dates have been triangulated with Datix safety incidents, ward FFT Peanut nights when the ward closed at midnight as no patients. scores and complaints information. No falls, pressure ulcers or In July there were six nights when the ward closed at 19:30 due nursing medication errors occurred on these shifts. to staffing levels. There were 14 nights with inpatients and 11 nights when the ward closed at midnight due to no inpatients. There was one patient transferred out for clinical reasons and no admissions declined on the nights the ward was closed.
A paper detailing the amount of risk the organisation is prepared to accept in balancing substantive and agency trained nurses was approved at July HMT. This will not be more than 50% of agency During June and July there were 3 /122 occasions where staffing trained staff per shift. All dates where escalation re staffing required numbers did not meet planned levels (3/12 in April and May). All have been triangulated with Datix safety incidents, ward FFT scores were escalated to site practitioner as per trust protocol. The and complaints information. No falls, pressure ulcers or nursing Critical Care (ITU) acuity and dependency of the patients affects the number of medication errors occurred on these shifts. There continues to be beds which can safely be staffed within the establishment, this is daily review of the number of critical care beds open decision is further adjusted to allow for agency fill rate. All escalated to the made by the multidisciplinary team at the morning hospital handover site practitioner as per trust protocol. meeting. This continues to be monitored throughout the day by the site and senior nursing teams. The CCU and burns unit was closed on 24 July due to IC issue and reopened on 7/8/18.
There was always a Site practitioner day and night with the Deputy During June and July there were 40/122 occasions where actual Director of Nursing, Heads of Nursing and critical care providing Site Practitioner did not meet planned levels of two staff on duty (36/122 April additional support as required to the team and the Trust. Twilight Team and May). Reasons for not meeting planned staffing were long shifts have been used to provide additional cover at the busiest term sickness accounting for the majority of these shifts. times of the shift. Data extracted from the workforce score card in appendix 1
QVH BOD September 2018: Session in public Page 101 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Qualified Nursing Workforce - Performance Indicators
QVH BOD September 2018: Session in public Page 102 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Unqualified Nursing Workforce - Performance Indicators
QVH BOD September 2018: Session in public Page 103 of 260 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Medical Workforce - Performance Indicators
2017/18 Quarter 2 Quarter 1 Year to Metrics total / Target Quarter 3 Quarter 4 Quarter 2 date average 2017/18 2018/19 actual Aug Sep Oct Nov Dec Jan Feb Mar April May June July Medical Workforce 13.98% Turnover rate in month, excluding trainees 12Mth <1% 0.00% 3.96% 0.98% 2.04% 1.01% 1.01% 0.00% 0.00% 85.00% 0.95% 0% 1.31% 9.50% rolling 51% Turnover in month including trainees 9% 12Mth 13.89% 2.11% 5.32% 2.17% 2.15% 0.73% 10.21% 0.00% 6.09% 2.12% 0.71% 10.76% 8.23% rolling Management cases monthly 0 0 0 0 0 0 1 0 0 1 1 3 3 7 Sickness rate monthly on total medical/dental headcount 2.77% 1.14% 0.33% 0.73% 1.27% 0.75% 0.61% 0.46% 1.29% 1.03% 0.55% 0.88% 0.86% 0.82% 88.80% Appraisal rate monthly (exclude deanery trainees) 82.98% 80.33% 82.39% 90.63% 86.00% 86.30% 81.76% 75.56% 82.35% 83.60% 90.38% 87.90 83.19% Mar 17 Mandatory training monthly 95% 81% 83% 85% 84% 84% 84% 85% 82% 85% 84% 83% 84% 84% Exception Reporting – Education and Training 0 0 0 0 0 0 0 0 1 0 0 0 1 Exception Reporting – Hours 0 0 0 0 0 0 5 0 0 0 0 1 6
There are currently 97 doctors for whom the QVH is their designated body. The completed appraisal rate for 2017/18 was 83.6%. All doctors are revalidated with a licence to practice. 12 positive recommendations for revalidation have been submitted in the previous two months, with currently no deferrals. Medical & Dental An AAC for a consultant appointment in Sleep Studies was held on the 2nd July. Dr Neil Munro and Dr Deirdre O'Rourke were appointed, Staffing sharing a one whole time equivalent job. Electronic job planning has been completed. This has resulted in a significant cost pressure, as several job plans were significantly out of date, and on-call were not being remunerated to reflect current expectations.
The GMC National Training Survey was published in July 2018, and is subject to a separate paper at Quality and Governance Committee. Results are improved on the position in 2017, particularly in OMFS and anaesthesia. 50% of domains for core surgical training were in the lower quartile, and this area requires ongoing improvement. Appointment of a new rota coordinator, a new Clinical Tutor and a new Education consultant rota supervisor is already have a beneficial effect, and in particular, the transformation of induction in August, led by Miss O'Neill, has been significant. Health Education England London visit on 10th September 2018, focusing on core surgical training and plastic surgery training.
QVH BOD September 2018: Session in public Page 104 of 260 NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries BURNS WARD Quart Quarter 3 Quarter 4 Quarter 1 Quarter 2 2017/18 Year to No. Indicator Description total/ Target er 2 2017/18 2017/18 2018/19 2018/19 Date Trend Comments average Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Actual SAFE 1 Total reported - All incidents 139 _ 13 13 14 9 7 19 8 11 8 12 17 131 2 Total reported - Patient safety 45 _ 4 6 5 3 3 8 2 7 2 7 4 51 Incidents 3 Internal investigation (Amber or Red) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 1 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 12 0 0 1 0 1 1 5 1 1 0 1 0 11 Falls 6 Falls - With harm 1 0 0 0 0 0 0 0 0 0 0 1 0 1 7 Pressure Damage G2 or above (hospital acquired) 1 0 1 0 0 0 0 0 0 0 0 0 0 1 8 Inoculation Injury Reported incidents 1 0 1 0 0 0 0 0 0 0 0 0 0 1 9 Elective patients 99.5% 95% 100% 100% 100% 100% 100% 100% 94% 93% 100% 94% 100% 98% 10 MRSA Screening Trauma patients 99.3% 95% 100% 91% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% 11 Reported cases 0 0 0 0 0 0 0 0 0 0 1 0 0 1 12 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13 Hand hygiene 94% 95% 93% N/S 73% N/S 100% 90% N/S 100% 100% 100% N/S 94% Hand Hygiene 14 Bare below the elbows 100% 95% 100% N/S 100% N/S 100% 100% N/S 100% 100% 100% N/S 100% 15 Drug Assessments % staff compliant 97% 100% 89% 100% 100% 100% 100% 100% 100% 85% 87% 100% 100% 96% 16 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 17 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 18 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 19 Medication Errors Reported errors 9 0 2 2 2 0 0 0 0 1 0 1 0 8 20 Harm Free Care % 98.3% 95% 100% 100% 100% 100% 100% 100% 100% 86% 100% 83% 100% 100% 97% Safety Thermometer 21 New Harm Free % 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 83% 100% 100% 99% 22 Assessment of patients (S. Therm) 99% 95% 100% 100% 100% 100% 100% 86% 100% 100% 100% 100% 50% 100% 95% VTE (Venous 23 24 hour follow up (S. Therm) 95.5% 95% n/a 100% 100% 100% 67% 83% 100% 100% 100% 100% 25% 100% 89% thromboembolism) 24 Monthly screening % (Informatics) 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
25 Shift meets requirement RN 96.7% 95% 98% 99% 93% 97% 91% 96% 98% 98% 97% 96% 97% 96% Staff skill mix in conjunction with patient acuity - current 26 Day % HCA 96.6% 95% 100% 100% 95% 84% 98% 100% 100% 100% 100% 64% 97% 94% vacancies, bank filled where possible 27 Shift meets requirement RN 95.7% 95% 95% 94% 90% 98% 82% 97% 102% 95% 98% 100% 97% 95% 28 Night % HCA 106.3% 95% 100% 100% 100% 100% 100% 175% 100% 100% 163% 100% 100% 113% EFFECTIVE
29 Nutrition Assessment Initial (Safety Thermometer) 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 83% 100% 100% 100% 99% 30 (MUST) 7 day review (Safety Thermometer) 100% 95% n/a 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Compliance in Practice 31 Inspection score 80%Reported 1/4ly Reported 1/4ly Reported 1/4ly 92.1% Reported 1/4ly 92% (CiP) CARING 32 Patient numbers (eligible to respond) 652 _ 41 57 52 64 62 62 56 69 65 74 52 654 Data collection increased greatly, situation noted to 33 % return rate 45% 40% 100% 37% 31% 38% 16% 42% 21% 6% 31% 7% 31% 33% Friends & Family Test Matron and team, required to be maintained. 34 % recommendation (v likely/likely) 98.3% 90% 92% 100% 100% 100% 96% 100% 92% 100% 85% 100% 100% 97% 35 % unlikely/extremely unlikely 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% QVH BOD September 2018: Session in public Page 105 of 260 Nursing Quality Metrics Data RESPONSIVE 36 Complaints No. recorded 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WELL-LED 37 Full Team WTE #DIV/0! Total establishment for ward = 30.72 WTE Vacancy 38 Vacancy WTE 6.43 10% 7.91 2.88 1.91 2.51 6.12 5.43 6.03 7.05 6.72 6.72 6.48 5.4 Establishment= 39 Vacancy (hrs) 1044.88 10% 1285 468 310 407 994.5 882 979 1145 1092 1092 1053 882.5 40 Temporary Staffing Agency Use 99.1 10% 69 121 46 11.5 69 161 384 226 425 107.5 266.25 171.48 41 excluding RMN Bank Use 360.1 10% 426 447 249 200 279 444 384.5 233 349 418 587.75 365.2 42 Hours 103.5 79.25 91.375 Sickness 43 % 3.1% 2% 3.8% 3.1% 2.9% 4.3% 6.6% 1.7% 4.6% 1.6% 1.0% 2.1% 1.6% 3.0% All sickness managed via policy currently 44 Maternity Hours #DIV/0! 45 Budget Position YTD Position >0 -1539 26714 55353 70673 85983 166689 249483 41143 62409 -39429 -44803 672676 Matron has communicated with all staff improvement of 46 Mandatory training 89.6% 95% 92% 90% 82% 93% 93% 91% 89% 91% 89% 89% 91% 90% CMTD required. Appraisals outstanding being Statutory & Mandatory completed.
47 Appraisal 87.1% 95% 93% 87% 92% 84% 84% 90% 90% 79% 82% 93% 92% 88% 48 Uniform Audit Compliance with uniform policy % 95% #DIV/0!
QVH BOD September 2018: Session in public Page 106 of 260 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries CORNEOPLASTIC OPD Quart Quarter 3 Quarter 4 Quarter 1 Quarter 2 2017/18 Year to No. Indicator Description total/ Target er 2 2017/18 2017/18 2018/19 2018/19 Date Trend Comments average Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Actual SAFE 1 Total reported - All incidents 86 _ 4 4 6 6 11 5 11 6 8 3 11 75 2 Total reported - Patient safety 29 _ 0 1 4 3 4 2 4 5 2 0 7 32 Incidents 3 Internal investigation (Amber or Red) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Falls 6 Falls - With harm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 Inoculation Injury Reported incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 MRSA Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11 Hand hygiene 100% 95% 100% N/S 100% 100% 100% 100% 100% 100% 100% 100% 93% 99% Hand Hygiene 12 Bare below the elbows 100% 95% 100% N/S 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 13 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 14 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 15 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 This relates to doctors prescribing - improvement in 16 Medication Errors Reported errors 18 0 0 1 1 3 1 1 2 4 2 0 4 19 month EFFECTIVE Compliance in Practice 17 Inspection score 80%Reported 1/4ly 80.1% Reported 1/4ly 90.7% Reported 1/4ly 85% (CiP) CARING 18 Patient numbers (eligible to respond) _ 1995 2280 1663 1667 2081 1633 1819 2007 2165 2020 2288 21618 Unit to raise awareness to patients to increase response 19 % return rate 22.8% 20% 22% 22% 24% 26% 23% 22% 20% 21% 21% 20% 24% 22% Friends & Family Test rate 20 % recommendation (v likely/likely) 94.7% 90% 95% 94% 96% 93% 94% 95% 94% 92% 93% 93% 91% 94% 21 % unlikely/extremely unlikely 1.3% 0% 2% 1% 1% 2% 2% 0% 2% 3% 2% 2% 4% 2% RESPONSIVE 22 Complaints No. recorded 4 0 0 0 1 0 0 0 1 0 1 1 2 6 Response provided - late clinic cancellations
QVH BOD September 2018: Session in public Page 107 of 260 Nursing Quality Metrics Data WELL-LED 23 Full Team WTE #DIV/0! Vacancy 24 Vacancy WTE 10% 1.91 1.91 3.11 2.8 2.48 2.48 2.4 Nursing establishment = 20.12 WTE Establishment= 25 Vacancy (hrs) 10% 310.4 310.4 505.4 455 403 403 397.87 26 Temporary Staffing Agency Use 10% 0 0 0 0 0 0 0 27 excluding RMN Bank Use 10% 407.4 206.5 125.5 173.5 170.5 168 208.57 28 Hours 27.5 30 0 17 47.5 0 20.333 Sickness 29 % 2% 0.5% 0.9% 0.0% 0.8% 1.5% 0.0% 0.6% 30 Maternity Hours 0 0 0 0 0 0 0 31 Budget Position YTD Position >0 92109 117732 19631 34880 49650 65400 379402 32 Mandatory training 95% 97% 97% 96% 94% 92% 91% 94% Matron addressing issues with staff compliance Statutory & Mandatory Significiant improvement, situation noted with Matron 33 Appraisal 95% 95% 95% 100% 95% 90% 95% 95%
34 Uniform Audit Compliance with uniform policy % 95% #DIV/0!
QVH BOD September 2018: Session in public Page 108 of 260 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries CRITICAL CARE UNIT Quart Quarter 3 Quarter 4 Quarter 1 Quarter 2 2017/18 Year to No. Indicator Description total/ Target er 2 2017/18 2017/18 2018/19 2018/19 Date Trend Comments average Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Actual SAFE 1 Total reported - All incidents 147 _ 8 6 12 14 16 13 9 16 11 16 8 129 2 Total reported - Patient safety 100 _ 6 4 6 8 11 8 5 10 6 11 8 83 Incidents 3 Internal investigation (Amber or Red) 4 0 1 0 0 0 0 0 0 1 0 0 0 2 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Patient in bathroom, patient refused to wear slipper 5 Falls - All 2 0 0 0 0 0 0 0 0 1 0 1 0 2 Falls socks 6 Falls - With harm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 Pressure Damage G2 or above (hospital acquired) 4 0 1 0 0 1 0 0 0 0 1 0 0 3 8 Inoculation Injury Reported incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 Elective patients 100% 95% n/a 100% n/a 100% 100% n/a 100% 100% n/a n/a 100% 10 MRSA Screening Trauma patients 89.1% 95% 100% 100% 100% 0% 80% 100% n/a 100% 100% 100% 87% 11 Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13 Hand hygiene 90.4% 95% 81% 87% 100% 100% 90% 78% 90% 100% 100% 90% 93% 92% Hand Hygiene 14 Bare below the elbows 98.8% 95% 100% 100% 100% 100% 100% 100% 90% 100% 100% 100% 93% 98% 15 Drug Assessments % staff compliant 95.9% 100% 100% 81% 88% 88% 94% 100% 100% 100% 100% 88% 93% 94% 16 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 17 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 18 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 19 Medication Errors Reported errors 4 0 0 0 0 1 1 0 0 0 2 0 0 4 20 Harm Free Care % 92.5% 95% 100% 100% 100% 100% 100% 67% 50% 100% 100% 100% 100% 100% 93% Safety Thermometer 21 New Harm Free % 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 22 Assessment of patients (S. Therm) 95.5% 95% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 100% 100% 96% VTE (Venous 23 24 hour follow up (S. Therm) 80% 95% 100% n/a 100% 100% 100% 100% 0% 33% 0% 100% 100% 100% 76% thromboembolism) 24 Monthly screening % (Informatics) 100% 95% 100% n/a 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 25 Shift meets requirement RN 96.8% 95% 99% 92% 96% 92% 100% 98% 96% 90% 96% 99% 90% 95% 26 Day % HCA 96.1% 95% 94% 100% 97% 93% 92% 95% 104% 94% 118% 91% 96% 98% short notice sickness 27 Shift meets requirement RN 88.5% 95% 83% 69% 94% 81% 94% 90% 91% 89% 99% 96% 88% 89% 28 Night % HCA 90.0% 95% 100% 125% 65% 53% 71% 86% 80% 400% 113% 50% 50% 108% HCAs booked to reflect patient acuity EFFECTIVE Compliance improved and noted 29 Nutrition Assessment Initial (Safety Thermometer) 90.9% 95% 100% 100% 100% 100% 100% 100% 50% 67% 100% 100% 100% 100% 93% 30 (MUST) 7 day review (Safety Thermometer) 89.3% 95% 100% n/a 75% n/a 50% n/a 100% 100% n/a 0% n/a n/a 71% Compliance in Practice 31 Inspection score 80%Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly #DIV/0! (CiP) CARING
QVH BOD September 2018: Session in public Page 109 of 260 Nursing Quality Metrics Data RESPONSIVE 32 Complaints No. recorded 2 0 0 0 0 0 0 1 1 0 0 0 0 2 WELL-LED 33 Full Team WTE #DIV/0! Vacancy 34 Vacancy WTE 9.32 10% 11.28 5.65 5.01 6.01 9.16 9.16 11.97 9.66 9.59 11.01 10.48 9.0 Ward Establishment = 29.37 WTE Establishment= 35 Vacancy (hrs) 1514.2 10% 1833 918 814 976 1488 1488 1945 1570 1558 1789 1703 1462 36 Temporary Staffing Agency Use 595.5 10% 839.5 444 827.5 482 689 641 846 950 1035 976.5 918 786.23 37 excluding RMN Bank Use 222.9 10% 182.5 175 223 149 316 410 353.5 226 246 172 171 238.55 38 Hours 360.5 360.5 Sickness Long term sickness staff, being managed within policy, 39 % 1.9% 2% 2.2% 2.3% 2.5% 4.1% 1.7% 3.0% 3.2% 7.7% 7.5% 5.0% 7.7% 4.3% alongside the short term sickness. 40 Maternity Hours #DIV/0! 41 Budget Position YTD Position >0 9594 -943 11190 25981 93023 93265 69733 -91455 -30308 -33259 -108905 37916 Difficulty in staff attendance due to vacancies, long term 42 Mandatory training 88% 95% 93% 89% 88% 90% 90% 90% 87% 85% 86% 86% 87% 88% sick and mat leave. Matron working to address. Statutory & Mandatory 43 Appraisal 90.8% 95% 100% 94% 91% 91% 91% 86% 72% 68% 77% 81% 90% 85% Compliance improving 44 Uniform Audit Compliance with uniform policy % 95% #DIV/0!
QVH BOD September 2018: Session in public Page 110 of 260 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries MAIN OUTPATIENTS Quart Quarter 3 Quarter 4 Quarter 1 Quarter 2 2017/18 Year to No. Indicator Description total/ Target er 2 2017/18 2017/18 2018/19 2018/19 Date Trend Comments average Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Actual SAFE 1 Total reported - All incidents 134 _ 8 8 8 10 12 24 16 11 7 14 12 130 2 Total reported - Patient safety 28 _ 2 0 5 1 2 4 3 2 2 1 3 25 Incidents 3 Internal investigation (Amber or Red) 1 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 1 0 0 0 0 0 0 1 0 0 0 0 1 2 Falls 6 Falls - With harm 1 0 0 0 0 0 0 1 0 0 0 0 1 2 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 Inoculation Injury Reported incidents 3 0 0 0 0 2 1 0 0 0 0 0 0 3 9 MRSA Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 This is dependant upon MDT collaboration. Departmental 11 Hand hygiene 84.8% 95% 94.7% 93% 56% 70% 56% 70% 86% 100% 89% N/S 80% 79% Matron working with staff to increase compliance and Hand Hygiene escalate issues to HoN. 12 Bare below the elbows 96.3% 95% 100% 77% 89% 90% 100% 100% 100% 100% 100% N/S 100% 96% 13 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 14 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 15 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 16 Medication Errors Reported errors 1 0 0 0 0 0 0 0 1 0 0 0 0 1 EFFECTIVE Compliance in Practice 17 Inspection score 80%Reported 1/4ly 82.1% 89.1% 90.3% Reported 1/4ly 87% (CiP) CARING
18 Patient numbers (eligible to respond) _ 12635 13767 11446 11458 13356 11446 11984 12479 12729 12866 12975 137141 Matron working closely with staff to increase compliance and response rate as remains static. Often challenging 19 % return rate 16.3% 20% 17% 16% 16% 17% 18% 17% 18% 17% 16% 16% 16% 17% Friends & Family Test when patients return several times within pathway.
20 % recommendation (v likely/likely) 94.4% 90% 94% 94% 95% 94% 95% 95% 94% 94% 95% 94% 94% 94% 21 % unlikely/extremely unlikely 2.3% 0% 2% 2% 2% 3% 2% 2% 3% 2% 2% 2% 2% 2% RESPONSIVE 22 Complaints No. recorded 4 0 1 0 0 0 1 1 0 0 0 1 0 4 awaiting data
QVH BOD September 2018: Session in public Page 111 of 260 Nursing Quality Metrics Data WELL-LED 23 Full Team WTE #DIV/0! Vacancy 24 Vacancy WTE 10% 1.26 1.22 1.18 1.18 1.81 1.3 Establishment = 15.50 WTE Establishment= 25 Vacancy (hrs) 10% 204.75 198.25 191.7 191.7 294.12 216.1 26 Temporary Staffing Agency Use 10% 0 0 0 0 0 0 27 excluding RMN Bank Use 10% 304.5 231.25 310.5 321.75 192.75 272.15 28 Hours 139 48 93.5 Sickness Long term sickness as well as short term, being 29 % 2% 5.3% 5.7% 8.9% 5.5% 1.9% 5.5% managed within the policy. 30 Maternity Hours 0 0 0 0 0 0 31 Budget Position YTD Position >0 117894 -7780 -6392 -12043 -8463 83216 Position improved significantly, feedback given to Matron 32 Mandatory training 95% 90% 91% 90% 94% 97% 92% Statutory & Mandatory and team 33 Appraisal 95% 85% 90% 90% 80% 89% 87% Requires some improvement, working with Matron 34 Uniform Audit Compliance with uniform policy % 95% #DIV/0!
QVH BOD September 2018: Session in public Page 112 of 260 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries MARGARET DUNCOMBE Quart Quarter 3 Quarter 4 Quarter 1 Quarter 2 2017/18 Year to No. Indicator Description total/ Target er 2 2017/18 2017/18 2018/19 2018/19 Date Trend Comments average Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Actual SAFE 1 Total reported - All incidents 180 _ 15 14 18 18 17 15 12 14 13 8 13 157 2 Total reported - Patient safety 118 _ 7 10 11 9 12 12 7 9 11 4 9 101 Incidents 3 Internal investigation (Amber or Red) 0 0 0 0 0 0 0 0 0 0 1 0 2 3 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 14 0 0 0 1 2 2 1 1 0 2 0 2 11 No harm, under investigation Falls 6 Falls - With harm 4 0 0 0 0 0 0 1 0 0 1 0 0 2 In process of investigation for these 2. Also new TVN for 7 Pressure Damage G2 or above (hospital acquired) 1 0 0 0 0 0 0 0 0 0 0 0 2 2 QVH now in post 8 Inoculation Injury Reported incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 Elective patients 97.4% 95% 98% 93% 94% 91% 100% 100% 97% 100% 98% 98% 98% 97% Matron working with Educator to sustain. HON and 10 MRSA Screening Trauma patients 95.4% 95% 94% 98% 93% 92% 93% 97% 100% 94% 93% 96% 100% 95% Educator have started a refresher 1-1 training plan - now in progress
11 Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13 Hand hygiene 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Hand Hygiene 14 Bare below the elbows 94.7% 95% 100% 100% 100% 93% 100% 60% 100% 100% 80% 100% 100% 94% 15 Drug Assessments % staff compliant 99.7% 100% 100% 100% 100% 100% 100% 100% 96% 100% 100% 100% 100% 100% 16 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 17 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 18 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 19 Medication Errors Reported errors 34 0 4 8 6 1 2 2 1 3 4 2 0 33 20 Harm Free Care % 99.4% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 93% 100% 99% Reflect above incidents - being investigated Safety Thermometer 21 New Harm Free % 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 93% 100% 99% HON and Educator have started a refresher 1-1 training 22 Assessment of patients (S. Therm) 99.1% 95% 100% 100% 100% 100% 100% 100% 89% 100% 92% 100% 87% 100% 97% plan - now in progress Matron leading on discussions with staff. HoN reviewed VTE (Venous data, 2/10 done within 24 hours, but others done after. 23 thromboembolism) 24 hour follow up (S. Therm) 89.3% 95% 100% 100% 89% 92% 54% 67% 80% 73% 42% 20% 82% 57% 71% HON and Educator have started a refresher 1-1 training plan - now in progress
24 Monthly screening % (Informatics) 97.4% 95% 99% 100% 96% 96% 99% 98% 86% 99% 96% 99% 99% 97% 25 Shift meets requirement RN 97.3% 95% 100% 98% 98% 95% 98% 97% 90% 96% 98% 99% 99% 97% 26 Day % HCA 99.5% 95% 100% 105% 102% 100% 104% 93% 107% 100% 102% 104% 98% 101% 27 RN 94.8% 95% 96% 93% 98% 88% 95% 97% 94% 101% 100% 96% 96% 96% Shift meets requirement Mixture of no show agency on the shift as well as shifts 28 Night % HCA 86.4% 95% 90% 68% 77% 88% 91% 88% 85% 94% 103% 86% 82% 87% not filled. Managed on the shift and agencies followed up
QVH BOD September 2018: Session in public Page 113 of 260 Nursing Quality Metrics Data EFFECTIVE Matron leading on discussions with staff. Educator 29 Initial (Safety Thermometer) 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 92% 80% 100% 98% involved. HON and Educator have started a refresher 1- Nutrition Assessment 1 training plan - now in progress (MUST) Matron leading on discussions with staff. Educator 30 7 day review (Safety Thermometer) 70.8% 95% 100% 100% 0% 67% 50% 100% 0% 100% 100% 100% 80% 33% 69% involved. HON and Educator have started a refresher 1- 1 training plan - now in progress Compliance in Practice 31 Inspection score 80%Reported 1/4ly 87.4% 86.8% Reported 1/4ly Reported 1/4ly 87% (CiP) CARING 32 Patient numbers (eligible to respond) 1737 _ 144 139 146 122 129 133 109 144 124 125 128 1443 33 % return rate 60.8% 40% 54% 49% 31% 77% 78% 63% 76% 63% 71% 55% 58% 61% Friends & Family Test 34 % recommendation (v likely/likely) 98.1% 90% 96% 100% 100% 95% 99% 96% 99% 100% 99% 99% 100% 98% 35 % unlikely/extremely unlikely 0.1% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% RESPONSIVE 36 Complaints No. recorded 1 0 0 0 0 0 0 1 0 0 0 0 1 2 WELL-LED 37 Full Team WTE 50.18 50.18 50.18 48.8 48.8 49.44 49.44 49.44 49.08 48.67 49.04 49.4 Vacancy 38 Vacancy WTE 8.2 10% 11.82 5.62 6.55 7.41 9.79 8.92 10.02 11.46 11.21 11.13 12.16 9.6 Establishment= 35 hours bank/agency used than 39 Vacancy (hrs) 1332.9 10% 1921 913 1064 1204 1590 1450 1628 1862 1822 1808 1976 1567.1 vacancy/sickness/maternity hours. Staffing above template required during busier than normal shifts, such as weekends. Agency and Bank 40 Temporary Staffing Agency Use 546.7 10% 464.5 331 799 968 1045 874 1229 1522.5 1464 1242.5 1207 1013.3 Usage less than Vacancies, sickness and maternity excluding RMN hours. 41 Bank Use 485 10% 360.5 541.5 732 302 557 553 827.5 736 940 899 901 668.14 42 Hours 56.5 370 250 310 439.5 596 448 312.5 121 306 132 303.77 Sickness 43 % 3.7% 2% 0.5% 4.6% 3.1% 3.9% 5.5% 7.4% 5.6% 3.8% 1.5% 3.8% 1.6% 3.7% 44 Maternity Hours 266 116 107 185 185 185 185 185 127 69 69 152.64 45 Budget Position YTD Position >0 47794 63502 72524 61585 36168 36 -20622 -49366 -72573 -96771 42277 46 Mandatory training 95% 95% 95% 94.8% 91% 93% 95% 96% 93% 95% 93% 90% 94% Educator and matron working on this Statutory & Mandatory 47 Appraisal 95% 91% 94% 94% 100% 98% 82% 83% 88% 95% 94% 88% 91% Educator and matron working on this 48 Uniform Audit Compliance with uniform policy % 95% #DIV/0!
QVH BOD September 2018: Session in public Page 114 of 260 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries MAX FAC OUTPATIENTS Quart Quarter 3 Quarter 4 Quarter 1 Quarter 2 2017/18 Year to No. Indicator Description total/ Target er 2 2017/18 2017/18 2018/19 2018/19 Date Trend Comments average Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Actual SAFE 1 Total reported - All incidents 30 _ 4 3 4 3 2 5 5 4 5 5 3 43 2 Total reported - Patient safety 8 _ 1 2 1 2 0 0 1 2 1 0 0 10 Incidents 3 Internal investigation (Amber or Red) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Falls 6 Falls - With harm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 Inoculation Injury Reported incidents 2 0 0 0 0 0 1 0 0 0 1 0 0 2 9 MRSA Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11 Hand hygiene 100% 95% 100% 100% 100% 100% 100% 100% 100% 90% 100% N/S 100% 99% Hand Hygiene 12 Bare below the elbows 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% N/S 100% 100% 13 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 14 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 15 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 16 Medication Errors Reported errors 2 0 0 1 0 1 0 0 0 0 1 0 0 3 Improvement noted EFFECTIVE Compliance in Practice 17 Inspection score 80%Reported 1/4ly Reported 1/4ly 83.3% 90.4% Reported 1/4ly 87% (CiP) CARING 18 Patient numbers (eligible to respond) _ 1235 1336 1440 1238 1379 1302 1436 1542 1589 1378 1477 15352 Discussed with team, aware to encourage patients to complete to improve this data and understand where 19 % return rate 17.9% 20% 18% 18% 17% 18% 19% 17% 17% 18% 18% 17% 17% 18% Friends & Family Test learning can take place etc. to improve our services.
20 % recommendation (v likely/likely) 92.3% 90% 91% 91% 92% 91% 95% 94% 91% 91% 92% 93% 94% 92% 21 % unlikely/extremely unlikely 3.1% 0% 5% 4% 2% 4% 2% 2% 4% 4% 2% 1% 1% 3% RESPONSIVE 22 Complaints No. recorded 13 0 1 0 1 0 3 2 0 1 2 1 2 13
QVH BOD September 2018: Session in public Page 115 of 260 Nursing Quality Metrics Data WELL-LED 23 Full Team WTE #DIV/0! Vacancy 24 Vacancy WTE 10% 0.79 2.39 0.76 1.76 1.76 1.76 1.5 Departmental Establishment = 21.37 WTE Establishment= 25 Vacancy (hrs) 10% 128.37 388 123.5 286 286 286 249.65 26 Temporary Staffing Agency Use 10% 0 0 0 0 0 0 0 27 excluding RMN Bank Use 10% 274.37 24 177 214 245 115.5 174.98 28 Hours 120.5 133.8 127.15 Sickness 29 % 2% 5.5% 0.5% 5.0% 2.2% 3.5% 3.8% 3.4% 30 Maternity Hours #DIV/0! 31 Budget Position YTD Position >0 8270 22807 -4197 -913 1333 3754 31054 32 Mandatory training 95% 93% 90% 92% 89% 92% 88% 91% HoN working with team to improve compliance Statutory & Mandatory 33 Appraisal 95% 85% 85% 100% 88% 90% 92% 90% HoN working with team to improve compliance 34 Uniform Audit Compliance with uniform policy % 95% #DIV/0!
QVH BOD September 2018: Session in public Page 116 of 260 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries PEANUT WARD Quart Quarter 3 Quarter 4 Quarter 1 Quarter 2 2017/18 Year to No. Indicator Description total/ Target er 2 2017/18 2017/18 2018/19 2018/19 Date Trend Comments average Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Actual SAFE 1 Total reported - All incidents 100 _ 11 11 14 9 10 13 2 7 30 28 25 160 2 Total reported - Patient safety 26 _ 3 1 3 2 3 2 0 0 4 3 1 22 Incidents 3 Internal investigation (Amber or Red) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 0 0 0 0 0 0 0 0 0 0 1 0 0 1 Falls 6 Falls - With harm 0 0 0 0 0 0 0 0 0 0 1 0 0 1 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 Inoculation Injury Reported incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 MRSA Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11 Hand hygiene 98.8% 95% N/S 94% N/S N/S 100% N/S N/S N/S N/S 70% 44% 77% Hand Hygiene 12 Bare below the elbows 98.2% 95% N/S 91% N/S N/S 100% N/S N/S N/S N/S 90% 100% 95% 13 Drug Assessments % staff compliant 99.5% 100% 100% 100% 100% 100% 100% 100% 94% 100% 100% 94% 94% 98% plan requested from ward matron 14 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 15 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 16 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 17 Medication Errors Reported errors 5 0 0 1 0 1 0 0 0 0 1 1 0 4 18 Harm Free Care % 100% 95% n/a 100% n/a n/a 100% n/a n/a 100% 100% 100% 100% 100% 100% Safety Thermometer 19 New Harm Free % 100% 95% n/a 100% n/a n/a 100% n/a n/a 100% 100% 100% 100% 100% 100% 20 Total no. of ward patients _ 189 180 194 176 178 226 145 1288 21 BMI Monthly No. patients screened & documented _ 171 172 187 171 171 208 143 1223 22 Patients with documented BMI % 95% #DIV/0! #DIV/0! #DIV/0! 90% 96% 96% 97% 96% 92% 99% #DIV/0! #DIV/0! 95% 23 Shift meets requirement RN 96.8% 95% 99% 101% 93% 87% 100% 99% 96% 94% 100% 95% 98% 97% 24 Day % HCA 98.0% 95% 97% 91% 100% 100% 91% 103% 100% 108% 97% 103% 96% 99% 25 Shift meets requirement RN 61.9% 95% 49% 67% 45% 55% 92% 88% 93% 83% 98% 84% 85% 76% 26 Night % HCA 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% EFFECTIVE Compliance in Practice 27 Inspection score 80%Reported 1/4ly 88.7% 88.1% 91.1% Reported 1/4ly 89% (CiP) CARING 28 Patient numbers (eligible to respond) 2340 _ 196 191 195 181 173 192 171 172 224 199 201 2095 29 % return rate 28.2% 40% 30% 18% 31% 33% 31% 34% 40% 42% 37% 33% 28% 32% Friends & Family Test 30 % recommendation (v likely/likely) 99.3% 90% 100% 97% 98% 97% 100% 100% 100% 99% 93% 98% 98% 98% 31 % unlikely/extremely unlikely 0.2% 0% 0% 0% 0% 2% 0% 0% 0% 0% 0% 0% 1% 0%
QVH BOD September 2018: Session in public Page 117 of 260 Nursing Quality Metrics Data RESPONSIVE 32 Complaints No. recorded 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WELL-LED 33 Full Team WTE #DIV/0! Vacancy 34 Vacancy WTE 3.3 10% 3.89 2.45 2.45 0.93 0 0 0 0.24 1.24 1.5 1.18 1.3 Establishment= 35 Vacancy (hrs) 542.9 10% 632 398 398 151 0 0 0 39 201.5 244 191.75 205.02 36 Temporary Staffing Agency Use 92.2 10% 236 197 17.5 57 22.5 10 1 28 110 71 92.5 76.591 37 excluding RMN Bank Use 273.8 10% 324.5 369 437.5 168 229 217 34 192 413 472.5 488.4 304.08 38 Hours 161.5 84 122.75 Sickness 39 % 5.5% 2% 8.7% 12.0% 5.6% 7.9% 4.5% 6.8% 3.6% 4.0% 1.0% 4.9% 2.6% 5.6% 40 Maternity Hours #DIV/0! 41 Budget Position YTD Position >0 -6253 1682 23045 811 -13480 -14325 -6784 99 5968 7514 -1723 42 Mandatory training 95% 86% 86% 84% 83% 83% 88% 88% 92% 92% 93% 93% 88% Statutory & Mandatory 43 Appraisal 95% 83% 79% 75% 75% 75% 77% 72% 80% 83% 91% 91% 80% 44 Uniform Audit Compliance with uniform policy % 95% #DIV/0!
QVH BOD September 2018: Session in public Page 118 of 260 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries ROSS TILLEY Quart Quarter 3 Quarter 4 Quarter 1 Quarter 2 2017/18 Year to No. Indicator Description total/ Target er 2 2017/18 2017/18 2018/19 2018/19 Date Trend Comments average Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Actual SAFE 1 Total reported - All incidents 194 _ 10 16 24 21 26 16 12 11 15 10 18 179 2 Total reported - Patient safety 111 _ 5 8 14 14 20 8 9 7 7 9 8 109 Incidents 3 Internal investigation (Amber or Red) 1 0 0 0 0 0 1 0 0 0 0 0 0 1 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 19 0 0 0 5 1 4 2 0 1 1 2 0 16 Falls 6 Falls - With harm 1 0 0 0 0 0 0 0 0 0 0 0 0 0 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 0 0 0 0 0 1 0 0 0 1 8 Inoculation Injury Reported incidents 2 0 0 0 1 0 0 0 0 0 0 0 0 1 9 Elective patients 97.8% 95% 100% 98% 100% 100% 98% 94% 95% 97% 94% 100% 100% 98% 10 MRSA Screening Trauma patients 97.2% 95% 96% 96% 98% 100% 99% 96% 99% 99% 97% 97% 95% 97% 11 Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13 Hand hygiene 100% 95% 100% 100% 100% 100% N/S 100% 100% 100% 100% 100% 100% 100% Hand Hygiene 14 Bare below the elbows 97.4% 95% 100% 100% 100% 87% N/S 100% 100% 87% 80% 100% 100% 95% 15 Drug Assessments % staff compliant 99.7% 100% 100% 100% 100% 100% 100% 100% 96% 100% 100% 100% 100% 100% 16 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 17 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 18 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 19 Medication Errors Reported errors 40 0 2 4 5 6 3 3 5 3 2 1 3 37 20 Harm Free Care % 99.4% 95% 100% 100% 93% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% Safety Thermometer 21 New Harm Free % 99.4% 95% 100% 100% 93% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% HON and Educator have started a refresher 1-1 training 22 Assessment of patients (S. Therm) 98.6% 95% 100% 100% 100% 94% 89% 100% 100% 100% 100% 93% 95% 100% 98% plan - now in progress Matron leading on discussions with staff. HoN reviewed VTE (Venous data, 2/10 done within 24 hours, but others done after. 23 thromboembolism) 24 hour follow up (S. Therm) 87.8% 95% 100% 100% 71% 88% 83% 60% 50% 93% 53% 46% 88% 64% 75% HON and Educator have started a refresher 1-1 training plan - now in progress
24 Monthly screening % (Informatics) 97.8% 95% 99% 99% 98% 96% 99% 99% 94% 98% 96% 94% 97% 97% 25 Shift meets requirement RN 97.8% 95% 99% 102% 99% 91% 95% 97% 93% 98% 96% 98% 100% 97% 26 Day % HCA 97.3% 95% 100% 100% 93% 96% 91% 102% 96% 102% 96% 98% 96% 97% Mixture of no show agency on the shift as well as shifts 27 Shift meets requirement RN 93.1% 95% 104% 93% 95% 89% 89% 95% 96% 93% 93% 90% 88% 93% not filled. Managed on the shift and agencies followed up Night % 28 HCA 86.0% 95% 81% 67% 79% 73% 86% 96% 100% 100% 90% 97% 88% 87% EFFECTIVE HON and Educator have started a refresher 1-1 training 29 Initial (Safety Thermometer) 98.9% 95% 100% 100% 93% 100% 100% 94% 100% 100% 100% 100% 100% 100% 99% plan Nutrition Assessment Matron leading on discussions with staff. Educator (MUST) 30 7 day review (Safety Thermometer) 84.5% 95% 75% 100% 50% 80% 100% 100% 25% 100% 100% n/a 75% 100% 82% involved. HON and Educator have started a refresher 1- 1 training plan - now in progress Compliance in Practice 31 Inspection score 80%Reported 1/4ly 90.6% 86.6% Reported 1/4ly Reported 1/4ly 89% (CiP) QVH BOD September 2018: Session in public Page 119 of 260 Nursing Quality Metrics Data CARING 32 Patient numbers (eligible to respond) 2418 _ 199 209 219 181 215 174 174 174 193 203 196 2137 33 % return rate 47.1% 40% 54% 56% 24% 79% 55% 43% 58% 60% 39% 39% 29% 49% Friends & Family Test 34 % recommendation (v likely/likely) 97.9% 90% 97% 97% 98% 99% 97% 99% 99% 95% 100% 95% 100% 98% 35 % unlikely/extremely unlikely 0.3% 0% 1% 0% 0% 0% 0% 0% 0% 2% 0% 1% 0% 0% RESPONSIVE 36 Complaints No. recorded 2 0 0 1 0 0 0 0 1 0 1 0 0 3 WELL-LED 37 Full Team WTE 50.18 50.18 50.18 48.8 48.8 49.44 49.44 49.44 49.08 48.67 49.04 49.4 Vacancy 38 Vacancy WTE 8.2 10% 11.82 5.62 6.55 7.41 9.79 8.92 10.02 11.46 11.21 11.13 12.16 9.6 Establishment= 35 hours bank/agency used than 39 Vacancy (hrs) 1332.9 10% 1921 913 1064 1204 1590 1450 1628 1862 1822 1808 1976 1567.1 vacancy/sickness/maternity hours. Staffing above template required during busier than normal shifts, such as weekends. Agency and Bank 40 Temporary Staffing Agency Use 546.7 10% 464.5 331 799 968 1045 874 1229 1522.5 1464 1242.5 1207 1013.3 Usage less than Vacancies, sickness and maternity excluding RMN hours. 41 Bank Use 485 10% 360.5 541.5 732 302 557 553 827.5 736 940 899 901 668.14 42 Hours 56.5 370 250 310 439.5 596 448 312.5 121 306 132 303.77 Sickness 43 % 3.7% 2% 0.5% 4.6% 3.1% 3.9% 5.5% 7.4% 5.6% 3.8% 1.5% 3.8% 1.6% 3.8% 44 Maternity Hours 266 116 107 185 185 185 185 185 127 69 69 152.64 45 Budget Position YTD Position >0 47794 63502 72524 61585 36168 36 -20622 -49366 -72573 -96771 42277 46 Mandatory training 95% 95% 95% 94.8% 91% 93% 95% 96% 93% 95% 93% 90% 94% Educator and matron working on this Statutory & Mandatory 47 Appraisal 95% 91% 94% 94% 100% 98% 82% 83% 88% 95% 94% 88% 91% Educator and Matron working on this 48 Uniform Audit Compliance with uniform policy % 95% #DIV/0!
QVH BOD September 2018: Session in public Page 120 of 260 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries SLEEP DC Quart Quarter 3 Quarter 4 Quarter 1 Quarter 2 2017/18 Year to No. Indicator Description total/ Target er 2 2017/18 2017/18 2018/19 2018/19 Date Trend Comments average Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Actual SAFE 1 Total reported - All incidents 26 _ 3 2 2 0 2 3 3 3 0 2 3 23 2 Total reported - Patient safety 9 _ 1 1 1 0 0 0 2 1 0 0 0 6 Incidents 3 Internal investigation (Amber or Red) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Falls 6 Falls - With harm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 Inoculation Injury Reported incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 MRSA Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11 Hand hygiene 100% 95% 100% 100% 100% 100% 100% N/S N/S 100% 100% N/S 100% 100% Hand Hygiene 12 Bare below the elbows 98.9% 95% 100% 90% 100% 100% 100% N/S N/S 100% 100% N/S 100% 99% 13 Medication Errors Reported errors 2 0 0 1 0 0 0 0 1 0 0 0 0 2 14 VTE Monthly screening % (Informatics) 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% EFFECTIVE Compliance in Practice 15 Inspection score 80%Reported 1/4ly 84.4% 89.0% Reported 1/4ly Reported 1/4ly 87% (CiP) CARING 16 Patient numbers (eligible to respond) _ 861 969 890 641 829 610 903 988 851 919 896 9357 17 % return rate 22.8% 20% 20% 24% 21% 23% 21% 21% 21% 17% 18% 17% 22% 20% Friends & Family Test 18 % recommendation (v likely/likely) 95.3% 90% 98% 99% 96% 95% 96% 94% 93% 93% 99% 96% 97% 96% 19 % unlikely/extremely unlikely 1.7% 0% 1% 0% 2% 1% 0% 3% 4% 4% 0% 2% 1% 2% RESPONSIVE 20 Complaints No. recorded 3 0 1 0 0 0 1 0 0 0 0 0 0 2
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Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/2018 Agenda reference: 140-18 Report title: Research & Development Annual Report 2017/18 Sponsor: Ed Pickles, Medical Director Author: Sarah Dawe, Research & Development Manager; Julian Giles, Clinical Lead for Research Appendices:
Executive summary: Purpose of report: An annual report of the work coordinated by the Clinical Research Department Summary of key There has been a 47% increase in recruitment to research studies over the previous issues year. In 2017-18 the Trust had four fully grant-funded studies ongoing which were initiated at QVH. The report gives details of all the research work at QVH across a very successful year. Recommendation: Note contents Action required Approval Information Discussion Assurance Review [highlight one only] Link to key KSO2: strategic objectives World-class (KSOs): clinical [Tick which KSO(s) this services recommendation aims to support] Implications Board assurance framework: BAF KSO2
Corporate risk register: No
Regulation: No
Legal: No
Resources: No
Assurance route Previously considered by: Quality and Governance Committee Date: 19/07/18 Decision: Recommended for approval by the BoD Next steps:
QVH BOD September 2018: Session in public Page 122 of 260
Holtye Rd, East Grinstead RH19 3DZ
Queen Victoria Hospital NHS Foundation Trust Research & Development Annual Report
Report covering the period from April 2017 to March 2018
Document Control: Q&G Committee, R&D Governance Group Executive sponsor: Ed Pickles
Authors: Sarah Dawe
Date: June 2018
Type: Annual Report Version: 2 Pages: Number Status: Public. Written and prepared for the Trust Board Circulation: QVH Trust Board
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Contents List
Item: Page number:
1 Executive Summary 3 2 Introduction 3
3 Service aims, objectives and expected outcomes 4 4 Activity analysis/achievement 5 5 Involvement and engagement 9 6 Learning from experience 13 7 Recommendations 13 8 Future plans and targets 13 9 Controls and Assurances 13 10 Appendices 14 11 Report approval and governance 26
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1. Executive Summary • We are delighted to report that QVH has had another extremely successful year, building on the achievements of 2016-17. This year we recruited 540 participants to research studies, of which 443 were National Portfolio recruits. This represents a 47% increase in total activity over the previous year, and a 26% increase for National Portfolio recruits. We have been working hard to continue growing our activity in National Portfolio studies, so this is a particularly pleasing result. We now have a very solid research portfolio on which to build our work going forwards, and are looking forwards to another strong performance in the coming year. • Initiating our own research is a major focus of our activity here at QVH, and in 2017-18 the Trust had four fully grant-funded studies ongoing. We were a collaborator on a Medical Research Council (MRC) grant with the University of Brighton for an award to develop novel infection detection dressings. The grant was worth £1.2 million across all partners. • We were also the holder of a prestigious National Institute for Health Research (NIHR) Invention for Innovation (i4i) grant, for which Charles Nduka was the lead applicant. This was a collaborative effort with the University of Nottingham Trent and a commercial partner (Emteq), to fund a study to develop a new device to assist with the rehabilitation of facial palsy patients. The grant is worth a total of £846,000 across all three partners. • The Anaesthetics Department, led by Julian Giles, was engaged in an NIHR Research for Patient Benefit (RfPB) grant-funded study (£79,688) looking at non-site-specific pain following breast surgery, whilst our Burns Research Nurse Simon Booth has been working on an NIHR grant-funded MRes with the University of Brighton (£37,504). • We are proud that four of our clinicians are acting as Chief Investigators on National Portfolio research studies (Julian Giles, Simon Booth, Charles Nduka and Raman Malhotra), and two are members of NIHR faculty (Julian Giles and Charles Nduka). This is a significant achievement for a small Trust. • Our major study looking at potential biomarkers in the role of scar formation has been recruiting well, and has been generously funded by the Blond McIndoe Research Foundation and the QVH Charitable Funds. This supports 4 day/week of a lab-based researcher to carry out the study. • We have built up a very productive relationship with the Brighton and Sussex Medical School to host a programme of undergraduate projects. This year we welcomed our eighth cohort of students, who spent nine months of their 4th year with us working on research/audit projects, supervised by QVH consultants. Students have brought a buzz to the departments they have been working in, and have delivered some excellent studies. These projects have also helped to foster closer links with our colleagues at BSMS. • The Trust is grateful for the ongoing support of our local Comprehensive Research Network (CRN), who have awarded core funding to support a variety of research posts at the hospital. We are actively working with them to grow research in Portfolio studies and to continue to improve set-up times.
2. Introduction 2017/18 has been a year marked by considerable successes. The key benchmark by which our research endeavours are judged is the number of patients recruited into National Institute of Health Research (NIHR) National Portfolio studies. These are studies that are deemed to be of national importance and are singled out for assistance. Such studies are felt to be capable of improving the quality of care that we can provide for patients, both within the NHS and beyond. I am happy to say that we have dramatically increased our recruitment into such studies, with a final tally of 443. The total number of patients at the QVH recruited into studies was 540. This massive increase in activity represents the culmination of several years work, with many studies have been at differing stages of development. Last year saw us finally capitalise on this work.
We undertake research studies at the QVH that are both initiated ‘in house’ by our clinicians, or multi- centre studies for which the QVH has been invited to join. We are one of the few Trusts within Kent, Surrey and Sussex (KSS) where local clinicians, with support for the R&D team, are able to develop and
QVH BOD September 2018: Session in public Page 125 of 260 deliver a research project from inception all the way through to recruiting patients, analysing and disseminating the results. We have worked hard to develop close links with a variety of partners that allow us to be able to develop such a comprehensive research service.
There are some shining examples of the success of QVH clinicians within this report. Emma Worrell, our principal maxillofacial prosthetist, has set up a national study to examine the quality of care delivered to those patients who use prosthetic eyes. Emma obtained external funding for this study and has been tireless in driving the project forward. It has been adopted onto the national portfolio. Thus far 472 patients have joined nationally. I am sure the results will improve the care delivered not just to those patients at the QVH but also throughout the country. In recognition of this, Emma received the ‘Rising Star’ award from the KSS CRN (Comprehensive Research Network) in February.
Other home grown talent includes Charles Nduka and Simon Booth. Charles is the recipient of a prestigious NIHR i4i grant. He spent last year on sabbatical developing technologies that can help restore facial movement after paralysis. We are all set to initiate the first clinical studies with QVH patients that will draw upon this novel technology.
Simon Booth has now completed his Masters in Research degree with the University of Brighton. His research project explored how best to identify and treat infection in burns wounds. This is a very real problem face by clinicians both at QVH and worldwide on a daily basis. His research was funded by the MRC and done in conjunction with the Universities of Bath, Brighton and Bristol.
The QVH is at the forefront of developing innovative research programmes with our growing band of academic and commercial partners.
We were sad when the Blond McIndoe Research Foundation (BMRF) finally moved away from the QVH campus in the spring of 2017. The BMRF had been integral to many of our research endeavours over the last twenty years. Several of the projects run jointly between the QVH and the BMRF have now come fully back within the remit of the QVH. We wish the BMRF well as they are reborn as a grant awarding body, with a particular remit to encourage research into wound healing and tissue repair. Their new home is the Royal College of Surgeons. Maxine Smeaton and her team worked tirelessly to promote links between the BMRF and the QVH.
The research team is small, dedicated and very hard working. Sarah Dawe and Emma Foulds have done an excellent job overseeing the labyrinthine administrative and governance framework that research sits under. The nursing team, composed of Gail Pottinger, Simon Booth and Debbie Weller, have done very well to increase recruitment at such a pace. They are now very stretched.
We have recently heard that in light of the successes at our Trust, the CRN are to significantly increase the core funding we receive. This investment will allow us to build on our successes into 2018-19.
3. Service aim, objectives and expected outcomes Research & Development aims to improve outcomes for patients both at QVH and in the wider NHS. This is achieved through a programme which focuses on quality, transparency and value for money.
R&D at QVH is measured and monitored by our local CRN. They monitor our research activity on a daily basis via an online system (Edge), as well as via regular meetings.
The key objective which we are set by the CRN is a Value For Money (VFM) measure. For the past two years, QVH has delivered one of the most efficient R&D programmes in Kent/Surrey/Sussex, with a very low cost per patient recruited.
QVH BOD September 2018: Session in public Page 126 of 260 4. Activity analysis/ achievement
Research Activity
The number of patients receiving NHS services provided or sub-contracted by the Queen Victoria Hospital NHS Foundation Trust in 2017-18 that were recruited during that period to participate in research approved by a research Ethics Committee was 540. This represents a 47% increase in total activity over the previous year
Participation in clinical research demonstrates QVH’s commitment to improving the quality of care we offer and to making our contribution to wider health improvement. Our clinical staff stay abreast of the latest possible treatment possibilities and active participation in research leads to successful patient outcomes.
QVH was involved in conducting 32 clinical research studies in 2017-18, as per the tables below.
Study ref National in Start Principle Portfolio Recruit- appendix Study title date Investigator Status study ment in 2017-18 1 Improving perioperative Yes care through the use of quality data: Patient Study of the Perioperative Quality Improvement Programme (PQIP) 02/05/17 Julian Giles Open 64 2 Ciclosporin 1mg/ml eye Yes drop emulsion (Ikervis) for the treatment of severe keratitis in adult patients with dry eye disease, which has not improved despite treatment with tear 25/09/17 Samer substitutes Hamada Open 13 3 Yes Head & Neck 5000 Follow Up Study 29/01/18 Brian Bisase Open 16 4 Validation of the Yes MIRROR facial expression tracking application in healthy subjects and facial 24/01/18 Charles Open paralysis patients Nduka 0 5 Pharmacists' No perceptions of patient medicines helplines. 08/02/18 Open External 0 6 No Infection Control Screen Survey Open External 0 7 In the Era of Brexit: The No Barriers and Facilitators to Reverse Innovation 31/07/17 Closed External 0
QVH BOD September 2018: Session in public Page 127 of 260 8 No COO: Cultures of 17/06/17 Open openness External 0 9 The NHS duty of No candour – a step forwards? 25/05/17 Closed External 0 10 No Lock & Key Open External 0 11 Lugol’s Iodine in No Surgical Treatment of Epithelial Dysplasia in the Oral Cavity and Oropharynx 27/12/17 Open Paul Norris 3 12 Yes Implementation, impact & costs of policies for 28/11/16 External Closed safe staffing 0 13 20/03/17 Yes MindSHINE 3 External Open 10 14 A nationwide survey of No prosthetic eye users: a collaborative study with Raman all NHS ocular Malhotra / prosthetic service 21/02/17 Emma Open providers. Worrell 108 15 Developing and Yes validating a new self- report measure of 27/01/17 Jenny Gu Closed compassion (External) 0 16 Ex-vivo Infection 15/11/16 Yes Detection - EVIDEnT Simon Booth Open 81 17 Evaluating the ten year Yes impact of the External Closed Productive Ward 22/08/16 0 18 Antibiotic Levels in Yes Burn wound Infection (ABLE) 01/09/16 Simon Booth Open 7 19 Samer Yes EuPatch 01/07/16 Hamada Open 0 20 WEB-RADR - Yes Comparison of ADR reports received via Yellow Card app with casenotes External Open 0 21 Investigation of No Potential Biomarkers in the Role of Scar 16/03/16 Baljit Formation Dheansa Open 94 22 Asit Yes SUBMIT 13/09/16 Khandwala Open 12 23 NexoBrid for children Baljit Yes with thermal burns 24/05/16 Dheansa With-drawn 0 24 A study to refine the Yes CAR burns scales 03/11/15 Simon Booth Open 31
QVH BOD September 2018: Session in public Page 128 of 260 25 Molecular mechanisms Yes and pathways of chronic inflammatory and degenerative diseases. (Dupuytrens 30/11/15 patients) Loz Harry Open 101 26 SILKIE 30/09/15 Simon Booth Closed Yes 0 27 Incidence of obstructive No sleep apnoea risk in 16/06/14 surgical patients Tim Vorster Suspended 0 28 Yes Molecular Genetics of Adverse Drug 31/01/12 Baljit Reactions Dheansa Open 0
Study ref Active studies not involving patient recruitment in 2017-18 Start Principal in date Investigator appendix 29 S100 and CD31 in tongue cancer 01/06/14 Bill Barrett 30 Molecular prediction of metastasis in oral tongue squamous 19/07/12 cell carcinoma Bill Barrett 31 Molecular determinants of head & neck cancer 10/09/10 Jag Dhanda
Study ref Studies fully recruited and in follow up during Start-date Principal in 2017-18 Investigator appendix 32 The effectiveness of Lugols Iodine to assist excision of Paul Norris marginal dysplasia at resection of oral and 10/07/12 oralpharyngeal squamous carcinoma
Involvement in NIHR Portfolio studies
Accruals for NIHR Portfolio studies are recorded and monitored via a national database, and the level of CRN funding received by the Trust is partly determined by accrual figures. In the past two years, the number of Portfolio participants recruited greatly exceeded the number of non-Portfolio recruits, reflecting a strategic push to increase the proportion of Portfolio studies we undertake.
QVH recruited 443 Portfolio participants in 2017-18.
Funding
Grant funding
The Trust had four fully grant-funded studies ongoing in 2017-18. We are the proud holder of a prestigious NIHR i4i grant, for which Charles Nduka was the lead applicant. This was a collaborative effort with the University of Nottingham Trent and a commercial partner (Emteq), to develop a new device to assist with the rehabilitation of facial palsy patients. The grant is worth a total of £846,000 across all three partners.
We were also a collaborator on a MRC (Medical Research Council) grant application with the University of Brighton for an award to develop novel infection detection dressings. The grant was worth £1.2 million across all partners, with £19,403 for QVH.
The Anaesthetics Department, led by Dr Julian Giles, was engaged in an NIHR RfPB grant-funded (£79,688)
QVH BOD September 2018: Session in public Page 129 of 260 study looking at non-site-specific pain following breast surgery, whilst our Burns Research Nurse Simon Booth completed an MRes at the University of Brighton, funded by an NIHR grant for £37,504.
Core funding
The CRN awarded the Trust £60,957 core funding in 2017-18, and £10,000 in-year (non-recurrent) funding. The CRN determines the level of funding using an algorithm based on the number of patients recruited to Portfolio studies over the previous two years. This activity-based funding formula is a key driver for how research work is prioritized at QVH.
Funding was allocated according to CRN guidelines in the following way:
Resource Staff Name Allocation Research Practitioner Debbie Weller 36,214 Research Nurse Simon Booth 6036 Research Nurse Gail Pottinger 5091 Consultant Julian Giles 4841 Clinical Trials Pharmacist Judy Busby 1682 R&D Manager Sarah Dawe 12,245 Training 610 Travel 234 Overheads 4004
The Trust also received £5,250 from the Brighton and Sussex Medical School to support the IRP students who undertake fourth-year research projects at the hospital.
Charitable Funding
The Blond McIndoe Research Foundation and the League of Friends generously provided funding for a 0.8WTE Research Technician to work on a study investigating potential biomarkers in the role of scar formation.
Publications
Linda Hollén, Rosemary Greenwood, Rebecca Kandiyali, Jenny Ingram, Chris Foy, Susan George, Sandra Mulligan, Francesca Spickett-Jones, Simon Booth, Anthony Sack, Alan Emond, Ken Dunn, Amber Young, The SILKIE (Skin grafting Low friKtIon Environment) study: a non-randomised proof-of-concept and feasibility study on the impact of low-friction nursing environment on skin grafting success rates in adult and paediatric burn. BMJ Open 2018;8:e021886. doi:10.1136/bmjopen-2018-021886s
, S. P. Booth, P. Scavone, P. Schellenberger, J. Salvage, C. Dedi, N.-T. Thet, A. T. A. Jenkins, R. Waters, K. W. Ng, A. D. J. Overall, A. D. Metcalfe, J. Nzakizwanayo and B. V. Jones (2018). Development of a High- Throughput ex-Vivo Burn Wound Model Using Porcine Skin, and Its Application to Evaluate New Approaches to Control Wound Infection. Frontiers in Cellular and Infection Microbiology 8(196).
J Dhanda. et al., Current trends in the medical management of osteoradionecrosis using triple therapy, British Journal of Oral and Maxillofacial Surgery, Volume 56, Issue 5, 401 – 405
Kahan BC, Koulenti D, Arvaniti K, Beavis V, Campbell D, Chan M, Moreno R, Pearse RM; International Surgical Outcomes Study (ISOS) group. Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries.
QVH BOD September 2018: Session in public Page 130 of 260 Intensive Care Med. 2017 Jul;43(7):971-979
R.Y.Kannan, C.Nduka. The Labio-Mandibular flap for upper lip and peri-commissural defects. Plast Aesthet Research 2018; 5:4.
F.Al-Husseini, D.James, C.Neville, T.Gwynn, C.Nduka, R.Y.Kannan. An occult MRI-negative primary parotid melanoma masquerading as an atypical Bell’s Palsy. Int J Surg Oncol 2018; 3:e54.
Neville C, Venables V, Aslet M, Nduka C, Kannan R. An objective assessment of botulinum toxin type A injection in the treatment of post-facial palsy synkinesis and hyperkinesis using the synkinesis assessment questionnaire. J Plast Reconstr Aesthet Surg. 2017 Nov;70(11):1624-1628.
Cooper L, Branagan-Harris M, Tuson R, Nduka C. Lyme disease and Bell’s palsy: an epidemiological study of diagnosis and risk in England. The British Journal of General Practice. 2017;67(658):e329-e335.
Cooper L, Izard C, Harries V, Neville C, Venables V, Malhotra R, Nduka C. Paradoxical Frontalis Activation: An Underrecognized Consequence of Facial Palsy. Plast Reconstr Surg. 2018 Feb;141(2):263e-270e.
WF Siah, AS Litwin, C Nduka, R Malhotra. Periorbital Autologous Fat Grafting in Facial Nerve Palsy. Ophthal Plast Reconstr Surg. 2017;33(3):202-208.
A Hussain, C Nduka, P Moth, R Malhotra. Bell’s facial nerve palsy in pregnancy: a clinical review. J Obstet Gynaecol. 2017 May;37(4):409-415.
Cooper L, Lui M, Nduka C. Botulinum toxin treatment for facial palsy: A systematic review. J Plast Reconstr Aesthet Surg. 2017 Jun;70(6):833-841. doi: 10.1016/j.bjps.2017.01.009. Epub 2017 Feb 16. Review
Siah WF, Litwin AS, Nduka C, Malhotra R. Periorbital Autologous Fat Grafting in Facial Nerve Palsy. Ophthalmic Plast Reconstr Surg. 2017 May/Jun;33(3):202-208. doi
Dawes TR, Eden-Green B, Rosten C, Giles J, Governo R, Marcelline F, Nduka C. Objectively measuring pain using facial expression: is the technology finally ready? Pain Management. 2018 Mar;8(2):105-113.
R.Vijayan, F. Al-Aswad, R.Y.Kannan. Supermicrosurgery-assisted venous supercharging of a reverse-flow angular artery perforator flap for nasal reconstruction. J Plast Reconst Aesthet Surg 2017; 70(2): 281-283.
R.Y.Kannan, J.Hardwicke. Expanded version pedicled free-style perforator flaps in clinical practice: A need for a more comprehensive classification system. Eur J Plast Surg 2018; 41(3): 345-350.
N Pandey N, A Jayaprakasam, I Feldman, R Malhotra. Upper eyelid levator‐recession and anterior lamella repositioning through the grey‐line: Avoiding a skin‐crease incision. Indian J Ophthalmol 2018;66:274‐8
AS Litwin, E Worrell, JCP Roos, B Edwards, R Malhotra Can we improve the tolerance of an ocular prosthesis by enhancing its surface finish? Ophthal Plast Reconstr Surg. 2017 Mar 7. doi: 10.1097/IOP.0000000000000891
5. Involvement & Engagement
Patient Public Involvement and Engagement
QVH continues to work to find meaningful ways to involve patients and members of the public in its research activity. We are fortunate to have on our R&D Governance Group two very involved patient representatives, who take an active role in advising on and monitoring the research activities of the Trust. Patients are also often involved in the early stages of research projects via focus groups, who feed into protocol development. We have set up a Research Panel which has been established to suggest as well as review new research ideas for the
QVH BOD September 2018: Session in public Page 131 of 260 QVH as they are being formulated. Work has also been undertaken on raising patient awareness of research via a publicity campaign, with features on local radio & television, in newsletters (QVH News, Research & You). We have also used leaflets, posters and videos within the hospital to inform patients and the public of the research we do.
Comprehensive Research Network (CRN)
The Trust is a member of the Surrey, Sussex and Kent Comprehensive Research Network (CRN). We work with the CRN to maximize opportunities for Portfolio studies, identify new studies the Trust may participate in, and implement new national systems and structures. The CRN distributes R&D resources amongst its members according to an activity-based algorithm. The CEO sits on the CRN Partnership Board, and the R&D Manager and the Clinical Lead for Research regularly attend local finance and performance meetings, working closely with the CRN Link Manager and her team. Meeting CRN targets is a priority area for the Trust.
CRN targets
National targets have been introduced to stretch and improve performance, with a variety of metrics being measured. In addition to recruitment targets, study set-up time and time to first recruit and are tracked according to these national metrics, with regular data returns made to both the CRN and the NIHR. These reports are made publically available on the QVH website.
Infrastructure
The R&D Department presently consists of one Clinical Lead for R&D, one R&D Manager (0.66WTE) and one Research Governance Officer (13.8h/wk).
Funding was received from the Comprehensive Research Network (CRN) to help support the R&D Manager’s post. Other income to support the R&D infrastructure comes from commercial studies, which in addition to paying general Trust overheads, contribute a fee for R&D Department services in handling their applications and setting up contracts.
Clinical Research Staff
In 2017-18, the Trust supported one Burns Research Nurse (1WTE), one Lead Research Nurse (0.5WTE) and one 1WTE Research Practitioner.
The Anaesthetics Dept has one Research Registrar (0.2WTE). These have traditionally been funded out of clinical budgets, but increasing support for them is being obtained from grant awards.
The Trust supported one MRes student in 2017-18, funded by a grant award. The student was registered at the University of Brighton.
Some clinical departments also each have their own arrangements for Research Fellows, which are funded by the departments themselves and which are not managed by the R&D Department. In addition, some clinical areas have identified nurses who are tasked with supporting research in their department.
QVH BOD September 2018: Session in public Page 132 of 260 Intellectual property
The Trust has engaged the services of NHS Innovations South East to assist with commercializing and developing its intellectual property, and this year they have been managing royalties for a tracheostomy dressing device originally developed at QVH, as well as advising on a telemedicine referral image portal system.
Training and Development
The Trust supported (via a grant award) one nurse to undertake an MRes at the University of Brighton.
Local Training Individual support tailored to the individual is provided by the R&D Department to all new researchers who require guidance developing their protocols, navigating the approvals process and setting up their studies. We are fortunate to have the additional help of Claire Rosten from the University of Brighton, who has provided us with invaluable advice on study design, methodology and putting together grant applications.
It is a legal requirement that all staff involved in clinical trials complete Good Clinical Practice (GCP) training, and the Trust has facilitated this for staff – either by providing an onsite trainer, enabling access to off-site courses at other Trusts, or by paying for staff to do an individual online course. One member of staff is a qualified GCP trainer, and also runs courses outside the Trust on behalf of the CRN. Commercial companies also regularly run refresher GCP courses for staff involved in the clinical trials they run at the Trust.
The R&D Manager regularly attends induction to speak to all new clinical recruits. This is a useful forum to quickly identify trainees who are interested in R&D, and provide them with guidance and assistance.
CRN training The Trust also has access to training provided by the CRN for any studies which are accepted onto the National Portfolio. A wide range of courses are offered.
Departmental meetings Individual departments also run their own Audit & Research meetings, providing a forum to discuss new ideas and present completed studies.
Research Design Service Our Research Design Service (RDS) at the University of Brighton provides a good service in training staff in RfPB grant applications, and supporting individual researchers on a one-to-one basis.
NIHR faculty membership Julian Giles has been made a member of the faculty of the National Institute for Health Research (NIHR), by virtue of his successful grant application to the NIHR RfPB funding stream. Charles Nduka is also a member of faculty, following his NIHR i4i award.
Governance Structure
R&D at the Trust is managed via a Research & Development Governance Group. Its members include: Clinical Lead for R&D, Chief Pharmacist/Clinical Trials Pharmacist,
QVH BOD September 2018: Session in public Page 133 of 260 Anaesthetics Lead, Burns Lead, Corneoplastics Lead, Hand Surgery Lead, Maxillofacial Lead, Deputy Director of Nursing, Oncoplastics Lead, Healthcare Science Lead, Orthodontics Lead, R&D Manager, Finance Department, Designated Individual with responsibility for Human Tissue Authority license, External academic advisors from the University of Brighton. The Group also has two very active patient representatives who play a valuable role in advising on new projects.
The R&D Governance Group reports to the Quality and Risk Committee.
The Director of Nursing acts as the Trust’s Nominated Consultee for research participants unable to consent.
Trust policies which cover R&D: Adverse Event Reporting Policy, Research Fraud Policy, Code of Practice for Researchers, Pharmacy policy for Clinical Trials, Intellectual Property Policy.
R&D approvals
QVH has very effective, streamlined systems for managing R&D approvals in proportion to risk, and our turnaround times are very swift. The R&D Dept provides guidance with using the national IRAS applications system, and works with the Health Research Authority (HRA) to approve studies and ensure they meet national guidelines. We have fully implemented the Edge online system to manage and monitor research here at the Trust. This system was funded by our local CRN.
There are national targets for the processing of R&D applications (40 days from date site selected; 30 days from local approval to first recruit; 70 days from date site selected to first recruit). QVH approval times for clinical trials and for commercial studies are also reported quarterly to the NIHR, and published on the QVH website. The mean time for approval of new studies requiring formal Confirmation of Capacity and Capability in 2017-18 was 11 days from date site selected. The mean time to first recruit from date site confirmed was 31 days (this excludes one study where Portfolio Adoption was delayed by the NIHR). The mean time from date site selected to first recruit was 43 days.
Sponsorship status
Some research carried out at QVH is investigator-led ie designed and conducted by our own staff, and these require the Trust to provide structures to support pre-protocol work and peer- review, as well as the subsequent management of active projects. We currently have four Chief Investigators at the Trust who have initiated QVH-Sponsored National Portfolio studies, as well as several Chief Investigators on non-Portfolio studies.
No research study may begin in the NHS without a Sponsor being identified. The Trust continues to offer its researchers the benefits of providing Sponsor status for the studies they initiate. QVH believes that it is right to support its researchers in developing new projects, and to encourage the spirit of intellectual enquiry, and so continues to provide Sponsorship status for all non-CTIMPs plus phase IV CTIMPs. The Trust’s capacity for R&D, and it’s commitment to research, is clearly stated in its official RDOCS (R&D Operating Capability Statement), which is a publically available document endorsed by the Board and published on the QVH website, according to national guidelines.
QVH BOD September 2018: Session in public Page 134 of 260 6. Learning from Experience QVH has made significant strides in increasing research activity, but this has been achieved without a concomitant increase in staffing. We are now one of the leanest Trust’s in Kent/Surrey/Sussex in terms of R&D, and this is not sustainable.
7. Recommendations R&D support infrastructure (Research Nurses and governance staff) is now stretched thin due to the 47% increase in activity in 2017-18, and we are having to turn down new studies because we do not have the staff to support them. Extra staff are needed to sustain and develop this increased activity going forwards. Funding has been now secured from the CRN and from commercial organisations to provide this.
8. Future plans and targets
Specific targets for 2018-19:
• Achieve cost-per-weighted-recruit (according to CRN algorithm) of no more than £100 per participant. • Meet CRN pledge for National Portfolio recruits of 500 • Meet national targets for study set up time (40 days) and time to first recruit (30 days) • Establish extra staff in governance and research nurse roles (funding already secured for this).
Progress towards these targets will be monitored by the R&D Governance Group.
9. Conclusions and assurance This has been an exciting year for Research at QVH, with a very significant upswing in activity and new consultants becoming involved in research. In order to maintain this momentum we need to put in place sufficient staff to sustain and develop progress. Funding has already been secured to support this.
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10. Appendices
Registered Research & Development projects (with HRA Approval) ongoing in 2017-18
1 Improving perioperative care through the use of quality data: Patient Study of the Perioperative Quality Improvement Programme (PQIP) Principal Investigator: Julian Giles Status: Open
Over ten million operations take place in the UK NHS every year. The number of patients which are at high risk of adverse postoperative outcomes has grown substantially in recent years: this is attributable to a combination of an ageing population, the increased numbers of surgical options available for previously untreatable conditions, and the increasing numbers of patient presenting for surgery with multiple comorbidities. Estimates of inpatient mortality after non-cardiac surgery range between 1.5 and 3.6% depending on the type of surgery and patient related risks. Major or prolonged postoperative morbidity (for example, significant infections, respiratory or renal impairment) occur in up to 15% of patients, and is associated with reduced long-term survival and worse health-related quality of life; this signal has been consistently demonstrated across different types of surgery, patient and healthcare system.
Data from the US demonstrate wide variation in risk-adjusted mortality & morbidity rates between healthcare providers, suggesting that at least some complications after surgery could be avoidable if standards of care were improved. It is likely that the same is true in the UK; however, there is currently no unified national system for measuring complications or patient reported outcomes across different types of major surgery in the NHS. In order to address this gap, the National Institute for Academic Anaesthesia’s Health Services Research Centre (NIAA-HSRC) has launched the Perioperative Quality Improvement Programme (PQIP) for the UK. PQIP will measure risk-adjusted morbidity and mortality, as well as process and patient- reported outcome data in adult patients undergoing major surgery (eg lower GI resection, upper GI resection, liver resection, cystectomy, major head and neck reconstructive surgery, thoracic resection).
2 Ciclosporin 1mg/ml eye drop emulsion (Ikervis) for the treatment of severe keratitis in adult patients with dry eye disease, which has not improved despite treatment with tear substitutes Principal Investigator: Samer Hamada Status: Open
Dry eye disease (DED), also known as keratoconjunctivitis sicca, is a multifactorial, chronic and progressive ophthalmic disease causing inflammation and damage to the ocular surface, caused in part by increased osmolarity of the tear film.
Treatment depends on disease severity. Currently available medical options include artificial tear products, lubricants, topical steroids and ciclosporin A (CsA). Lubricants are classified as ‘health products’, proof of their efficacy is not required by Health Authorities 15, and many are available over-the-counter. Mild to moderate DED can usually be treated symptomatically with tear substitutes, but few effective treatments exist for moderate to severe DED. Artificial tears provide short-term relief at best, and require frequent dosing.
The efficacy of Ikervis has been explored in trials however there is a lack of evidence from the real-world, observational setting. This non-interventional prospective study will evaluate the effectiveness, tolerability and safety of Ikervis in routine clinical practice. As such, the study will recruit a substantially more heterogeneous patient population than would be seen in a clinical trial.
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3 Head & Neck 5000 Follow Up Study Principal Investigator: Brian Bisase Status: Open
Head & Neck 5000 is a large observational study of people with head and neck cancer from across the United Kingdom. The overall aim of the Head & Neck 5000 Follow-up Study is to describe the social, lifestyle and clinical outcomes in people with head and neck cancer and relate these to information gained from the original Head & Neck 5000 study. In order to achieve this, participants who have taken part in Head & Neck 5000 for at least three years will be sent an invitation to complete the Follow-up Study questionnaire. Data will be collected from the medical notes and through linkage to national databases for all participants who consented to this.
4 Validation of the MIRROR facial expression tracking application in healthy subjects and facial paralysis patients Principal Investigator: Charles Nduka Status: Open
Facial paralysis (FP) presents from either a peripheral nervous abnormality (most commonly Bell's Palsy) or a central nervous lesion (usually a cerebro-vascular accident (CVA)). Bell’s Palsy accounts for 60% of cases of facial palsy, causing up to 24,800 new UK cases annually, leaving upwards of 100,000 people living with permanent disability. Of the 152,000 CVAs per year in the UK, many patients suffer resultant chronic facial movement problems. Current methods for tracking facial expression recovery include subjective measures, e.g. doctor- delivered grading systems, and objective measures, e.g. 2D / 3D imaging (photography and/or stereophotogrammetry) or videos of dynamic facial function. However, a consensus method for objectively measuring initial paralysis and monitoring progress towards normal facial expressions remains elusive. Gold standard treatment for FP includes daily rehabilitative exercises, but patients often fail to perform these regularly due to lack of feedback on exercise efficacy leading to demotivation and non-compliance with the prescribed physiotherapy. This in turn reduces patients’ likelihood of recovery of normal facial function.
A new iPad-based non-invasive physiotherapeutic software application (MIRROR) has been developed, allowing FP patients to objectively track their paralysis / facial expressions in real- time via MIRROR’s immediate feedback on exercise performance. To validate MIRROR, a study has been designed to analyse the facial movements of healthy and FP patients pre- and post-administration of Botulinum toxin (BT). Each subject’s response to BT over the period of action of the injected BT will be assessed. Subjects will have their facial expressions quantitatively analysed via subjective grading scales validated for use in FP analysis, 2D / 3D imaging, via surface-electromyography (sEMG) and using MIRROR.
5 Pharmacists' perceptions of patient medicines helplines. Principal Investigator: External Status: Open
The aim of the study is to explore pharmacy professionals’ perceptions of the benefits of patient medicines helplines, their limitations, and ways that they can be improved. Through learning about pharmacy professionals’ experiences and perceptions of medicines helpline services, we aim to make suggestions to improve how helplines are operated so that they better meet the needs of service users and providers. This accords with the NHS agenda of seeking service providers’ views and experiences to improve service quality.
QVH BOD September 2018: Session in public Page 137 of 260 6 Infection Control Screen Survey Principal Investigator: External Status: Open
Enterobacteriaceae are bacteria commonly found in the human intestinal tract. Over the past decade these bacteria have become increasingly resistant to antibiotics known as carbapenems which are used to treat patients with severe infections. Such bacteria are called carbapenem-resistant Enterobacteriaceae or CRE. CRE pose a significant global threat to public health as they cause infections which are easily spread and are associated with high mortality rates. CRE infections are more common in countries where the use of antibiotics is not as regulated as it is in the UK.
The spread of CRE can be prevented by screening patients who have recently been in hospitals (in the UK or abroad) known to have problems with CRE. However, the European Centre for Disease Control also advises screening patients who have recently travelled to countries known for their high rates of CRE, even if they were not in contact with a healthcare institution.
This study aims to establish whether or not NHS Trusts are indeed screening all such high risk patients and if not why. The results will provide useful information for Infection Prevention and Control teams who are currently developing or reviewing their own CRE screening policies.
7 In the Era of Brexit: The Barriers and Facilitators to Reverse Innovation Principal Investigator: External Status: Closed
8 COO: Cultures of openness Principal Investigator: External Status: Open
This study comprises telephone interviews with senior stakeholders and is one element of a wider research project, ‘Building a culture of openness across the healthcare system: From transparency through learning to improvement?’ This project provides:
• An examination of attitudes and behaviour in relation to openness at every level in organisations providing NHS services • An understanding of whether, why and how high-level strategic initiatives translate into positive action at the level of patient care • Practical recommendations that will make a real difference to how openness is put into practice.
Divided in to two work streams, the project uses both quantitative and qualitative methods.
9 The NHS duty of candour – a step forwards? Principal Investigator: External Status: Closed
This study seeks to examine the impact that the Duty of Candour has had on the state of practice in relation to open disclosure in the NHS, from the perspective of those who play key patient safety roles in English NHS Trusts. The study should help inform debate about the extent to which a legal obligation can overcome known barriers to open disclosure.
The Duty of Candour is a statutory requirement which NHS hospitals must meet. It was introduced in November 2014 for all NHS Trusts and Foundation Trusts, in response to recommendations made by the Francis Inquiry. The Duty of Candour regulation combines a general duty to be honest with a prescribed set of actions that providers must take in cases where a mistake has resulted in significant harm to a patient.
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10 Lock & Key Principal Investigator: External Status: Open
At any time, around 10% of people carry meningococcal bacteria in the nose and throat, which can cause meningitis, blood poisoning and other serious illnesses. Most people carry these bacteria and never become ill, yet a very small proportion go on to develop these illnesses which can result in life long disabilities or death. The mechanism by which this happens is poorly understood and has been studied in various ways, usually focussing on the bacteria or on the individual, but none has given a definitive answer. This study will be the first of its kind and will assess the interaction between the host and the bacteria at the genetic level, through genetic mapping, helping us to understand what makes some people susceptible to this infection.
The study will have minimal impact on individuals as we hope to use residual samples from those collected whilst they were in hospital or convalescing, though we will have the mechanism for collection of a new sample in the few cases where no residual is available. The study will include all cases recorded within a five year period regardless of age, and whether or not they survived. This is essential in gaining a breadth of information. The study will not affect the care pathway, which is explained in the information leaflet, but could contribute to the development of new treatments and vaccines, which it is anticipated would be of interest to anyone who has experienced this infection as those being invited to participate will either personally have done, or as the family of a case.
11 Lugol’s Iodine in Surgical Treatment of Epithelial Dysplasia in the Oral Cavity and Oropharynx Principal Investigator: Paul Norris Status: Open
When patients are referred with abnormal lining tissue (mucosa) in the mouth or throat which has been present for more than two weeks a sample of this tissue (a biopsy) is taken to assess the surface cells under the microscope. In these abnormal areas, there can be changes to the cells: this is called dysplasia. The cells can be slightly abnormal or very severely abnormal. If they are very severely abnormal, a cancer is more likely to develop from them in the future. This is why these changes are also referred to as precancerous changes. We know that removing these cells can reduce the risk of cancer developing. However it is often difficult for surgeons to see clearly where the abnormal tissue ends and normal tissue starts.
Lugol’s iodine stain, which has been used as an antiseptic for many years, is used in some other parts of the body to help identify these precancerous cells. We think that this stain might help us to be more sure of removing all of the precancerous/abnormal cells and leaving behind the normal areas. There is evidence which suggests that if we do this, fewer patients will develop cancer after surgery and so more will be successfully treated.
12. Implementation, impact & costs of policies for safe staffing Principal Investigator: External Status: Closed The Francis Inquiry highlighted the lack of evidence-based decisions on nurse staffing as a factor contributing to poor care and higher death rates at Mid-Staffordshire. He recommended that the research evidence be used by NICE (the National Institute For Health and Care Excellence) to develop guidance on safe nurse staffing levels. Guidance for acute adult wards was published in 2014. NICE also endorsed the Safer Nursing Care Tool (SNCT), which estimates nursing staff requirements for acute hospital wards by assigning patients to one of five categories, based on how ill they are and the typical time taken to care for similar patients (known as ‘dependency’).
QVH BOD September 2018: Session in public Page 139 of 260 Our study will examine implementation of safe staffing policies in the NHS. We will undertake a national survey to identify how implementation of safe staffing approaches have varied. At four case study sites we will examine implementation in more depth, using economic and qualitative methods. We will look at how patients’ need for nursing care, as measured by the SNCT, varies from day to day and compare it to actual staffing, and explore the costs and consequences of different approaches
13. MindSHINE 3 Principal Investigator: External Status: Open Stress, anxiety and depression are significant causes of sickness absence among NHS employees, and contribute to the NHS having higher rates of sickness absence than any other public sector organisation in the UK. The effects of psychological distress not only impact healthcare workers as individuals, but can also have negative consequences for their patients via a compromised quality of care.
The term mindfulness refers to a specific way of paying attention, non-judgmentally, to present moment experiences. The development of mindfulness skills is considered to lead to a number of therapeutic benefits including increased compassion for oneself and others, and reductions in negative emotional states. A wealth of empirical research supports the effectiveness of mindfulness-based interventions (MBIs) among both clinical and non-clinical populations. More specifically, recent research reports significant benefits of traditionally delivered, face-to-face MBIs among NHS employees, and mindfulness-based self-help (MBSH) among medical students. Especially when considering the limited number of qualified practitioners available to deliver face-to-face MBIs, and the 24/7 nature of NHS working hours, MBSH may offer particular potential among NHS employees in terms of flexibility, accessibility and cost-effectiveness.
The proposed Randomised Controlled Trial (RCT) is primarily intended to investigate the effectiveness of smartphone-delivered MBSH intervention ‘Headspace’ in reducing stress among NHS staff. A large sample of NHS staff will be randomly allocated to receive either Headspace or an active control condition (NHS website for work-stress). The RCT will also aim to answer questions relating to the effectiveness of Headspace in improving other markers of psychological well-being and psychological distress, sickness absence, and compassion. Objective and subjective measures of engagement will be taken, and mediation and moderation analysis will be conducted in order to establish the processes and factors influencing MBSH engagement and outcomes.
14. A nationwide survey of prosthetic eye users: a collaborative study with all NHS ocular prosthetic service providers. Principal Investigator: R Malhotra Status: open Patients who wear an ocular prosthesis often suffer with dry eye symptoms. Up to 90% will also complain of socket discharge, many on a daily basis. No literature exists on their quality of life post eye loss or adapting to monocular vision. Psychometric questions from the National Eye Institute Visual Functioning Questionnaire, investigate the patient’s quality of life and how the loss of an eye has impacted on patients’ well-being.
Participants receive a questionnaire covering aetiology, length of prosthetic eye use, length of eye wear, age of prosthesis, cleaning regime, lubricant use, inflammation, comfort and discharge. Lower scores relate to a better-tolerated prosthesis. Is there an association between deposit build up, frequency of ocular polish, to socket discharge and dry eye symptoms? A series of quality of life questions probe the effects of monocular vision on day- to-day activities, hobbies, driving and how each patient regards their own general health after the loss of an eye.
QVH BOD September 2018: Session in public Page 140 of 260 15. Developing and validating a new self-report measure of compassion Principal Investigator: Jenny Gu Status: Closed Compassion is defined as consisting of the following five elements: (1) recognising suffering, (2) understanding the universality of suffering in human experience, (3) feeling moved by the person suffering and connecting with their distress, (4) tolerating uncomfortable feelings aroused (e.g. distress, anger, fear) so that we remain open to and accepting of them in their suffering, and (5) acting or being motivated to act to alleviate suffering. This definition of compassion was put forward following a review of theoretical conceptualisations of compassion. As part of the same review paper, the authors also systematically reviewed questionnaire measures of compassion and concluded that none of the existing measures comprehensively captured the construct and many had poor or inadequately tested psychometric properties. The current project aims to address the omission in the literature and develop a new, psychometrically-robust questionnaire measure of compassion, both towards the self and towards other people. Participants will be 1,300 NHS employees working in an NHS Trust in the Kent, Surrey, and Sussex region.
16. Ex-vivo Infection Detection - EVIDEnT Principal Investigator: S Booth Status: Open Burn wound infections are difficult to diagnose. Diagnosis involves removing dressings, which may slow the healing process. A new dressing (SmartwoundT) may help to diagnose infection without needing to remove dressings, and capsules within the dressing will change colour if the number of bacteria in the burn wound indicate that it is infected. Before it is used with patients, we need to check whether the capsules can identify when bacteria are, or are not, present in wounds. This study will use samples from patients with and without infected wounds to check whether the capsules change colour in the presence of bacteria that are causing a wound infection. The samples will come from burn wound fluid (exudate) taken from used wound dressings, and from swabs and gauze used during normal care of patients with burns. Both adults and children with and without infected burn wounds, who attend one of four participating Burns Services will be asked to participate. Participants will be asked to consent to have their dressings kept by the study team once they have been removed during the course of their normal treatment, and for swab samples to be taken. From these a sample of exudate will be tested. Information will be recorded from participants' notes about their health, care, suspected presence of infection and need for antibiotics. Participants will be followed-up within 21 days, either as part of normal scheduled clinic visits or by phone, and will be asked about their wound healing and health status. The Smartwound dressing's ability to detect infection will be measured using visual assessment of colour change. Bacteria from the swab will be tested separately to confirm presence of infection. Findings from this study will indicate whether capsules are effective in detection of infection prior to studies into the development of their use in dressings.
17. Evaluating the ten year impact of the Productive Ward Principal Investigator: External Status: Closed Our overall research question is whether the ‘Productive Ward: Releasing Time to Care’ programme (PW) has had a sustained impact at the clinical microsystem level in English NHS acute trusts since its introduction in 2007. Clinical microsystems can be a team, practice, ward or clinical unit; this proposal focuses on a quality improvement intervention specifically designed to improve the efficiency of hospital wards. The PW programme aims to: (1) increase the proportion of time nurses spend in direct patient care, (2) improve experience for staff and patients, and (3) make structural changes to the use of ward spaces to improve efficiency in terms of time, effort and money. Consequently the PW has the potential to meet health needs (by improving the efficiency of care) and is directly concerned with the organisation and delivery of health care. The NHS Institute for Innovation & Improvement (NHSI) developed PW in 2005 and 2006 and first implemented it in England in 2007. It is a self-directed quality improvement (QI) toolkit consisting of three
QVH BOD September 2018: Session in public Page 141 of 260 foundational or ‘core’ modules and eight process modules. In subsequent years, the PW has been adopted and implemented internationally. Our study will identify and evaluate any sustained impacts and wider legacies of the PW in Trusts in England which have adopted the programme. We will explore how varying times of adoption (‘early’, ‘late’) and differing local approaches to implementation (e.g. whole hospital roll out, pilot wards) have shaped such impacts and/or wider legacies over the previous decade.
18. Antibiotic Levels in Burn wound Infection (ABLE) Principal Investigator: S Booth Status: Open Burn wounds have a high risk of developing infections. Oral or intravenous antibiotics are routinely given to manage such infection; however, the appropriate use of antibiotic therapy as a means of treating infection has become a topic of international debate due to rise in antimicrobial resistance (AMR). Several issues within the management of burn wound infection have led to the question of therapeutic levels being found in the burn wound. The most common antibiotic used, Flucloxacillin, belongs to a family of antibiotic known as Beta- Lactam antibiotics. Unfortunately this group of antibiotics is known to bind to serum proteins in the blood, meaning a fraction of the original dose is available and active at treating infection. Secondly, the antibiotic needs to be transported to the area which needs treating. The body does this by transporting the drug through the blood; however, burn wounds have an impaired blood supply which would lead to the supposition that very low levels enter the wound. Furthermore, the wound environment may have an altered pH which may further prevent effective utilisation of the antibiotic as antimicrobials such as Flucloxacillin have a narrow band of acid/alkali that they can be effective in.
The main question that the study will answer will be whether we can find therapeutic levels of antibiotics in patients wounds, which are sufficient to treat the infection. Participants will give consent to participate and then give a wound exudate swab and blood test to measure their levels of antibiotic. At each subsequent dressing change the wound swab and blood samples will be repeated until the participant finishes their course of antibiotics. This is likely to be up to a maximum of 4 blood samples and 4 additional wound swabs
The study population will be adults with burn injuries over and including 1% total body surface area who are being treated with antibiotics for suspected or confirmed infection.
19. EuPatch Principal Investigator: Samer Hamada Status: Open Amblyopia (also called lazy eye) is the most common disease affecting vision in childhood. It affects between 2 to 5% of the population and 90% of visits to children’s’ eye clinics are for the purpose of treating amblyopia. Currently 30% of children treated for amblyopia do not reach normal vision after a year or more of treatment. Amblyopia is usually treated with glasses wearing and by patching the better eye.
There is controversy whether a long period of glasses wearing before patching, called refractive adaptation, helps in treating children with amblyopia. Refractive adaptation has not been tested in a randomised controlled trial, and currently we do not know how long children wear glasses each day.
The purpose of this study is to perform the first randomised controlled trial to test whether refractive adaptation before patching improves the number of successfully treated children with amblyopia. We will use electronic monitors to measure how much children wear their glasses and patches each day and will determine how this relates to their improvement in vision. We will also investigate whether different types of amblyopia respond better to different treatments.
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20. WEB-RADR - Comparison of ADR reports received via Yellow Card app with casenotes Principal Investigator: External Status: Open At the moment reporting of adverse drug reactions by hospital personnel is mainly done by paper or through the web-based form. The aim of creating a new reporting tool, the app, is to increase reporting and to make reporting easy with the hope of gathering new information about ADRs which will help to evaluate the benefit-harm of drugs. However, it is important to make sure that the reports received through the app capture the clinical data accurately. The following study will be aimed at investigating the accuracy and trustworthiness of reports received through the app. The live App data covers the whole of the UK. All adverse drug reactions reported through the Yellow Card app from patients and health care professionals (HCPs) nationally. HCPs will include pharmacists, doctors and nurse specialists. Depending on workload, the study team will investigate all reports, where the reporter agrees to supply extra information from patient case notes.
21. Investigation of Potential Biomarkers in the Role of Scar Formation Principal Investigator: Baljit Dheansa Status: Open The reason for the development of a scar is not clearly understood and the causes are multi- factorial. In simple terms, scarring may be a direct consequence of evolutionary changes that have lead to a rapid healing of the wound site in order to prevent infection. As a consequence of this speed of wound epidermal closure, the cells in the dermis of the skin are prone to produce inappropriate amounts of extracellular matrix molecules. It is this over production that leads to the formation of a scar.
The only example of scar-free healing is in utero. Surgery performed on a foetus in the third trimester (and these often save lives of unborn children) do not leave any traces of surgical intervention. A child is born without a scar. This amazing ability is lost shortly after birth and for the rest of adulthood, any post-traumatic event to the skin results in the production of a scar. The Queen Victoria Hospital (QVH) is a regional centre for burns and plastic surgery. The hospital treats patients with acute wounds and those undergoing surgical reconstruction or scar revision. As part of this treatment scar tissue will often be removed and disposed of as clinical waste. This redundant scar tissue offers the possibility of developing a clearer understanding of the mechanisms of scar formation.
22. SUBMIT Principal Investigator: Asit Khandwala Status: Open Metacarpal fractures are common, accounting for 40% of all hand injuries and many can be treated non-operatively. However, surgery is reserved for cases in which an adequate reduction of both angular and rotational deformity cannot be maintained or where an adjacent ray is damaged. A variety of surgical strategies exist, including percutaneous kirschner wiring, intramedullary fixation, and fixation with plate and screw construction. A plate secured along the dorsal midline of the metacarpal has been shown to be the best biomechanical method of fixation, and allows early aggressive hand therapy post-operatively.
Traditionally, bicortical fixation is the standard practice, where both dorsal and palmar cortices of the metacarpal are drilled though. However, such practice is not without risk. In this method, the flexor tendons and neurovascular bundles at risk from over-zealous drilling through the palmar cortice. Correct screw size selection is also critical as overly long screws can irritate and cause rupture of flexor tendon. More recently, with the advent of a new generation of locking plates, unicortical fixation, where only the near cortex is drilled, has been used to treat fractures. Unicortical fixation is a surgically less complex operation, can theoretically cause less damage to surrounding soft tissues and avoids the complications associated with
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This trial aims to compares the functional outcomes and complications of patients having unicortical versus bicortical fixation for diaphyseal metacarpal fractures.
23. NexoBrid for children with thermal burns Principal Investigator: Baljit Dheansa Status: Withdrawn Nexobrid is a gel containing enzymes derived from the pineapple plant. These enzymes can remove or breakdown unhealthy tissue, thereby avoiding the need for surgery. Whilst Nexobrid is approved for use in adults, it is currently not licensed for use in paediatric cases. The present study aims to assess the use of Nexobrid in children with deep burns between 1 and 30% total body surface area, versus standard of care.
24. A study to refine the CAR burns scales Principal Investigator: Simon Booth Status: PIC study; Open A burn injury can greatly impact upon a person’s quality of life. In order to provide the most useful support it is vital for health workers such as doctors, nurses, psychologists and physiotherapists to know what are the most important issues to patients affected by burns. Therefore in collaboration with burn patients themselves, a survey has been developed which explores adult’s experiences of living with a burn injury. The plan is for all adults that are seen in hospital for a burn injury to complete this survey, so health professionals can identify their support needs and their treatment progress. We are asking adults living with a burn to complete this survey to test out the questions. The results of this study will help us shorten and refine the survey, so it can be used in burn units throughout the UK to provide the best possible care and support for patients and their families.
25. Molecular mechanisms and pathways of chronic inflammatory and degenerative diseases Principal Investigator: Lorraine Harry Status: Open Using synovial tissue in explant cultures obtained from rheumatoid arthritic patients undergoing joint replacement surgery, the Kennedy Institute was the first research laboratory in the world to identify the pathogenic role of the inflammatory cytokine tumour necrosis factor alpha (TNF) in Rheumatoid Arthritis (RA). Biological therapies that block the function of TNF are now clinically proven and over one million people worldwide have been treated successfully with this drug. However, this is not a cure for RA, so current research activities at the Kennedy are aimed at understanding those events that trigger RA, and developing better therapies for this disease. Patients scheduled to undergo a surgical procedure as a result of arthritis or other inflammatory diseases, will be given the option to take part in our study. In addition waste tissue will be obtained from an amputation as a result of a traumatic injury and adipose as a result of an abdominoplasty. A qualified clinician / GCP trained team member will take written, informed consent prior to surgery. Waste tissue from surgery is collected in a sample pot and couriered to the Kennedy Institute. This waste tissue includes joints (cartilage and bone), periarticular tissue, connective tissue (muscle and fascia) and other soft tissue such as skin.
The tissue will be processed ex vivo to liberate single cell suspensions, which will then be cultured for up to 5 days or long term lines will be derived. Cell supernatants will be analysed for cytokine, MMP and other inflammatory mediators by ELISA and cell phenotype determined by Flow cytometry. In addition mRNA will be harvested and gene expression determined by TaqMan PCR. The histopathology of the tissue will also be looked at.
QVH BOD September 2018: Session in public Page 144 of 260 26. SILKIE - Can skin grafting success rates in burn patients be improved by using a low friction environment – a feasibility study? Principal Investigator: Simon Booth Status: closed This study aims to find out if it is feasible to use low friction (slippery) sheets for burn patients requiring skin grafts.
Skin grafts are required to ensure healing after burns that are deeper or take longer than 21 days to heal. Each year approximately 1000 skin grafts are undertaken in England and Wales; 75% in adults and 25% in children (1). Around 20% will fail completely or partially, with some wounds needing re-grafting. Further surgery, taking skin from another part of the body, longer hospital stays and increased scarring are all consequences which can be distressing for patients and expensive for the NHS. Graft loss can be caused by rubbing or stretching skin and moving new graft cells causing failure of attachment to the wound. Friction between dressings and bed sheets can cause this rubbing or stretching causing shearing. If dressings and patients were able to slide over the sheet when the patient moves in bed, then the graft may have more chance of ‘taking’. Reduced friction bed sheets are in use in the UK with premature babies and other patients to prevent pressure sores, but not yet in burns services.
Adult and paediatric patients with burns and scalds who are selected to undergo skin grafting to achieve healing after burn injury as part of normal clinical care and are nursed on sheets for at least one overnight hospital stay.
27. Quantifying the incidence of obstructive sleep apnoea (OSA) in a surgical cohort attending pre-assessment Principal Investigator: Tim Vorster Status: Suspended OSA (obstructive sleep apnoea) is a condition that causes interrupted breathing during sleep as a result of a blockage or partial blockage to the airway. The resultant lack of oxygen causes the individual to come out of deep sleep in an attempt to restore normal breathing. This happens cyclically overnight and results in unrefreshed sleep. Symptoms can include loud snoring and regularly feeling tired during the day despite getting adequate sleep. We plan to screen all surgical patients for OSA using two validated screening tools called the STOP-Bang questionnaire and the Epworth Sleepiness Scale. Studies have shown that a STOP-Bang score of 4 or more OR an Epworth score of 12 or more is suggestive of OSA.
28. Molecular genetics of adverse drug reactions Principle Investigator: Baljit Dheansa Status: open Adverse drug reactions (ADR's) are a common cause of drug-related morbidity and may account for about 6.5% of all hospital admissions. A meta-analysis of studies performed in the USA has shown that ADRs may be the fourth commonest cause of death. ADRs are also a significant impediment to drug development, and a significant cause of drug withdrawal. The purpose of this research is to (a) identify patients with different types of adverse drug reactions; (b) using DNA obtained from blood or Saliva samples from these patients, identify genetic factors which predispose to adverse reactions. The net effect of our research will be the development of genetic tests which can help in predicting individual susceptibility to adverse reactions prior to the medication's administration. Patients with a pre-disposition to reacting adversely can be prescribed alternative medication of monitored more closely during their treatment. This will reduce the harm for patients and save valuable resources for the NHS. We aim to recruit 250 cases for each reaction for a period of eight years throughout multiple sites in the UK. Specific adverse drug reactions we are looking at include:
- Statin induced myotoxicity, characterised by high CK - Severe hypersensitivity reactions including Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
QVH BOD September 2018: Session in public Page 145 of 260 - Anaphylaxis induced by NMBA anaesthetics - ACE inhibitor or ARB induced angioedema - Taxane hypersensitivity - Chemotherapy induced peripheral neuropathy - Bleomycin induced lung toxicity - Clozipine induced agranulocytosis or neutropenia - Bisphosphonate-related osteonecrosis of the jaw - Tenofovir associated renal injury - Serious bleeds induced by warfarin or other anticoagulants
29. S100 & CD31 in tongue cancer (Perineural and vascular invasion in tongue cancer: is detection improved using markers for nerves and blood vessels?) Principal Investigator: Bill Barrett Status: ongoing Microscopic invasion of nerves and blood vessels in oral cancer is an unfavourable prognostic indicator, but depends on the histopathologist sampling the tumour adequately and then identifying these features in tissue sections using routine haematoxylin and eosin (H&E) stains. There is evidence that suggests that staining the section for a marker of nerves (S100 protein) and the cells lining blood vessels and capillaries (CD31) increases the microscopic detection of perineural and vascular invasion by 52% and 12% respectively. Thus nerve and vascular invasion could be significantly underreported.
We are currently auditing the incidence of perineural and vascular invasion by cancers arising in subsites within the oral cavity, and aim to assess the degree of underreporting, if any, in a sample of 60 cancers of the tongue. Thirty of these were originally reported as showing nerve invasion in the excision specimen, thirty were reported as negative. Only two were reported as showing vascular invasion.
30. Molecular prediction of metastasis in oral tongue squamous cell carcinoma (external study) Principle Investigator: Bill Barrett Status: ongoing A cDNA microarray study carried out in Utrecht (Netherlands) discovered genetic differences between primary squamous cell carcinomas of the oral cavity and oropharynx that spread to the neck and those that do not. This work leaves the door open to genetic analysis of a tumour of the tongue that has yet to spread to the neck. It may be possible to check the genetic makeup of the tumour, using a combination of antibodies to help surgeons decide how likely a tumour is to spread to the neck and to decide whether or not a neck dissection operation or radiation to the neck is necessary. This could avoid unnecessary morbidity and mortality. Patients with squamous cell carcinoma of the oral tongue are to be identified with at least 5 year follow up i.e. diagnosed before October 2004. Two groups are to be identified: those with spread to the neck, and those who did not develop spread to the neck. Case notes are to be reviewed and all clinical data and treatment, overall and event free survival are to be recorded. The histopathology slides and blocks of tumour archival material are to be identified will be used to make a tissue microarray. This is a research technique which allows for genetic analysis of samples to be done more quickly than routine techniques. No new samples collection or patient interventions are to be undertaken. The data will then be analysed to see which markers show differential expression between the two groups, or have relationship to overall and event free survival. These markers, used in combination, may be used in future prospective studies and in treatment planning.
31. Molecular determinants of head & neck cancer
Principle Investigator: Jag Dhanda Status: closed Current methods of detecting and monitoring oral cancer rely on biopsy and imaging
QVH BOD September 2018: Session in public Page 146 of 260 techniques such ultrasound and computerised tomography scans. The most aggressive and ultimately fatal type of oral cancer, which is the commonest head and neck cancer, is one in which the disease has spread to, and spilled out from, lymph nodes in the neck. Cancer is ultimately a genetic disease and detecting these genetic abnormalities in tissue derived from the original cancer site, lymph nodes, blood and saliva may provide clues as to the clinical course of the disease. Ultimately, detection of these abnormalities may aid in diagnosis, direct treatment modalities and monitor patient responses.
32. A multi-centre, randomised controlled trial assessing the effectiveness of Lugol’s Iodine to assist excision of moderate dysplasia, severe dysplasia and carcinoma insitu at mucosal resection margin of oral and oropharyngeal squamous cell carcinoma Principle Investigator: Paul Norris Status: in follow-up Research evidence suggests that persistence of precancer tissue at the edges of tissue resected to treat oral cavity and oropharynx cancer leads to greater risk of recurrence of cancer at the primary site.
Currently, tumour tissue can be distinguished clinically by the surgeon operating to remove cancer.
Unfortunately, detected precancer change in the tissue next to the cancer itself is much more difficult. This leads to precancer tissue persisting at the edges of the removed tissue in around a third of patients treated. We aim to test whether use of a staining method will enhance accuracy of removal of precancer tissue. Precancer cells are abnormal in many ways. One effect of the changes is that they cannot store glycogen. This means that they do no stain darkly with iodine, as normal tissue does. This difference may allow us to better identify these precancer cells at the time of cancer excision and so remove all precancer cells at the same time. This may reduce the risk of second primary cancers developing in the same area of the mouth and throat. This study will be a randomised, controlled, blinded trial. Patients will be randomised to have cancer resection with or without the staining method. We will then compare the proportion of cancers removed which have precancer cells at the edges in each of the groups. This will allow us to assess whether this method is effective in helping us to remove all of the precancer tissue.
The pathologist will assess resected cancer specimens in exactly the same way as it is carried out currently. They will not know which patients are in the staining group and so assessment of the effect of using the stain is blinded.
Planned projects – studies which had not been given Approval as of 01/04/18, but which are expected to start in 2018-19
• FRAME – ambulatory measurements of facial expression in health and disease • NINJA - A study to investigate paediatric nail bed injuries • XEN45 in angle closure glaucoma • Smartmatrix 2 • Facial co-contractions in normals • DEFeND • NICO • Validating extubation scores
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11. Report approval and governance This annual report has been reviewed by our R&D Governance Group, as well as by the Quality and Governance Committee.
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Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/2018 Agenda reference: 141-18 Report title: Safeguarding Adults & Children’s Annual Report 2017/18 Sponsor: Jo Thomas, Director of Nursing Author: Pauline Lambert, Safeguarding Named Nurse and MCA lead Appendices: 5 Executive summary Purpose of report: Each year a safeguarding report is produced to provide assurance that the Trust is undertaking its safeguarding duties and responsibilities safely and effectively. Summary of key Current challenges: issues • Changes to the specialist safeguarding team • Limited space and facilities for children in outpatient departments • Safeguarding advice and support for staff 24 hours per day • QVH compliance with Mental Capacity Act • Demonstrating compliance with WRAP training to the required 85% target Current achievements • Data reporting systems using Datix put in place • Paediatric Safeguarding Level 3 training now running twice a year on site • Adult safeguarding level 3 training has been set up • Robust connections with West Sussex safeguarding Boards • Overview of QVH policies and guidance which inform safeguarding • Roll out of PREVENT training for all staff • QVH contributions to safeguarding reviews • National Child Protection Information Systems (CP-IS) being used at QVH
Recommendation: The board is asked to approve the annual safeguarding report Action required Approval Link to key strategic KSO1: KSO2: KSO3: KSO4: KSO5: objectives (KSOs): Outstanding World-class Operational Financial Organisational patient clinical services excellence sustainability excellence experience Implications Board assurance framework: Applicable to KSO1,2, 4 and 5 Corporate risk register: Safeguarding level 3 training risk recently rescored and removed from CRR to local RR. Regulation: All Boards must publish an annual safeguarding report and demonstrate to regulators that appropriate safeguards are in place to protect vulnerable adults and all children. Legal: All health care providers are required to meet safeguarding criteria for adults- Care Act 2014. Section 11 of The Children Act 2004 places a statutory duty on all NHS organisations to safeguard and promote the welfare of children. Resources: No new resources required Assurance route Previously considered by: QVH Strategic Safeguarding group and Quality and Governance Committee Date: 23.04.18 Decision: Recommended for approval at board 19.07.18 Next steps: To QVH Board for approval
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Holtye Road, East Grinstead RH19 3DZ
Safeguarding
Queen Victoria Hospital NHS Foundation Trust Service Annual Report
Report covering the period from April 2017 to March 2018
Document Control: committees and groups who have approved this report Executive sponsor: Jo Thomas, Director of Nursing
Authors: Pauline Lambert, Safeguarding Named Nurse Dr Oli Rahman, Safeguarding Children Named Doctor
Date:
Type: Annual Report Version: DRAFT V1 Pages: Number Status: Public. Written and prepared for the Trust Board Circulation: QVH Trust Board
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Contents List
Item: Page number:
1. Executive Summary 3 2. Introduction 3 3. Legislative frameworks 5 4. Sussex Clinical commissioning groups (CCGs) Safeguarding 6 Standards Standard 1: Strategic Leadership 7 Standard 2: Lead Effectively to reduce the potential for abuse 9 Standard 3: Responding effectively to allegations of abuse 10 Standard 4: Safeguarding practice and procedures 11 Standard 5: Staff Competence 13 Standard 6: Safer Recruitment 15 Standard 7: Learning from Incidents 16 Standard 8: Commissioning 17 Standard 9: Safeguarding data requested by Department of 17 Health 5. Activity analysis, achievement 18 6. Involvement and engagement 19 7. Learning from experience 19 8. Recommendations 20 9. Delivering the Safeguarding Agenda 20 10. Conclusions and assurance 21 Appendices Appendix A : Safeguarding Training Evaluation Samples 23 Appendix B: Safeguarding Activity data for QVH 26 Appendix C: Safeguarding Audit Programme 27 Appendix D: Policy, procedures and guidance overview 28 Appendix E: QVH Safeguarding Actions Plan 30
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1. Executive Summary Each year a Safeguarding Report is produced for QVH Board to provide assurance that the Trust is undertaking its safeguarding duties and responsibilities safely and effectively.
The report is reviewed and scrutinised by the Quality and Governance Committee before being shared with the Board for information.
QVH safeguarding systems and arrangements have continued to improve and strengthen during the last year. They are more transparent and safeguarding support for staff is well established. Safeguarding Audits continue to provide assurance for the organisation and also identify any key development areas.
Current challenges are:
Changes to the specialist safeguarding team and one vacancy
Limited space and facilities for children in outpatient departments.
Safeguarding advice and support for staff 24 hours per day
QVH compliance with Mental Capacity Act
Demonstrating compliance with WRAP training to the required 85% target, currently 66.5 %
Current achievements are:
Data reporting system put in place during 2017-2018.
Paediatric safeguarding Level 3 training running twice a year
Adult safeguarding level 3 training set up
Robust connections with West Sussex Safeguarding Boards
Overview of all relevant QVH polices, protocols, standards and guidance
Roll out of PREVENT training for the organisation’s clinical staff
QVH contributions to safeguarding reviews
National Child Protection Information System ( CP-IS) being used by MIU and Paediatric Ward
2. Introduction 2.1 Each year a Safeguarding Report is produced for QVH Board to provide assurance that the Trust is undertaking its safeguarding duties and responsibilities safely and effectively.
2.2 QVH is registered with the Care Quality Commission (CQC). To be registered, QVH must be
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assured that those who use the services are safeguarded and that staff are suitably skilled and supported to provide effective safeguarding as part of health care delivery. As a Foundation Trust, QVH is licensed via NHS Improvement which is conditional upon registration with the CQC.
QVH must demonstrate that there is safeguarding leadership and commitment at all levels of the organisation and that staff are fully engaged. To support local accountability and assurance structures QVH safeguarding leaders need to engage with West Sussex Safeguarding Children Board (WSSCB), West Sussex Safeguarding Adults Board (WSSAB) and relevant commissioners.
QVH must ensure a culture exists where safeguarding is every bodies business and poor practice is identified and tackled.
QVH must have in place effective safeguarding arrangements to safeguard children and adults who are at risk of abuse or neglect. These arrangements include: safe recruitment, effective training for staff, effective supervision arrangements, working in partnership with other agencies, identification of a Named Doctor and Named Nurse for safeguarding children, plus a Named Nurse for adult safeguarding.
The named professionals have a key role in promoting good professional practice within QVH, supporting local safeguarding systems and processes, providing advice and expertise, and ensuring safeguarding training is in place, is delivered and of a suitable quality. They are expected to work closely with QVH Director of Nursing, West Sussex Designated Professionals, WSSCB and WSSAB.
2.3 The effectiveness of safeguarding systems is assured and regulated by a number of mechanisms. They include:
• Internal assurance processes and Board accountability
• Partnership working with WSSCB and WSSAB
• external regulation and inspection by Care Quality Commission (CQC) and NHS
Improvement.
• Local safeguarding peer review and assurance processes
• Effective contract monitoring
2.4 QVH Board members review monthly safeguarding metrics and receive an annual safeguarding report which is provided so the Board can be assured that the Trust is undertaking its safeguarding duties and responsibilities, as well as delivering its statutory safeguarding responsibilities safely and effectively.
The Board should critically appraise the QVH safeguarding report by making sure patient safety, staff activity, governance arrangements and safeguarding data are transparent and clear so that they can confirm they are assured.
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3. Legislative Frameworks and National Safeguarding Agenda. 3.1 Safeguarding Adults: Safeguarding means “protecting an adult’s right to live in safety, free from abuse and neglect” (Care Act 2014)
The arena for safeguarding adults continues to evolve since the implementation of the Care Act (2014). However, the aims of safeguarding adults remain unchanged. Organisations such as QVH, must stop abuse or neglect wherever possible, prevent harm and reduce the risk of abuse or neglect to adults with care and support needs, safeguard adults in a way that supports them in making choices about how they want to live their lives and provide information in accessible ways to help adults understand how to stay safe and what to do to raise a concern. In order for staff at QVH to achieve these aims, it is necessary to ensure that all staff are clear about roles and responsibilities, create strong multi-agency partnerships and support the development of a positive learning environment.
As an organisation, QVH adhere to the Sussex Safeguarding Adults policy & procedures as this provides an overarching framework to coordinate all activity undertaken where a concern relates to an adult experiencing or at risk of abuse or neglect. These procedures represent standards for best practice in Sussex and have been endorsed by Brighton & Hove, East Sussex and West Sussex Safeguarding Adults Boards.
They are available online, with links to the website via the internal intranet (QNET). This document is reviewed and updated by the West Sussex Safeguarding Adults Board.
3.2 Safeguarding Children: ‘The welfare of the child is paramount’ principle was enshrined in the Children Act 1989 and has driven the development of systems and arrangements used to safeguard and/or protect children since that time.
Section 11 of The Children Act 2004 places a statutory duty on all NHS organisations to ensure that services are designed to safeguard and promote the welfare of children.
National guidance also stipulates that each NHS trust must identify a lead nurse for Child Sexual Exploitation (CSE) and Looked After Children (LAC, sometimes referred to a ‘children in care’). These responsibilities are part of the Safeguarding Named Nurse Job Description.
3.3 Mental Capacity Act (MCA) 2005 & Deprivation of Liberty Safeguards (DoLS): The Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) have place an emphasis on ensuring that the rights of vulnerable people (aged 16 and over) to make decisions are protected. Decisions made on behalf of people should only be made using the MCA legal framework. Capacity is described as a person’s ability to make a specific decision at a specific time, for example - for specific serious medical treatment.
The DOLS were added into the MCA and is an additional Safeguard providing guidance on procedures that ensures care and treatment for those who lack capacity to consent to their accommodation is only delivered in their best interest and using the least restrictive options to ensure their safety. To be lawful, it needs to be authorized by the local authority, but in the hospital urgent self-authorization can be used when necessary.
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QVH staff are required to understand and comply with the requirements set out in the MCA 2005.
The QVH Mental Capacity and Deprivation of Liberties Policies have been reviewed and are currently out for consultation.
At year end compliance rates for Mental Capacity Act training are currently at 89% across the organisation. A departmental risk assessment for MCA is in place until a clear organisational overview of implementation in practice is embedded using Datix to capture the required data.
3.4 PREVENT The United Kingdom’s long-term strategy for countering international terrorism is called ‘CONTEST’. Published in 2006 and updated in 2009 and 2011, its aim is ‘to reduce the risk to the UK and its interests overseas from terrorism, so that people can go about their daily lives freely and with confidence’.
CONTEST comprises of four key elements: • Pursue: to stop terrorist attacks ~ detecting and disrupting threats of terrorism. It is targeted at those who have committed a crime or are planning to commit a crime.
• Protect: to strengthen our protection against a terrorist attack ~ strengthening our infrastructure from an attack including buildings, public spaces and our borders.
• Prepare: to mitigate the impact of a terrorist attack. Focuses on where an attack cannot be stopped and aims to reduce its impact by ensuring we can respond effectively.
• Prevent: to stop people becoming terrorists or supporting terrorism. ‘Prevent’ is different from the other three in that it focuses on early intervention before any illegal activity takes place and hence operates in the non-criminal sphere. Involving a broad range of partners, it is about minimising the risk, at an early stage, of people adopting extremist views which support violence or terrorism.
NHS providers are expected to contribute to the Prevent agenda. All clinical staff are expected to undertake Level 3 Prevent training. Prevent basic awareness training is provided to all QVH staff as part of safeguarding training sessions at levels 1 and 2.
4.0 Sussex Clinical Commissioning Groups (CCGs) Safeguarding Standards During 2016-2017 the CCGs used the Safeguarding Vulnerable People in the Reformed NHS : Accountability and Assurance Framework (March 2013) to produce a set of Sussex Safeguarding Standards to make explicit their expectations of NHS providers in relation to safeguarding.
The CCGs across Sussex have in place quality and safety systems, and processes in order to enable continuous improvements and the ‘safeguarding standards guidance’ now forms part of these arrangements.
The nine standards were developed to enable assurance to be provided to demonstrate patients of all ages are safeguarded effectively. The standards enable all parties to identify
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key benchmarks to ensure an effective, systematic, auditable approach to ensuring the safeguarding of all patients, whatever their age. The standards were shared with the QVH Board at a safeguarding seminar during November 2016. The standards enable the safeguarding team at QVH, as well as commissioners to audit against benchmarks to ensure effective measures are in place. This section of the report is organised based on these standards.
4.1 STANDARD 1: Strategic Leadership The Executive Board Lead for safeguarding vulnerable people, MCA & DoLS is the Director of Nursing who oversees compliance with safeguarding legislation and trust responsibilities. This is to monitor protection of people who use services at QVH and to ensure these are understood by staff and implemented throughout the organisation.
The QVH Safeguarding Strategy (2015) supports a progressive response to the changing landscape framing the delivery of healthcare services at QVH and will be reviewed and updated in 2018. Appendix D provides an overview of QVH safeguarding documents and information available for staff or the public via the Website or QNET intranet.
QVH has robust safeguarding governance arrangements in place, which are led and supported by a team of specialist safeguarding clinicians. The QVH governance structure provides transparent lines of accountability, clear partnership connections with internal QVH meetings which are in place to support learning from practice and delivery of effective safeguarding.
The QVH safeguarding team comprises of; Jo Thomas, Director of Nursing and Quality, Executive Board Lead for Safeguarding Pauline Lambert, Named Nurse for Safeguarding (covers: Children, Child Sexual Exploitation (CSE) lead and Looked After Children (LAC) lead Adults, MCA & DoLS Lead and Prevent Lead) Dr M Z (Oli) Rahman, Named Doctor Safeguarding Children (via BSUH SLA) Debra Yeoh, Nurse Specialist Safeguarding Children Katy Fowler, Nurse Specialist Safeguarding children & WRAP Training Facilitator Vacant Post, Nurse Specialist Safeguarding Adults, MCA & DOLS.
The purpose of this team is to continuously work to improve and update all staff including volunteers regarding their safeguarding knowledge and responsibilities. This is achieved through case discussions and supervision, advice, practice review and audit; provision of training; provision of policy, procedures, protocols and guidance.
The Non-Executive Director who chairs the Quality and Governance Committee is working to support scrutiny of the agenda with ‘Safeguarding’ identified as a discreet responsibility.
Across QVH there is a network of link champions for safeguarding from service areas. They attend either or both safeguarding steering groups to discuss clinical issues, access information, review learning and to share practice improvement across the organisation.
The Joint Hospital Governance Group provides a far reaching internal audience where safeguarding discussions are also undertaken, such as sharing learning from Safeguarding Reviews and Audit, and how improvements in practice might be applied in QVH.
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Driving improvement in all aspects of safeguarding practice is a continuous process and as such has to be reviewed, evaluated, developed and adapted over time. The Safeguarding Named Nurse is in the process of reviewing and creating one safeguarding learning and development strategy for the organisation to steer and facilitate staff competency development. A sample of staff training evaluation summaries is included in APPENDIX A.
The delivery of effective safeguarding is dependent on multiagency working. Across agency strategic work is set by the children and adult Safeguarding Boards in West Sussex and translated into work streams which are monitored by QVH Strategic Safeguarding Group or QVH Safeguarding Team to ensure relevant involvement and contributions for the trust.
QVH through the safeguarding team has well established links with local and regional safeguarding networks and committees.
West Sussex Adult Safeguarding NHS Professionals Network: This group is chaired by the Designated Nurse for safeguarding adults from Coastal West Sussex CCG. The Adult Safeguarding NHS Professionals group meet quarterly. Membership of these groups includes all adult safeguarding leads from across Sussex & Surrey, including Safeguarding Adult’s Board representation. The forum is an arena in which to share learning, reflect on practice and support peers. QVH Safeguarding Named Nurse attends these meetings.
West Sussex Safeguarding Children NHS professional Networks: This group is chaired by the West Sussex Designated Nurse for safeguarding children. The group meets quarterly. The group is attended by all West Sussex NHS Provider Trusts Named Nurses and provides a forum which can share learning from practice, inform and influence the WSSCB. Representatives from QVH attend regularly and raise awareness of QVH issues and safeguarding practices.
QVH has a case peer review system in place in the Burns Unit. Meetings to discuss paediatric and adult cases occur every Monday (except Bank Holidays). These meetings review injury mechanism and explanation, medical and nursing treatment, risk assess, discuss any safeguarding issues, patient capacity or deprivation of liberties issues and agree actions required.
Safeguarding supervision is offered to all QVH staff as required on a case by case basis and also via bespoke training sessions for teams or via discussions in team meetings. The purpose of these activities is to strengthen communication, networking and dissemination of safeguarding information and practice across the organisation.
Regular safeguarding supervision is provided to the specialist safeguarding nurses on a regular basis.
The Safeguarding Named Nurse continues to network with hospital consultants to discuss and review whether safeguarding systems are working for them and their teams.
Safeguarding priorities are central to achieving high quality and safe care. Quality and component parts of safety, effectiveness and patient experience are at the heart of QVH values. As an organisation QVH are committed to the protection and prevention of abuse & neglect for all vulnerable people whilst in the care of Queen Victoria Hospital NHS
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Foundation Trust (QVH). The safeguarding team continue to review and strengthen systems, methods and arrangements for managing episodes where we might be considering or suspect abuse/neglect has occurred either within the organisation or prior to admission.
Staff are provided with support to manage any concerns identified.
Human Rights: Protecting the vulnerable and those at risk, is a key component of our trust objectives. Focussing on quality and patient experience we work alongside partner agencies to promote the safety, health and well-being of people who use our services.
QVH has effective systems in place to highlight and respond to shortfalls in capacity which have an impact on the ability to meet safeguarding responsibilities. These are highlighted to the board through the internal DATIX reporting system, and regularly discussed at the strategic safeguarding group meetings and reviewed by the Safeguarding Named Nurse.
There are currently no safeguarding corporate risks identified.
There are three safeguarding departmental risks. Not able to demonstrate full compliance with implementation of the MCA (risk rating 9 - LOW) Nursing and Quality department Looked After Children safeguarding systems not fully in place (risk rating 6 - LOW) Nursing and Quality department National directive to ensure WRAP training (Level 3 Prevent) uptake is 85%. (risk rating 6 - LOW) Nursing and Quality department
QVH has a safeguarding audit programme in place for 2016 to 2018 which includes information on the audit methodology being used, involvement of managers and staff and how the findings from audit will be disseminated.
2017 audit analysis is included later in this report and overview of the audit programme can be found in Appendix C.
4.2 STANDARD 2: Lead effectively to reduce the potential of abuse QVH has policies, processes and procedures in place to enable staff to report any concerns they have for patients or members of the public attending QVH sites. If their concerns are not heard there are escalation processes which can be used. Escalation processes were not used during 2017-18.
Training and procedures highlight how diversity, beliefs and values of people who use QVH may influence the identification, prevention and response to safeguarding concerns. The documents and information safeguarding overview is provided for the organisation and staff is identified in APPENDIX D.
QVH has a clear, accessible and well-publicised complaints procedure. This includes information about how to complain to external bodies such as regulators and service commissioners, relevant advocacy and advisory services. Information regarding Gillick competence, mental capacity and Lasting Powers of Attorneys (LPAs) is cross-referenced with the other policies (such as consent) and safeguarding procedures. A pilot data collection system to capture safeguarding (adults, children and MCA) practice and learning was set up using Datix for recording purposes. Safeguarding Datix reports are now being shared across
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the organisation to aid case discussion and to share learning.
QVH place great importance on ensuring patients have an excellent experience. The trust continues to develop ways to engage and listen to patients, collecting views, comments and ideas from them, their families and carers which then form future plans to further improve patient experience. Board committees review results from Family and Friends Tests and the annual staff Survey.
QVH safeguarding team have produced a range of information for patients and their families. Including: QVH safeguarding children and young people leaflet for families. Information leaflet regarding attendance at the trust with dog bite injuries for all patients. Next of Kin: understanding decision making authorities Mental Capacity Act Guide for patients and their families
Work on a set of QVH posters and leaflets encouraging patients to talk to staff, clinical managers, PALs and the safeguarding team if they have any concerns about for a patient continues, is in the process of being rolled out.
During 2017-18 audits were undertaken to assess QVH compliance with the Mental Capacity Act (MCA) 2005 and DOLS. This has led to a review and update of trust policy and delivery of training for staff.
The recurring audit of quality of safeguarding referrals was undertaken during September to October 2017. The new audit process was based on West Sussex referral standards and demonstrated QVH adherence to these.
4.3 STANDARD 3: Responding effectively to allegations of abuse QVH have arrangements in place to ensure that patients are safeguarded by responding appropriately to any allegation of abuse or neglect.
Safeguarding Adults Activity The Safeguarding Named Nurse receives notification of any safeguarding concerns relating to adults via the DATIX reporting system. Each DATIX report is reviewed and investigated. Process issues and learning from each event is now shared using monthly and quarterly safeguarding Datix Reports.
This approach provides oversight of all safeguarding adult referrals to social care services.
The table in Appendix B provides details of the monthly safeguarding adult activity reported on DATIX for the past year.
Safeguarding Children Activity The Paediatric Safeguarding team receive reports of any safeguarding children concerns which occur within QVH via a centralised email address. Follow up by Specialist Paediatric Safeguarding Nurses provides support for staff managing these situations as well as a means to review case management, follow up outcomes with statutory partners and to enable learning to be shared.
Safeguarding children incidents are reported on the DATIX system when the level of harm
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indicates the need for referrals to social care or police. This approach is now going to be aligned with adult safeguarding, all safeguarding children concerns will be captured on the Datix system during 2018-19.
The paediatric safeguarding team continued to use an Access database and log information about any concerns raised during 2017-18. See Appendix B for overview of paediatric safeguarding activity during the past year.
The QVH Electronic Document Management system (also known as Evolve) is currently being rolled out across the trust. There is a safeguarding section for all patients which can be used to file safeguarding information so that it is available for staff seeing the patient.
A safeguarding section has also be added to the QVH Electronic Discharge Summary. So that the handover of care can provides an opportunity to inform others of concerns or create a request contact for more information. This new approach will be audited during 2018-19.
The national Child Protection Information systems (CP-IS) is used by Minor Injuries Unit and Peanut Paediatric Ward to check whether children or young people have a child protection plan or are looked after by a local authority.
Allegations Against Staff The Director/Deputy Director of Human Resources would manage the Trust response to any allegations against trust staff. ‘Allegations against staff’ procedures are followed.
During the last year, no concerns relating to staff have been raised.
When required investigations are co-ordinated by West Sussex County Council. Advice was taken from the Local Authority Designated officer on one occasion; a formal investigation was not instigated. We do not currently have any data with which to compare with other trusts.
4.4 Standard 4: Safeguarding practice and procedures The Safeguarding Team develop a wide range of guidance for the organisation, staff and patients in the form of policy, procedures, protocol, guidelines and leaflets. For a list of what is in place for QVH please refer to Appendix D.
All documents are placed on the Website or QNET intranet. All documents are systematically reviewed and updated in collaboration with relevant services and governance groups.
Information is monitored and reviewed regularly and updated on the QNET, including information on who to contact for advice and support. A new set of laminated safeguarding prompt cards are now available for all staff at QVH and are shared at training and governance events.
Prevent: The delivery of the ‘Prevent’ agenda in the trust, is led by the Safeguarding Named Nurse who is ‘Prevent Lead’ for the trust and one of the Specialist Nurse for safeguarding who delivers all face to face level 3 Workshops. Staff are made aware of the Prevent delivery plan which is a tool kit for staff and is available to via the QNET.
Level 3 Prevent training compliance data is at 66.5% across QVH. Face to face sessions will
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continue during 2018. Many of the trainee doctors who transfer to the trusts have not undertaken the training in their previous organisations so this means our uptake data is hard to improve. After discussion with the Regional Prevent Coordinator it has been agreed that some staff who have been unable to attend face to face sessions will be able to undertake the new national Level 3 Prevent eLearning option. This will help improve our training uptake data. QVH report Prevent data to NHS England quarterly, we have not made any Prevent referrals during 2017-18.
Basic awareness of prevent will continue to be provided in adult and child safeguarding level 1 and 2 training sessions.
QVH Safeguarding Forms which are available via the QNET are written in accordance with the local and national guidelines.
Where a patient is identified as needing any form of control, restraint or therapeutic holding QVH have policies in place to protect all patients against the risk of such control or restraint being unlawful or excessive.
All QVH staff are required to understand their legal responsibilities under the Mental Capacity Act including undertaking mental capacity assessment, best interest decision making processes, capacity assessments and when to complete a deprivation of liberties safeguard process. MCA data is now captured on the Datix system. Monthly reports are shared to aid case discussion and to share learning.
Domestic violence and abuse (DVA)
Managing domestic violence and abuse situations can be challenging for staff. Managing risks, keeping individuals safe and seeking the right specialist advice are all important aspects of patient care when DVA is being considered a possibility or has been confirmed. Raising awareness of and managing DVA situations is included in level 2 and 3 safeguarding training.
The QVH psychological therapies team and the QVH safeguarding team can undertake Domestic Abuse Stalking Honour (DASH) risk assessments to help inform next steps for the patient. Worth DVA specialist services and the police can provide advice and support to staff at QVH.
Patient DVA procedures are in place. Staff experiencing DVA policy has been ratified. Three members of staff experiencing DVA have been supported this year.
Safeguarding Audit Audit of service efficacy is an integral element of the work of the Safeguarding Team. A three year cycle of audit activity has been developed including core elements such as NICE guidance alongside aspects of clinical practice. ( see Appendix C)
MAZAARS undertook an Internal Audit of specific procedures and controls in place over the process for Safeguarding Adults and Children in accordance with the 2017/18 Internal Audit Plan. The report provided substantial assurance. Three medicaum priority areas were followed up, they include: DBS Reminder Letters, Adult Safeguarding Training, Safeguarding Records.
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During 2016-17 two safeguarding audits were undertaken: NICE CG 89 When to suspect child maltreatment, and NICE PH 50 DVA quality standards audit Feb 2016.
During 2017-18 the following audits were completed. Reports and action plans are reviewed and monitored either in the QVH strategic safeguarding group or on of the QVH safeguarding steering groups.
2017 Topic/s Progress Next Steps Referrals audit – adult and Completed December 2017 Repeat next 2018 children CG89 and PH 50 Survey Competed February 2018 Report to Steering group monkey for medical staff Roll out across QVH medical staff MCA staff knowledge audit Completed December 2017 Report to SSG Action plan being monitored MCA compliance audit Completed December 2017 Report to SSG Action plan being monitored
Recognition of Child Sexual Exploitation (CSE) or child sexual abuse requires careful assessment and consideration when concerns arise. The Paediatric Safeguarding Named Nurse is the CSE lead for QVH and supports staff to access specialist advisors if required.
Looked after children (LAC) or Children in Care are a group of children and young people who are cared for by the local authority. There can be consent implications for these children and clinicians needs to understand what voluntary or court agreement is in place for each child. The Safeguarding Named Nurse is the LAC lead for QVH and supports staff to understand court orders and how to make contact with a child’s social worker or NHS LAC team from the area in which they live.
If QVH staff comes across private fostering arrangements for children less than 16 years of age they need to notify social care services so that a social care assessment can be undertaken of the situation. Raising awareness of staff responsibilities in these situations is included in paediatric safeguarding training sessions.
The safeguarding team have close links with the communications team at QVH where there are strict guidelines for dissemination of information internally for all staff across the organisation, including updates and reviews.
4.5 STANDARD 5: Staff competence QVH Staff have access to a comprehensive training programme regarding: safeguarding adults, safeguarding children, Mental Capacity Act and Prevent training programme across levels 1, 2 and 3 internally.
In addition to this external training and conferences are also used to enhance knowledge and competencies where required.
Safeguarding Learning and development Strategy. QVH Adult Safeguarding learning and development strategy was updated in October 2016. This framework is aligned with the core skills framework document, with the national guidance from the NHS England Safeguarding Adults: Roles and competences for health care
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staff – intercollegiate document.
QVH Paediatric safeguarding learning and development strategy was ratified during March 2016. This framework is aligned to national guidance. It provides transparent QVH expectations for staff including the Board with regard to paediatric safeguarding training and development.
During 2018 the strategy will be updated and one safeguarding strategy will be produced and used across the organisation.
Safeguarding Training:
During 2017 the safeguarding training programme on offer at QVH has been reviewed and updated.
Session Participants At end of year training uptake is currently: Safeguarding children Non-clinical staff 100% Induction Level 1 (includes: Prevent, DVA, LAC and CSE) Safeguarding Children Clinical Staff ( includes level 1 100% Induction level 2 competencies) (includes: Prevent, DVA, LAC and CSE) Safeguarding Children Clinical Staff ( includes level 1 88% Refresh level 2 competencies) Required every (includes: Prevent, DVA, LAC three years and CSE) Safeguarding Children For specified clinical staff 84% Refresh level 3 (includes Level 1 and level 2 (includes: Prevent, DVA, LAC competencies) and CSE) Required every three years
Consultants attend QVH in- house training session, or undertake specified eLearning, or passport existing training evidence from another NHS trust Adult Safeguarding and MCA All staff 100% Induction level 1 and Level 2 (includes: Prevent and DVA) Safeguarding Refresh Level 1 Non-clinical staff 95% (covers children and adults) Required every three years (includes: Prevent and DVA) Adult Safeguarding and MCA Clinical Staff (includes level 1 92% Refresh Level 2 competencies) Required every (includes: Prevent and DVA) three years
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Adult Safeguarding and MCA For specified clinical staff Stared February 2018 Refresh Level 3 (includes Level 1 and level2 30 participants (includes: Prevent and DVA) competencies) Required every three years DVA DASH Workshops Level 3 For specified clinical staff 100% Safeguarding Children Safeguarding Named Nurse as 100% Refresh level 4 part of personal development Safeguarding Children Named Doctor as part of personal development
Adult Safeguarding and MCA Safeguarding Named Nurse as 100% Refresh Level 4 part of personal development Safeguarding Induction Trainee Doctors 100% Passport existing safeguarding training over or update to Level 2 (children and adults) whilst at QVH WRAP All clinical staffx1 66% (72% permanent staff)
Specialist Support Provision of clinical supervision and support for specialist safeguarding staff is provided by West Sussex Designated professionals who are employed by Clinical Commissioning Groups. Trust policy requires that provision of specialist safeguarding advice and support to QVH staff is accessed on a case by case arrangement from safeguarding team members when needed.
All staff job descriptions include a safeguarding which recognise responsibilities for safeguarding and these are reviewed through the appraisal and/or PDR process.
QVH Safeguarding team received regular supervision from the West Sussex Designated Nurses.
4.6 STANDARD 6: Safer recruitment QVH work to ensure that those working or who are in contact with children, young people and adults are safely recruited and Human Resource processes take account of the need to safeguard and promote the welfare of all. Making sure that QVH do everything we can to prevent appointing people who pose a risk to vulnerable people is an essential part of safeguarding practice and QVH recruit staff and volunteers following safer recruitment procedures.
All staff at the Trust are employed in accordance with the NHS pre-employment check standards.
As part of their induction, new employees, including volunteers are expected to undertake mandatory training in safeguarding at either level 1 or 2.
During 2017-18 an internal Safeguarding Audit was undertaken which covered as an objective: “all staff which are eligible for a criminal record check under the Rehabilitation of
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Offenders Act 1974 (Exceptions) Order 1975 have received the appropriate level of DBS check”. Testing of a random sample of 20 members of staff requiring a DBS check identified five cases where a DBS check was made more than three years ago and a reminder had not been sent to the relevant person. Reminder letters were last sent in February 2017 however, these did not include the current exceptions noted. A recommendation was raised and completed to address this.
4.7 STANDARD 7: Learning from incidents Statutory Safeguarding Reviews:
Safeguarding Adult Reviews (SAR) Safeguarding Adult Boards (SABs) must arrange a SAR when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult.
In January 2017, QVH were notified by Wandsworth Adult Safeguarding Board that they had made a decision to undertake such an investigation under section 44 of the Care Act, for an adult who died in July 2016 as a result of a fire in her home. A range of services were involved in her care between 2015 until her death in 2016, including QVH.
The Review report was published by Wandsworth in July 2017. QVH Action plan was discussed at a Burns Unit meeting where learning was shared and new ways of working with regard to safety and discharge planning were identified by unit staff.
Safeguarding Children Reviews:
Serious Case Reviews (SCRs)
When a child dies or is seriously harmed, including death by suspected suicide, and abuse or neglect is known or suspected to be a factor in the death, West Sussex safeguarding Children Board (WSSCB) is required to conduct a Serious Case Review into the involvement of organisations and professionals in the lives of the child and the family.
The purpose of a Serious Case Review is to establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard children, identify what needs to be changed and, as a consequence, improve multi-agency working to better safeguard and promote the welfare of children.
One Serious Case Review involving QVH was commenced in January 2017 by WSSCB. QVH provided unexpected out of hours care to a child known to and working with a range of other services. The review process was completed in November 2017. Findings will not be released until the police investigation is complete.
The QVH action review was led by a Specialist Nurse for paediatric safeguarding and the action plan has been completed. Learning from the review and action plan has been shared with QVH Staff.
Child Death Reviews. The WSSCB is also required to conduct a review of every child death to
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identify whether there are any lessons to be learned to prevent child deaths in the future.
QVH has not contributed to any child death reviews this year.
Other types of reviews. The WSSCB carry out a range of learning activities in order to understand how to improve safeguarding. This includes reviews into individual cases and reviews of practice across areas of safeguarding.
QVH has not contributed to any other case reviews during the year.
QVH Staff have access to specialist advice and support through the named nurse, specialist nurses and link champions. Where appropriate, staff and staff groups are provided with debriefing/supervision sessions by the Named Nurse and/or other senior staff at QVH.
4.8 STANDARD 8: Commissioning Contract Monitoring -Sussex Clinical Commissioning Groups (CCG's) Safeguarding Standards CCG’s as commissioners of local health services need to assure themselves that the organisations from which they commission services have effective safeguarding arrangements in place. A self-assessment tool is completed annually and contributes to providing evidence of assurance in conjunction with assurance site visits and submission of audits as part of an audit programme. There is overlap between this report and the Section 11 self-assessment for WSSCB.
CCG exception reports are provided by QVH Safeguarding Team in April, July, October and January of each year.
No issues of concern were raised during the last year.
External regulation and inspection by CQC and Monitor West Sussex safeguarding standards and compliance reporting is completed on a quarterly basis by Safeguarding Named Nurse on behalf of QVH.
Any safeguarding issues or concerns are captured and reported to the Board alongside the Board’s monthly safeguarding metrics.
Monthly CQC reporting via the Deputy director of Nursing over the last year: • no specific paediatric safeguarding concerns were raised during the last year. • no specific adult safeguarding concerns were raised during the last year.
QVH CQC overall - good rating.
4.9 STANDARD 9: Safeguarding data requested by Department of Health Female Genital Mutilation (FGM)
Understanding of FGM and mandatory reporting duty is incorporated into QVH mandatory safeguarding training for staff. DH/NHS approved and recommended FGM e-Learning packages are also available to staff to enhance their knowledge and understanding of this subject and required practice.
FGM guidance and information, with particular regard to risk assessment, mandatory reporting and recording, can be accessed by staff via the Trust QNET Safeguarding page.
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At QVH no FGM risk assessments were undertaken on any patients during the last year.
Prevent Returns QVH submit quarterly reports to Regional Coordinator at NHS England with prevent information which reflects the number of prevent referrals and details of staff compliance with training. This information is also copied to the CCG for assurance.
At QVH no PREVENT referrals were made during the last year.
5.0 Activity analysis/ achievement 5.1 Health care at QVH is patient centred and QVH works closely with partners to ensure effective safeguarding is achieved for all vulnerable patients whether they are children, young people, adults or other family members.
National metrics are reported on a monthly basis to CQC and DH including: FGM assessments and PREVENT referrals.
QVH continuously strives to develop staff knowledge, competence and support its staff to achieve the best outcomes for patients at risk of harm. A streamlined safeguarding training programme was introduced this year. Level 3 training session were introduced for Consultants as part of their mandatory training days.
QVH promotes a culture where staff are able to raise concerns and to whistle blow without fear, this is evidenced in the staff survey.
QVH also promotes feedback from patients and encourages them to raise concerns about anything they see and are worried about. There are close working links with the Patient Experience Manager and the Director of Nursing. There have been 2 safeguarding plaudits from patients this year.
5.2 Training for staff is reviewed annually and updated in line with legislative requirements. Training data uptake continues to improve each year.
Paediatric safeguarding systems in QVH have been well established for many years. They continue to be strengthened. There is a transparent overview of what is in place and of paediatric safeguarding activity occurring in the organisation.
The embedding of Adult Safeguarding was developed throughout 2016-17. During 2017-18 there has been a change in leadership arrangements, this has provided opportunities to streamline and rationalise systems and processes. Feedback from staff has been positive.
Safeguarding governance arrangements embedded well during the last year.
5.3 QVH has a range of internal assurance processes in place.
An overview of adult and paediatric safeguarding, and MCA activities in QVH are in place using the Datix systems for reporting purposes.
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QVH staff training programmes for adult and paediatric safeguarding have been reviewed and continue to be updated and clinically focused. Staff provide evaluations which are used to identify areas in which to improve training. Evaluations are reviewed after each training session.
QVH has an overview of all relevant safeguarding information and documents, which are systematically developed, reviewed and/or updated.
Three safeguarding departmental risk assessments are in place. These are discussed at strategic safeguarding group quarterly, monitored monthly and details reviewed at least every 6 months by the Safeguarding Named Nurse.
5.4 QVH has local external regulation undertaken by the CCGs, WSSCB and WSSAB.
NHS Improvement ensures QVH are registered with the CQC. A Care Quality Commission (CQC) inspection occurred during 2015. The report published in 2016 identified two areas that the safeguarding team have worked on to improve: reporting of departmental risks and increase uptake of MCA training. Both these have improved and are reflected in this report. 5.5 Local safeguarding peer review and assurance processes are in place.
The Named Nurse for Safeguarding is well supported by the Director of Nursing, Deputy Director of Nursing, Heads of Nursing and the West Sussex Designated Professionals.
QVH staff are guided and supported by a team of specialist safeguarding clinicians. This team are supported by Peanut Paediatric ward staff, Site Practitioners and Heads of Nursing. Consultants now received level 3 training for all aspects of safeguarding. 5.6 Partnership working with WSSCB and WSSAB is in place.
A number of practice developments have embedded in the last year including: management of CSE, DVA and the roll out of the national Prevent training workshop.
5.7 Effective contract monitoring is undertaken through audits and regular exception reporting to WSSCB, WSSAB, CCGs and the CQC.
6. Involvement & Engagement There is involvement of staff members in safeguarding work streams via Joint Hospital Governance Group, Strategic Safeguarding Group, Safeguarding Steering groups, Nurse Quality Forum, Patient Information group, Volunteers forum and other QVH governance groups, to involve others in: Identifying safeguarding priorities as part of discussions Undertaking key areas of safeguarding work/projects Sharing safeguarding information
7. Safeguarding Learning from Experience Safeguarding learning and development is a continuous process; there are a number of key regular routes for this to occur. Experience without reflection does not always result in learning. It is through the reflective process that meaning is created and new
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insights gained.
During the year: Patients’ situations and experiences are regularly reviewed at Safeguarding Steering groups. Learning I then shared more widely by Safeguarding Link Staff. This approach has been supported by producing Safeguarding Link Worker briefing notes and also the use of the Datix reports for Adult Safeguarding, Safeguarding Children and MCA.
Two case reviews have involved QVH staff and learning has been shared and discussed in team meetings and other governance groups.
Feedback back from other agencies, peers, patients and their families either written or verbal is used as art of safeguarding discussions to enable staff to understand the impact of care provided whilst at QVH.
8. Recommendations Recommendations to take forward in the coming year include: Roll out use of Datix to capture all safeguarding and MCA activity across the trust. Capture safeguarding and MCA verbal feedback on the Datix system Build up use of EDM/Evolve to capture safeguarding information into the safeguarding section so that information is visible to staff who need to access it Continue specialist development and succession planning with the QVH safeguarding team
9. DELIVERING THE QVH SAFEGUARING STRATEGY
QVH Safeguarding strategy will be reviewed and updated during 2018. Delivery of the safeguarding agenda at QVH will continue to include:
Ensure all aspects of safeguarding work and practice are considered and incorporated into all QVH services. Service developments take account of the need to safeguard all patients and are informed by service users and quality impact assessments. Processes in place to disseminate, monitor and evaluate outcomes of all case review recommendations and actions. Ensure there are effective arrangements in place to share information when required. Safeguarding training and systems compliance will be monitored by safeguarding leads. QVH will demonstrate it is meeting its statutory requirements via annual reporting and an audit programme
In addition to this a Human Rights Framework will be incorporated into the strategy to make transparent protection of vulnerable patients at QVH.
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10. Conclusions and assurance Incorporating safeguarding legal frameworks into every day clinical practice is a continuous process. Safeguarding patients and their families is every bodies responsibility.
All health care at QVH is patient centred and QVH works closely with partners to ensure effective safeguarding is achieved for all vulnerable patients whether they are children, young people, adults or other family members
MAZAARS internal safeguarding audit provided substantial assurance.
National metrics are reported on a monthly basis to CQC and DH including: FGM assessments and PREVENT referrals.
QVH continuously strives to develop staff knowledge, competence and support its staff to achieve the best outcomes for patients at risk of harm.
QVH promotes a culture where staff are able to raise concerns and to whistle blow without fear, this is evidenced in the staff survey.
QVH also promotes feedback from patients and encourages them to raise concerns about anything they see and are worried about. There are close working links with the Patient Experience Manager and the Director of Nursing.
Safeguarding systems in QVH continue to be strengthened. There is a transparent overview of what is in place and of safeguarding activity occurring in the organisation.
Safeguarding team membership and governance arrangements have been strengthened during the last year.
QVH has a range of internal assurance processes in place.
QVH staff training programmes for adult and paediatric safeguarding have been reviewed and continue to be strengthened. Staff provide feedback which identifies areas in which to improve training. Evaluations are reviewed after each training session.
QVH has an overview of all relevant safeguarding information and documents, which are systematically developed, reviewed and/or updated.
Three safeguarding departmental risk assessments are in place. These are discussed at strategic safeguarding group quarterly, monitored monthly and reviewed at least every 6 months.
QVH has local external regulation undertaken by the CCGs, WSSCB and WSSAB.
NHS Improvement ensures QVH are registered with the CQC. A Care Quality Commission (CQC) inspection occurred during 2015. The report published in 2016 identified two areas that the safeguarding team have worked on to improve: reporting of departmental risks and
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increase uptake of MCA training. Both these have improved.
Local safeguarding peer review and assurance processes are in place.
The Safeguarding Team are well supported by the Director of Nursing, Deputy Director of Nursing, Heads of Nursing and the West Sussex Designated Professionals.
QVH staff are guided and supported by a team of specialist safeguarding clinicians. This team are supported by Peanut Paediatric ward staff and Site Practitioners out of hours.
Partnership working with WSSCB and WSSAB is in place.
Effective contract monitoring is undertaken through audits and regular exception reporting to WSSCB, WSSAB, CCGs and the CQC.
11. Report approval and governance
The QVH safeguarding team present this report to provide assurance to the Board that the Safeguarding agenda is robustly overseen and managed within the trust and with partners.
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APPENDIX A Safeguarding training – evaluations sample Safeguarding Adults, Children, MCA and PREVENT Level 1
Rate the Session ( 21) Poor Satisfactory Good Excellent Were aims and objectives of the session met? 6 15 How would you rate the quality of the content of the session? 2 19 How would you rate the skills and knowledge of the trainer for the 21 session? How well was the event organised? 5 16 Overall how would you rate the event? 2 19
Comments: Very knowledgeable trainer Very good and informative Explained all information, very informative and easy to understand Good idea to combine adult and children safeguarding refresher, handouts very useful. Great improvement on previous training. Clear and cohesive with pointers to additional information as and when required. Very informative, lots of information. Covering all these topics in one session where only the basic information is required for non-clinical staff works very well. Excellen refresher- covered everything in sufficient detail Very informative and well presented, rasiign my awareness in all areas. Very well explained. Covering adult and children safeguarding together is a positive change in my opinion.
Adult Safeguarding, MCA and PREVENT Level 2 find sample for this section
Rate the Session Poor Satisfactory Good Excellent Were aims and objectives of the session met? How would you rate the quality of the content of the session? How would you rate the skills and knowledge of the trainer for the session? How well was the event organised? Overall how would you rate the event?
Comments:
Adult Safeguarding, MCA and PREVENT Level 3
Presenters: Edel Parsons CCG MCA Lead, Ellie Dunn LD link Nurse, Safeguarding Named Nurse
Rate the Session Poor Satisfactory Good Excellent Were aims and objectives of the session met? 17 How would you rate the quality of the content of the session? 17 How would you rate the skills and knowledge of the trainer for the 17 session? How well was the event organised? 17 Overall how would you rate the event? 17
Comments: Good explanation of difficult topic, good resource provided for use in clinic.
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Safeguarding Children, MCA, and PREVENT Level 2
Rate the Session (11) Poor Satisfactory Good Excellent Were aims and objectives of the session met? 1 9 How would you rate the quality of the content of the session? 10 How would you rate the skills and knowledge of the trainer for the 10 session? How well was the event organised? 1 9 Overall how would you rate the event? 10
Comments: Best child protection presentation I have ever been to I valued this training session which was delivered brilliantly. The depth of knowledge imparted and supporting people in the group to contribute was refreshing. A hard area that supported me to reflect further on how to access colleagues. Very enjoyable training and will leave well informed Very good update- very helpful Very informative, topic covered very well – interesting A harassing topic that was delivered well with a human touch- memorable Really helpful and interesting
Safeguarding Children, MCA and PREVENT Level 3
Presenters: Ms Tania Cubison, Burns Consultant, Dr Ms Sapna Radia Orthodontist, QVH Safeguarding Named Doctor, Dr Jo Webber, Psychologist, Pauline Lambert, QVH Safeguarding Named Nurse
Rate the Session ( 9 evaluations provided) Poor Satisfactory Good Excellent Were aims and objectives of the session met? 2 7 How would you rate the quality of the content of the session? 9 How would you rate the skills and knowledge of the trainer for the 9 session? How well was the event organised? 9 Overall how would you rate the event? 9
Comments: It was a very interesting session with a good variety of speakers and managed to cover a vast amount of areas. Safeguarding case studies made it especially interesting. I would have liked a longer session. Clear presentation. Informative, would recommend Excellent thank you, Photos very informative, Enjoyed different professional input. And perspective. It was a really good opportunity to understand the elements of child protection, also case studies really help to understand the different situations and how to act upon them. Excellent update, very interesting approach Very clear , great refresher Very informative, my first session of level 3
WRAP Level 3
Rate the Session (20) Poor Satisfactory Good Excellent Were aims and objectives of the session met? 14 6 How would you rate the quality of the content of the session? 14 6 How would you rate the skills and knowledge of the trainer for the 15 5 session? How well was the event organised? 11 9 Overall how would you rate the event? 12 8
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Comments: Managed to make presentation interesting Very good, useful The case studies really helped the discussion and awareness Good structure Raised awareness of what to be vigilant to Excellent presentation Thank you very good awareness raising
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APPENDIX B Safeguarding Activity Reported to Board 2017-2018
Description Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Paediatric safeguarding 15 18 21 23 24 20 18 17 17 24 15 15 activity Paediatric SG training Level 1 92 90 90 91 91 90 90 91 90 90 90 93 as % Paediatric SG training Level 2 88 88 88 90 90 88 86 86 87 86 87 89 as % Paediatric SG training Level 3 92 48 53 51 51 75 79 78 77 76 84 84 as % Updated staff list SCR – child 0 0 0 0 0 0 0 0 0 0 0 0
FGM assessments 0 0 0 0 0 0 0 0 0 0 0 0
Allegations against staff 0 0 0 0 0 0 0 0 0 0 0 0
Prevent referrals 0 0 0 0 0 0 0 0 0 0 0 0
WRAP training as % 56 56 64 63 63 66 64 68 68 70 73 66 (72)
MCA assessments Datix 2 3 2 Pilot BI decision Datix 2 3 2 Pilot DOLS application 0 0 1 0 0 0 0 0 1 0 0 0
Case Reviews – Adult 0 0 0 0 0 0 0 0 0 0 0 0
Adult SG training + MCA level leaflet 92 93 94 94 96 96 1 – Leaflet as % Adult SG training + MCA level 65 69 79 81 82 87 86 89 90 89 89 92 2 as % Adult SG training level 3 as % ------30 - staff
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APPENDIX C SAFEGUARDING AUDIT PROGRAMME 2017-2018, 3 year cycle
2016 Topic/s Progress Next Steps NICE PH50 DVA Baseline assessment march Completed 2016 Report had gone to Strategic Organisation audit to start Safeguarding Group August 2016 NICE CG89 Organisation audit to start Completed August 2016 Report had gone to Strategic Safeguarding Group
2017 Topic/s Progress Next Steps Referrals audit – adult and Completed December 2017 Repeat next 2018 children CG89 and PH 50 Survey monkey Competed February 2018 Report to Steering group for medical staff Roll out across QVH medical staff MCA staff knowledge audit Completed December 2017 Report to SSG Action plan being monitored MCA compliance audit Completed December 2017 Report to SSG Action plan being monitored
2018 Topic/s Progress Next Steps Referrals audit – adult and Due Sep to December 2018 children Safeguarding Prompts Card Survey Monkey Sep 2018 audit Child not brought to 2018 appointment protocol audit EDN safeguarding section audit 2018
2019 Topic/s Progress Next Steps Referrals audit – adult and Due Sep to December 2019 children NICE PH50 DVA Organisation audit to start August 2019 NICE CG89 Organisation audit to start August 2019
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APPENDIX D Policy, procedures, protocols, guidance and information for QVH, staff and patients
QVH SAFEGUARDING DOCUMENTS AND INFORMATION March 2018
1 Item Date Location Actions 1.1 QVH assurance statement 2017 Website Review 2019 1.2 QVH safeguarding strategy 2016 Website Update 2018 1.3 QVH QNET ongoing Intranet Ongoing review and update as required 1.4 Sussex Child Protection and Safeguarding Web-based Link via QNET Ongoing review and Procedures update as required by WSSCB 1.5 QVH safeguarding annual report 2017-18 Next due July 2018 Drafted 1.6 QVH and BSUH Paediatric SLA 2016 updated Copy with Deputy Director of Nursing 1.7 QVH Safeguarding Strategic Group terms of October 2017 Held by PA for Director of reference Nursing 1.8 QVH Safeguarding Children Steering Group October 2018 Annual review terms of reference 1.9 QVH Safeguarding Adults Steering Group 2018 Annual review terms of reference 1.10 QVH safeguarding prompt cards for clinical June 2017 In use, given out at staff training sessions
2 Item Date Location Actions 2.1 QVH Managing allegations against staff 2015 QNET 2.2 QVH Whistle blowing policy 2015 QNET 2.4 QVH Handling complaints policy 2014 QNET 2.5 QVH producing user information policy 2015 QNET 2.6 QVH Translation policy 2013 QNET 2.7 QVH supervision support guidance 2014 QNET 2.8 QVH Recruitment and selection policy 2015 QNET (includes Checking and DBS) 2.9 QVH Risk management and incidents 2014 QNET policy 2.10 QVH Consents policy 2015 QNET Includes Gillick competence/Fraser Guidelines –staff development re implementation of Fraser guidelines offered by Named Doctor 2.11 QVH Information security policy,-Patient 2015 QNET photographic and video recording Police taking photographs on QVH site Guidance added to Access Requests Procedures 2.12 QVH Chaperone Policy 2016 QNET BEING UPDATED IN LINE WITH Cambridgeshire Policy 2.13 QVH information governance policy 2015 QNET 2.14 QVH Health records policy 2012 QNET Being updated NR and PL review from safeguarding perspective 2.15 QVH support for staff experiencing DVA 2018 QNET policy/guidance 2.16 QVH JD and person specification template 2016 QNET 2.17 QVH Restrictive Physical Interventions and 2016 QNET Child section expanded and Therapeutic Holding Policy EQIA completed 2.18 QVH Abduction or suspected Abduction of 2016 QNET Finalised May 2016 an Infant/Child Policy 2.19 QVH Routine pregnancy screening 2016 Leaflet approved and Paediatric anaesthetics and surgery matron setting up training 2.20 QVH DVA procedures for patients 2017 QNET
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QVH SAFEGUARDING CHILDREN AND YOUNG PEOPLE
3 Item Date Location Actions 3.1 QVH Child Protection and Safeguarding Policy 2016 QNET and Procedures Includes QVH Peanut missing children risk assessment QVH children not brought to appointments risk assessment QVH Referral Form 3.2 QVH Paediatric Safeguarding Learning and 2016 QNET Strategy being updated Development strategy Plus appendix A level 3 development options 3.3 QVH safeguarding children Trauma Proforma Being updated QNET Paediatric matron and child protection documents 3.4 NAI photographs Policy and protocol 2017 To be a departmental procedure 3.5 QVH trainee doctor and dentists paediatric Updated 2016 QNET Now using prompt cards safeguarding guidance 3.6 QVH safeguarding children leaflet for all staff 2016 QNET Now using prompt cards
3.7 QVH safeguarding children volunteers 2016 QNET Now using prompt cards guidance 3.8 QVH Paediatric safeguarding risk assessments ongoing Overseen by strategic safeguarding Group 3.9 QVH NMC examples of revalidation forms- 2016 completion for safeguarding practice 3.10 QVH posters for patients 2017 QVH site 3.11 QVH leaflet for patients 2016 QNET Dog bites 3.12 QVH leaflet for families 2016 QNET Safeguarding children and young people
QVH SAFEGUARDING ADULTS
4. Item Date Location Actions 4.1 QVH Safeguarding Adults Policy 2016 QNET To be reviewed 2018 4.2 QVH Safeguarding Adults Learning & 2016 QNET Strategy being updated Development Strategy 4.4 QVH Prevent Delivery Plan 2017 Q-Net
4.5 QVH Safeguarding Adults Leaflet (For all 2016 Q-Net Now using prompt staff including volunteers) cards 4.6 QVH Examples of Revalidation Forms 2016 (DRAFTED) Q-NET
4.7 QVH Mental Capacity Act 2005 Policy & 2015 Q-Net Updated out to Procedures consultation 4.8 QVH Deprivation of Liberty Safeguards 2015 Q-Net Updated out to Policy consultation 4.9 QVH Adult safeguarding risks assessments ongoing Overseen by strategic safeguarding Group
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APPENDIX E TITLE: Safeguarding Strategic Group Action Plan
2017-18 work plan for group based on Safeguarding Strategy Objectives, which contribute to achieving key strategic objectives of the trust: Outstanding patient care World class clinical services Operational excellence Financial stability Organizational excellence
Rating Action Implement- Progress/ Strategic Objective QVH initial assessment Timescale (RAG) Required ation Lead comments
1. To provide senior and QVH require: Green Review Director of Safeguarding Named Nurse Board leadership Lead Board Director allocated Ongoing Nursing & post created team in place Nominated Non-Executive Board specialist Quality Director resources in One vacant post. Specialist Paediatric Safeguarding Named coming year Nurse Adult safeguarding, Nurse recruitment under way Paediatric Safeguarding Named Doctor Departmental risks in place Adult Safeguarding Named KPIs to Board Nurse MCA & DOLs lead Annual report to Board Prevent lead WRAP Facilliators Child Sexual Exploitation Lead 2. Senior leadership QVH require: Green Sustain Director of Website safeguarding responsibility and lines Safeguarding Accountability and systems Ongoing Nursing a & statement updated of accountability for communication document on Quality safeguarding Website Annual QNET update ongoing arrangements are clearly Safeguarding Strategy on review and with outlined to employees update Quality assurance processes
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and members of QVH, website training Named in place as well as to external Safeguarding QNET page program professionals partners. Safeguarding Policy, standards, Policy review and updates protocols, guidance Use ongoing. MCA & DOLS Information for staff Evolve/EDM policies reviewed and updated Information for patients safeguarding currently out for consultation Safeguarding training strategy section as and program in place new system Training uptake data and Longer term solution to manage rolled out. evaluations scrutinized safeguarding activity data monthly required. Use Datix to capture data Datix - piloted use to capture safeguarding and MCA data. Now being used permanently
Development of new leaflets for patients and their family drafted
3. QVH contribute to the QVH require; Green Overlap Director of Safeguarding Children Section work of West Sussex Regular representation at LSCB between Nursing a & 11 self-assessment updated LSCB and SAB and their Regular representation at SAB reporting Quality Concerns regarding DVA strategic Business Plans Completion of Section 11 self- requirements systems addressed. and priorities, and audit – manage with provide support to Monthly reports to CQC and sustain Director of nursing attending ensure that the Boards Bi-monthly reports to LSCB and effectively Named WSSCB meet their statutory SAB professionals responsibilities. Quarterly reports to CCGs Regular Safeguarding named Nurse Quarterly reports to NHS representatio attending WSSAB England – prevent coordinator n at LSCB and SAB
Regular updates from NHS England – optional
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teleconferenc es
4. QVH support their QVH require; Green Paed SG Director of Supervision in place safeguarding leads to Named professionals Named Nursing a & contribute to and involvement in specific Nurse to join Quality Attendance at Regional and influence the work of the subgroups Improving national conferences this year LSCB and SAB Supervision from designated Practice with for: subgroups and other professionals for named group Safeguarding children national and local professionals Named MCAS & DOLS safeguarding Attendance at West Sussex professionals Executive safeguarding implementation networks networks. Attendance at Regional Networks
DELIVERING THE STRATEGY Ensure all aspects of safeguarding work and practice are considered and incorporated into all QVH services. Service developments take account of the need to safeguard all patients and are informed by service users and quality impact assessments. Processes in place to disseminate, monitor and evaluate outcomes of all case review recommendations and actions. Ensure there are effective arrangements in place to share information when required. Safeguarding training and systems compliance will be monitored by safeguarding leads. QVH will demonstrate it is meeting its statutory requirements via annual reporting and an audit programme.
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Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/2018 Agenda reference: 142-18 Report title: Infection Prevention & Control Annual Report 2017/18 Sponsor: Jo Thomas, Director of Nursing Author: Sarah Prevett, Infection Control Lead Nurse Appendices: 3
Executive summary Purpose of report: To provide assurance that there is a systematic leadership in place in the organisation for the effective management of infection prevention and control for patients, staff and visitors and note the developments planned in 2018/19 to further increase the safety and effectiveness of patient care. Summary of key The Board’s attention should be drawn to the following key areas of infection issues prevention and control management detailed in the report: • The Trust has continued to achieve low rates of reportable infections with our targets being met in three of the four required areas and the fourth still remaining significantly lower than other specialist trusts. • Assurance process has been maintained through a robust audit process however there remains room for improvement with compliance from all staff with regards to infection control policy. Recommendation: The Board is asked to approve the annual report. Action required Approval
Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence experience services Implications Board assurance framework: Infection Prevention & Control contributes directly to the delivery of KSO 1 and KSO 2
Corporate risk register: Infection, Prevention and Control contributes to compliance with the regulated activities in Health and Social Care Act 2008 and the
CQC’s Essential Standards of Quality and Safety. Regulation: Compliance with regulated activities and requirements in Health and Social Care Act 2008. Legal: As above Resources: This annual report was produced using existing resources.
Assurance route Previously considered by: Quality and Governance Committee Date: 19/07/18 Decision: Recommended for approval by BoD Next steps:
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Holtye Rd, East Grinstead RH19 3DZ
Infection Prevention and Control
Queen Victoria Hospital NHS Foundation Trust Service Annual Report
Report covering the period from April 2017 to March 2018
Document Control: committees and groups who have approved this report Executive sponsor: Director of Nursing and DIPC
Authors: Lead Infection Control Nurse
Date: 13/04/2018
Type: Annual Report Version: Final Pages: Number Status: Public. Written and prepared for the Trust Board Circulation: QVH Trust Board
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Contents List
Item: Page number:
1 Executive Summary 3 2 Introduction 3 3 Service aim, objectives and expected outcomes 3 4 Activity analysis/ achievement 10 5 Learning from Experience 25 6 Conclusion and Assurance 25 7 Report approval and governance 26 8 Appendices Appendix A: Infection Control & Control Structure Chart 27 Appendix B: Infection Control annual Programme 2018/19 28 Appendix C: Infection Control Policies ratified 2017/18 References 31
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1. Executive Summary The infection prevention and control annual report provides the Board with the overarching assurance that there is systematic leadership for the effective management of infection prevention and control arrangements in place for all patients, staff and visitors. The Board is committed to the Code of Practice for the Prevention and Control of Healthcare Associated Infections as outlined in the Health & Social Care Act (2015) and Clean, Safe Care (Department of Health, 2008) outlines the accountability of the Board in reducing infections and the importance of hospital cleanliness. The Board has received regular updates on infection, prevention and control related matters via the Quality and Governance committee.
The Trust had zero “attributable” MRSA bacteraemia against an objective of zero thereby meeting its annual target. The Trust had zero “attributable” Clostridium difficile infection (CDI) against an objective of zero thereby meeting its annual objective. The Trust had zero “attributable” E coli bacteraemia against an objective of zero thereby meeting its annual objective.
2. Introduction
The purpose of this report is to provide the Board with information on trust performance and provide assurance that suitable processes are being employed to prevent and control infections. This paper provides the board with an overview of work completed during the previous year and goals for the continuing programme of infection prevention and control for the upcoming financial year.
3. Service aim, objectives and expected outcomes
The Code of Practice (Part 2) sets out the 10 criteria against which the Care Quality Commission (CQC) will judge a registered provider on how it complies with the infection prevention requirements. The infection control policies are published in the trust policy section of Qnet. These documents are reviewed and updated by the infection control nurses (ICN’s) and ratified by the Infection Control Group (IPG).
The QVH infection prevention and control strategy 2017/18 utilises appropriate methods to prevent the acquisition of infection by patients and to prevent the transmission of organisms between patients. This report collates infection surveillance data, audit results, progress with actions identified on the annual programme and all information necessary to assure the board that suitable systems and processes are being employed within the trust to prevent and control infections.
The aim and objective of the infection control team is to continue promoting compliance with all aspects of Infection prevention and control to all staff within the Trust, enforcing the message that ‘Infection Control is Everyone’s Responsibility’ in order to maintain the low rates of infection, both reportable and non-reportable, that the Trust has achieved
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over the years.
Internal assurance processes and board accountability. QVH has an infection prevention and control structure and processes in place which are led and supported by a team of specialist infection prevention and control clinicians. (See Appendix A for QVH infection prevention and control structure chart).
As an organisation QVH is committed to the prevention of health care associated infection (HCAI) for patients, staff and visitors whilst on the premises or in the care of the hospital. This is done through robust infection prevention and control programme involving policies and procedures for staff to follow which conform to current best practice guidance, an audit programme to ensure compliance against the policies and a team of specialist infection control staff to offer education, guidance and advice to all staff and patients on infection control. Mandatory surveillance of certain infections are undertaken to ensure that correct and timely advice on treatment and precautions required is given to the clinical staff in order to provide the best care possible for all patients.
The purpose of the infection prevention and control group (IPCG) is to promote the highest standards of practice in the Trust in the prevention and control of infection, and to ensure compliance with the Code of Practice for the Prevention and Control of HCAI (2015). The IPCG meets quarterly or more frequently if required and provides a report to the Quality and Governance Committee (QGC) through the Director for Infection Prevention and Control (DIPC). The QGC receives a quarterly infection control report on each of the key elements of infection control management. In addition, the DIPC also provides updates to the Clinical Governance Group, Hospital Management Team, and Executive Management Team and to the Trust Board. There is also oversight of antimicrobial issues at this group via attendance of the trust antimicrobial pharmacist.
Members of the IPACT share infection control information and learning with a number of groups and committees which include: • Quality & Governance Committee • Health and Safety Group • Clinical Audit • Estates and Facilities Group • Learning & Development Group • Medicines Management Optimisation Governance Group (MMOGG) • Patient Led Assessment of the Care Environment (PLACE) • Pathology Meeting Nursing and Quality Forum Professional networks Clinical Audit Meeting
IPACT work closely with all clinical teams, Estates and Facilities and Hotel Services to ensure that infection prevention and control is included in the planning stages of every new project and development or refurbishments.
Infection Prevention and Control clinical activity All the trust microbiology specimens are processed by a local acute hospital in accredited laboratories. The results of all microbiology samples including blood specimens and swabs are checked for positive colonisation or infection that may have the potential to spread and cause harm. A further check for any positive specimens from a daily lab report is undertaken by the ICN. Although labour intensive this scrutiny provides oversight of
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every specimen taken from QVH ensures that information and clinical advice is then given to the relevant ward/clinical staff. Significant or unexpected results are also relayed to the IPACT or the ward via the on-call microbiologist.
Infection prevention & control link persons (ICLP) Infection prevention and control remains central to the maintenance and promotion of high standards throughout QVH. The ICLP Group meets every quarter although during the 2017/2018 period was only able to meet 6 monthly. Its purpose is to provide a link between the IPACT and ward/departmental staff in all clinical and non-clinical areas in order to facilitate the dissemination of information and to promote compliance with infection control policies and the Health & Social Care Act (2015). Every meeting includes an educational element. The ICLP members are reviewed on an annual basis. Or more frequently if there has been staff changes. The link staff conduct monthly infection control audits and champion good infection control practices within their teams/departments.
External Meetings Infection control remains high on the national agenda. The DIPC has attended a seminar presented by the chief nurse at NHSI on infection control priorities and specifically preventing Gram-negative bloodstream infections for E. coli. Relevant sections of the resource pack have been shared within the trust. The infection control lead nurse at the clinical commissioning group and a representative from Public Health England attend the quarterly infection control meetings which provided external scrutiny to our trust policy and plans and ensures that emerging themes are incorporated into our work plan.
Mandatory Surveillance Mandatory surveillance data is required to be submitted to Public Health England (PHE) for the following alert organisms:
Staphylococcus aureus (S. aureus) bacteraemia – both Meticillin Resistant Staphylococcus aureus (MRSA) and Meticillin sensitive Staphylococcus aureus, (MSSA) Clostridium difficile infection (CDI) Escherichia coli (E. coli) bacteraemia
Glycopeptide Resistant Enterococci bacteraemia (GRE) and Vancomycin Resistant Enterococcus bacteraemia (VRE) are reported to the CCG as required and to the PHE on a quarterly basis.
In addition, bi-monthly reports are made to the Clinical Commissioning Group (CCG) and the Trust Board; these are also published on the Trust webpage for the public to read. Weekly reporting is also undertaken to PHE/ CCG for any alert organisms isolated in patients and any other outbreaks that may occur.
IPACT also monitor Urinary Tract Infection (UTI), Acinetobacter, Pseudomonas, Klebsiella spp and any other Multi Drug Resistant (MDR) organisms. An alert organism spreadsheet is in place to assist with this.
The Secretary of State for Health has launched an important ambition to reduce healthcare associated Gram-negative bloodstream infections by 50% by 2021 and reduce inappropriate antimicrobial prescribing by 50% by 2021. Gram-negative bloodstream infections are believed to have contributed to approximately 5,500 NHS patient deaths in 2015. Initial focus is on reducing Escherichia coli bloodstream
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infections because they represent 55% of all Gram-negative bloodstream infections.
NHSI published the ‘reducing gram negative bloodstream infections and inappropriate antibiotic prescribing in at risk groups’ quality premium (QP) measure for 2017-19 in March 2017. The quality premium has two parts. Part A deals with reducing gram negative blood stream infections and Part B with reduction of inappropriate antibiotic prescribing for urinary tract infections. The Part A baseline data and targets have now been published on the quality premium web page. QVH data for 2017/2018 shows zero numbers of E coli bacteraemia which is the gram-negative organism under surveillance for 2017/18.
Root Cause Analysis (RCA) The Trust continues with the protocol for RCA review for all reportable infections and, for all MRSA bacteraemia and the Post Infection Review (PIR) process.
MRSA Bacteraemia
QVH have a limit of zero cases of avoidable MRSA bacteraemia every year – the trust achieved this target in 2017/18 with zero cases. Figure 1 shows previous year’s performance.
Figure 1
Period No. of cases of MRSA DH target bacteraemia Apr 2006 – Mar 2007 2 4 Apr 2007 – Mar 2008 3 3 Apr 2008 – Mar 2009 2 3 Apr 2009 – Mar 2010 1 1 Apr 2010 – Mar 2011 2 1 Apr 2011 – Mar 2012 2 1 April 2012 – Mar 2013 2 1 Apr 2013 – Mar 2014 0 0 Apr 2014 – Mar 2015 0 0 Apr 2015 – Mar 2016 0 0 Apr 2016 – Mar 2017 0 0 Apr 2017-Mar 2018 0 0
To date there has not been a revision of this target for 2018/19.
Before April 2018 all MRSA bacteraemia cases underwent a formal post-infection review: From April 2018 this requirement has been modified by NHS England so that formal reviews must only be undertaken for organisations with the highest rates of infection (excluding specialist trusts). This change has been made to refocus trusts and CCGs on infection prevention and control and to focus teams’ attention on gram- negative infections and antibiotic resistance. It should be noted that all MRSA bacteraemia should still be subject to robust clinical review, regardless of the requirement for PIR. Trusts and CCGs should continue to undertake patient safety reviews on all cases to identify best practice and areas for improvement/learning.
Clostridium difficile infection (CDI) In 2014/15 NHS England introduced a change in the methodology for calculating organisational CDI objectives and encouraged commissioners to consider sanctions for
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breach of CDI objectives only where those CDIs were associated with lapses in care. The CDI lapse in care objective target for QVH was set at zero. The Trust had no cases of CDI in 2017/2018 and therefore reached its objective. Figure 2 shows previous performance.
Figure 2
Period No. of cases of CDI Jan 2004 – Dec 2004 5 Jan 2005 – Dec 2005 5 Jan 2006 – Dec 2006 5 Jan 2007 – Mar 2007 1 Apr 2007 – Mar 2008 5 Apr 2008 – Mar 2009 4 Apr 2009 – Mar 2010 1 Apr 2010 – Mar 2011 6 Apr 2011 – Mar 2012 0 Apr 2012 – Mar 2013 0 Apr 2013 – Mar 2014 1 Apr 2014 – Mar 2015 1 Apr 2015 – Mar 2016 1 Apr 2016 – Mar 2017 2 Apr 2017 – Mar 2018 0
NHS England and Public Health England will undertake a review of CDI reporting ahead of planning for 2019/20. The current methodology for calculating new CDI objectives relies on requiring organisations that are worse than the median in terms of their rate of CDI to improve by the same amount that the wider median CDI rate has improved from one year to the next. Organisations with 10 or fewer cases should aim to remain at or below 2017/18 financial year outturn. Therefore, the CDI lapse in care objective target for the Trust remains at zero for 2018/2019.
The possibility of continuing to breach this extremely challenging limit remains on the risk register. The CCG will continue to review the details of any confirmed cases and determine if it should count towards the total/aggregate number of cases apportioned to the Trust. If the Commissioner concludes that there has not been a `lapse` in care the case may still be attributable to the Trust but a sanction unlikely. The contractual sanction if a breach is identified remains the same at £10,000 per positive case.
Figure 3 shows the 2017/18 Trust acquired CDI benchmark against similar acute providers.
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Figure 3
Source validated PHE DCS HCAI data April 2018
MSSA bacteraemia No target has been set for MSSA bacteraemia to date. There has been a noticeable increase in cases. This is a countrywide trend and has been noted by the DH. QVH have had three MSSA bacteraemia cases in 2017/18. RCA has shown issues with line care and documentation in both cases. Figure 4 shows the year on year numbers of trust acquired MSSA bacteraemia.
Figure 4 Period No. of cases of MSSA bacteraemia Apr 2012 – Mar 2013 6 Apr 2013 – Mar 2014 0 Apr 2014 – Mar 2015 1 Apr 2015 – Mar 2016 7 Apr 2016 – Mar 2017 3 Apr 2017 - Mar 2018 3
Figure 5 shows the 2017/18 Trust acquired MSSA bacteraemia benchmark against similar acute providers.
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Figure 5
Source validated PHE DCS HCAI data April 2018
E. Coli bacteraemia
No DH target has been set for E.coli bacteraemia though the NHSI ambition to reduce gram negative bacteraemia by 10% year on year until 2020 through a Quality Premium was introduced in March 2017. QVH had zero Trust acquired E.coli bacteraemia in 2017/18. Figure 6 shows the 2017/18 Trust acquired E.coli bacteraemia benchmark against similar acute providers.
Figure 6
Source validated PHE DCS HCAI data April 2018
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Glycopeptide resistant enterococci bacteraemia (GRE) No reportable GRE’s have been identified at the QVH. No target has been set by DH to date. There have been no Trust acquired GRE infections in the last 10 years.
MRSA positive patients April 2017 to March 2018 (Infected and colonised) During the period of 2017/2018 there were 151 patients who were confirmed MRSA positive either colonised or infected. None of the positive results were from the blood stream (bacteraemia). Of these 15 were classed as healthcare associated or hospital acquired (HCAI), 85 were identified from admission or pre-admission swabs (O/A), 44 were from patients known to be previously positive (PP) and 7 patients it was difficult to determine the source of acquisition, these was either because they were not admitted at the time of the result and therefore could have acquired the MRSA during outpatient appointments or whilst at home/in the community or where positive results are received from paediatric patients as this group of patients are not routinely screened on admission therefore there is no baseline data to determine if the MRSA was acquired in the hospital setting or in the community before admission. RCA’s are completed for all HCAI cases to look at any lapses in care or areas of improvement.
4. Activity analysis/ achievement
External regulation and inspection by Care Quality Commission (CQC), NHSI and commissioners
The CQC did not conduct any infection prevention and control inspections between April 2017 and March 2018. The Trust continues to monitor the standards set out in the Health & Social Care Act (2010) via an annual programme of PLACE compliance inspections. Findings are reported to QGC.
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The Trust Board The Trust Board has responsibility for overseeing infection control arrangements and has been kept informed by the DIPC update at every meeting. A key element of the role of DIPC is the direct line of communication with the Chief Executive and Medical Director.
Compliance in Practice Assessments These assessments examine practices in the clinical environment. They cover many different aspects of care part of which is compliance with infection control practices such as hand hygiene. The results are collated and fed back to the relevant clinical area as well as the QGC. The results of the assessments concur with the audit findings conducted by the IPACT in that improvement is required in the usage and management of sharps boxes around the Trust.
Assurance Framework The Trust has devised an assurance framework to ensure all aspects of the Health & Social Care Act (2010) and CQC Outcomes are met. This is reviewed quarterly by the DIPC and ICNS. It is reported to the ICG and any significant concerns are raised at the Quality & Governance Committee.
Key Performance Indicators (KPIs) KPI’s set for the IPACT include monitoring hand hygiene compliance, monitoring MRSA screening compliance and monitoring trust acquired reportable infections. Results for these are all included within the document. Ensuring policies are in line with national guidance and within date, a list of all updated policies is included in this document, and that regular audits are completed to monitor compliance against the policies. Completed audits are included in this report in the udit section of this report. Some audits were not undertaken during the year April 17 to March 18 due to resource issues within the IPACT.
The remaining KPI’s are ensuring all members of the IPACT are attending mandatory training and are undertaking an annual appraisal. All members of the IPACT achieved this during the year April 2017 to March 2018.
Complaints If necessary the IPACT will liaise with the Patient Experience Manager to assist with the investigation of complaints associated with infection prevention and control. The outcomes of these are fed back at the monthly IPACT and quarterly committee meetings. There were no complaints or claims made during 2017-2018 relating to infection control.
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Infection Prevention and Control Learning and Development Infection Prevention and Control is part of the Trust’s mandatory training programme. Three sessions a month are held, two for clinical staff and one for non-clinical. Induction training days are also held monthly for all categories of staff, with separate sessions for new Doctors’ Induction. Training is carried out by the ICN’s.
The theme for 2017-2018 was once again “Infection Prevention & Control is everyone’s responsibility” and the presentations were based on the National passport`s key learning outcomes. Topics covered included:
• How does infection spread? • How staff can help prevent the spread of infection (looking after themselves and the environment) • Hand hygiene and bare below the elbows • Correct wearing of PPE • Theatre clothing policy • Spillage management • Sharp safety • Safe disposal of waste • Compliance with DH Pseudomonas guidance • Deep cleaning • What is an HCAI • CPE • The history of infection control • The Health and Social Care Act (2015) • Food hygiene • Flu preparations including FIT testing
Along with clinical, non-clinical and consultant mandatory training IPACT have also given additional teaching to staff on current issues highlighted through audit and surveillance relating to infection control. This has been incorporated into the department meetings and additional training session that have been identified as required through the RCA process following reportable infections.
Due to capacity and workload there was no Annual Infection Control awareness Week in 2017/18. A relaunch of Infection Control awareness in conjunction with Estates and Facilities is planned for the beginning of 2018/19.
Infection Prevention and Control audit Clinical audit is a fundamental component of clinical governance and underpins the assurance process for a high-quality service (CQC, 2010). The following audits have been undertaken in the period April 2017 to March 2018. All Ward/Department Managers are informed of audit results pertinent to their area as they are completed. They are asked to complete any recommendations made within the audit reports.
Saving Lives – Department of Health High Impact Intervention (HII) Audits: The Saving Lives Delivery Programme was last revised in June 2007. Its purpose is to deliver a programme which will reduce HCAIs and allow Trusts to demonstrate compliance with the Health and Social Care Act (DH, 2010), using techniques known as HIIs, of which there are seven. Not all the audits are appropriate for the patient groups in the Trust therefore only five HII are used.
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Each HII consists of a series of elements (known as care bundles) and the Trust audit the following:
1. Central venous catheters (CVCs) 2. Peripheral intravenous catheters (audit incorporated into the Trust’s Intravenous Therapy audit twice a year) 3. Prevention of surgical site infection (audit incorporated into the Trust’s National Patient Safety Agency Checklist annual audit) 4. Urinary catheters 5. Reduction of risk from C. difficile. (All cases of C. difficile are subject to RCA and learning/training needs are identified).
These audits are incorporated into the safety thermometer audit which is conducted and reported to the individual department leads on a monthly basis.
Surgical Site Infection (SSI) Audit Due to staffing capacity within the Infection Control Team, no SSI audit was carried out during the period April 2017 to March 2018. Any infection results are closely monitored as a daily task.
Hand Hygiene Audits
Monthly hand hygiene and bare below the elbows compliance audits have continued. This audit is conducted by the Infection Control Link staff in their own areas. The audit tool is modelled on the NPSA 5 moments of hand hygiene. Overall compliance with hand hygiene and bare below the elbows remains between 95 and 100%. Where areas drop below compliance staff are encouraged to identify members of staff not compliant. These staff are then spoken to and given additional training in the importance of compliance within infection control standards.
Aseptic Technique Due to staffing capacity this audit was not carried out during the period April 2017 to March 2018.
Isolation Room Audit The audit is conducted as a one day spot check and demonstrated that at the time of the audit the Trust was allocating its isolation rooms appropriately as all patients deemed to be an infection risk were nursed in side rooms. Where patients were in side rooms who were not deemed to be infectious this was also appropriate as they were in the rooms for either privacy and dignity reasons or based on clinical need of the patient. At all times the IPACT
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are monitoring and ensuring, with the cooperation of the ward staff, that all patients deemed to be high risk are isolated as per Trust policy and where this is not possible risk assessments are completed with the advice of the consultant microbiologist to minimise any risk to both the patients and staff.
MRSA screening Monthly audits are undertaken to ascertain the level of compliance with Trust policy for the mandatory screening of all elective and trauma in-patients.
MRSA Decontamination Audit Due to staffing capacity this audit was not carried out during the period April 2017 to March 2018.
MRSA Screening Audit of High Risk Patients. Due to staffing capacity this audit was not carried out during the period April 2017 to March 2018.
Cleaning chart, mattress and documentation spot check Overall areas appear clean and tidy. Cleaning charts are often not fully completed and staff in each area were spoken to and reminded to complete these daily. All cleaning charts were reviewed by the IPACT and standardised throughout the Trust.
Environmental Audits Environmental audits continue to be covered by the PLACE inspections. Resulting action points are logged on to the Estates Piranha system, prioritised and carried out by the Estates Department. It is the responsibility of the Department Mangers to ensure all actions for their area are completed and they must then inform Hotel Services all actions have been done.
Infection control issues noted include: • De-cluttering of departments • Repairing floor damage and an ongoing need for general repair and redecorating of the hospital structure • General cleaning
Sharps Box Audit
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18 Wards/Departments were visited during the audit and 141 sharps containers were sighted. The audit found zero sharps containers with protruding sharps, 14 that were not properly assembled, (these were immediately assembled properly and staff were informed that sharps containers which were not assembled properly could lead to the lids coming off if dropped or during transportation) and one that was more than three quarters full, (staff were advised to only fill to the line). One sharps container had the wrong lid on the wrong base. Staff were advised to check the colour of the lid and label. 3 sharps containers were sited on the floor or at an unsuitable height or place, staff were advised to have them bracketed if possible or remove them from public areas. Seven containers were sighted with the label not endorsed. 3 sharps containers had significant inappropriate non sharp contents. Staff were advised not to put packaging or non-sharp items in sharps containers. Seven sharps containers did not have the temporary closure in place when the container was left unattended or during movement. Small sharps containers and trays were available to take to the bedside. Staff were spoken to at the time of the audit and additional training has been arranged for staff on the correct assembling and use of sharps boxes. The results were fed back to the department managers. A re-audit has been rescheduled for 6 months time rather than annual in order to provide assurance that practice has improved.
Patient bedside equipment During the audit some equipment was not able to be viewed due to patient activity. In these areas the nurse in charge was asked to check the equipment and report any concerns to the IPACT. In the Burns unit the patient’s bedside lockers were looking worn through repeated cleaning. The edging strips had come off leaving exposed wood. All the lockers in this unit will need to be condemned and replaced as soon as possible, all other equipment sighted in the ward was clean and intact. In Peanut ward all patients’ bedside equipment was, clean and intact. Sleep Studies has domestic bedside tables as well as standard hospital lockers. These domestic lockers are clean and intact and have been cleared for use by the Infection Prevention and Control Team. Sleep Studies are to replace the bedside tables with hospital approved ones when they need replacing. All other patient’s bedside equipment was clean and intact. None of the beside equipment is labelled in Sleep Studies as it was decided by the Infection Prevention and Control Team that this area was such a low risk area for outbreaks there is no need to label the equipment. In Ross Tilley and Margaret Duncombe. All the equipment sighted was intact however some of the tables and chairs were missing the number labels. Also the patient’s bedside chairs were very faded and worn, and whilst they are intact they do not look good. Ideally these will need to be replaced.
Sink audit Minor Injuries Unit, OPD, Pre-assessment, Peanut Assessment Unit, Rehab Unit, Photographic, radiology, Admissions Lounge, Peanut, Sleep, Main theatre including recovery, Rowntree and Maxillo Facial Unit all compliant with current guidance.
The Burns Unit and C Wing are no longer compliant as they only have one wash-hand basin per bay (they were compliant with guidance at the time of building). This has been mitigated by the placement of portable sinks in the Burns Unit and alcohol gel in the other areas.
Ross Tilley bays contain six beds, Margaret Duncombe and Burns bays contain 4 beds. All single rooms, clinical rooms and sluices in the Trust comply with current guidance. In addition to the clinical sinks all wards and departments have alcohol gel at the ward
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entrance/exit, in the corridors and at each bedside.
The exception is Peanut Ward due to the nature of the patients; personal tottles are available to staff should they require them. Portable sinks are available as required.
Estates are aware to ensure all new builds and refurbishments comply with current HTM requirements on sink allocation. All projects are reviewed by IPACT before being open to use and sink inspection is part of this assessment therefore it has been agreed by the Infection control group that there is no need to audit sinks on annual basis.
Infection prevention and control policies, procedures and guidance for QVH staff and patients
IPACT have developed guidance for the organisation, staff and patients in the form of policy, procedures, protocol, guidelines and leaflets. All documents are placed on Qnet. All documents have been systematically reviewed and updated in collaboration with relevant services and governance groups (see Appendix C).
IPACT have produced information for patients about the main infection prevention and control issues which are generally raised. These are Pandemic Flu, Norovirus, MRSA, MRAB, Hand Hygiene, Group A Strep, GRE, and CDI. All these leaflets are available for the public and have been updated and approved by the patient information group.
The QVH Infection Prevention and Control team are available to speak to any patients, visitors or staff if they have any concerns about infection.
Local peer review and assurance processes QVH has a case peer review system in place in the Burns Unit. Meetings to discuss cases occur every Monday (except Bank Holidays). These meetings review injury mechanism and explanation, treatment, risk assess, discuss any Infection Prevention and Control issues and agree actions required.
The purpose of these groups is to strengthen communication and dissemination of infection prevention and control information and practice across the organisation. The meeting is attended by the Consultant Microbiologist and the ICN’s when capacity permits.
Mazar’s audit In July 2017 the infection control team was audited by Mazars Internal Audit. The audit was completed by an independent auditor with assistance from the IPACT. Areas covered in the audit were: Policies and Procedures; Infection Control Programme; Periodic / Annual Reporting and Performance Monitoring; Infection Control Team; Training; and Board Reporting.
There were 2 recommendations; Arrangements should be developed to ensure that relevant Infection Prevention and Control Policies are aligned with the national guidelines provided by the Department of Health. In addition to the regular review activities, Policies should be updated timely and taking into account latest legislation and/or guidance from national frameworks. The Infection Control Annual Report including the Infection Control Programme should be clearly sent, reviewed and approved by the Trust's Board. Minutes detailing reception of the Report should clearly state whether the Board approved the Annual Report including the Infection Control Programme. Infection Control Audits should
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be undertaken regularly and in accordance with the established Audit Timetable. The recommendations have been addressed by the IPACT
Influenza arrangements During 2017/18 support has again been given to the management of influenza (flu), with the ICN’s encouraging vaccination of staff within the annual flu vaccination programme. Uptake for the flu vaccination was higher than in previous years with an uptake of 59.2%. This is an improvement on the 2016/17 figure of 51.5%. As with last year, a CCG locally agreed variance to the CQUIN allowed us to include all staff officially declining the vaccination producing a final figure of 72.9%, exceeding the target of 70%.
The Emergency Planning Lead and the infection control nurse continue to co-ordinate the FIT testing programme for clinical staff to ensure safe practice is delivered, update the emergency plan and submit the Trust vaccination data as this is a mandatory requirement.
Untoward Incidents including Outbreaks April 2017 to June 2017 Emergency Burns Assessment Clinic (EBAC) identified as being no longer fit for purpose and requiring improvements. Burns charitable fund approved funding for the refurbishment of the EBAC area however project put on hold to allow for discussion around the requirement of ventilation within the area. MSSA positive blood culture received from a very high risk Burns patient. RCA completed and learning needs identified which included staff shortages, several new starters, high use of agency nurses and poor documentation. Increase in hospital acquired MRSA colonisation cases. RCA’s completed for each case. Common theme identified is that wounds are not being screened on admission for MRSA. Paperwork on the wards amended and check list produced to
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follow patient.
July 2017 to September 2017 MSSA positive blood culture received from a Burns patient. Patient well at time of result therefore no treatment required. Probable cause of bacteraemia – contaminant from skin. RCA completed and learning needs identified which continue to be predominantly around poor documentation. Increase in Hospital acquired MRSA cases. 9 patients have been identified as having a hospital acquired MRSA colonisation positive result during this quarter. However, in some of these cases it has been difficult to say if this is hospital acquired as the patient has been discharged in between the original negative result being received and the positive one. RCA’s completed for each case.
October 2017 to December 2017 A patient on C Wing was diagnosed as Tuberculosis (TB) positive after being an inpatient in a bay area for five days. Patient was admitted from another acute hospital for skin grafting following a trauma injury. Patient was coughing during the admission period but did not report any other TB symptoms however patient did not speak English which inhibited the amount of information he provided. PHE contacted and ICN’s liaised with TB specialists from both areas. Approximately 75 members of staff cared for the patient whilst he was an inpatient and 14 patients were nursed in the same bay. All risk assessed by ICN’s and 1 patient further reviewed by a TB specialist due to being identified as high risk. All tests came back TB negative. All other patients written to via their GPs to inform them of the situation. 1 member of staff reviewed by Occupational health and discharged. All other staff written to and informed of the situation. PHE satisfied with all actions taken and incident closed no recommendations for going forward were made as staff followed policy at the time of the incident.
January 2018 to March 2018 MSSA bacteraemia: patient admitted to Margaret Duncombe ward on the 5/3/18. Blood cultures sent on 12/3/18 returned MSSA positive. Source of unknown origin. Pseudomonas bacteraemia: Patient admitted to Burns on the 17/03/18 blood cultures sent on the 21.03.18 which returned Pseudomonas positive. Source appears to be transfer of organism from patient’s wounds. VRE: Patient admitted to Burns on the 17/03/18 Swab sent on the 29/03/18 returned VRE positive. Result known on the 09/04/18 after patient had been discharged. VRE: patient admitted to Margaret Duncombe ward on the 27/12/18. Swab sent on the 03/01/18 returned VRE positive. Treatment discussed with the Consultant Microbiologist and no secondary cases seen. CPE: patient admitted to the Burns unit on the 20/03/18. Tissue samples sent on the 20/03 positive with highly resistant Enterobacter (CPE). Patient did not show as being a high-risk patient for carrying CPE and was therefore not screened or isolated on admission as there was no requirement to. All patients within the unit swabbed weekly for 3 weeks and all returned negative. No secondary cases. PHE informed of the result by Consultant Microbiologist. Patient continues to be seen in EBAC with strict infection control precautions in place. Campylobacter: patient admitted to the Burns unit on the 1/2/18 and was sedated and ventilated. First available stool sample obtained on 5/2/18 which returned positive for Campylobacter – a reportable organism. Consultant Microbiologist informed PHE. No explanation available as to where/how the patient became infected as they were not eating. No secondary cases. Streptococcus pyogenes (Strep A) in wounds. There has been an increase in the
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cases of patients being diagnosed with Strep A. A total of 19 cases in this quarter which is an increase when compared to the 6 received from the same quarter last year. On investigation there does not appear to be any links between the patients with the majority of them being identified on admission. Consultant Microbiologist advised to monitor the situation but no other action required.
Associated services reports
Antimicrobial report
Service aim, objectives and expected outcomes The main objectives and expected outcomes relating to antimicrobials for 2017-18 were:
Delivery of the antimicrobial resistance (AMR) CQUIN part 2d: 1% reduction in overall antibiotic use as well as 1% reductions in the use of piperacillin/tazobactam and carbapenems. Ensure submission of all required data within deadlines. Expected outcome is that the first two reductions will be met but it is unlikely that the carbapenem reduction will be made. This is due to the challenging (in terms of infections) patient type on the Burns unit in recent times. Provide quarterly progress reports to the CCG on progress with the CQUIN to provide assurance of ongoing commitment in trying to achieve the CQUIN so as to facilitate any due payments. Development of antibiotic guidelines for hand trauma to drive through improvement in antibiotic prescribing for this group of patients. Publish antimicrobial guidelines onto the MicroGuide App to facilitate ready access to the guidelines. Manage national antimicrobial shortages so that patient care is not impacted. Regularly review and update the Trust’s antimicrobial stewardship framework to ensure compliance with national directives and quality standards. Produce quarterly reports on cost and usage of antimicrobials to identify and investigate any areas of higher than expected usage. Produce quarterly antimicrobial update reports for the Trust’s Medicines Management Optimisation and Governance Group (MMOGG), which is the committee responsible for antimicrobial stewardship (AS), to provide scrutiny of AS activities. Ensure ongoing governance of the Trust’s restricted antimicrobial list to provide continuing assurance of appropriate use. Involvement in the investigation of all reported antimicrobial incidents at the Trust so as to recommend and implement any necessary actions to mitigate against future recurrence. Improvement of documentation of indication and duration or review dates on in- patient antimicrobial prescriptions through audit and feedback of results to bring about progress.
Activity analysis/ achievement • Compiled and submitted data to Public Health England within quarterly deadlines for the antimicrobial CQUIN. • Compiled quarterly update CQUIN reports for the CCG • Compiled and then reviewed and updated CQUIN action plan on a quarterly basis • Reviewed published data relating to CQUIN achievements and fed back to clinical directors, MMOGG and IPACC and Board (via written reports). • Developed antibiotic guidelines for hand trauma • Presented CQUIN feedback and areas for improvement at Joint Hospital Audit Meeting
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• Reviewed recommendations made by the Regional Medicines Optimisation Committee (South) for tackling AMR and developed an action plan to ensure compliance. • National antibiotic shortages were managed by changing recommended antibiotics on guidelines to alternative available options, whilst maintaining limited stock for serious infections such as sepsis. • All antimicrobial guidelines published on the MicroGuide App in June; uptake figures show a good response. • World Health Organisation (WHO) Antibiotic Awareness Week in November 2017 was marked with various email communication to nursing, medical and pharmacy staff. • Proactive action was taken to stock up on antivirals for the treatment of influenza infections as soon as it became known that the number of infections were on the rise. • Compiled quarterly antimicrobial reports for MMOGG • Compiled antimicrobial updates for Board • Reviewed all reported antimicrobial related incidents, no patient harm resulted from any; actions taken centred around issuing reminders to prescribers • Snap shot audits of documentation of indication done and results fed back to directorates as a whole, as well as to individual prescribers.
Plans for 2018-19 • Delivery of the antimicrobial resistance (AMR) CQUIN part 2d. Analyse ways in which consumption of Access category of antibiotics can be increased in relation to reducing antibiotic use in the Aware and Reserve categories. • Update inpatient prescription chart to include dedicated antimicrobial prescribing section. Work on this has already begun. • To introduce pharmacist presence on trauma ward rounds to engage with prescribers in reviewing antibiotics in a timely manner and taking appropriate action following the review. • To introduce regular good antimicrobial prescribing (GAP) audits • Continue to inform MMOGG of antimicrobial stewardship activities and issues. • Continue to monitor antibiotics on the restricted list. • Increase engagement with trauma clinic, Minor Injuries Unit and day case theatre patients to ensure appropriate antimicrobial use in these areas.
Decontamination and disinfection report Routine water sampling taken from the Wassenburg (endoscope washer disinfector) in July 2017 showed high counts of mycobacterium within the clean water system. Remedial action was implemented which included water and filter changes and full decontamination of the machine. Despite this further water samples continued to return positive. The company engineer visited site and attempted repairs however further sampling also returned positive. During this period an agreement was reached for Eastbourne sterile services department to undertake the disinfection and decontamination of many of our scopes and surgical instruments that required decontamination through the wassenburg, where possible some instruments were manually decontaminated using the approved Tristel 3 stage wipe procedure. The decision was made in conjunction with the Trusts Authorised Engineer that the reverse osmosis (RO) machine which supplies the water to the wassenburg was no longer fit for purpose and an alternative machine was sourced, purchased and installed. Further water sampling was then done which returned clear of all organisms. The wassenburg was then put back into service in February 2018. All water sampling since has been within normal levels.
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Steris continue to provide the Trust with sterile services for all reusable equipment that cannot be processed through the wassenburg machine. They are an accredited company licensed to perform sterilisation for healthcare premises in line with national guidance and requirement.
Decontamination roles In August 2017 the AE(D) audit identified lack of Authorised person (AP(D)) a role that is normally undertaken by a Trust estates team. There were no other concerns raised within the audit which looked at the Trusts ability to satisfactorily sterilise, decontaminate and disinfect reusable equipment. The Decontamination lead stood down in November 2017 although will remain as the decontamination lead for theatres until a replacement is in post. Review of the management & operational structure has been undertaken. A new Trust Decontamination Lead has been appointed and commenced in post in April2018..
Decontamination Group A separate decontamination group has been formed to ensure that there are standard practices that are in line with national requirements being performed throughout the Trust and in spoke sites. The first meeting was held in November 2017 where terms of reference were agreed and the decision made to hold the meeting quarterly alongside the Infection Control Group.
Decontamination roles The current Authorised Engineer (Decontamination) remains in place. A formal structure with allocated roles as outlined in the Health and Social care act will be assigned once the new Decontamination Lead is in post.
Cleaning report In the last 6 months, the work has progressed to align the cleaning services with the National Standards of Cleanliness (2007). The daily cleaning checklists with 49 elements (items of cleaning as appropriate), area risk rating, audit frequency, corrective actions and deep cleaning programmes have been based on this national guideline. This provides greater assurance on uniformed cleaning methods and monitoring. The audit scores are presented at the monthly Estates & Facilities Steering Group.
Month Cleaning Cleaning Comments Audits to Audits be completed carried out October 2017 12 November 56 54 An Auditing system based on the 2017 (31 Fails) National Standards of Cleanliness implemented to ensure very high, high, significant and low risks areas are audited in line with the risk category. Corrective actions sheets completed by domestics followed by each audit. Audit fails indicate that cleaning processes need to be reviewed asap December 66 66 Includes all weekly, monthly and
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2017 (18 Fails) scheduled three monthly audits Concern areas MIU & Rowntree – new cleaning checklists implemented to be able to measure improvements. National Standards Info to be displayed in all areas Daily cleaning checklists to be implemented Staff re-training needed Review needed to be done to check the suitability of cleaning equipment January 2018 62 62 (8 fails) New cleaning checklists completed in Ross Tilley, Peanut, OPD1, Rowntree, MIU and MOPD, OPD1. Staff and Supervisors training needs identified. Review of the Current cleaning Policy and cleaning equipment to be done February 2018 62 62 (1 fail) March 2018 63 56 (6 fails) Positive feedback from Domestic Supervisors after visiting Horsham Hospital Facilities Department. Cleaning checklists process finished in all clinical areas. National Standards of Cleanliness display in patient waiting areas.
Estates report – Associate Director of Estates
IPACT continues to work closely with the Estates department and are consulted on infection control issues as well as project works. Examples are;
• Carpet in clinical areas replacement programme • General maintenance and improvement of facilities • Urgent works following poor weather conditions during February winter freeze • Urgent works following outbreaks • Urgent works due to a mains water failure feeding Jubilee building • Legionella monthly water sampling programme • Pseudomonas 6 monthly water sampling programme. • Project Works
Water Safety The Trust continues to take monthly water sample (Approximately 25 tests per month) for the monitoring of legionella Pneumophila bacteria within the domestic water supplies. This work is undertaken by TSS and so far there attendance and performance has met expectations.
During October 2017 a positive result was returned from a cleaner’s cupboard within the Rowntree unit. Estates work undertaken immediately, included cleaning/disinfection the pipe work services and a daily flushing schedule was implemented by the domestic’s Team. Legionella sampling in November then returned another positive result from the same area in Rowntree estates works completed including:
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All outlets were inspected for the presence of flexi pipes / dead legs / blind ends. Any defects identified are rectified e.g. flexi pipes removed & replaced with copper hard piping. Dead Legs / blind ends to be removed as far as practically feasible. All sensor taps removed & replaced with manual equivalent (Markwik 21+) tap sets.TMV valves located and cleaned / chlorinated. External tap feed from CY 26 to be removed & wall cladding aperture repaired.
Further legionella sampling for November and December 2018 all returned negative Pseudomonas samples were taken on 26th March 2018. One sample returned a positive pseudomonas species from a tap outlet in ITU1 AX05. The laboratory did not confirm if pseudomonas Aeruginosa was detected. As a precaution on the 5th April 2018 Estates implemented an action plan which included a local disinfection of the tap outlet and put in place a flushing regime. A further sample was taken on the 10th April. The sample was tested for Pseudomonas Aeruginosa and proved to be negative. No further action required risks.
The Trusts risk register has been reviewed monthly in 17/18 and risks related to Water management have been updated or closed. A risk relating to ventilation within the Burns and CCU remains open on the risk register.
Infection Control Risk
The ICN’s also receive notification of any suspected Infection Prevention and Control incidents via the Datix reporting system. The ICN’s respond to each Datix report. The response may be in the form of advice or it may trigger further investigation. This activity allows the lead ICN to maintain oversight of all Infection Prevention and Control incidences.
There were 15 x Infection Risk Incidents reported on Datix for the period 1st April 2017 to 31st March 2018. Each risk identified on the Datix system is investigated by the ICN. Some risks require no input as they are dealt with at the time and entered onto the Datix system as a formal record, for example a case of a hospital acquired infection. Some risks whilst flagged to IPACT are dealt with by an alternative department, for example a needle stick injury by a member of staff is coordinated through occupational health. Each risk is reviewed and appropriate action taken if require by the IPACT or through an alternative department.
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Contract monitoring -Sussex CCG Infection Prevention and Control Standards CCG’s as commissioners of local health services need to assure themselves that the organisations from which they commission services have effective Infection Prevention and Control arrangements in place. A self-assessment tool is completed annually and contributes to providing evidence of assurance in conjunction with assurance site visits and submission of audits as part of an audit programme.
There have been no infection control concerns raised by the commissioners at the bimonthly contract review meeting throughout 2017/18.
CCG exception reports are provided by QVH in April, July, October and January of each year. The areas of concern that were raised during the last year was decontamination. The work the trust has undertaken on decontamination in year has provided assurance to the CCG and this is not an issue moving forward into 2018/19. By the appointment of a new decontamination lead the CCG the CCG have been assured that Decontamination throughout the Trust and its spoke sites will be monitored and all aspects of decontamination will be coordinated in line with national guidance ensuring best practice standards are met where possible.
Infection Prevention and Control Risks The Trust need to increase the percentage of staff that have completed Infection Prevention and Control training. At the end of the year 2017-2018 staff that had completed the mandatory Infection control training was 97% of non-clinical staff, 84% of clinical staff with a Trust total of 92%. The infection control teams delivers all scheduled mandatory training sessions and offers staff the option of undertaking ward based or one on one training for all staff to ensure as many options for training are made available to staff as possible. Infection Control with continue to work with the staff development co-ordinators to increase the percentage of staff compliant with mandatory training.
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5. Learning from Experience Patients and staff can be put at risk by failure to adhere to good infection control practice. The Trust continues to strive to improve compliance with all aspects of Infection Control in order to safeguard the patients, service users and staff through a robust programme of education, audit and reporting. Whilst the rates of both reportable and non-reportable infections remained low there is still improvement to be made. Most notably in relation to compliance with MRSA screening, compliance with hand hygiene and bare below the elbows and appropriate prescribing and usage of antibiotics. Due to an increase in antibiotic resistant organisms across the UK (e.g. Carbapenemase-producing Enterobacteriaceae), effective antibiotic stewardship is essential to preserve the future efficacy of antibacterial agents. Improving compliance with antibiotic usage and maintaining excellent standards of hygiene both personal and environmental the risk to patients and staff from hospital acquired infections will kept to as few as possible. Root cause analysis has shown that improvement in documentation and line care is a risk factor and this will be highlighted to staff during clinical wards rounds and IPC teaching as well as through senior nurses. The infection control team will continue to champion and promote the implementation of infection control to all staff in all departments.
6. Conclusions and assurance QVH continuously strives to develop and support its staff to achieve the best Infection Prevention and Control practice.
The infection prevention and control team has strived to ensure that high standards of infection prevention and control are utilised throughout the Trust. That all staff are aware of there roles and responsibilities in ensuring that patients are cared for in a clean, safe environment and that all policies and procedures are followed to minimise their chances of contracting a health care associated infection. This is done through the writing and implementing of policies in line with best practice guidance, a robust audit process and programme of education and staff engagement which has been detailed in this report. This has assisted in maintaining the Trusts low rate of healthcare associated infections across all departments.
QVH also promotes feedback from patients and encourages them to raise concerns about any Infection Prevention and Control issues they see and are worried about.
QVH has a range of internal assurance processes in place.
An overview of Infection Prevention and Control activities in QVH are in place. The ICN’s also works closely with the CCG ICN to provide reassurance on processes and practice within the trust.
QVH staff training programmes for Infection Prevention and Control have been reviewed and strengthened. Areas to improve training update have been identified.
QVH has an overview of all relevant Infection Prevention and Control information and documents, which are systematically developed, reviewed and/or updated.
QVH has local external regulation undertaken by the CCGs. Monitor ensures QVH are registered with the CQC.
Local Infection Prevention and Control peer review and assurance processes are in
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place. IPACT are well supported by the Director of Nursing/ DIPC. QVH staff are guided and supported by the specialist Infection Prevention and Control clinicians.
The QVH Infection Prevention and Control team present this report to provide assurance to the Board that the Infection Prevention and Control agenda is robustly overseen and managed within the trust and with partners.
7. Report approval and governance The Board is asked to consider the contents of this report and raise any issues of concern or outline any specific action they request.
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8. Appendices
APPENDIX A Infection Prevention and Control Structure Chart 2017/2018
Chief Executive
Medical Director Issue escalated to if Director of Nursing and Quality, DIPC medical staff related
Head of Nursing Lead Infection Emergency Consultant Microbiologist Control Nurse Elective (3 Doctors on a monthly Specialist Manager of Perioperative rotational basis from Services Brighton and Sussex University Hospitals NHS Trust) Director of Estates Infection Control Nurse and Facilities
Issue escalated to if related to the Management of the Trust Estate
Admin Assistant Link Persons in each Head of Hotel Dept Services 27 Issue escalated to if
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Appendix B Infection Control Annual Programme Objectives for 2018/19
Infection prevention and control continues to be a top priority at both National and local level. The IPACT, under the direction of the DIPC and with the full support of the Board of Directors and Governors, will continue to ensure that the highest possible standards in infection prevention and control are applied and achieved at the QVH.
This action plan contains new areas of activity and a number of on-going areas of particular importance. A large amount of activity is on-going and not included in the action plan.
Department Section Action Frequency Microbiology Management Continued review of pathology provider to ensure On-going safe and efficient service delivered Microbiology Management Continued review of pathology provider IT systems, On-going e.g., the provision of electronic reporting in a useable, reliable format and request for regular list of blood cultures taken Microbiology Management Continued review of antimicrobial prescribing On-going Microbiology Management Maintain input into Clinical Audit Meetings and Quarterly Consultant mandatory training Microbiology Management Maintain input into the review of any new Estates On-going project from start to finish IC Management Continue to review the Board Assurance Framework Quarterly related to the Health and Social Care Act (2010) IC Management Quarterly IPACT report for Board Quarterly IC Management Role of Decontamination lead to be taken on by the One off and Infection control lead nurse. Decontamination then continue throughout the Trust to be reviewed and audit standardised. programme as required IC Management Decontamination Lead to continue monitoring of Ongoing decontamination of equipment in conjunction with the decontamination staff within Theatres IC Management Review policies in line with DoH and NICE National As required guidance and Trust timescale IC Management Continued attendance at external meetings and On-going Infection Prevention Society annual conference IC Management DIPC to raise attendance on PLACE inspections with As required the Matrons, Estates and Risk Management Depts IC Surveillance Continue mandatory surveillance and reporting in Monthly line with DH requirements including MRSA, MSSA, C. difficile and E. Coli IC Surveillance Enhanced surveillance (RCA/PIR) of C. difficile, When new MRSA, MSSA and E. coli bacteraemia case identified IC Surveillance Continue speciality specific surgical site infection Annual audit IC Audit Audit sharps policy compliance Trust wide annual IC Audit Continue hand hygiene audit and compliance Monthly IC Audit Spot check of infection control documentation and Bi-monthly
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mattress decontamination IC Audit Continue to review external contracts e.g. laundry As required IC Audit Continue to implement the DH Saving Lives audit On-going programme IC Audit Continue PLACE inspections Monthly IC Audit Audit compliance with MRSA policy Twice yearly Audit compliance with MRSA screening Monthly IC Education Updates for Clinical Practice Educators / Department As required Managers / departments IC Education Mandatory training: Clinical X2 month Non-clinical X1 month Induction X1 month Junior doctors X6 year Consultants X2 year IC Education Link person training quarterly IC Education Infection control awareness week Annual IC Education Hand hygiene roadshow Twice a year IC Education Hand hygiene training On-going IC Education Deliver training to staff on current issues and attend As required department meetings on request IC Education Relaunch the infection control team to promote As required compliance with infection control trust wide Estates Management Involvement in the Capital Programme As required Estates Management Review of estates policy and new guidance As required Estates Management Involvement in reviewing water sampling and As required ventilation results Estates Management Involvement in the prioritising of general As required refurbishment works within the Trust Estates Management Update for IPG Quarterly Estates Audit Waste facility Annual Decontamination Management Review of decontamination and disinfection policy As required Decontamination Management Update for ICC Quarterly Decontamination Management Review decontamination/traceability processes for As required equipment trust-wide Decontamination Management Formalise Decontamination structure and roles As required within the Trust Decontamination Management Review policy for the decontamination, transport and As required storage of endoscopes used in spoke clinics Decontamination Management Audit decontamination/traceability processes for all Annual spoke sites Decontamination Management JAG audit Twice a year Decontamination Audit Synergy service Annual
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Appendix C
IC Policies Ratified April 2017 – March 2018
Reference Title Lead Ratifying Ratified Review Director Committee Date Date
IC.7005.4 Aseptic Director of Infection 13/04/2017 13/04/20 Technique Nursing Control Standard Group Operating Procedure IC.7029.2 Carbapenemase- Director of Infection 06/11/2017 06/11/20 producing Nursing Control Enterobacteriace Group ae (CPE) Policy IC.7011.4 Taking Blood Director of Infection 19/04/2017 19/04/20 Cultures Policy Nursing Control Group IC.7018.3 Policy for Director of Infection 13/04/17 13/04/20 Mandatory Nursing Control Reporting of Group Episodes of Infection IC.7024.8 Management of Director of Infection 19/01/17 19/01/20 Outbreaks Nursing Control Group
IC.7025.4 Policy for the Director of Infection 06/11/2017 06/11/20 prevention of Nursing Control healthcare Group associated infections in short and long term urinary catheterisation in acute care
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References
British Medical Association. 2009. Tackling healthcare associated infection through effective policy action. Available from www.bma.org.uk
Control of Substances Hazardous to Health Regulations 2002.
Curran, E.T. 2014. Outbreak Column 13: Nosocomial Staphylococcus aureus outbreaks (part 2 – guidelines). Journal of Infection Prevention. 15 (2): 69-73.
Available from http://www.hse.gov.uk/coshh/
Department of Health. 2008a. Clean, safe care – reducing infections and saving lives. http://antibiotic-action.com/wp-content/uploads/2011/07/DH-Clean-safe-care-v2007.pdf
Department of Health. 2008b. Board to Ward. – How to embed a culture of HCAI prevention in acute trusts. Available from www.dh.gov.uk/publications
Department of Health. Health and Social Care Act 2010. Available from www.dh.gov.uk/publications
Department of Health. 2012. Choice Framework for local policy and procedures 01-06 Decontamination of flexible endoscopes (series)
Department of Health. 2012. Choice framework for local policy and procedures 01-01 Management and decontamination of surgical instruments (medical devices) used in acute care. Part A: the formulation of local policy and choices manual. Version 1.0: England.
Health & Safety at Work Act 1974. Available from http://www.hse.gov.uk/legislation/hswa.htm
HTM 2030. 1997. Decontamination of surgical instruments. Available from http://www.reverseosmosis.co.uk/Documents/HTM0105bookletv2.pdf
National Audit Office. 2009. Reducing healthcare associated infection in hospitals in England. Available from www.tsohop.co.uk
NHS England. 2015a. Clostridium difficile infection objectives for NHS organisations in 2015/16 and guidance on sanction implementation.
NHS England. 2015b. Quality improvement and clinical leadership; Clinical audit. Available from http://www.england.nhs.uk/ourwork/qual-clin-lead/clinaudit/
NHS Estates. 2001, revised 2003 and 2004 – Revised Guidance on Contracting for Cleaning as The National Specifications for Cleanliness.
Public Health England. 2015. Seasonal influenza vaccine uptake amongst frontline healthcare workers (HCWs) in England. February survey 2014/15.
World Health Organization, 2015. Health care-associated infections - FACT SHEET. Available from http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
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Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/2018 Agenda reference: 143-18 Report title: Patient Experience Annual Report 2017/18 Sponsor: Jo Thomas, Director of Nursing Author: Nicolle Ferguson, Patient Experience Manager Appendices: None
Executive summary Purpose of report: The Patient Experience Annual Report 2017/18 aims to present a rounded picture of patient experience and, as such, provides information on all aspects of experience, good and less positive. Summary of key This report covers the period of April 2017- March 2018. We received 52 complaints issues during this time. This is 1 less number of complaints than received during the same period last year. There are full analysis details of the complaints along with outcomes and actions taken. Including within the report are details of the annual Friends and Family Test scores, outcomes of national inpatient and children and young adults surveys which compare very positively when compared with other trusts. Recommendation: This report is provided to the Board for information Action required Information
Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence experience services Implications Board assurance framework: Links to KSO1, KSO2, KSO3, KSO4, KSO5
Corporate risk register: Links to workforce and access and performance risks on CRR Regulation: Reputational implications of delivering sub-standard safety and care Legal: The trust adheres to Regulation 18 of the The Local Authority Social Services and National Health Services Complaints (England)
Regulations 200, which requires NHS bodies to provide an annual report on complaint handling and consideration, a copy of which must be available to the public. Resources: No new resource requirements identified
Assurance route Previously considered by: Quality & Governance Committee Date: 19/07/18 Decision: Recommended for approval by the BoD Next steps:
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Holtye Rd, East Grinstead RH19 3DZ
Patient Experience Annual Report
Queen Victoria Hospital NHS Foundation Trust
Report covering the period from April 2017 to March 2018
Document Control: Quality and Governance Committee
Executive sponsor: Jo Thomas, Director of Nursing
Authors: Nicolle Ferguson, Patient Experience Manager
Date:
Type: Annual Report Version: FINAL Pages: Number Status: Public. Written and prepared for the Trust Board Circulation: QVH Trust Board
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Contents List
Item: Page number:
1 Executive Summary 3 2 Introduction 3 3 Friends and Family Test 4 3.1 How likely are you to recommend our ward to family and 4 friends? 4. National Inpatient Survey 2017 5 5. National Children and Young Person’s Inpatient Day 7 Case Survey 6. Analysing the patient experience feedback 8 6.1 Using the patient experience feedback 8 7. Patient Experience Group (PEG) 9 8. Learning Disability Peer Review 9 9. Accessible Information Standards 10 10. Complaints 10 10.1 Complaints received 11 10.2 Investigation outcomes 12 10.3 Learning from complaints, concerns and feedback 14 10.4 Further analysis of formal complaints 15 10.5 Parliamentary and Health Service Ombudsman (PHSO) 15 11. Patient Advice and Liaison Service (PALS) 15 12. Website feedback 16 13. Key achievements 17/18 17 14. Future developments 18/19 18
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1. Executive Summary
Patient Experience features as an the Trust’s quality priorities for 2017/18, therefore placing it firmly at the heart of the Trust’ continuous drive to improve the quality of the services we provide.
At board level, the Trust’s Director of Nursing and Qualtiy has responsibilty for patient experience which includes: Delivery of our patient experience stragety Compliance with the national Friends and Family Test (FFT) Reporting and demonstrating that we have used patient experience feedback to improve the experience of care and our services.
Patients provide their feedback in real-time thorugh , socal media, NHS Choices, Care Opinion, focus groups, PALS/complaints and, of course, routinely throughout the Trust via FFT. In patient adults and children are also eligible to provide feedback via the annual CQC national inpatient survey.
Patient stories are shared at the begining of the public board, which may be in person or an agreed written format, which highlights a complaint or plaudit and demonstrates the experience of the patient and family. Patient stories are obtained either through the complaints process, letters to the Chief Executive or from patients who have approached the Trust. The value of the patient being present to give a more detailed account, allows the Board to see and hear first-hand the impact of the Trust’s work and the impact this has on patients.
Trust wide Patient Experience Reports are routinely reviewed by the Clinical Governance Group (monthly) Quality and Governance Committee (bi-monthly) and the Board of Directors (bi-monthly) meetings.
All complaints are shared with the team or individual where they originate and also with departmental or business unit manager and lead clinician to ensure awareness and learning is shared.
The reports continue to bring together a range of patient experience information from across the Trust. This ensures that key patient experience monitoring information is routinely considered at the most senior level.
2. Introduction
One of the key trust values is driving continuous improvement in care for our patients. We do this in many ways; an example of this is collating and responding to all forms of patient feedback to embed a culture of active listening and action for patients, families and careres to improve patient experience.
As a trust we welcome feedback from our patients, their families and carers, which includes formal complaints, concerns raised through our Patient Advice and Liaision Service (PALS), feedback on Patient Opinion, National Inpatient Surveys and Friends and Family Test. This feedback is shared with our departmental managers and clinical leads to identify ways in which we can improve the experience for people who use our services and their families. We take very seriously all feedback recieved and we strive to share the learning from
3 QVH BOD September 2018: Session in public Page 217 of 260 complaints investigations across the trust to miniimise the risk of the same issues occuring in another area.. The key themes and changes made in the last year focus on improving communication between our clinical staff and patients.
The trust adheres to Regulation 18 of the The Local Authority Social Services and National Health Services Complaints (England) Regulations 200, which came into effect in April 2009. The regualtations require NHS bodies to provide an annual report on complaint handling and consideration, a copy of which must be available to the public.
3. Friends and Family Test
The Friends and Family Test (FFT) gives patients who have received care throughout the Trust the opportunity to provide immediate feedback about their experience via the question “How likely are you to recommend our ward/hospital/department/service to friends and family if they needed similar care and treatment?”
Patients are invited to respond to the question by choosing one of six options, 'extremely likely' ‘likely’ ‘neither likely nor unlikely’ ‘unlikely’ 'extremely unlikely' and ‘don’t know’.
To enable us to drive this agenda forward we outsourced this service to support the data collection and reporting elements If a patient has been treated in our Minor Injury Unit, Outpatient Departments or Therapy Department they will be sent either a SMS text to their mobile phone or an Interactive voice message (IVM) to their landline phone within 48 hours of their appointment and asked to rate and comment on their experience. Patient’s feedback is anonymous and is completely FREE of charge for patients to reply.
All wards and departments continue to display their monthly Friends and Family Test results on information boards that provide an opportunity for wards to demonstrate to patients and their carers, actions they are taking in response to feedback. The information shown gives the Matron and ward managers an opportunity to discuss this openly with staff, patients and their loved ones to identify improvements.
FFT results are routinely reported to the Trust Board. Patient experience data is shared and welcomed by clinical and operational teams. The Patient Experience Manager provides a report to the Business Units on a monthly basis.
3.1 How likely are you to recommend our ward/department to family and friends?
The response rate to the Friends and Family Test question for In-Patients who are ‘extremely likely/likely’ to recommend us to a friend or family during that period from Margaret Duncombe ward, Ross Tilley ward, Burns ward and Peanut ward is 44% (the national response rate target to achieve is 40% for inpatient returns).
As with previous years, the vast majority of our patients are more than satisfied with the high standards of care they receive, citing the friendliness, helpfulness, excellence, clinical outcomes, professionalism and overall very positive patient experience.
Where patients felt their visit could have been improved, cited communication and waiting times in clinic as their main concerns. Of the other suggested improvements, the majority concerned issues relating to their clinic experiences while waiting, such as the availability of refreshments, communication about waiting times and processes.
Other issues concerned parking, staff behaviour and appointments management. The
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Patient Experience Group will monitor improvements against the issues raised over the coming year.
The following figures show the Friends and Family Test inpatient recommended rate:
Inpatients 2017/18 National average 2017/18 QVH recommended rate 98% 96% QVH response rate 44% 26%
The following chart show the breakdown per month for patients admitted as inpatients:
The following chart shows the breakdown per month for patients that attend our outpatients:
The following chart shows the breakdown per month for patient that our minor injuries unit:
4. National Inpatient Survey 2017
The latest national NHS inpatient survey shows that QVH continued to achieve some of the best feedback from patients in the country. This year’s survey carried out by the Care Quality Commission surveyed 77,850 people who received care at an NHS hospital in July 2016. The findings help the NHS to continually improve, enabling hospitals to see how they are doing year-on-year and how they compare with others.
Overall, QVH scored better than other trusts across all ten relevant sections of the survey – and we scored significantly better than other trusts for 49 of the 63 questions asked. Areas where QVH scored particularly highly were:
Feeling safe during their hospital stay Privacy, respect and dignity
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Whether they felt they were well looked after by hospital staff Whether staff did all they could to control pain Staff providing a quiet environment at night Being involved in decisions around care and treatment, and having confidence about decisions made by staff Whether there was enough information given to family or friends about how to help care for them if needed Advice and information about what would happen after discharge including having medicines explained to them in a way they could understand (if applicable) Whether there were enough nurses on duty Opportunities to feed back. The Trust will continue to seek and learn from patient experience feedback to improve our services.
Key facts about the inpatients who responded to the survey:
• 71% of patients were on a waiting list/planned in advance and 26% came as an emergency or urgent case. • 73% had an operation or procedure during their stay • 49% were male; 51% were female • 14% were aged 16-39, 31% were aged 40-59; 25% were aged 60-69 and 31% were aged 70+.
Eight acute trusts were classed as ‘much better than expected’ in 2017 including QVH as shown below:
QVH is one of only five acute specialist trusts to have consistently maintained a ‘much better than expected’ rating over the last four years.
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5. National Children and Young Persons Inpatient Day Case Survey
The latest national children and young people’s hospital survey shows that we are the only acute trust in the country to achieve the highest rating from its patients in both age groups.
The Care Quality Commission’s children and young people’s inpatient and day case survey analysed feedback from 34,708 patients who received care in 132 NHS trusts. A total of 11,166 young patients aged 8-15 directly gave their experiences through questionnaires designed especially for them, and parents and carers for children aged 0-15 years also shared their experiences.
Two scores were given for each trust – one for the age category 15 days to 7 years old, and one for the group 8 to 15 years. QVH achieved the highest band in both categories – the only acute trust to come top for both older and younger children.
In 25 of the 63 questions asked, QVH was the highest scoring hospital nationally.
QVH was categorised in the highest band as it was identified as ‘much better than expected’ for both age groups.
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6. Analysing the patient experience feedback
Analysis and triangulation of all forms of patient experience feedback, including complaints, results in the production of monthly detailed patient experience reports. These reports are then discussed at clinical governance group and quality and governance committee prior to public board. Exceptions are reviewed and actions taken, an example of this was targeting wards with lower inpatient feedback- discharge nurse and patient experience manager encouraged patients to provide feedback (which can be anonymous or named) and this was successful in improving response rates.
Developing an understanding of the patient experience by identifying and gaining knowledge of what people feel is crucial to the process of enabling the Trust to improve the experience of patients in our care. As a result of analysis, improving communication was chosen as a patient experience initiative in 2018/19.
6.1 Using the patient experience feedback
Receiving, analysing and presenting feedback and then involving users and staff in developing the solution completes the ‘you said – we did’ cycle.
The following examples highlight how we have used this information to implement learning and improvement based on patient feedback:
Patient information: A patient told us that they needed more guidance on why nail varnish should be removed prior to any surgery. We are looking add to our literature patient information about why it is necessary to remove all cosmetics e.g. false eyelashes and nails prior to surgery. We offer a wide range of information to patients, relevant to their condition or treatment along with information about the Trust. We seek to consistently meet the Assessable Information Standard introduced by the CQC. Meeting this standard will improve the access to our services, how people experience our services, and the outcome that patients receive.
Patient information: It was also identified that not all patient information notice boards were consistent throughout the Trust. We have standardised the information displayed on public notice boards throughout departments in the Trust and will also be putting up new display boards within clinical areas.
Patient experience: A patient told us of their experience with a delay in being discharged from the ward. We aim to discharge patients as promptly as possible however; we have delays from the doctors when writing up discharge forms and prescriptions. The ward Matron is working with the staff to encourage the doctors to work in a more proactive way.
The waiting times in clinic: We are currently undertaken a review of the waiting times and the reasons for these. This part of the process involves ensuring that the feedback is heard and understood by the relevant clinical and managerial teams.
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7. Patient Experience Group (PEG)
Every quarter the multi-disciplinary members of PEG meet to discuss and triangulate patient experience, quality, complaints and national surveys to identify themes and areas of concern. This meeing is chaired by the Director of Nursing. PEG allows the data from all parties to be shared, producing a group discussion between members on what the data is telling us. The data sources and feedback are discussed and traiangulated at the PEG meeting and actions assigned to leads to address concerns, understand more or resolve the problem causing the feedback.
Over the year 2017/18, PEG sought assurance that patient experience improvement projects and action plans were continuing and effective and project leads and action plan authors we invited to the PEG to discuss progress.
The current project that the group is involved with is in relation to the waiting times in clinics which have been identified as a key concern from our outpatients. We have put together a small working group to capture specific data on waiting times from patients. The work to achieve these objectives is in progress.
Due to increasing patient activity, there was increasingly negative feedback from patients, with many encountering long periods of waiting in the clinic when they came for appointments.
The is aim of the project is to improve patient experience by identifying the problems and improve the waiting time, better patient engagement, improve communication and workflow between the various healthcare professionals, and improve the overall clinic experience for both patients and staff.
For the improvement of the patients experience, the group will review the clinic operations to identify causes (missing notes, missed diagnostics, DNAs) and the actual issue the patient identifies as sub-optimal experience (delayed clinics). Once this evidence has been gathered, analysis will be undertaken to show where quality improvement initiatives can be made to ensure we maximise the benefit to patient.
The outputs from PEG are discussed at the Quality and Govenernace Committee, a sub- committee of the Board. Also feeding the work of PEG are any care reviews or reports from Healthwatch West Sussex.
8. Learning Disability Peer Review
We conducted an external learning disability review in January 2017. This involved members of Sussex Community NHS Foundation Trust together with service users with learning disabilities visiting wards and departments across the Trust and reviewing our compliance against key standards.
The key areas for improvement were around easy read information, provision of an adult changing area and implementing learning disability awareness training. Over the next year, the Trust will work to ensure that improvements for these keys issues are made.
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9. Accessible Information Standards
The Accessible Information Standard (this is overseen by PEG) is an NHS England requirement that all organisations providing NHS or adult social care are required to implement. The standard requires a specific and consistent approach to identifying, recording, flagging, sharing and meeting the information and communication needs of patients, service users, carers and parents, where those needs relate to a disability, impairment or sensory loss.
It is designed to ensure that people who have a disability or sensory loss receive information they can access and understand, whether this be large print formats, braille, email, or with professional communication support should they need it, for example from a British Sign Language interpreter.
We were not fully meeting the standards and there is an action plan in place to address these issues. Some of the changes that we have made have included:
Action: Displaying posters and information in different formats encouraging patients and service users to inform the service if they have any information or communication needs
Current status: The notice boards in all patient areas have been updated with corporate information (action complete).
Action: Signage not clear and navigating around the hospital is a challenge.
Current status: A Wayfinding Site Analysis and Audit has been undertaken and new signage is due to commence mid August 2018.
In addition, whereas most of our patients communication needs can currently be met on an individual basis and upon request, the challenge for us is to identify their needs ahead of time. We need to establish processes where needs can be automatically met (e.g. the automatic emailing of letters from our Patient Administration System). In addition, we need to develop clear processes for staff should a patient require audio, braille, easy read letters or information and ensuring that seldom heard groups such as those with a learning disability or dementia are catered for.
The role of PEG will be to ensure that this major piece of work is managed in to place, that momentum is maintained and that goals are achieved
10. Complaints
In accordance with NHS Complaints Regulations (2009), this Annual Report provides detailed information about the nature and number of complaints Queen Victoria Hospital NHS Foundation Trust received, as well as feedback and concerns via the Patient Advice and Liaison Service (PALS). The Trust deals with complaints and concerns from patients and users, their relatives/carers, in accordance with its Complaints Policies and Procedures and the Care Quality Commission’s (CQC) Essential Standards of Quality and Safety.
The Trust uses the following definitions:
complaints are expressions of displeasure or dissatisfaction where the complainant wishes a formal investigation to be undertaken;
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concerns are issues that are of interest or importance affecting the person raising them, including displeasure or dissatisfaction and where the complainant is content for the issue to be dealt with via the PALS route;
feedback is information/suggestions about care or services that we provide, which may be complimentary or critical;
Compliments are expressions of thanks and praise.
The distinction between a ‘concern’ and a ‘complaint’ is challenging. Both indicate a level of dissatisfaction and require a response. It is important that concerns and complaints are handled in accordance with the needs of the individual, and investigated with an appropriate level of scrutiny.
In order to ensure that complainants have access to appropriate support, as part of our complaints handling process, complainants are signposted to SEAP (Support Empower Advocate Promote) for help in making their complaint. All complainants are signposted to the Parliamentary and Health Service Ombudsman (PHSO) of the NHS complaints process in case they wish to take their complaint further.
The Trust has an integrated service – Complaints and PALS - to manage complaints, concerns and feedback in accordance with its Complaints Policy.
10.1 Complaints received
The time limit for making a complaint as laid down in the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 is currently 12 months after the date on which the subject of the complaint occurred or the date on which the matter came to the attention of the complainant.
All complaints are acknowledged within 3 working days. We aim to respond to all complaints within 30 working days in an honest, open and timely manner. If it is clear on receipt of the complaint or at any point during the investigation that the investigation cannot be completed on time, for example when a complaint is more complex or requires a joint response from services/organisations a new timeframe will be agreed with the complainant.
It has been a challenge to achieve the 30 working day response timeframe particularly at times of increased clinical pressures having only achieved 50%. Many of the complaints closed outside of the agreed timescales were either complex ones which involved more than one service area or organisation, or those which raised additional issues during the course of the investigation and complaint handling.
Improving the number of responses made within 30 working days will remain one of our aims for 2018/19 as a continued commitment and desire to improve the effectiveness and responsiveness of our complaints handling.
The Trust aims to remedy complaints locally through investigation and meetings if appropriate. However, if the complainant remains dissatisfied they have the right to refer their complaint to the Parliamentary and Health Service Ombudsman (PHSO) as the final step of the complaints system. The NHS complaints procedure is the statutorily based mechanism for dealing with complaints about NHS care and treatment and all NHS organisations in England are required to operate the procedure.
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At Queen Victoria Hospital we aim at all times to provide local resolution to complaints and take all complaints seriously. We listen carefully, we are open, honest and transparent in our responses and welcome the opportunity to do all we can to put things right. Our complaint system gives the opportunity for complainants to meet with managers/clinicians to discuss their concerns and we ensure that staff are made aware if concerns are raised about them and encourage them to look at ways they can change their practice or behaviours where appropriate.
Many complaints are resolved locally by front line staff that are empowered to resolve the client’s concerns/issues to their satisfaction in a timely manner. The Trust actively encourages front line staff to deal with concerns as they arise so that they can be remedied promptly, taking into account the individual circumstances at the time. This timely intervention can prevent an escalation of the complaint.
During 2017/18 we received 52 formal complaints, which is one less than the previous year (2016/17 = 53).
Under the NHS complaints regulations, the Trust is required to acknowledge receipt of complaints within 3 working days. Of the 52 complaints we investigated 50 complied with this requirement. The remaining 2 complaints were acknowledged as soon as possible, however, due to other complexities such as clarifying the address or gaining the necessary patient consent.
We take all negative feedback very seriously and our Chief Executive sees all complaints when they arrive and reviews all responses personally before they are sent. Complaints handling and any trends or themes identified from them are shared and discussed regularly by the Executive Team and the Board of Directors.
10.2 Investigation outcomes
The complaints investigator is required to conclude, on completion of the investigation, whether a complaint is upheld, upheld in part or not upheld. Establishing if a complaint is upheld/not upheld can be complex, as often there are a number of concerns/allegations within an individual complaint, some of which may prove to be unfounded whilst other elements are.
Complaints received during 2017/18 included the following themes and whether the complaints was upheld, upheld in part or unsupported:
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Total number Complaints received by subject of complaint Complaints Complaints Complaints of complaints upheld upheld in part unsupported 2017/18 received Access and waiting (waiting time in clinic) 0 0 0 0 Aids, appliances and equipment 1 0 1 0 Appointments/admission delay/cancellation 12 3 7 2 Attitude of staff 11 5 4 2 Communication/information to patients (written & oral) 3 2 1 0 Discharge 1 0 0 1 Equipment 0 0 0 0 Health records 2 1 1 0 Surgery treatment/procedure 11 3 4 4 Treatment (medical) 10 1 3 6 Treatment (nursing) 1 0 1 0 Total 52 15 22 15
The fifteen complaints that were graded to be upheld included incidents relating to service failure. This is categorised for example as: appointment cancellations and communications.
The twenty two upheld in part complaints were categorised as such because there were clear concerns about a patient’s experience being poor. This included poor communication, certain aspects where care could be improved and expectations not being met.
The fifteen complaints that were unsupported, as the investigation concluded that care and treatment provided was timely and appropriate.
The assessment of the outcome of complaints as to status of upheld, not upheld or partially upheld continues to be developed.
There have been a number of complaints about poor staff attitude. These focused on what was perceived as unprofessional or insensitive behaviour by doctors, optometrists or reception staff. Although instances of this are low, and regardless of whether the behaviour was intended, this is not what we expect from our staff and we need to learn from such examples to improve matters for other patients in future.
Another key theme for complaints communication and information; there continues to be a focus on effective communication skills at induction based on our customer care standards and as part of on-going staff training. Encouraging and enabling staff to avoid problems and concerns arising in the first place and to seek and welcome feedback so that any issues and concerns can be dealt with quickly and satisfactorily is a priority.
Patients, their relatives and carers have told us how important it is to them to need to be kept informed about their care and treatment and there are several developments to improve the handover of information between staff to improve the information provided about medicines and about discharge from hospital.
One of our quality account initiatives for 2018/19 is to improve communication and customer care expectations. This indicator was selected as although the Trust receives only a small number of complaints, a consistent theme has been around communication and customer care expectations. As part of our organisational development strategy we will develop a toolkit of resources to support and enable our workforce (clinical and non-clinical) to deliver the values and behaviours.
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Appointments, delay/cancellation; are areas identified for improvement as part of the Trusts transformation programme. There are 2 key programmes of work. Working together to improve the experience of patient’s having surgery and using our outpatient services by removing unnecessary delays, reducing waiting times and exploiting the use of technology for the benefit of patients and to improve efficiency and productivity.
10.3 Learning from complaints, concerns or feedback
The Trust seeks to make changes following incidents, complaints and concerns to improve the care and services received by patients, users and their representatives.
As soon as a complaint is received, it is the responsibility of the Patient Experience Manager to immediately consider whether the complaint should be escalated (for example to the Director of Nursing, Medical Director) to establish whether any immediate and/or remedial action(s) should be taken, prior to the investigation, in the interest of safeguarding safety, equality and quality. The Patient Experience Manager works closed with our Head of Risk and Patient Safety to ensure that there is collaborative approach to the analysis of incidents, complaints and claims, as well as any additional internal sources of information or Root Cause Analysis (RCA) reports, to ensure that wherever possible the organisation learns from events that occur.
Work continues to ensure that the Trust complies with equality and diversity principles. It is noticeable that the received complaints have not verged on an unfair/discriminatory act pertinent to these individual characteristics. Where the complaint warrants further investigation pertaining to an individual characteristic then this would be forwarded back to the Lead for Equality and Diversity for scrutiny and assessed for the nine individual protected characteristics.
Where nursing issues are raised within the complaint, a copy of the complaint is sent to the Heads of Nursing for learning and training purposes.
The Trust is committed to learning from any complaint received and considerable focus is placed on this aspect of the complaints process. We aim to ensure that all complaints are robustly investigated and that, where action is needed to improve the care or service a patient receives, this is reflected in the complaint response.
Complaints may highlight a need to change a practice or improve a service in an individual area. When identified, a change in practice will be implemented to avoid recurrence. Individual complaint (in an anonymised format) is used in training levels and for all staff.
We act on feedback to make improvements to our services wherever possible. In response to the complaints received this year we have taken the following actions:
Noise at night monitored by ward sisters and spot checks carried out John’s Campaign implemented which ensures that carers are updated and involved in decisions about care and discharge planning. Removal of nursing desks, replaced with small working areas in each bay to ensure nursing staff are more visible and available to patients being piloted across the Trust Lessons learned from complaints shared with teams for understanding and improvement Emphasis on junior doctor training to improve the writing of discharge summaries
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10.4 Further analysis of formal complaints
None of the fifty two patients who had raised a formal complaint, approached advocacy services to support them through the complaints process. The Trust received no requests for a complaint response in large print or brail. As in previous years, all formal complaints were received in the English language with no requests made by a complainant (or enquirer) for the assistance of the Trust’s Interpreting Service. The Trust received no formal complaints where people stated that they had a learning disability nor did this become evident during any of the investigations. Of the 52 complaints, none of the complainants asked to meet with a senior member of staff on completion of the investigation. No external reviews of care were commissioned as part of the Trust investigation during 2017/2018. In line with the Duty of Candour (November 2014) the trust investigation responses have been scrutinised to ensure they are open and transparent. Where it has been established that errors occurred this was shared with the complainants and an apology given and lessons identified to enhance learning for the Trust.
10.5 Parliamentary and Health Service Ombudsman (PHSO)
During 2017/18 two complainants were referred their complaint to the Ombudsman following the Trust’s investigation, which is the same number as 2016/17 and 2015/16.
The decisions made by the PHSO, for both cases, were that no further actions were required and no recommendations were made about these cases to the trust.
11. Patient Advice and Liaison Service (PALS)
This section of the annual report concentrates on the nature and number of PALS contacts and issues raised within those contacts during 2017/18. PALS remain an invaluable source of help/guidance to people using services and for the Trust to understand the experiences of our patients.
During 2017/18 a total of 70 PALS enquiries were recorded. All of these enquires where dealt with satisfactorily and no patients asked for their issues to be dealt with in accordance with the NHS complaints procedure.
In addition, we also deal with information, advice and support requests. Many service users will contact PALS for reasons other than complaints. This may be about:
Care and treatment Services which the trust provides Signposting to other services Outpatient clinic appointments (patients may occasionally ask PALS to attend with them) Assisting families who arrive in East Grinstead with a patient but do not live locally and require local orientation and signposting, to further help about local finding somewhere to stay e.g. local hotels
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Examples of typical enquiries about advice and information include:
What is the waiting time for a procedure? How do I get a copy of my health records? Who can I contact to ask about what I need to bring with me into hospital? My transport has not arrived and I am going to miss my appointment. Who do I contact? I was an inpatient last week and lost my glasses. What do I need to do?
The common actions taken to resolve the concerns were:
Staff would be asked to reflect on their attitudes and behaviours. A review of the new Trust signage following feedback from patients and relatives Work continues on more effective advertising and visibility of PALS within the hospital, promoting an open and engaging culture that may help in more timely and appropriate resolution of concerns and issues at the point at which they occur.
The PALS telephone contact line is operated during working hours Monday to Friday. A voice mail service is available during ‘out of hours’ and calls are returned on the next working day. During out of hours the Site Practitioner is the contact for patients/relatives who have urgent issues that require action.
PALS are an invaluable service for enabling patient involvement and engagement, providing a rich source of effective feedback about the patient experience.
12. Website feedback
During the year, the Trust has been responding to feedback posted onto social media websites. This is an important source of feedback for us with 49 comments regarding the Trust being posted over the past 12 months on the two main patient feedback websites, NHS Choices and Care Opinion.
We posted 427 times on Facebook – an average of 35 posts a month. Each comment received on the QVH page is acknowledged (liked or responded to)
Our Facebook followers increased from 795 at the start of April 2017, to 1,315 by the end of March 2018
During that time we received 26 reviews on Facebook – 25 of which gave QVH a 5* rating.
We don’t actively push the review aspect of our page so these are always left by patients who want to genuinely feedback on their experience of our hospital. We thank each person that leaves a review and ask if we can share the feedback with staff to help us to continually improve our services
In the same period we posted 2,009 times on Twitter.
On Twitter we have increased the people who like our page from 2441 in April 2017 to 2922 in March 2018.
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In that period the amount of impressions our tweets had (times they appeared on peoples timelines) was an incredible 1,365,800.
All comments are viewed by all staff via the Trust’s intranet website and passed to relevant staff across the Trust for action.
13. Key achievements We understand that complaints are an important part of feedback and that they are a strong indicator of patient experience and have taken the following actions to support continued improvement;
Provided ‘investigation’ training and ‘human factors’ training for staff that handle incidents and complaints to ensure that investigations are proportionate and fair.
Used complaint case scenarios and learning from complaints within customer care and communication skills training.
Provided complaints training for staff involved in handling and responding to concerns and complaints
Developed an ‘easy read’ version of our complaints leaflet “Putting Things Right – When you tell us what’s wrong”
Established a data quality audit to monitor and review the standard of data collection in relation to complaints.
Used other sources of data alongside complaints data to explore themes of patient experience including the friends and family test survey responses.
We have developed ways of sharing the themes and learning from complaints at divisional and ward/departmental level. These have included sharing the monthly Patient Experience Report with these areas and attending departmental monthly meetings with staff to discuss key themes.
Used the opportunity of patient satisfaction surveys and our programme of regular ‘walk rounds’ and our team of volunteers to increase the awareness of how to raise concerns and complaints for patients, their relatives and carers
Introduced the ‘Freedom to Speak Up’ system to provide another way for staff to feel safe to raise any concern they have and feel confident that they will be listened to and some action taken. The system enables staff to raise things anonymously.
We have used the themes from complaints, concerns, the Friend and Family Test feedback and patient surveys to inform service improvement activities at divisional, specialty and ward level. We used this variety of feedback in 2017/18 to inform our quality priorities for 2018/19.
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14. Future developments 2018/19
The aim of the Trust and its Patient Experience Manager is to increase the confidence of our patients by having a flexible approach to resolving concerns. There is extensive work being undertaken with the staff on the wards and in departments to help prevent complaints by listening to and responding when things can be put right. When further support is needed, the Trust aims to ensure that the complaints process is signposted locally so that patients know how or where to complain.
Improving access to information for patients on a range of patient experience initiatives, including complaints is a key focus for the Trust. The predominant method for making a complaint remains letter or email but by signposting other options such as the Trust’s website, social media and patient opinion websites we ensure patients are given a choice. Where contact is initially made in person or by telephone, staff supports the complainant in registering their concerns formally with the Trust.
In order to improve the services provided to patients further, additional developments will be implemented.
We will continue to work alongside Trust teams to improve the patient and carers experience. As such we believe further developments during 2017/18 will promote this.
Increase the percentage of people who receive a response within 30 working days and when this is not achieved ensuring that patients are informed.
The Patient Experience Manager will continue to work with each of the directorates and teams to ensure a fully collaborative approach is provided regarding improving the patient and carers experience.
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Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/2018 Agenda reference: 144-18 Report title: Emergency Preparedness Resilience and Response and Business Continuity Annual Report 2017/18 Sponsor: Jo Thomas, Director of Nursing Author: Nicky Reeves, Deputy Director of Nursing/EPRR Lead Appendices: 2
Executive summary Purpose of report: To assure the Board of the preparedness of QVH from a major incident perspective. It is a requirement of NHSE to ensure an annual report is completed. Summary of key The 2017/18 NHS England annual assurance review process undertaken in issues conjunction with our Clinical Commissioning Group and a burns specialist team placed our compliance with national standards as partial but meeting essential requirements. The report identifies the assurance process, work plan and learning from incidents Recommendation: The report is provided to the Board for information. Action required Assurance
Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Financial (KSOs): Outstanding World-class Operational Organisational patient clinical excellence sustainability excellence experience services Implications Board assurance framework: BAF reviewed when compiling this report
Corporate risk register: CRR reviewed when compiling this report
Regulation: Compliance with regulated activities and requirements in Health and Social Care Act 2008. National requirement working with NHSE
and local CCG Legal: The Civil Contingencies Act 2004 places a number of duties on responding agencies in the event of a Major Incident
Resources: No new resources have been allocated to achieving this work plan in 2017/18
Assurance route Previously considered by: Quality & Governance Committee Date: 19/07/18 Decision Recommended for approval by the BoD Next steps:
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Holtye Rd, East Grinstead RH19 3DZ
Emergency Preparedness Resilience and Response and Business Continuity Annual Report
Queen Victoria Hospital NHS Foundation Trust Service Annual Report
Report covering the period from April 2017 to March 2018
Document Control: Quality and Governance Committee Executive sponsor: Jo Thomas
Author: Nicky Reeves
Date: May 2018
Type: Annual Report Version: FINAL Pages: 8 Status: Public. Written and prepared for the Trust Board Circulation: QVH Trust Board
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1. Executive Summary The EPRR annual report highlights the significant events and activities during 2017/18. It also identifies the rational behind the duties placed on the trust regarding emergency planning.
The 2017/18 NHS England annual assurance review process undertaken in conjunction with our Clinical Commissioning Group and a burns specialist team placed our compliance with national standards as partial (appendix 1).
The work plan in appendix 2 identifies the work ongoing to further improve compliance in 2018/19
2. Introduction The Civil Contingencies Act 2004 places a number of duties on responding agencies in the event of a Major Incident. QVH is categorised as a Category One responder which include the following responsibilities:
To carry out a risk assessment of our operational areas To make emergency plans To make business continuity plans To warn and inform the public To cooperate with other responders through a Local Resilience Forum To share information with other responders
During 2017/18, Emergency Preparedness Resilience and Response and Business Continuity Executive leadership within QVH was held by the Deputy Director of Nursing and Quality who represented the organisation at the Local Health Resilience Partnership Executive Group (LHRP).
The Quality and Governance Committee has received 3 papers in 2017/18 to provide assurance that this work has been undertaken.
This report provides a summary of the work undertaken in relation to Emergency Planning and Business Continuity within QVH in 2017/18.
3. Service aim, objectives and expected outcomes The requirements of being a category one responder for the basis of the service aims and objectives. The EPRR lead has co-ordinated activities which demonstrate the trust has met its responsibilities as a category one responder the key outcomes being: Updated EPRR policy Refreshed and tested plans related to emergency plans Collaborative working with LHRF Establishing QVH in the wider EPRR health economy and utilising expertise within this network Resilience test of business continuity. Maintaining effective continuity of our business is of critical importance to QVH. We are committed to the implementation, maintenance and continual improvement of an effective Business Continuity Management (BCM).
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4. Activity analysis/ achievement Policy Emergency Preparedness policies are held centrally on the Trust intranet pages accessed via there won “tile” within the Policies section; for ease they are divided into sections to reflect specific guidance. Policy review is ongoing; seasonal policies (Cold Weather and Heatwave) have been changed in line with national guidance and local action cards for major incident have also been revised. Work is carried out during the year to ensure the policies are up to date. , Two sections of the emergency plan required review in 2017/18, response to terrorism and the site evacuation are currently being refreshed. All other policies were updated within the required timeframes. As reported later in the paper, there have been a range of situations under which the plans have been tested.
Incident Co-ordination Centre (ICC) The ICC is located in the Jubilee Meeting room. The equipment is tested on a bi monthly basis by the emergency planning lead. This process provides assurance that all necessary equipment is always in good working order including the fax machine; telephone lines; computer and television.
5. Involvement & Engagement Assurance process
Internally: Bi-monthly on-call manager meetings continue with all managers and directors who undertake on call duties being invited to the meeting. At these meetings the on-call logs and incidents are reviewed and learning is shared and actioned.
In year there has been a review of the managers who undertake on call, inclusion of new managers within the rota has brought a new perspective to these meetings.
New managers receive an induction session from the EPRR lead and to facilitate the transition into the element of their role. A buddy system for new on-call managers to ‘test’ decisions is offered for the first couple of on-call periods. There is also a system in place for non-clinic on-call managers without an operational remit to have the contact details of a manager with a clinical background to call for advice as required.
EPRR updates have been presented six monthly at Quality and Governance Committee and the annual report is presented for information at Board. These updates have been presented by the Director of Nursing or Deputy Director of Nursing during 2017/18.
Externally: All NHS Trusts who are category 1 and 2 responders (Civil Contingencies Act 2004) are required to complete a self-assessment and submit a statement of readiness to NHS England stating compliance against the national requirements of EPRR. We are considered a Category 1 responder. The Trust
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reviewed its compliance with the EPRR Core Standards and the Statement of Readiness as part of the LHRP process in September 2017. This was submitted to NHS England in October 2017 and discussed at the Quality and Governance Committee in October and Board in November 2017. The process will be repeated in autumn 2018. In 2017 the organisation again demonstrated partial compliance (appendix 1) following the review and the work plan to address these is contained within appendix 2.
6. Learning from Experience Practice Exercises and Live Events During 2017/18 QVH has tested its emergency planning resilience during a number of “live” incidents including power cuts, a burst pipe, a number of IT failures, a telephone upgrade and severe winter weather.
The learning from these exercises and incidents was utilised to ensure the emergency plan remains up to date and is reviewed in the light of any recommendations as a result of these scenarios. For example, Hotel Services have a supply of bottled water in case of further water supply issues. A standard operating procedure is being devised to address issues when the trust is running on the generator. Any changes to the emergency plans are approved via the Quality and Governance Committee. Other than general review of the plans, no significant changes have been made following incidents.
A national burns table top exercise was planned for March 2018 to test the revised surge and escalation response however, due to adverse weather this was not carried out and the trust is awaiting a new date to undertake this exercise.
Winter Planning
Snow There was one significant snowfall in the winter of 2017/18 that impacted on QVH. This had significant operational impact. There was a robust response from an EPRR and business continuity perspective; daily snow planning meetings, provision of overnight accommodation, mobilisation of 4 x 4 assist for staff transfer ensured the disruption to services and patients was minimised.
Flu The 2017/18 flu vaccination programme concluded in March 2018 with all data submissions to IMMFORM uploaded successfully.
Final uptake for staff receiving the vaccination was 59.2%, a significant improvement on the 51.5% for 2016/17. This year, a CCG locally agreed variance to the CQUIN allowed us to include all staff officially declining the vaccination producing a final figure of 72.9%, exceeding the target of 70%.
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% of staff group ImmForm Data Submission headcount 52.0% All Doctors 150 78 8.0%
Qualified 52.2% 207 108 nurses 11.0% All other 60.1% professional 138 83 qualified 8.5%
Support to 64.3% 484 311 clinical staff 31.8% ImmForm 979 580 59.2% CCG 979 714 72.9%
Training Face to face training continues to be delivered at trust induction and also at clinical and non-clinical mandatory update sessions. Mandatory training for Non-clinical staff is delivered every 3 years. This session involves an overview of the roles and responsibilities and reminders of the relevant sections of the plan. The content of the training has been reviewed in light of feedback following the 2017 peer review.
Fit testing Staff who may be involved in the care of pandemic flu patients are taught how to wear their protective equipment annually. This has taken place in all services throughout 2017/18 and is managed at a departmental level.
Business Continuity Maintaining the effective continuity of our business operations is of critical importance to QVH. We are committed to the implementation, maintenance and continual improvement of an effective Business Continuity Management capability in line with BS 25999 Business Continuity Management. This includes the development of business continuity plans for core business activity.
All business continuity plans can be accessed by the on call managers and site practitioner team via folders on the “N” drive and hard copies of the emergency plan area available in the incident control room in the event of a power or IT failure and all departmental leads have a copy of their individual plans.
Other activity undertaken over the year: Training sessions on Emergency Planning Preparedness were delivered for all new employees on induction and current employees at mandatory training as an ongoing rolling programme. Bi monthly meeting for on-call managers, control personnel and bleep
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holders. The Trust maintained its membership with the Sussex Resilience forum Attendance at the LHRP executive Group
8. Future plans and targets The EPRR lead has developed a work plan for 2018/19 to ensure the organisation has satisfactory arrangements in place to meet the requirements of the peer review.(appendix 1)
During 2018/19 the organisation will need to review the Chemical, Biological, Radiological and Nuclear section of the emergency plan.
9. Conclusions and assurance As reported to the Board in November 2017, the Trust currently has effective policy and systems in place for the effective management of expected and unexpected EPRR and business continuity incidents. It meets the requirements of the category one responder and demonstrates partial compliance to the national standards. (appendix1).
Delivery of the work plan should ensure the organisation achieves substantial compliance in the 21018/19 review.
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Appendices
Appendix 1
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Appendix 2
QVH EPRR Work plan Printed/opened: 05-Jun-18 Key to status: On track Delayed Slippage On track Completed ID Issue Outcome Key Deliverables Deadline Current Status Lead Updates
1 Development and creation of Fuel Plan for QVH To create a QVH Fuel Plan in line with 1. Estates to review existing best practice plan 01/07/18 on track Head of Estates Outline plan forwarded as initial national guidance guidance for QVH Plan
2 Update the QVH evacuation Plan 1. Review initially 31 10 17 on track DDN In progress
Evacuation Plan 2. Forward to Estates following review for further input 01/07/18 on track Head of Estates
3 Ensure On call managers have attended external EPRR events Evidence of external participation 1. Allocate OCM to attend as events arise on-going on track DDN DoN attended Flu EPRR in Dec 17. All external oportunities circlated to on call 4 NED development in EPRR role Ensure NED is fully briefed on EPRR 1. EPRR assurance process to Q&G October 2017 30 09 17 Completed DDN and NED managers agenda and work plan
2. EPRR Assurance Process onwards to November Board 31 10 17 Completed DDN and NED
5 Continued Development of EPRR oversight Group Rebrand and relaunch on call managers Agenda reformatted to include EPRR requirements 30 09 17 Completed DDN and EPRR Group
6 Excess Deaths/mass fatalities To ensure we have up to date policy 1. Review of exisitng arrangements. 2. Write policy/ensure 01/07/18 on track DDN covered in policy
7 Inventory of CBRN Equipment Inventory completed Inventory reviewed by MIU clinical services manager 01/07/18 on track MIU Clinical Services manager
CBRN Training for MIU and Site Staff To ensure QVH is aware of training Review other provider plans 01/07/18 on track MIU Clinical Services requirements and has plans to delver manager
8
Review training availability 01/07/18 on track MIU Clinical Services manager
Book staff training as appropriate 01/07/18 on track MIU Clinical Services manager
EPRR Annual Report 2017/18 QVH BOD September 2018: Session in public 8 Page 241 of 260
Report cover-page References Meeting title: Board of Directors Meeting date: 06/09/2018 Agenda reference: 145-18 Report title: Appraisal & Revalidation Annual Report 2017/18 Annual Statement of Compliance 2018 Sponsor: Dr E Pickles, Medical Director Authors: Ms Katy Ally, Revalidation Administration Support Dr E Pickles, Medical Director Appendices: Consultant revalidation statement of compliance Executive summary:
Purpose of report: Mandatory Board of Directors’ report of annual compliance with requirements for medical appraisal and revalidation. Summary of key The Trust was 89.9% compliant with doctors’ appraisals at 31 March 2018. issues Appraisal Data Packs were launched in January 2018, providing doctors and appraisers with data relating to the doctor’s statutory and mandatory training compliance, plus recorded incidents and complaints. All revalidation recommendations to the GMC were made on time. The paper includes an actions resulting from the Annual Organisation Audit 2018 and an internal audit review. Recommendation: Action required Approval Information Discussion Assurance Review [highlight one only] Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence experience services Implications Board assurance framework: KSO2 Corporate risk register: Regulation: GMC and NHSE Legal: Resources: Assurance route Previously considered by: Quality and Governance Committee Date: 19/7/18 Decision: Approved Next steps:
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Framework of Quality Assurance for Responsible Officers and Revalidation – Annual Board Report 1st April 2017 to 31st March 2018
1. Executive summary Revalidation is the process by which doctors will have to demonstrate to the General Medical Council (GMC) that they are compliant with relevant professional standards, have up to date skills and competencies and are fit to practice. Revalidation of licenced doctors will be required every 5 years.
Appraisal and revalidation are the focal point of ensuring and enhancing the delivery of high quality care to our patients. Additionally, it is intended to assist in the early identification of performance issues.
Doctors in both training and non-training grades are required to participate in the revalidation process. However, doctors in training are revalidated through Health Education England London and Kent, Surrey & Sussex (HELON & HEKSS).
As of 31 March 2018, 98 doctors had a ‘prescribed connection’ with the Responsible Officer (RO).
2. Purpose of the Paper
Appraisal for the purposes of revalidation is made up of two elements:
• The appraisal element, which is the process by which a doctor is supported in their continuing professional development
• The revalidation element, whereby a doctor demonstrates that they remain up to date and fit to practice.
The purpose of this report is to provide the Board with information regarding the current position as of 31 March 2018 in respect of the numbers of doctors who have been revalidated, any pertinent issues and general assurance regarding the revalidation process including future plans for improvement.
3. Background
Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system.
Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations1 and it is expected that provider boards will oversee compliance by:
• monitoring the frequency and quality of medical appraisals in their organisations; • checking there are effective systems in place for monitoring the conduct and
1 The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013’ and ‘The General Medical Council (Licence to Practice and Revalidation) Regulations Order of Council 2012’
QVH BOD September 2018: Session in public Page 243 of 260 performance of their doctors; • confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and • ensuring that appropriate pre-employment background checks (including pre- engagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed.
This is the fifth formal report to the Board laying out the role and responsibilities of the Responsible Officer and detailing how the revalidation team at QVH have delivered, documented and assured the process has been carried out in accordance with national requirements. Dr Ed Pickles, Medical Director was appointed RO from the 3rd October 2016.
The Responsible Officer regulations are wide-ranging but in summary cover the whole governance system that exists around the recruitment, monitoring, training and development of all medical staff at the QVH. As revalidation approaches the end of first 5 year and in response to 2017 Sir Keith Pearson’s report Taking revalidation forward2, the GMC has committed to work with others to make revalidation accessible and meaningful to patients and the public, while reducing unnecessary burdens and bureaucracy on individual doctors’ cycle.
The RO is obliged to attend regional meetings and events to ensure the organisation is kept up to date with new developments. The QVH revalidation team are also instrumental in ensuring our systems and processes are reviewed and continue to deliver the changing requirements.
4. Governance Arrangements The Appraisal & Revalidation Recommendation Panel (the panel) is a non-statutory, non- executive committee and is accountable to Board of Directors. The Panel is authorised by the Board of Directors to monitor the progress in implementing the Responsible Officer Regulations and ensure that appraisals, recommendations, HR processes (pre-engagement checks) and governance processes are in place and functioning effectively. The Panel consists of Responsible Officer, Deputy Medical Director, Appraisal Lead, Lay representation and Medical Workforce and meet on a quarterly basis.
Additional quarterly returns on completed and missed appraisals are submitted to NHS England. Incidents/complaints relating to medical and other staff are reviewed monthly at the Clinical Governance Group, to which the Medical Director (Responsible Officer) is joint Chair. Concerns raised through any other mechanism, such as whistle-blowing, are managed according to Trust policy but within the Responsible Officer regulations.
The Trust has systems in place to collect the information in line with revalidation requirements. Doctors have access to their individual revalidation file in which they are expected to upload and maintain their own appraisal and revalidation documents. The system is administrated by dedicated staff in the Medical Workforce Office who also provide assistance and advice on revalidation issues both to the doctors and the Responsible Officer.
The Responsible Officer is required to submit an Annual Organisational Audit in May of each year which is designed to provide assurance to the Board, High Level Responsible Officers and other interested bodies. Crucially, it provides a mechanism for assuring NHS England, the England Revalidation Implementation Board and the GMC that systems for evaluating doctors’ fitness to practice are in place, functioning, effective and consistent. The Responsible Officer is
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22017 Sir Keith Pearson’s report Taking revalidation forward
QVH BOD September 2018: Session in public Page 244 of 260 subject to annual audit covering his “total practice” but primarily focused on the governance systems and quality control in place within the organisation. The appraiser is appointed from outside the Trust by NHS England.
During March 2018; Mazars conducted an internal audit of the controls in place relating to Doctors Revalidation, as the Trust had a number of risks within its Corporate Risk Register around medical staffing. Areas of good practice/compliance were identified plus 2 areas of risk. (See action plan)
An accurate list of prescribed connections is managed by the Medical Workforce Office. When a new doctor is recruited contact information of their previous RO is sought from the doctor and a Medical Practice Information Transfer Form is sought. The new doctor is added to the list. When a doctor leaves the Trust the doctor is removed from the list. a. Policy and Guidance The Trust has a published Appraisal, Revalidation & Remediation Policy which aims to ensure doctors within its employ receive high quality appraisals. This along with other supporting information enables the RO to make a recommendation to the General Medical Council (GMC). The policy includes a number of QA processes. In addition, all new applicants are asked questions based on the Trust’s values, in additional to the standard clinically based questions. The purpose of this is to assess organisational fitness and ensure that they are able to converse and understand medical terminology at an appropriate level in English. References follow a set format and must include last employer, most recent Responsible Officer declaration.
A similar although more extensive assessment process using Stakeholder Panels is part of the recruitment process for Consultants and consideration will be given to the possible introduction for permanent non-consultant career grade staff.
Appraiser Job descriptions and personal specifications provide explicit guidance on the expectations of the role and provide clarity on lines of responsibility & accountability and are shares with all new appraisers.
5. Medical Appraisal a. Appraisal and Revalidation Performance Data as at 31 March 2018
No. of doctors No. of completed appraisals* Compliance Specialty Head & Neck 13 12 92.31% Plastic Surgery 42 39 92.86% Anaesthetics 21 18 85.71% Corneo-plastics 13 11 84.62% Radiology 2 2 100.00% Histopathology 2 2 100.00% Sleep Studies 5 4 80.00% Total 98 88 89.80%
QVH BOD September 2018: Session in public Page 245 of 260 Level No. of doctors No. of completed appraisals* Compliance Consultants 67 63 94.03% Staff grade, associate 8 7 87.50% specialist, specialty drs Temporary or short-term 23 18 78.26% contracts TOTAL 98 88 89.80% *Also includes staff who joined QVH within reporting period with a valid medical annual appraisal or an approved missed appraisal. (See Annual Report Appendix A; Audit of all missed or incomplete appraisals audit) b. Appraisers There are currently 18 trained appraisers. 1 appraiser relinquished the appraiser role and 1 new appraiser was recruited within the last 12 months. We are collaborating with East Sussex Healthcare NHS Trust and Brighton and Sussex University Hospitals Trust to provide quality assured training for new appraisers to ensure quality and consistency.
It is important that medical appraisers maintain and develop their skills on an ongoing basis. This is primarily the responsibility of the appraiser, however in order to support our appraisers QVH delivers annual in-house refresher training which incorporates peer support group discussions with more scheduled in September 2018 and February 2019. The aim of these sessions is to continually improve the documentation of evidence, evaluation and completion of the Medical Appraisal Forms by both Appraiser and Appraisee whilst also providing a greater understanding of the NHS England’s audit process. These sessions have been incorporated into the Consultants Mandatory Training Update Days coordinated by the Medical Education Department to improve the attendance rate over the coming year. c. Quality Assurance The Trust samples appraisal outputs using NHS England’s generic Appraisal Summary and PDP Audit Tool (ASPAT). The data identifies further training needs for doctors and appraisers
Triangulation of data from incident and complaint reporting to the appraisal documentation is undertaken and this has been an area of improvement. Data packs have been developed however the implementation has been slow due to heavy reliance of manual input by Medical Workforce Administrator.
Quality assurance of appraisals has begun by monitoring feedback from appraisees using Survey Monkey as a tool for collecting data. The response rate is slowly improving. The feedback has been cascaded to the individual appraisers in order for reflection whilst also support key areas of development and discussion at the appraiser network groups over the coming year. (See action plan)
(See Annual Report Template, Appendix B; Quality assurance audit of appraisal inputs and outputs) d. Access, security and confidentiality There are secure systems in place for access to revalidation files. The file of each doctor can only be accessed by the individual doctor themselves, the Responsible Officer, the Medical Manager and the Medical Workforce Administrator.
QVH BOD September 2018: Session in public Page 246 of 260 Doctors are required to anonymise correspondence with patient identifiable data which is then submitted for the purposes of revalidation. Further action needs to be taken in this respect to ensure that all doctors undertake this prior to submission.
No information governance breaches have been reported. e. Clinical Governance As the organisation lacks the capacity to supply individual corporate data, such as incidents, complaints and performance metrics, we remain dependant on the individual doctor to collect and present this information themselves as a result of the disparate information systems currently in existence. This was an area of development over the previous 12 months and resulted in Appraisal Data Packs being launched in January 2018, the pack provide doctors and appraisers with data relating to the doctors statutory and mandatory training compliance, plus recorded incidents and complaints. Appraisal Data Packs are shared prior to a revalidation recommendation. (See action plan)
6. Revalidation Recommendations It should be noted by the Board that all recommendations to the GMC were made on time.
See Annual Report Appendix C; Audit of revalidation recommendations
7. Recruitment and engagement background checks All doctors, including locums, are recruited in line with NHS Employment Check Standards.
All locum doctors are sourced through the Crown Commercial Service (formerly Government Procurement Service) or Health Trust Europe. These bodies are required to meet the NHS Employment Check Standards.
The Trust has extended its clinical offering to patients through expanding services using clinicians who do not have a prescribed connection with the Trust. These include locums, visiting doctors and doctors who provide services through a Limited Liability Partnership and Any Qualified Provider. The Trust has processes in place to ensure that the information required to support the NHS Employment Check Standards and RO Regulations are met, however the speed of growth has presented some challenges relating to the information flows. This has been identified as an area of development.
Receipt of information relating to previous appraisals and revalidation data in a timely fashion continues to be a challenge to obtain from newly recruited doctors. New starter paperwork has been modified to incorporate a self-declaration relating to conduct issues or performance investigation by a previous employer
See Annual Report Appendix E: Audit of recruitment and engagement background
8. Monitoring Performance All doctors are required to have an annual appraisal which is undertaken with a designated, trained appraiser. Should issues arise in the interim these are fed back through the Clinical Directors and Clinical Leads and are, where possible, dealt with informally in the first instance.
Incidents and trends relating to performance will also be fed back through the Clinical Governance Group which reports on a monthly basis.
Any serious concerns regarding practice from any other source will be reported to the Medical Director.
QVH BOD September 2018: Session in public Page 247 of 260 9. Responding to Concerns and Remediation The Trust has an Appraisal, Revalidation and Remediation Policy which includes the Trust’s approach to remediation and links with other related policies. The Trust manages concerns raised about doctors and dentists in accordance with the NHS Framework, Maintaining High Professional Standards. As of 31 March 2018 there was 1 doctor in remediation or subject to a disciplinary process. 1 doctor is carrying a formal written warning relating to conduct following an MHPS disciplinary hearing.
See Annual Report Appendix D; Audit of concerns about a doctors practice
10. Risk and Issues The key risks that have been identified are as below:
• That the Trust’s information systems do not adequately capture and report all concerns and incidents relating to performance.
• That the appraisal system is not sufficiently robust to detect and manage concerns of poor performance.
11. Board Reflections Whilst Revalidation has become embedded and is beginning to impact on clinical practice, professional behaviour and patient safety it is a new process and difficulties and challenges will remain whilst taking forward 2Sir Keith Pearson’s recommendations to ensure it is meaningful to patients and the public, while reducing unnecessary burdens and bureaucracy.
______22017 Sir Keith Pearson’s report Taking revalidation forward
QVH BOD September 2018: Session in public Page 248 of 260 12. Corrective Actions, Improvement Plan and Next Steps The following table reflects the result of the Annual Organisation Audit (AOA) 2018 and Mazars Internal Review.
Corrective Actions/Areas for Improvement/Further Action/Timescales development All actions to be completed by 31st March 2019 unless stated below. All appraisers at the Trust should receive training on All appraisers to attend Consultants conducting appraisals. Mandatory Training Updates session on an annual basis. 3/9/18 A Terms of Reference (ToR) document should be 31 March 2018 drawn up for the quarterly Appraisal and Revalidation Panel meetings Cascade medical appraisal feedback to appraisers. ASPAT and Survey Monkey appraiser feedback to collated and circulated to all appraisers. Distribute data packs to doctors and appraisers prior to Streamline processes in order to provide revalidation recommendation. data packs to doctor prior to a revalidation recommendation Improve rates of appraisal for trust grade junior Conduct a review to change the appraisal doctors. reporting period to inclusively April to December and include examination of all communication, induction of new doctors and make clear requirements of GMC for formal appraisal in addition to supervisor and ISCP information. Extension to fixed term employment contracts without a valid appraisal to cease. Recruitment and Engagement background checks – More robust procedure for the collection information flows of appraisal and revalidation data on appointment, in line with NHSE Information Flows to support medical governance and RO statutory functions.
13. Recommendations The Board is asked to accept the report and note that it will be shared, along with the annual audit with the High Level Responsible Officer. It is also asked to approve the ‘Statement of Compliance’ which confirms that the Trust is in compliance with the regulations.
QVH BOD September 2018: Session in public Page 249 of 260 Annual Report Appendix A
Audit of all missed or incomplete appraisals audit* (over the course of the reporting year) – source of information – RO/ESR
Doctor factors (total) 9 Maternity leave during the majority of the ‘appraisal due window’ 1
Sickness absence during the majority of the ‘appraisal due window’ 0
Prolonged leave during the majority of the ‘appraisal due window’ 0
Suspension during the majority of the ‘appraisal due window’ 0
New starter within 3 month of appraisal due date 0
New starter more than 3 months from appraisal due date 4
Postponed due to incomplete portfolio/insufficient supporting 0 information
Appraisal outputs not signed off by doctor within 28 days 0
Lack of time of doctor 1
Lack of engagement of doctor 3
Other doctor factors 0
Describe doctor under investigation 0
Appraiser factors 1 Unplanned absence of appraiser 0
Appraisal outputs not signed off by appraiser within 28 days 0
Lack of time of appraiser 1
Other appraiser factors (describe) 0
Organisational factors 0 Administration or management factors 0
Failure of electronic information systems 0
Insufficient numbers of trained appraisers 0
Other organisational factors (describe) 0
*Headcount basis
QVH BOD September 2018: Session in public Page 250 of 260 Annual Report Appendix B Quality assurance audit of appraisal inputs and outputs – for the reporting year up until March 31st 2018 – source of information: audit undertaken by Appraisal Lead & Medical Workforce Administrator using ASPAT tool
Total number of appraisals completed 78 Scale: Number of Score based 0 Unsatisfactory appraisal on scale 1 Needs improvement portfolios 2 Good sampled (to demonstrate Score each item out of two adequate sample size)
1. Setting the scene and overview of supporting information 1. Setting the scene and overview of supporting information
a) The appraiser sets the scene summarising the doctor’s scope of work 10 20 b) The evidence discussed during the appraisal is listed (not all senior appraisers feel that this is necessary, so if not 10 20 required score 2) c) There is documentation of whether the supporting information covers the scope of work 10 19 d) Specific evidence is summarised with a description of what 10 20 it demonstrates e) Objective statements about the quality of the evidence are 10 20 documented f) All statements made by the appraiser are supported by 10 20 evidence g) Appraiser comments about evidence refer/fit in to the four 10 20 GMC domains and associated attributes h) Reference is made to whether speciality specific guidance for appraisal has been followed e.g. college recommendations for CPD and quality improvement activity 10 20 (this is not a GMC requirement so if the senior appraiser does not feel that this is necessary, score 2) i) Reference to completion of locally agreed required training (e.g. safeguarding training, basic life support training) is made 10 20 (please insert agreed requirements, score 2 if none agreed)
2. Reflection and effective learning a) There is documentation of evidence showing that reflection on learning has taken place or that the appraiser has 10 20 discussed the need for reflection
b) There is documentation of evidence showing that learning has been shared with colleagues or that the appraiser has 10 20 challenged the doctor to do so
QVH BOD September 2018: Session in public Page 251 of 260 c) There is documentation of evidence showing that learning has improved patient care/practice or that the appraiser has 10 20 explored how this might be taken further with the doctor
3. The PDP and developmental progress a) There is positive recording of strengths, achievements and 10 20 aspirations in the last year b) There is documentation of appropriate challenge in the 10 20 discussion and PDP e.g. significant issues discussed and new suggestions made c) The completion (or not) of last year's PDP is recorded 10 16 d) Reasons why PDP learning needs were not followed 10 16 through are stated (if the PDP was completed then score 2) e) There are clear links between the summary of discussion 10 20 and the agreed PDP f) The PDP has SMART objectives 10 20 (specific, measurable, achievable, relevant, timely) g) The PDP covers the doctor's scope of work and personal 10 20 learning needs h) The PDP contains between 3-6 items 10 19 4. General standards and revalidation readiness a) The documentation is typed and uploaded onto an 10 18 electronic toolkit in clear and fluent English b) There is no evidence of appraiser bias or prejudice and no 10 20 identifiable patient/third party information c) The stage of the revalidation cycle is commented on 10 18 d) There is documentation regarding revalidation readiness 10 20 relating to supporting information (e.g. states that feedback and satisfactory QIA are already done). Any outstanding supporting information/other requirements for revalidation are commented on with a plan of action if revalidation is due that year e) Appraisal statements (including health and probity) have 10 20 been signed off or if not, an explanation given (if signed off score 2)
TOTAL SCORE (OUT OF 500) 483
QVH BOD September 2018: Session in public Page 252 of 260 Annual Report Appendix C
Audit of revalidation recommendations
Revalidation recommendations between 1 April 2017 to 31 March 2018
Recommendations completed on time (within the GMC recommendation 6 window)
Late recommendations (completed, but after the GMC recommendation 0 window closed)
Missed recommendations (not completed) 0
TOTAL 6
Primary reason for all late/missed recommendations For any late or missed recommendations only one primary reason must be identified
No responsible officer in post 0
New starter/new prescribed connection established within 2 weeks of 0 revalidation due date
New starter/new prescribed connection established more than 2 weeks 0 from revalidation due date
Unaware the doctor had a prescribed connection 0
Unaware of the doctor’s revalidation due date 0
Administrative error 0
Responsible officer error 0
Inadequate resources or support for the responsible officer role 0
Other 0
Describe other
TOTAL [sum of (late) + (missed)] 0
QVH BOD September 2018: Session in public Page 253 of 260 Annual Report Appendix D Audit of concerns about a doctor’s practice High Medium Concerns about a doctor’s practice Low Total level3 level3 level3 Number of doctors with concerns about their practice 0 1 0 0 in the last 12 months Explanatory note: Enter the total number of doctors with concerns in the last 12 months. It is recognised that there may be several types of concern but please record the primary concern Capability concerns (as the primary category) in the 0 0 0 0 last 12 months Conduct concerns (as the primary category) in the last 0 1 0 0 12 months Health concerns (as the primary category) in the last 0 0 0 0 12 months Remediation/Reskilling/Retraining/Rehabilitation Numbers of doctors with whom the designated body has a prescribed connection as at 1 31 March 2018 who have undergone formal remediation between 1 April 2017 and 31 March 2018 Formal remediation is a planned and managed programme of interventions or a single intervention e.g. coaching, retraining which is implemented as a consequence of a concern about a doctor’s practice A doctor should be included here if they were undergoing remediation at any point during the year Consultants (permanent employed staff including honorary contract holders, NHS and 1 other government /public body staff) Staff grade, associate specialist, specialty doctor (permanent employed staff including 0 hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere, NHS and other government /public body staff) General practitioner (for NHS England only; doctors on a medical performers list, Armed 0 Forces) Trainee: doctor on national postgraduate training scheme (for local education and 0 training boards only; doctors on national training programmes) Doctors with practising privileges (this is usually for independent healthcare providers, 0 however practising privileges may also rarely be awarded by NHS organisations. All doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade)
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3http://www.england.nhs.uk/revalidation/wp content/uploads/sites/10/2014/03/rst_gauging_concern_level_2013.pdf
QVH BOD September 2018: Session in public Page 254 of 260
Temporary or short-term contract holders (temporary employed staff including locums 0 who are directly employed, trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixed-term employment contracts, etc) All Designated Bodies Other (including all responsible officers, and doctors registered with a locum agency, 0 members of faculties/professional bodies, some management/leadership roles, research, civil service, other employed or contracted doctors, doctors in wholly independent practice, etc) All Designated Bodies TOTALS 0 Other Actions/Interventions 0 Local Actions: Number of doctors who were suspended/excluded from practice between 1 April and 0 31 March: Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be included Duration of suspension: 0 Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be included Less than 1 week 1 week to 1 month 1 – 3 months 3 - 6 months 6 - 12 months Number of doctors who have had local restrictions placed on their practice in the last 0 12 months? GMC Actions: 0 Number of doctors who: Were referred by the designated body to the GMC between 1 April and 31 0 March Underwent or are currently undergoing GMC Fitness to Practice procedures 0 between 1 April and 31 March Had conditions placed on their practice by the GMC or undertakings agreed 0 with the GMC between 1 April and 31 March Had their registration/licence suspended by the GMC between 1 April and 31 0 March Were erased from the GMC register between 1 April and 31 March 0 National Clinical Assessment Service actions: 0 Number of doctors about whom the National Clinical Advisory Service (NCAS) has 0 been contacted between 1 April and 31 March for advice or for assessment Number of NCAS assessments performed 0
QVH BOD September 2018: Session in public Page 255 of 260 Annual Report Appendix E
Audit of recruitment and engagement background checks
Number of new doctors (including all new prescribed connections) who have commenced in last 12 months (including where appropriate locum doctors) excluding deanery appointments. Permanent employed doctors 3 Temporary employed doctors 31 Locums brought in to the designated body through a locum agency 4 Locums brought in to the designated body through ‘Staff Bank’ arrangements 4 Doctors on Performers Lists Other 1 Explanatory note: This includes independent contractors, doctors with practising privileges, etc. For membership organisations this includes new members, for locum agencies this includes doctors who have registered with the agency, etc TOTAL 43 For how many of these doctors was the following information available within 1 month of the doctor’s starting date (numbers)
going - date Total GMC Local Local check (DBS) officer officer issues outputs 2 recent from last last from due date concerns On Appraisal Language Reference Past GMC GMC Past references Unresolved responsible responsible GMC/NCAS competency Revalidation Revalidation Qualification Name of last last Name of performance conditions or conditions or undertakings undertakings investigations Identity check Appraisal due Disclosure and Barring Service
Permanent employed 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 3 doctors Temporary employed 31 31 31 31 31 31 20 3 7 31 31 24 13 8 8 8 doctors Locums brought in to 4 4 4 4 4 4 0 1 0 0 0 4 0 0 0 0
QVH BOD September 2018: Session in public Page 256 of 260 the designated body through a locum agency Locums brought in to 4 4 4 4 4 4 4 2 2 2 4 4 2 2 1 4 the designated body through ‘Staff Bank’ arrangements Doctors on Performers 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Lists Other 1 1 0 0 0 1 1 1 0 1 1 1 1 1 1 1 (independent contractors, practising privileges, members, registrants, etc) Total 43 43 42 42 42 43 39 30 12 43 39 36 19 14 12 16
For Providers of healthcare i.e. hospital trusts – use of locum doctors: Explanatory note: Number of locum sessions used (days) as a proportion of total medical establishment (days) The total WTE headcount is included to show the proportion of the posts in each specialty that are covered by locum doctors Consultant: SAS doctors: Total establishment in Trainees (all Overall Total Overall Locum use by specialty: specialty (current Overall grades): Overall number of number of locum approved WTE number of number of locum locum days days used headcount) locum days days used used used Surgery 98.49 0 0 226 226 Medicine 0 0 0 0 0
QVH BOD September 2018: Session in public Page 257 of 260 Psychiatry 0 0 0 0 0 Obstetrics/Gynaecology 0 0 0 0 0 Accident and Emergency 0 0 0 0 0 Anaesthetics 27.92 19 0 0 19 Radiology 2.70 0 0 0 0 Pathology 3.00 0 0 0 0 Other 11.06 0 0 0 0 Total in designated body (This includes all 143.17 19 0 226 245 doctors not just those with a prescribed connection) Pre- Concerns Number of individual locum attachments by Induction or employment Exit reports reported to duration of attachment (each contract is a orientation Total checks completed agency or separate ‘attachment’ even if the same completed completed (number) responsible doctor fills more than one contract) (number) (number) officer (number) 2 days or less 0 0 0 0 0 3 days to one week 0 0 0 0 0 1 week to 1 month 4 4 2 0 0 1-3 months 4 4 2 0 0 3-6 months 0 0 0 0 0 6-12 months 0 0 0 0 0 More than 12 months 0 0 0 0 0 Total 8 8 4 0 0
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