Board of Directors

Time: 1130 – 1330 hours Venue: Board Room, Level 7, 64 Victoria Street Date: Tuesday, 28 October 2014 SW1E 6QP

Presenters are reminded to provide a succinct and focused introduction, highlighting the key questions and only things which have changed since the preparation of the report 1 Administrative items and Quality report Time 1.1 Welcome, introduction and apologies: Pamela Chesters Verbal 1130 J Reilly, CEO (first part of meeting1) 1.2 Patient story Stephanie Verbal Matuszak2 1.3 Written questions from the public3 Pamela Chesters To be tabled4 1.4 Interests to declare Pamela Chesters Verbal 1.5 Minutes of meeting held 30.09.14 Pamela Chesters Pages 3-11 1.6 Matters arising and action log Pamela Chesters Pages 12 1.7 Chairman’s report Pamela Chesters Pages 13-15 1.8 Chief Executive’s report James Reilly Pages 16-26 1.9 Quality report – Q2 Louise Ashley Pages 27-52 2 Operational items 5 2.1 Integrated performance and finance report Ian Millar Pages 53-72 1200 2.2 Staffing monthly report Louise Ashley Pages 73-92 3 Governance / assurance items 3.1 Serious incident report Louise Ashley Pages 93-127 1230 3.2 Francis and other national reports – six month James Reilly Pages 128-147 update 3.3 Board Governance Memorandum – update James Reilly Pages 148-173 3.4 FT Timeline - update Ian Millar Pages 174-178 3.5 Safeguarding mid-year review Louise Ashley Pages 179-183 6 3.6 Medical Director’s report Joanne Medhurst Pages 184-191 3.7 Medicines management annual report Joanne Medhurst Pages 192-197 3.8 Health and safety – quarterly report Ian Millar Pages 198-211 3.9 Board self-certifications (September 2014) James Reilly Pages 212-224 3.10 Board committee reports Committee chairs Verbal 3.10.1 Quality Committee Terms of Reference Pages 225-231 3.10.2 Quality Committee report, 22.10.14 Pages 232-242 3.11 Risks identified during meeting Pamela Chesters Verbal 3.12 Issues/items for which further assurance is Pamela Chesters Verbal required 4 Items to agree/note without discussion7 4.1 Committee Minutes 4.1.1 Quality Committee 16.09.14 Pages 215-221 4.2 Date of next meetings in public: Board meeting in public - Thursday, 27 November 2014, 64 Victoria Street, London SW1E 6QP

Attached – list of commonly used abbreviations Pages 243-244 and key performance indicator definitions Received 245-246

1 Meeting with David Flory, NTDA tripartite meeting to 1300 hours 2 Occupational therapist 3 Written questions that are relevant to the agenda must be submitted in advance (at least two clear days) before the meeting to the Trust Secretary 4 Routinely if any questions are received 5 including formal review of KPIs and review of reserves and surpluses 6 including role as Caldicott Guardian, clinical framework update and telemedicine 7 Unless notified in advance In the interests of transparency, at the end of the meeting, ten minutes will be allowed for members of staff / public in attendance to have an opportunity to ask questions relevant to the agenda or the work of the Trust. Questions will be accepted at the discretion of the chairman; it will not be possible to answer any questions which refer to named staff or patients.

RESOLUTION “That representatives of the press, and other members of the public, be excluded from part of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”, section 1 (2), Public Bodies (Admission to Meetings) Act 1960.

Circulation: Board members, Trust Secretary, Committee Administrator

Agreed by chairman 06.10.14 Board of Directors1 Minutes of the meeting held on Tuesday, 30 September 2014 Soho Centre for Health, Frith Street, London W1D 3HZ Present Pamela Chesters Trust Chairman Louise Ashley Chief Nurse and Director of Quality Governance Anne Barnard Vice Chairman, Non-Executive Director Julia Bond Non-Executive Director Tony Brown Non-Executive Director Carol Cole Non-Executive Director Joanne Medhurst Medical Director Ian Millar Executive Director of Finance, Performance and Corporate Resources Richard Milner Deputy Chief Executive James Reilly Chief Executive David Sines Non-Executive Director

In attendance2 Rachael Bhella Care Navigator, Care Navigation Service (part) Ken Erharhine Case Manager, Care Navigation Service (part) Louisa McGeehan Head of Communications and External Relations (part) Neil Snee Service Transformation Director (part) Jayne Walbridge Trust Secretary

BoD/163/14 Welcome, introduction and apologies 163.1 The Chairman welcomed Dr Carol Cole to the meeting who had joined the Trust as a Non- Executive Director on 1 August 2014.

163.2 All members were present.

BoD/164/14 Written questions from the public 164.1 No written questions had been received; however a new facility for staff to ask executive directors questions on any subject had now been introduced.

164.2 Questions and the Board’s responses to all previous questions are published on the Board Meetings page of the web site.

BoD/165/14 Interests to declare 165.1 There were no interests declared.

BoD/166/14 Minutes of the Board of Directors meeting held on 31 July 2014 166.1 The minutes of the Board of Directors meeting held on 31 July 2014 were agreed as an accurate record, subject to correction of minute 142.1 to read “slowed due to CQC staff pressures” and minute 145.1 to read I Millar.

BoD/167/14 Minutes of the annual general meeting (AGM) held on 19 September 2014 167.1 The minutes of the Board of Directors meeting held on 19 September 2014 were agreed as an accurate record.

BoD/168/14 Matters arising and action log 168.1 The action log was reviewed and it was agreed that completed actions could be closed,

1 T Sentences marked include an action for ELT members that does not require report back to the Board. 2 1 member of the staff in attendance, and 4 external assessors (Grant Thornton and Niche Consultancy) who were observing the meeting. 1

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subject to correction of the comment for action BoD/50/14 - to confirm that the proposed suggestions regarding children had been incorporated into the safeguarding annual report.

168.2 It was noted that issues in relation to Winterbourne would be referenced in the dementia strategy and the learning disabilities protocol.

168.3 BoD142.7 Information Commissioner’s Office – it was confirmed that the report had been circulated to all Board members.

BoD/169/14 Chairman’s report 169.1 The Chairman reported that she had hosted an interesting medicine for members event the previous day with an excellent presentation by the falls team which had been very well received.

169.2 Members had found the engagement workshops following the AGM helpful and sought confirmation on how feedback would be used.

169.3 It was confirmed that the Executive Team would review actions in response to table discussions and that themes would be used to inform the listening events planned in all boroughs later in the year.

169.4 Resolved The Chairman’s report was noted.

169.5 It was agreed that a copy of the engagement workshop report would be circulated to all members. Action BoD/56/14 (J Walbridge) BoD/170/14 Chief Executive’s report 170.1 J Reilly introduced his report, highlighting the achievements of staff. R Milner added that since publication of the report, the Trust had received an HSJ award for the ‘redesigning of acute care’ work with Chelsea and Westminster.

170.2 Foundation Trust Status The Trust intended to seek confirmation in October regarding the timing of the CQC inspection in order to clarify the programme timetable for the foundation trust application.

170.3 Better Care Fund It was noted that this had direct implications for the Trust and that services in Barnet had already seen an increase in urgent care centre attendances which would be discussed with commissioners.

170.4 Unison J Reilly reported that the Trust had been notified of industrial action on 13/10/14 (for 4 hours) and plans for a work to rule on 4 other days; for which contingency plans were in place.

170.5 CQC Inspections Members were pleased to note that a recent unannounced inspection of Garside House Nursing Home had found standards in relation to the care and welfare of people who use services and assessing and monitoring the quality of service provision had been met. The inspection had been in response to a former member of staff’s concerns raised directly with the CQC.

170.6 L Ashley confirmed that the issue also being investigated internally to help understand the reason why concerns had been raised; conclusions would be included in the serious incident report to the Board.

170.7 Annual General Meeting It was noted that the annual report and accounts had in fact been received (having 2

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previously been approved) by the Board.

170.8 Resolved The Chief Executive’s report was noted, including the success of the annual staff awards and recognition of individuals and teams for their projects which the executive team were encouraged to use to promote the Trust.

BoD/171/14 Patient story3 171.1 Ken Erharhine read a story from a patient who had been referred to the Trust’s Care Navigation Service. While reluctant to accept help, the patient had found the service ‘first class’ and a great benefit, particularly the liaison undertaken by the team with her GP and pharmacist.

171.2 In response to questions, K Erharhine confirmed that care navigators were part of a multidisciplinary team, including mental health, primary care, acute care, social services and the London Ambulance Service; in order to provide a holistic assessment of patients’ needs.

171.3 Discharge medication from acute care was noted to be a complex and common problem; largely due to multiple admissions at different hospitals and delays in GPs receiving discharge summaries from acute care. It was confirmed that all patients referred to the service had a medication review. While a single clinical system between community care and GPs would help, this would not resolve communication issues with acute trusts.

171.4 J Medhurst confirmed that issues in relation to discharge medication were being discussed by medical directors and that this was on the Trust’s risk register.

171.5 Resolved The Board noted the positive feedback on the Care Navigation Service and the risks and issues being managed in support of patient safety and care.

BoD/172/14 Future engagement strategy 172.1 L Ashley thanked members of the Quality Committee for their comments which had been incorporated as far as possible within the timescale. It was emphasised that the strategy sought to integrate the key themes of the Trust’s engagement plans in support of patients, staff and stakeholders.

172.2 Clinical business units (CBU) had been tasked with preparing individual plans. Engagement events for each borough, hosted by members of the Board4, would be arranged twice annually.

172.3 Events for CBU staff (fit for the future) had commenced the previous day, hosted by L Ashley, and this first event had been well received.

172.4 The engagement of clinical staff would also be prioritised and throughout December quality team leads would be visiting clinical areas across the Trust.

172.5 The following comments / amendments were agreed for inclusion: • A direct link to the commercial strategy (commissioners) • How CBUs will engage directly with commissioners • To expedite timelines from 2015/16 to 2015 as far as possible • To correct Herefordshire to Hertfordshire • To ensure all sections include measures of success • To clarify how staff will be involved in redesigning care pathways and organisational decision making.

3 Delayed to due travel problems 4 NEDs where possible 3

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• To confirm how governors will engage members in informing the Trust’s plans

Action BoD/57/14 (T Pritchard for L Ashley) 172.6 Resolved The Board approved the strategy, subject to the comments and correction listed above, for promotion through the Hub and publication on the web site and circulation to membersT.

172.7 Progress to be monitored quarterly by the Quality Committee.

BoD/173/14 Whole systems - update 173.1 Neil Snee provided an extensive overview of the programme - a 5 year journey to re-shape the way care is provided across north west London to make integrated care ‘business as usual’. This had been actively discussed by stakeholders for some 9 months. While the programme and pioneer bids did not include Barnet, the principles were being applied to the borough through a more local strategy. The Chairman commented that, notwithstanding the need for further detailed discussion at the confidential Board meeting later the same day, it would have been helpful if the details reported had been included in the published report.

173.2 CLCH had been actively participating in the programme, including locally agreed priorities and plans, specifically ‘models of care’ for implementation in 2015/16.

173.3 J Medhurst emphasised the need to consider quality and to ensure that plans did not widen the gap in health inequalities.

173.4 It was confirmed that commissioners were planning to continue the whole systems work with existing providers over the next three years rather than re-tendering contracts.

173.5 Resolved The Board received the progress report noting the challenge of getting detailed information regarding referrals and costs for a nominated population, without which it was difficult to make decisions.

BoD/174/14 Current communications and engagement implementation update 174.1 Louisa McGeehan explained that having agreed the strategy in January 2014, the report provided an update on implementation against the key objectives and themes.

174.2 Members discussed various initiatives, noting the refreshed approach to staff engagement which had commenced the previous day (see minute 172.3 above).

174.3 In response to C Cole’s questions regarding alignment of the strategy with the overarching engagement strategy, L McGeehan confirmed that this had been developed in liaison with the communications team and these would remain complementary.

174.4 It was noted that the team no longer included any agency staff.

174.5 Resolved The Board congratulated the team on progress against the key themes of the strategy which would in future include measurable objectives.

BoD/175/14 Integrated performance and finance report 175.1 I Millar introduced the report which had been considered in detail at the Finance, Resources and Investment Committee the previous week, including KPIs against goals which were rated red (complaints resolved within 25 days of receipt; vacancy level; recurrent QIPP5 and planned QIPP savings in-year).

175.2 The financial position at month 5 (August) confirmed a surplus of £1,064k in line with plan.

5 Quality, innovation, productivity and prevention 4

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The recurrent value of identified QIPP remains £10.4m against a target of £12m; focused work to confirm recurrent savings for estates and networked community nursing would continue.

175.3 I Millar reported that the cash position had improved significantly (£4-5m receivables in September).

175.4 With regards to cost improvement plans, L Ashley confirmed that the next quality assessment with the Medical Director had been scheduled for October. Any reduction in quality identified would have to be addressed and thus have an adverse impact on CIP savings. Should this be the case, then new schemes would need to be identified. In order to seek greater assurance, a joint letter to all staff had been planned to ask staff to report any concerns about the impact of CIPs on quality.

175.5 In response to J Bond’s questions regarding 5 staff leaving due to lack of opportunities and the serious concerns regarding the accuracy of appraisal data, I Millar confirmed that he T would seek further information . It had been identified that there were problems with the way the appraisal system software (PADR) had been written, for example the ability to reset objectives at year end, and it was therefore possible that managers would have to revert to paper.

175.6 Statutory and mandatory training compliance was discussed at length. L Ashley confirmed that revised, robust processes had been implemented and that she expected to see improved compliance in future. It was agreed that when the figures for resuscitation had been received, a comprehensive report would be circulated to all Board members and that T this would be discussed at the Workforce Committee in October .

175.7 Resolved The integrated finance and performance report was noted. A revised format had been agreed for implementation from October and it was agreed that it would be helpful for the requirement for resuscitation training for non-clinical posts (ie only registered professionals) T to be clearer in the report .

175.8 It was agreed that it would be helpful for I Millar and C Cole to discuss the service development improvement plan risks and performance trajectory monitoring arrangements prior to the October meeting. Action BoD/58/14 (I Millar and C Cole)

175.9 It was agreed that a position paper on the appraisal system would be considered by the T Workforce Committee in October .

BoD/176/14 Monthly nurse staffing skill mix review 176.1 The monthly (not six monthly as stated in paragraph 2.2) staffing report was discussed at length and in detail. Overall, percentages had been met and risks in relation to the nursing homes were being managed, including the recruitment of a retired CLCH matron to lead the service until the formal handover to a new provider. Overstaffing issues (Marjory Warren) were being addressed by the Divisional Director of Operations (J Benson).

176.2 A crude attempt to compare staffing levels with prevalence and incidence quality data had been included, however it was recognised that while this was useful for pressure ulcers which developed over time, it would be better to triangulate the information for falls and T omitted doses with the number of staff on shift at the time of the fall .

176.3 Resolved

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The Board noted the monthly nurse staffing skill mix review report for August and action being taken to address risks in relation to the nursing homes.

BoD/177/14 Serious incident report 177.1 L Ashley introduced the serious incident report which included internal incidents which the Trust chooses to investigate.

177.2 While there had been a welcome decrease in the total number of pressure ulcers, work continued to reduce level 3 and 4 pressure ulcers. The Quality Committee had received a helpful presentation from Jean Lewis, Professional Lead, Adult Nursing, at their meeting in T September which it was agreed would be useful to repeat at the end of a Board seminar for the other Board members.

177.3 Resolved The serious incident report was noted including the reduction in pressure ulcers.

BoD/178/14 Patient stories, six month update 178.1 In response to A Barnard’s questions regarding the low number of stories to date, L Ashley confirmed that the focus had been on training staff; having appointed a patient experience facilitator for each division, a rapid increase in the number of stories recorded could be expected.

178.2 Resolved The patient stories update was noted. It was agreed that providing the process to learn from stories (which are monitored by the patient experience group which reported to the Quality Committee) remained robust, and that all directors could have access to the library of stories, no further reports would be required.

178.3 The Executive Team were asked to consider how the lessons from patient stories could be used to promote the Trust and whether it would be possible for some stories to be presented T by patients .

BoD/179/14 Charitable trust annual report and accounts 179.1 A Barnard and I Millar confirmed that the auditors, KPMG, had been given an unqualified opinion on the accounts which had been agreed by the Charitable Funds Committee and recommended for Board approval.

179.2 Resolved As the corporate trustee, the Board approved the charitable trust annual report and accounts for signature and submission.

BoD/180/14 Quality governance assurance framework – action plan 180.1 Further to the self-assessment in July, an action plan had been prepared to address areas where the score was considered to be higher than zero. L Ashley highlighted that much of the work was being progressed in support of the risk management strategy, quality strategy and quality account with which staff had been involved. Risks and mitigations had been considered and it was noted that paragraph 7.1 should read ‘areas of development’ rather than ‘concern’.

180.2 The quality assessment of CIPs was discussed. It was confirmed that while no CIPs had been refused, some were being tested through pilots. The reason for a reduction in the total recurrent value of CIPs in some divisions was noted to be due to changes in the management team and a review of inherited schemes to ensure these were feasible.

180.3 Progress in implementing Qlikview was discussed. I Millar confirmed that the focus was on delivering support for KPIs and functionality was progressing. R Milner was confident that this robust and comparable data at CBU level would be in place during October and 6

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confirmed that Divisional Directors of Operations had been asked to prioritise their needs over and above scorecard requirements.

180.4 Resolved The Board approved the action plan, for submission to the Trust Development Agency (TDA) within the agreed timescale.

BoD/181/14 Board governance memorandum – action plan 181.1 The draft action plan was considered in detail and suggested amendments were recorded by the author for inclusion. It was agreed that Board evaluation requirements and timing would be reconsidered following receipt of the external assessment report and that J Reilly would T clarify with the TDA any further evaluation required .

180.4 Resolved The Board approved the action plan, subject to the comments above and inclusion of actions in response to the external assessor’s report (Grant Thornton).

BoD/182/14 Annual infection prevention and control report 182.1 J Medhurst introduced the summary annual infection prevention and control report; a copy of the full report was also available on request. The Trust continued to perform well against national targets for infection prevention with the exception of mandatory training for which a recovery plan to improve compliance had been launched.

182.2 It was confirmed that the risk in relation to student nurse immunisation had been referred to the Local Education Training Board (LETB), kindly supported by D Sines.

182.3 Resolved The Board noted the annual report and asked for the outcome of discussions with the LETB T regarding student nurse immunisation to be shared with all Board members .

BoD/183/14 Annual update on revalidation and appraisal 183.1 J Medhurst explained that the discrepancy regarding the number of doctors with a prescribed connection (23 in the report and 25 in the letter from Dr Berwick) was due to a timing issue; 23 was correct.

183.2 A number of other doctors working for the Trust were not prescribed6 but, as Medical Director, J Medhurst had responsibility for the quality of their work. The governance arrangement to manage this issue had been discussed by responsible officers and it was proposed that the summary appraisal (form 4) would be shared with the Medical Director of Trust’s for whom the doctor provided services.

183.3 L Ashley reported that revalidation of nurses (>1000) would commence in 2015; it was expected that other family health practitioners, for example pharmacists would follow thereafter.

183.4 Resolved The Board noted the report and confirmed that they would expect form 4 to be shared by any doctor working for the Trust who was not prescribed.

183.5 It was noted that, of the total number of doctors appraised, only 7 had been recommended for revalidation to date.

183.6 It was agreed that all information regarding staff appraisals should be linked on a single database.

6 Having been prescribed to other designated bodies 7

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BoD/184/14 Risk management strategy 184.1 Following extensive review and helpful input from NEDs, particularly A Barnard and J Bond, the improved strategy was presented for approval.

184.2 Resolved The Board approved the risk management strategy.

BoD/185/14 Board self-certifications 185.1 Resolved The self-certifications for August 2014 were approved, for submission to the TDA.

BoD/186/14 Board Committee reports 186.1 An update following the Finance, Resources and Investment Committee would be provided at the confidential meeting later the same day.

186.2 Charitable Funds Committee – 09.09.14 A Barnard reported that the Committee had considered the Charitable Fund annual report and accounts and had agreed a strategic review of the options for Pembridge, to include the optimum use of available charitable funds. The first stage of the review would cost a maximum of £5k. J Medhurst added that J Scourse’s work would commence in October and members would be invited to be interviewed.

186.3 An urgent decision in relation to the investment manager had been taken at a virtual committee meeting, due to very late notification. Resources to support the Charity would be considered in December.

186.4 A tender document provision of investment management services was being drafted for consideration in December, including the proposed signatory on behalf of the corporate trustee.

186.5 Quality Committee – 16.09.14 J Bond provided a summary of matters discussed at the Quality Committee which included: a presentation on pressure ulcer management and reduction, the quality scorecard, an update on volunteers and serious incidents. Triangulation of information (linking staffing levels with quality of care and records management) was also discussed. It had been agreed that in order for contemporary information to be received from groups reporting to the Quality Committee, unconfirmed minutes would be acceptable.

186.6 Audit Committee – 09.09.14 T Brown summaries agenda items discussed which included: counter fraud, economic crime rates, the draft risk management strategy, clinical audit, data quality and information governance. A confidential report had also been circulated with the confidential Board papers.

BoD/187/14 Risks identified during meeting 187.1 A risk in relation to linking quality data with staffing levels was noted and would be assessed by L Ashley as agreed (see minute 176.2 above) for report to the Quality Committee.

BoD/188/14 Issues / items for which further assurance is required 188.1 Governance arrangements in relation to doctors working for the Trust who are not prescribed to be assessed by J Medhurst (see minute 183.2 above)

188.2 Statutory and mandatory training compliance (see minute 175.6 above)

188.3 Student nurse immunisations (see minute 182.2 above)

BoD/189/14 CLCH annual audit letter 2013/14 189.1 Noted for publication on the web site with annual report and accounts. 8

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BoD/190/14 Confirmed Committee minutes received 190.1 Charitable Funds Committee, 03.03.14 and 06.08.14 Audit Committee, 03.06.14 Quality Committee 23.06.14 and 07.08.14

BoD/191/14 Date of next meetings in public 191.1 Board meeting in public - Tuesday, 28 October 2014, 64 Victoria Street, London SW1E 6QP

The meeting closed at 1320 hours

RESOLUTION “That representatives of the press, and other members of the public, be excluded from part of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be

prejudicial to the public interest”, section 1 (2), Public Bodies (Admission to Meetings) Act 1960.

Signature …………………………………………………………….. Pamela Chesters, Chairman

Date ………………………………………………

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Items marked complete will be closed following the meeting

Action number Date of meeting Subject Action Responsible officer Due date Comments Last reviewed / to be reviewed Status BoD/56/14 30.09.14 Chairman's report (AGM J Walbridge 14.10.14 Circulated 07.10.14 28.10.14 Complete enagement workshop) It was agreed that a copy of the engagement workshop report would be circulated to all members.

BoD/57/14 30.09.14 Engagement strategy The following comments / amendments were T Pritchard for L Ashley 20.10.14 Full minutes shared with TP for 28.10.14 Complete agreed for inclusion: A direct link to the clarity commercial strategy (commissioners); How CBUs will engage directly with commissioners;To expedite timelines from 2015/16 to 2015 as far as possible; To correct Herefordshire to Hertfordshire; To ensure all sections include measures of success; To clarify how staff will be involved in redesigning care pathways and organisational decision making; To confirm how governors will engage members in informing the Trust’s plans

BoD/58/14 30.09.14 Integrated Finance and It was agreed that it would be helpful for I Millar I Millar and C Cole 28.10.14 Meeting took place on 15 28.10.14 Complete Performance Report and C Cole to discuss the service development October. improvement plan risks and performance trajectory monitoring arrangements prior to the October meeting.

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BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Chairman’s report to Board of Directors

Agenda item number: 1.7

Report of: Chairman

Contact Officer: Trust Secretary

Relevant CLCH 14/15 Goal(s) 1. Embody the best of the NHS for our patients: delivering great results with compassion and thoughtfulness 2. Be responsive to our patients and partners’ needs: promoting integration and partnership by demonstrating our capacity, character and competence 3. Employ only the best staff: selecting staff who care and supporting them to go the extra mile for our patients Freedom of Information Report can be made public Status

Executive Summary: External events, approval of minute, membership and engagement update.

Report for: Decision Discussion Information

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1.0 Urgency Committee

1.1 During early October 2014, a virtual urgency committee met (reference Business Opportunities Framework) to consider the Hertfordshire Sexual Health Tender which had been provisionally submitted. Having considered the information, the urgency committee confirmed that the bid submitted by the trust was compliant with Trust guidelines and should stand.

2.0 Membership update

2.1 Membership numbers

The monthly target of 70 new members was not met this month. The shortfall is expected to be made up in October as there are three major recruitment days planned including HR recruitment at the London job show (Westfield) and an Age UK Health and Wellbeing Fair in Kensington Town Hall.

August Public Clinical Non-clinical Total staff staff No. of members as at 31 August 2014 5,780 2,173 739 8,692 New public members September 2014 41 Total as at 30 September 2014 5,788 2,047 723 8,558

3 4 members deleted

The membership target is less than the previous month’s figure. The net increase in public members increased by just 8 in September but the reduction in staff members has contributed to the decrease.

3.0 Membership engagement

3.1 I chaired a medicine for members talk on falls prevention was held on 29 September at the Abbey Centre in Westminster. The talk was attended by FT members and the Monday club, a group who meet regularly at the community centre. Natasha Booton, clinical lead for falls and bone health, presented an overview of the falls service and offered people much re-assurance of the benefits and support provided through the service.

3.2 Barnet members were invited to attend the carers afternoon tea held at Edgware Hospital on 2 October organised by the PPE team with a view to collecting patient stories.

3.3 Members from the inner boroughs have been informed about the Age UK Health and Wellbeing fair on 17 October where CLCH will have a strong presence from a range of services including membership, diabetes, stroke, oral health and continence.

3.4 Members have been invited to attend another talk on falls prevention, this time in association with Chelsea and Westminster NHSFT on the topic of falls and fracture prevention on Thursday, 13 November. Natasha Booton, clinical lead for falls and bone health will present for CLCH and Emer Bouanem, nurse specialist for orthopaedics for Chelsea and Westminster.

4.0 Listening events

As set out in the integrated engagement strategy a planned programme of engagement events will be arranged to strengthen the ways in which our engagement with members, patients and the public informs the quality strategy. The following provisional dates for 2015 have been booked. A series of pilot events, one in each borough, will be arranged for end of January 2015. 14

Borough Venue May date Time Nov date Time Education Centre, Thursday 17.00 - Thursday 19 Barnet conference room 1&2 21 May 20.30 November 13.00 - 16.30 Hammersmith Tuesday 13.00 - Tuesday 10 & Fulham tbc 19 May 16.30 November 17.00 - 20.30 Kensington & Thursday 17.00 - Thursday 12 Chelsea St Charles, large room 14 May 20.30 November 13.00 - 16.30 Soho Centre, 1st Floor Tuesday 13.00 - Tuesday 17 Westminster conference room 12 May 16.30 November 17.00 - 20.30

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BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Chief Executive’s Report

Agenda item number: 1.8

Report of: Chief Executive

Contact Officer: Trust Secretary

Relevant CLCH 14/15 1. Embody the best of the NHS for our patients: Goal(s) delivering great results with compassion and thoughtfulness 2. Support people safely out of hospital: providing safe, high quality value for money alternatives to hospital admissions 3. Deliver better value than competitors in our selected markets: securing our sustainability by providing effective and efficient services 4. Be responsive to our patients and partners’ needs: promoting integration and partnership by demonstrating our capacity, character and competence 5. Employ only the best staff: selecting staff who care and supporting them to go the extra mile for our patients 6. Be innovation and technology pioneers: leading transformation of out of hospital services to empower staff and improve patient health Freedom of Report can be made public Information Status

Executive Summary: The CEO’s Report provides to the Board a summary of key issues and developments that impact upon the trust which emanate from regulators, national, regional and local arenas and which are occurring within the Trust itself.

Report for: Decision Discussion Information

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1. REGULATION

1.1 Care Quality Commission (CQC)

There have been no CQC inspections since the September Board meeting.

CQC have informed the Trust that its Trust Wide Inspection planned to take place in the first quarter of 2015 is now scheduled for April 2015. This represents a short delay on the timescale planned which we will discuss at our monthly meeting with the Trust Development Agency but it is not anticipated to impact materially on our Foundation Trust Application timetable.

1.2 CQC have published their Annual State of Care report for 2013-14. Since 2013/14 the CQC introduced a new, tougher approach to inspecting care services. These are now providing a deeper understanding of the quality of health and social care, including widespread unacceptable variations in quality. Using the new rating system, we rated 38 NHS acute trusts by the end of August 2014. • 9 trusts achieved an overall rating of good • 24 trusts were rated requires improvement • 5 trusts were rated inadequate.

1.3 The consultation setting out the CQC’s proposed guidance for providers to help them meet the requirements of the regulations, and the proposed guidance on how the CQC will use their enforcement powers concluded on 17 October 2014. This will lead to the replacement in its entirety, from April 2015, of CQC’s current Guidance about compliance: Essential standards of quality and safety and the 28 ‘outcomes’ that it contains. It will also replace CQC’s current enforcement policy.

1.4 Health and Social Care Act 2008 (regulated activities) Regulations 2014 Implementation of the draft regulations, including the fit and proper persons test (FFPT) and fundamental standards (duty of candour), have been postponed from October to mid-November.

2. CLCH DEVELOPMENTS

2.1 Central London Community Healthcare to deliver new and improved respiratory service Following the successful tender I am pleased to announce the launch of the Trust’s new and improved community respiratory service for patients in West Hertfordshire. Beginning this October, the new service will mean hundreds of patients with respiratory conditions such as asthma; bronchiectasis and obstructive sleep apnoea will be seen, assessed and treated in the community. The new service expands on CLCH’s current community chronic obstructive pulmonary disease service which already provides healthcare to patients across West Hertfordshire.

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2.2 Emergency Care Service Award I extend congratulations to all in CLCH and our partners, Chelsea and Westminster Hospital Foundation Trust with North West London Clinical Commissioners for their success in the Health Service Journal (HSJ) ‘Values in Healthcare’ awards, for jointly initiated Emergency Care Pathway Programme to improve boundary less patient flow between their services. We partnered with GE Healthcare Performance Solutions to achieve this. The HSJ award judges said: “The winner offered an excellent and grounded piece of work, demonstrating solid outcomes. The plan was well integrated and recognised the need for close system working and effective partnership”.

2.3 CLCH fit for the future staff engagement events Our “Fit for the Future” Executive Leadership Team (ELT) engagement sessions commenced on Monday, 29 September led by Louise Ashley, Chief Nurse and Director of Quality Governance. There are twenty four sessions scheduled across all the Clinical Business Units (CBU) and 4 sessions in the corporate services between now and the end of November and ELT are committed to attend up to 6 sessions each. The purpose of these sessions is to share our strategy for CLCH and hear thoughts on it, find out more about CBU’s plans to develop services for patients and to create more opportunities for staff to engage with ELT. Feedback so far has shown that staff have welcomed the opportunity to share their views and appreciate the increased visibility of ELT.

2.4 Senior Staff Changes: I am pleased to welcome new Clinical Business Unit managers for the Network Community Nursing and Rehabilitation division (NCNR), Kathryn Brook, Stephen Lord, Francis Mulhern and Dr Phil Lee the new Acute Divisional Clinical Director. At the end of November, Jennifer Allen our Divisional Director of Operations for the same division will be going on maternity leave and we welcome Gerard Timson who will be joining us as an interim from 1 December 2014 to cover this role. Gerard is doing a similar role in Bridgewater Community Healthcare Trust in Merseyside and has many years of experience in community and primary care services.

2.5 Congratulations to the CLCH Specialist Weight Management Service (SWMC) who received the best practice award for the innovative work of the team. The service was recognised at the inaugural annual congress of the Association for the Study of Obesity (ASO) in Birmingham last month for their significant contribution to the treatment of overweight and obese individuals or to obesity prevention. Congratulations to the team members:- Dr Veronica Greener, Obesity Consultant, Perryn Carroll, Dietitian, Charlotte Butlin, Physiotherapist, Lucy Turnbull, Clinical Lead Dietitian, Troy Chase, Clinical Psychologist.

2.6 Mobile Working: Kensington and Chelsea and Westminster Community Rehabilitation Services, represented by Helen Curry, Nigel Miller and Melissa Andison, presented two papers at the International Digital Health and Care Congress organised by the King’s Fund in September. The team shared their experiences of mobile working at the congress and presented at two of the breakout sessions at the three day event which saw 500 delegates from all over the globe. The presentations presented were ‘digitally enabling service

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transformation’ and ‘Age is not a barrier to using healthcare technology’, these presentations can be accessed via the links here and here.

2.7 Further progress in our roll out of digital patient data records was achieved when SystmOne went live in six of our bedded rehabilitation units. This is a further stage in progressively moving our patient records from RiO to SystmOne to improve our capacity to work in an integrated fashion with primary care and other key partners.

2.8 Congratulations to Isabel dos Santos who has achieved a first class honours degree in counselling. Isabel works in the North East locality in Westminster as a rehabilitation assistant and took up the opportunity to go into higher education by making use of the CLCH flexiwork and bursary scheme. Isabel faced many challenges in managing her work and study together with the restructuring of the service, and none of this would have been a success without the support and encouragement from her managers, Clare Nyanzi and Neal Gething whom she is grateful for their full support.

2.9 CLCH FOUNDATION TRUST (FT) APPLICATION:

The external assessments for the Board Governance Assurance Framework (BGAF), conducted by Grant Thornton, and the Quality Governance Assurance Framework (QGAF), conducted by NICHE consultancy, have been completed. We have received the final report on the BGAF and a separate report updating the action plan in the light of it 14 recommendations are being presented to the Board. We expect to receive the final QGAF report within the next fortnight. The feedback that we have received indicates that our application will proceed according to the timetable agreed with the Trust Development Agency.

There will be a separate quarterly briefing document submitted by the FT project team.

3 Regional Developments

3.1 The inner London Clinical Commission Groups together with the Tri-Borough Council Commissioners have just issued a process to select from amongst existing local health Trusts and GP’s a leading healthcare partner to lead with social care in co-ordinating the delivery of a Community Independence Service to reduce the level of non- elective admissions to hospitals. They intend to invest £1.7m in further developing rapid response, community rehabilitation and re-ablement services to achieve this aim. Our Trust will be submitting an application for this role.

3.2 In October, Imperial College Health Partners, published their partner briefing providing an update on interoperable clinical systems, patient safety, mental health and chronic obstructive pulmonary disease projects. I participated in a partnership board workshop reviewing the work and processes of the board which will inform its future direction, programmes and structures.

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This partnership hosts the Academic Health Sciences Network (AHSN). Jeremy Hunt, Secretary of State for Health, launched a new national programme to improve the safety of patients and ensure continual learning sits at the heart of healthcare in England. The programme, coordinated by NHS England and NHS Improving Quality (NHS IQ) will see a network of 15 patient safety collaboratives established, each led by an Academic Health Science Network (AHSN). These collaboratives will focus on improving safety and empowering patients, carers and staff to highlight, challenge and implement local improvements in patient care. NHS IQ and NHS England will work with AHSNs to provide support and opportunities for the collaboratives to learn from each other, ensuring the most effective and successful solutions are shared and adopted across England. The programme is borne out of Professor Don Berwick’s report last year into the safety of patients in England, and builds on learning from the Francis and Winterbourne View recommendations. Each collaborative will be funded for the next five years by NHS England. For more information, visit the NHS IQ website.

3.3 Winter Pressures Plans: The flu campaign is underway and we would urge you all to have the flu vaccination to reduce the incidence of flu. We are totally committed to patient safety and it is very serious for young children and vulnerable adults. Clinics are available throughout October and there will be a flu fighter clinic for senior managers and clinicians at the next senior managers’ workshop on 13 November.

3.4 I attended the formal launch of the London Healthcare Commission Report at City Hall where Lord Ara Darzi presented the report to Mayor Boris Johnson. The report contains a range of recommendations to secure better public health for London’s population and system changes to advance these. Particular value has been placed on the wider debate and engagement across communities in London that this process has engendered. Included in the recommendations are population based categories and outcomes as well as the deployment or capitated budgets. The report references and commends how these are being developed in the North West London whole systems integrated care programme in which the Trust is fully engaged.

3.5 Transforming London Community Services: Caroline Alexander, Chief Nurse for NHS England in London has led a group focused on city wide transformation of community services to which our Trust has been contributing. Attached as an appendix to my report is the declaration which was distilled from an analysis of 10,000+ ideas, propositions, comments and votes, from 1,000+ people within 100+ organisations, 45 papers and 32 Better Care Fund Plans. It describes, in the words of staff, the consensus that is held across London on how a community-led revolution in health and social care can be delivered, which will ultimately transform the health and well-being of our city.

4 National Developments and Reports

4.1 On 16 October the Secretary of State for Health made a speech at Birmingham Children’s Hospital on the theme of good care costs less. This referenced the CQC’s annual state of care report published on the same day.

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He emphasised the themes of the ‘Sign up to Safety’ campaign to which our Trust was one of the initial signatories. To illustrate this key theme a poster has been produced drawn from independent research published by Frontier Economics suggesting that the NHS spends up to £2.5bn a year – the annual cost of 60,000 nurses – treating patients harmed by avoidable errors. The independent study found that each year, almost 800,000 patients – one in 20 of all those admitted to hospital in England – suffer harm which could have been avoided. The speech received wide media coverage in which Louise Ashley our Chief Nurse and Director of Quality Governance was interviewed by Sky News on our participation in the “Sign up to Safety” campaign.

4.2 Healthcare Foundation and the Foundation Trust Network: The Health Foundation and the Foundation Trust Network (FTN) co-hosted a workshop on 5 August 2014 to tackle the question of whether the NHS can maintain quality in the short to medium term without additional resources. The event brought together around 25 senior representatives of provider organisations, covering the acute, mental health, community and ambulance sectors. The workshop was part of the Health Foundation's work examining the implications of the NHS’s ‘financial gap’ for quality of care. The workshop is further discussed in the report More than money: closing the NHS quality gap.

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4.3 The King’s Fund: In October, The King’s Fund published a report ‘financial failure in the NHS – what causes it and how best to manage it’. Key findings include that: • even the best managed organisations face a financial struggle in the current climate • the balancing act between finance and performance cannot be maintained • there are many factors that contribute to financial failure and some of these are not under the control of one organisation • there is a lack of leadership within local health economies following the abolition of strategic health authorities • national bodies need to agree a shared approach to dealing with funding challenges.

This comes at a time when all the main parties in the party conference seasons have made their pledges including increases to NHS funding, better access to general practice and integrated care.

An analysis by Monitor published in October its quarterly performance report, also indicates that Foundation Trusts are providing more treatment and that this increased activity, when combined with the continuing need to make cost savings and an over-reliance on expensive agency staff, is putting trusts under unprecedented pressure. Both Monitor and the Trust Development Agency have reported to their boards a forecast deficit in the region of £500m for the outturn of this financial year.

Systems Leadership in Integrated Care published by the Kings Fund in October 2014.

This report details lessons and learning from the Advancing Quality Alliance’s (AQuA) integrated care discovery communities. It seeks to identify the skills, knowledge and behaviours required of new system leaders and to learn from systems attempting to combine strong organisational leadership with collaborative system-level leadership approaches. The paper draws on three years' development work with leaders in health care systems in north-west England, undertaken by the Advancing Quality Alliance (AQuA) and The King's Fund which has adopted a 'discovery' approach to developing integrated care and the leadership capabilities supporting it.

4.4 Industrial Action: On October 13 a number of unions took strike action for four hours and a work to rule in the following days of that week (for Unite members this continues for the rest of the month). This was to support a claim for all staff to receive the 1% pay award. It is reported that nationally 8000 took this action of the 200,000 staff who are members of these unions and the impact was greatest within the ambulance services. In CLCH the returns received indicated that 10 staff supported this action.

5 Summary of key decisions from recent Private Board meetings

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5.1 At the confidential Board meeting on 30 September 2014 we considered a report on contracts and new business, later discussing at our seminar event the proposed commercial strategy for the Trust.

An update on the Trust’s long term financial position was also discussed.

6 Report on the use of the Trust Seal: The Trust seal has been applied in the following circumstances:

Date of Reason for use Signatory Witness Use 6 October Contract between CLCH and Ian Millar, Jayne 2014 Virgin Medical Business Limited Director of Walbridge, for the provision of services for Finance, Trust the wireless project. Information Secretary Seal 53 and Corporate Resources

James A Reilly Chief Executive October 2014

8 23 g London’s community se #TRANSFORMLDN transformin rvices

*1,000+ health and social care staff from 100+ organisations, representing all 32 London boroughs have co-created this declaration.

WE DECLARE THAT A COMMUNITY-LED REVOLUTION IN HEALTH AND SOCIAL CARE WILL TRANSFORM THE HEALTH AND WELL-BEING OF LONDON THE FOUNDATION OF OUR REVOLUTION HAS FOUR PARTS…

GET PERSONAL

London’s community health and social care services PERSONALISED CARE PLANS use simple language to help people decide touch our lives at times of basic human need, when care We must place LONDONERS at their own goals and manage their own health. and compassion are what matter most. They support us CARE is provided in PLACES THAT ARE CONVENIENT for those that need it. to keep mentally and physically well, to get better when One point of contact makes ACCESS SIMPLE. we are ill and when we cannot fully recover, to stay as THE HEART Londoners have a POSITIVE EXPERIENCE of services in the community. well and independent as we can till the end of our lives. ALL SERVICES are designed around the NEEDS OF LONDONERS and the They are here to improve the health and well-being in our city. resources available. PERSONALISED CARE PLANS are developed in partnership between those London’s growing population with more complex needs is OF CARE who use and provide services and they support partnerships between creating unsustainable pressure for our partners in EVERYTHING DESIGNED & DELIVERED the community, primary and secondary care and the voluntary sector. hospital, social and primary care. Something needs to People who commission, provide and use services DEVELOP AND ASSESS change and the solution lies close to home. AROUND THEIR PERSONAL NEEDS SERVICES TOGETHER.

REAL LEADERS, MAKE FOCUS ON HAPPY WORKERS BOUNDARIES OUTCOMES INVISIBLE We must have WE MUST ALWAYS INSPIRING LEADERS WE MUST ENSURE THE focus on improving TO COORDINATE CARE BOUNDARIES THE HEALTH AND AND A SKILLED, OF ORGANISATIONS & SERVICES ARE FULFILLED AND INVISIBLE TO OUR SERVICE USERS WELL-BEING MOTIVATED OUTCOMES FOR LONDONERS WORKFORCE We understand the desired HEALTH AND RESOURCES, INVESTMENT AND WELL-BEING OUTCOMES of individuals, RISK ARE SHARED between all OUR LEADERS INSPIRE AND COACH their people, this nurtures the right ORGANISATIONAL BOUNDARIES ARE Teams of health and social care groups and the population we serve. organisations involved in skills and talent for London's complex needs. IRRELEVANT to Londoners. staff, with different and delivering care. complementary skills, WORK ALL HEALTH AND SOCIAL CARE STAFF HAVE CLEAR CAREER DEVELOPMENT PLANS that value and nurture We have SEAMLESS TRANSITIONS TOGETHER. organisations SHARE RESPONSIBILITY The amount of time people their talent, this makes the community an attractive place to work. between services and organisations and incentives for improving health and spend in acute and residential because communication and We help people access SERVICES well-being outcomes. care is reduced as health and LEADERS of different organisations WORK TOGETHER WITH PATIENT LEADERS trust are actively developed FROM THEIR OWN HOME and well-being are improved and to bridge boundaries and share knowledge. between everyone involved in community - THIS IS OUR Those at RISK ARE IDENTIFIED to enable more people are supported to providing care. COMMUNITY FIRST APPROACH. early intervention and PROMOTE MANAGE THEIR OWN CARE NEEDS LOCAL TEAMS ARE EMPOWERED with autonomy to flexibly meet local needs. WELL-BEING, rather than reacting to AND HEALTH CONDITIONS IN THE SERVICE USERS can access their OWN CARE RECORDS, as can the teams involved crises. COMMUNITY. in their care and these records are shared across all professionals providing care.

FIND FIND OUT HOW YOU CAN USE OUR DECLARATI ON AND JOIN THECOMMUN ITY REVOLUTION TODAY, 24 VISI T WWW.. TRANSFORMLDN.ORG How was our Who was involved in this project? declaration built? The Design Group: leaders from the following organisation steered this project and its outputs This project was designed to capture a crucial perspective in the debate surrounding the transformation of London’s community services: the voice of the frontline - practitioners, volunteers, carers and leaders from organisations that deliver or commission health and social care. To achieve this, we deployed a research process blended with physical and on-line crowdsourcing events. This created and empowered a network of people to share their views on what excellent community services look like. Our design group analysed 10,000+ ideas, comments and votes, from 1,000+ people, representing 100+ organisations as well as 45 papers and 32 Better Care Fund Plans. The distillation of this work led to the creation of a new declaration for community services. The Crowd: 1,000+ people from the following 100+ organisations had their voices heard Adult Social Care Newham Hertfordshire community NHS trust Royal Brompton and Harefield NHS Foundation Allied Healthcare Hillingdon Hospitals NHS Foundation trust Trust Barking, Havering and Redbridge University Homerton University Hospital NHS Foundation Royal College of Nursing How can you use Hospitals NHS Trust Trust Royal Free London NHS Foundation Trust Barnet CCG Housing Learning and Improvement Network Royal National Orthopaedic Hospital NHS Trust o ur declaration? Barnet, Enfield and Haringey Mental Health Imperial College Healthcare NHS Trust Society of Chiropodists & Podiatrists NHS Trust Institute of Sport, Exercise & Health South Essex Partnership NHS Foundation NHS Our declaration is designed Barts Health NHS Trust Islington CCG Trust South London and Maudsley NHS Trust as a tool to support and Bexley CCG Kensington and Chelsea Age UK South London CSU Brent CCG King’s College Hospital NHS Foundation Trust South West London and St George’s Mental inspire service Buckinghamshire County Council Kingston CCG Health NHS Trust improvements in the Bucks New University Kingston Council Southern Health NHS Foundation Trust Camden Adult Social Care Kingston Hospital NHS Foundation Trust Southwark council delivery and commissioning Camden and Islington NHS Foundation Trust Lambeth Council St Andrew’s Medical Practice of health and social care Camden CCG Lewisham and Greenwich NHS Trust St George’s Healthcare NHS Trust Care & Repair England London Ambulance Service NHS Trust St Joseph’s Hospice services in the community. Central London CCG London Borough of Barnet Surrey county council Central London, West London, Hammersmith London Borough of Bromley Sussex community NHS Trust Some parts of London have and Fulham, Hounslow and Ealing CCG London borough of Hillingdon Sutton Age UK already implemented these partnership London Borough of Lewisham Sutton CCG Chelsea and Westminster Hospital NHS London Borough of Newham The Hillingdon Hospitals NHS Foundation Trust foundations, some still have Foundation Trust London Borough of Sutton The King’s Fund work to do and others are Circle Podiatry London Clinical Senate The North West London Hospitals NHS Trust Compass Wellbeing CIC London Councils The Tavistock and Portman NHS Foundation yet to set clear plans. Connect Physiotherapy London Leadership Academy (NHS) Trust Whatever stage your Cricket Green Medical Practice London South Bank University UCL Partners Academic Health Science Croydon Care Solutions Ltd Londonwide LMCs Partnership organisation is at, our Croydon Health Services NHS Trust Merton CCG University College London declaration can support and Department of Health Ministry of Defence Rehabilitation Services University College London Hospitals NHS inspire your work . We want Dulwich Podiatry Limited Monitor Foundation Trust Ealing Hospital NHS Trust Moorfields Eye Hospital NHS Foundation Trust University of East London staff to spread the word. East One Health Namaste Care CIC Virgin Care Visit our community Enfield CCG NHS England Waltham Forest CCG Epsom and St Helier University Hospitals NHS NHS Partners Network Wandsworth Council website to share and learn Trust North East London Commissioning Support Unit Watling Medical Centre from best practice and to First Community Health & Care North East London NHS foundation Trust West London CCG Great Ormond Street Hospital for children North West London Collaboration of CCGs West London Mental Health NHS Trust access and enhance latest NHS Foundation Trust Pembridge Podiatry Practice West Middlesex University Hospital NHS Trust thinking. Groundswell Populus Health Whitfield Podiatry Guy’s & St Thomas’ NHS Foundation Trust Public Health England Whittington NHS Trust Hammersmith and Fulham CCG Redbridge CCG Wragge & Co. Haringey CCG Regents Park Foot Clinic Haringey Learning Disability Partnership Richmond CCG Learn more and help turn our declaration into a movement, visit www.transformldn.org Havering CCG 25 Appendix – Transforming London Community Services Declaration www.transformldn.org has been completely repurposed in direct response to the crowd's requests. Instead of producing a long report, our site now shares the details behind the declaration and, importantly, shares case studies, literature and best practice to support learning across the city. It is now live already, for you to draw from and to contribute to. A great resource to share successes and challenges and to learn from others.

We now need your help...

1. Transform London has started a movement, a movement that could help create the revolution that so many of us seek. Here's how you can support:

2. Please read Our Declaration, print out the attached poster and share it with your networks and colleagues. You can find out more about our declaration and how to use it on our project website: www.transformldn.org

3. Please let us know what you think broadly about this project by visiting www.transformldn.org and offering you feedback https://email.clevertogether.com/l/Jcq5ZeHsdlVNvMb6Er763mfg/Q2tsa1mHmjaG64 MPqJc5Bw/ZIfwX

Please share your experiences of transforming community health and social care services so we can continue to learn from each other; specifically, how you have or have struggled to achieve the four foundations of community transformation:

Get Personal https://email.clevertogether.com/l/Jcq5ZeHsdlVNvMb6Er763mfg/opOYF5w0M44jk aY7eUbOGQ/ZIfwX6jadxtnq32mLHm98A

Make Boundaries Invisible https://email.clevertogether.com/l/Jcq5ZeHsdlVNvMb6Er763mfg/ZIfwX6jadxtnq32mLHm98A /ZIfwX6jadxtnq32mLHm98A>

Real Leaders, Happy Workers https://email.clevertogether.com/l/Jcq5ZeHsdlVNvMb6Er763mfg/t8k3w88KuAk9ei7LDngJPA /ZIfwX6jadxtnq32mLHm98A>

Focus on Outcomes https://email.clevertogether.com/l/Jcq5ZeHsdlVNvMb6Er763mfg/oeaVpQSvIVYVXKQQRbQ bQA/ZIfwX6jadxtnq32mLHm98A>

To share your views on our declaration at [email protected] or post on www.TransfomLDN.org

26

BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Quality Report Q2 2014/15

Agenda item number: 1.9

Report of: Chief Nurse and Director of Quality Governance

Contact Officer: Director of Patient Safety

Relevant CLCH 14/15 Goal: • Embody the best of the NHS for our patients • Support people safely out of hospital • Deliver better value than competitors in our selected market • Be responsive to our patients and partners’ needs Freedom of Information Report can be made public Status

Summary: • The RAG rating on the balanced score card this month shows: o 11 green KPIs o 6 amber KPIs o 10 red KPIs

Key areas for focus: o Pressure Ulcers o PALS response times o Clinical Outcomes

Assurance provided: Continue monthly reporting to the Quality Committee

Report provenance: First presented at the Quality Committee on 20.10.14

Report for: Decision Discussion Information

27

1. Purpose

To provide a summary key quality indicators for the Q2 2014/15

2. Introduction

Please see main body of report

5. Proposal

Not applicable for information only

6. Quality Implications and Clinical Input

The report is focussed on quality. The quality committee has significant clinical representation.

7. Equality Implications

None

8. Comments of the Director of Finance, Performance & Corporate Resources

Not applicable

9. Risks and Mitigating Actions

Quality indicators at risk of not being achieved are highlighted throughout the report

10. Consultation with Partner Organisations

Quality reports are broken down to CCG level and presented at relevant Clinical Quality Review Meetings between CLCH & CCGs.

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11. Monitoring Performance

Quality dashboard is submitted to the Quality Committee monthly

12. Recommendations

None, for information only.

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Trust Quality Report Quarter 2 2014/15 Report Contents Item Item Page number number 1.0 Balanced Score Card 2 2.0 Positive Patient Experience 3 2.1 Patient Reported Experience Measures (PREMS) 3 2.2 Number of PREMS received 3 2.3 Respect & Dignity 3 2.4 Friends & family test 4 2.5 Overall experience 5 2.6 Involvement in care 5 2.7 Explaining care 6 2.8 Complaints, Claims, PALS and Compliments 6 2.9 Details of complaints received in Quarter 2 2014 7 2.10 PALS Performance 11 3.0 Preventing Harm 15 3.1 Incidents 15 3.2 Category of harm 15 3.3 Incidents reported by Clinical Commissioning Group (CCG) 16 3.4 Serious incidents 16 3.5 Timeliness of reporting serious incidents to North West London Commissioning 17 Support Unit (NWLCSU) 3.6 Harm free care 18 3.7 Patients free from venous thromboembolism (VTE) 19 3.8 Patients free from catheter associated urinary tract infections (CAUTI) 19 3.9 Patients free from pressure ulcers 19 3.10 Patients who did not fall 20 4.0 Smart Effective Care 21 4.1 Satisfaction with wait for treatment 21 4.2 Goal attainment score 22 5.0 Care Quality Commission (CQC) 22 5.1 Inspections 22 5.2 Compliance programme 22

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1.0 Balanced Scorecard

Number This Month A Positive Patient Experience of End of Yr. Trajectory Records Target Target Ytd / Avg Sept 14 Patients' Experience 14-09 Mth Proportion of patients who were treated with Respect and 1095 95% 95% 93% 94% Dignity Patients who would recommend the service (National) 1103 58 54.5 47 52 Patients who would recommend the service (incl. "likely" 1103 85 84 77 83 Promoters) Proportion of patients whose care was explained in an 1063 90% 90% 91% 91% understandable way Proportion of patients who were involved in planning their 1026 80% 80% 76% 78% care Proportion of patients rating their overall experience as 1090 80% 80% 88% 91% excellent or good Number of PREMS responses is above threshold 1090 1424 1090

Patients' Complaints, Concerns and Compliments The number of compliments received this month 36 n/a n/a 36 33 Proportion of patients' concerns (PALS) resolved within 1 56 80% 80% 71.4% 76% week The number of complaints received this month 9 n/a n/a 9 7 Proportion of complaints responded to within 25 days 13 80% 80% 61.5% 64% Proportion of complaints responded to within agreed deadline 8 100% 100% 100% 100%

Preventing Harm

Incidents & Risk Proportion of Patient related Incidents that were Harm Free 366 49% 43% 36.1% 46% 10% reduction in incidents affecting Patients that caused harm 366 204 204 234 215 10% reduction in Pressure Ulcer Incidents 53 416 35 52 46 10% reduction in Medication Incidents that caused harm 43 13 13 12 18 10% reduction in Falls that caused Harm 35 13 15 9 15 Reported incidents affecting patients per 1000 OBDs (bedded 68 20 20 40 19 units) Proportion of external S.I.s with reports completed within 20 100% 100% 95% 98% deadline Prevalence NHS Safety Thermometer) Proportion of Patients with Harm free care 1293 98% 98% 91.3% 92.1% Proportion of Patients who did not have a Pressure Ulcer 1293 98% 98% 93.5% 94.2% Proportion of Patients who did not have a Catheter Associated 1293 98% 98% 99.7% 99.2% UTI Proportion of Patients who did not have a Fall 1293 98% 98% 98.2% 98.6% Proportion of Patients who did not have a Venous 1293 98% 98% 99.7% 99.7% Thromboembolism Proportion of Patients who did not have any NEW Harms 129 98% 98% 97.1% 97.1%

Smart, Effective Care 0% Standardised Mortality Ratio in Bedded Units Proportion of Services capturing Patients' Clinical Outcomes 74 66% 66% 22% 20% Proportion of patients who were satisfied with the wait for 1044 80% 80% 77.50% 76% treatment Proportion of Patients reporting a Positive Goal Attainment 283 90% 90% 90% 88% Score

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2.0 Positive Patient Experience

2.1 Patient Reported Experience Measures (PREMS) PREMS are predominately collected through telephone interviews with patients and service users. The Trust is committed to receiving feedback from as many patients as possible and from a group that represents our patients’ diversity. To this end CLCH also uses electronic tablet surveys, face to face interview and paper questionnaires through the post. CLCH has a long established program that works with our patients who have learning disabilities to make sure their voice is heard.

2.2 Number of PREMS received Each division is establishing targets for the number of PREMS they aim to receive every month. The number of PREMS received was artificially elevated in the autumn of 2013 when the new company contracted to conduct the surveys over performed. The company collating the surveys did not count all positive responses over the last few months; this has now been corrected, as reflected in current and historical data presented in this report.

Graph 1: Number of PREMS responses received

2.3 Respect & Dignity Patients are asked if they were treated with respect and dignity. The data presented in the graph represents the proportion of patients who responded “yes definitely” to this question. The target of 80% for 2013/14 was comfortably achieved, the new target for 2014/15 of 95% is more challenging, but the Compassion in Care Coordinator is continuing to work across all services to improve performance in this area.

32 4

Graph 2: Proportion of patients who reported that they were treated with respect and dignity

2.4 Friends & Family Test In the friends and family test patients are asked how likely they would be to recommend our services to their friends and family. The local CLCH metric includes those patients who respond that they are “likely” to recommend the service; the national metric excludes these patients. This explains the difference between the two sets of data in Graphs 3 & 4. A national standard has not been set for this test in community trusts, but the CLCH Board has set a target of 58% for 2014/15 (graph 4). CLCH significantly and consistently exceeded the locally set target of 58% for the local metric (graph 3) in 2013/14 and due to this high performance a stretch target of 85% has been set for the current year. The Compassion in Care project continues to work with staff to improve scores in this area.

Graph 3: Number of patients who would recommend the service to their families and friends (including likely promoters, local metric)

33 5

Graph 4: Number of patients who would recommend the service to their families and friends (excluding likely promoters, national metric)

2.5 Overall Experience Patients are asked to rate their overall experience of care. The data presented below represents those patients who said that their care was good or excellent. CLCH has set a threshold for this measure of 80% and continues to consistently exceed this.

Graph 5: Proportion of patients who rated their overall experience as good or excellent

2.6 Involvement in care Patients are asked how involved they are in planning their own care. The data below represents those patients who said that they were as involved as they wanted to be. The target set for this PREM is 80%. Involvement in care has been set as a priority in the 2014/15 CLCH Quality Account and it is hoped that this level of commitment will address this month’s performance, together with the compassion in care project.

34 6

Graph 6: Proportion of patients who were as involved in planning their care as they would like to be.

2.7 Explaining Care Patients are asked if their care was explained to them in a way they could understand, the data below represents those patients who said that their care was explained in an understandable way. For 2013/14 the CLCH Board set a target that 80% of patients would report that their care was explained in an understandable way. The Trust exceeded this expectation throughout 2013/14. This excellent performance led to a more challenging target of 90% for 2014/15, which is being achieved.

Graph 7: Proportion of patients who said their care was explained to them in an understandable way.

2.8 Complaints, Claims, PALS and Compliments CLCH categorises complaints as either simple or complex. This decision is made on an individual basis depending on the nature of the complaint and the difficulty involved in effectively investigating it, to provide the complainant with a response which thoroughly addresses their concerns. The national target required NHS Trusts to respond to all complaints within a time limit agreed with the person making the complaint. The Trust had good performance against this target in 2013/14 and so to drive quality and performance a more challenging target has been set of responding to 80% of simple complaints in 25 working day and 100% of complex complaints within the agreed timescale. This level of

35 7

performance has not yet been sustained but there has been overall improvement since March 2014 and recent recruitment within the team is expected to further improve performance.

Graph 8: The number of complaints received.

Graph 9: Percentage of complaints resolved within 25 days.

2.9 Details of complaints received in Quarter 2 2014/15

This table shows the number of complaints received by Borough (July to September 2014)

CCG July August September Total

Barnet CCG 2 5 4 11 Hammersmith and Fulham CCG 0 1 1 2 West London CCG 2 3 1 6 Central London CCG 1 2 4 7 Totals: 5 11 10 26

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In a change from the last Quarter report, but in line with the previous 2 quarter reports, Barnet has received the most complaints in the second Quarter of this year, with London receiving the next highest amount of complaints.

This table records the total number of new Complaints received by Division

Total July August September Received Division Allied Primary Care Services 0 2 0 2 Children's Health and Wellbeing 1 1 2 4 Corporate Services 0 0 0 0 Networked Nursing and Community Rehab 0 2 4 6 Specialist Community Nursing & Therapies 4 6 4 14 Totals: 5 11 10 26

Specialist and Community Nursing and Therapies received the most complaints. Most of these were concerning all aspects of clinical care and treatment however s no particular trend was identified in respect of specific location or staff group from these complaints, since they relate to a variety of services across the boroughs.

This table shows complaints received for July - September 2013 and 2014 and a decrease for two of the three months compared with last year.

Month 2013 2014 July 7 5 August 16 11 September 8 10

This table shows the comparison of complaints received by subject for April - June 2013 and 2014, as noted ‘All aspects of Clinical Treatment’ is still the main theme of complaints.

Complaints received by Subject 2013 2014

Aids and Appliances, Equipment, Premises (Including Access) 0 1

Appointments, Delay / Cancellation (Out-patient) 5 6

Attitude of Staff 5 7

All aspects of Clinical Treatment 17 9

Communication 1 2

Personal records 2 0

Records management 1 0

Appointments, Delay/Cancellation (inpatient) 0 1

37 9

Graph 10 shows complaints received July to September 2014 by CCG and Clinical Business Unit.

10 9 8 7 6 West London 5 Hammersmith & Fulham 4 Barnet 3 Central London 2 1 0 APCS CHD SCN NCNR

Complaint Closure Data Of the 31 complaints closed in Quarter 2, 17 were closed following issue of first responses, 6 were closed following onward referral or withdrawal from the complaints process, and 8 were re-opened cases that were closed after further work to achieve local resolution.

Graph 11 documents the number of complaint closed by subject and CCG during Quarter 1

38 10

Graph 12 documents total complaint closures in Quarter 1 by month and CCG

14 12 10 8 6 Jul 4 Aug 2 Sep 0 Barnet CCG Hammersmith West London Central Totals: and Fulham CCG London CCG Health CCG

Graph 13 This demonstrates the timescale achieved by Division of complaints closed in Quarter 1. Also shown are cases that were not subject to these timescales [N/A], which includes those referred on or withdrawn and re-opened cases.

20 18 16 14 NCNR 12 10 CHD 8 APCS 6 SCN 4 2 0 <25 working >25 working Re-opened N/A days days

Re-opened Complaints / Referrals to Second Stage (Ombudsman) 7 Complaints were re-opened following issue of a CEO response for further work/local resolution meetings during the period July to September 2014. This is the same amount as complaints that were re-opened in the previous quarter. The complaints to which these cases related were originally opened and handled between January 2014 and July 2014. Of these cases, 1 had originally been “upheld”, 1 had been partially upheld and 5 were not upheld. The case that was “partially upheld” has been going on for some time and the service has received multiple letters from the complainant. A further investigation was conducted to clarify issues, and some parts of the response were reiterated. The response was issued no further contact has been made by the complainant so far.

39 11

The 1 case that was “fully upheld” had originally been upheld but the complainant asked for further information, which was given along with unreserved apologies. Of the 5 cases that had been “not upheld” when first responded to, all received further written responses and the service has not received any further or outstanding issues from the complainant. There are no cases at present that the Ombudsman has confirmed they will be investigating. However, one complainant who received a further response in Quarter 1 has approached the Ombudsman dissatisfied with the outcome of his complaint, and a decision is awaited following provision of the case file to the Ombudsman’s office.

Claims 5 claims have been logged with the NHSLA during Quarter 2. 2 of these claims are regarding the CHD division, 1 concerns the NCNR division, 1 concerns APCS and 1 is for CORP division. All of these are at very early stages and we are currently providing further documentation to the NHSLA.

2.10 PALS Performance PALS logged 290 contacts in Quarter 2, mostly received via telephone and email. This includes 134 Issues for Resolution and 117 Compliments.

Of 109 PALS contacts that were deemed “Issues for Resolution”, the following is a list of areas where more than one contact with PALS was logged.

Sexual Health Services 4 Intermediate Care 2 Child Health Information Hub 3 Health Visiting 4 Dental Services 2 Nutrition and Dietetics 2 Continence Care 2 Phlebotomy 12 District Nursing 15 MSK Physiotherapy 18 General Practice 5 Podiatry 32 Intermediate Care 2 Rehabilitation - Community 4 Health Visiting 4 Rehabilitation - Inpatient 2 Nutrition and Dietetics 2 Urgent Care / Walk In Centre 6 Phlebotomy 12 Wheelchair Services 5

The following documents the top 10 main themes associated with the “Issues for Resolution” logged and handled by PALS in Quarter 2.

Appointment Issues 29 Appointments, Delay/Cancellation (Out-patient) 22 Communication/information 20 Attitude of Staff 14 Clinical Care 12 Access to Services 9 Aids and Appliances, Equipment, Premises (Including Access) 7 Admissions, Discharge and Transfer 5 Staff relations 3 Waiting times / delays 3

40 12

In keeping with the trends reported in previous Quarterly reports, Appointment issues continue to be the top concern received by PALS, but rather than staff attitude being the next main concern, as in the previous 2 quarters, it is communication/information. Whilst not all PALS “Issues for Resolution” specify a service, the following indicates the total number of enquiries received by Division, and where known, by Service.

APCS Sexual Health Services 4 Dental Services 2 General Practice 5 Offender Healthcare 1 Urgent Care / Walk In Centre 6 CHD Child Health Information Hub 3 Children and Young People Occupational Therapy 1 Health Visiting 4 Speech and Language Therapy 1 NCNR Continuing Care Assessment 1 Community Neuro-Rehabilitation 1 District Nursing 10 Rehabilitation - Community 1 Rapid Response Nursing Team 1 Wheelchair Services 5 SCN Continuing Care 1 Continence Care 2 District Nursing 5 Ear, Nose and Throat 1 Intermediate Care 2 Nutrition and Dietetics 2 Orthopaedic 1 Phlebotomy 12 MSK Physiotherapy 18 Podiatry 32 Rehabilitation - Community 3 Rehabilitation - Inpatient 2 Respiratory / COPD 1 Rheumatology 1 Single Point of Access (SPA) 1

41 13

A comparison of PALS concerns raised in the last 2 Quarters of 2013-14 and Quarter 1 2014- 15 by CCG.

CCG Q4 (2013-14) Q1 (2014-145) Q2 (2014-15)

Barnet CCG 59 57 67

Central London Health CCG 28 18 19

West London CCG 26 19 22

Hammersmith and Fulham CCG 16 13 23

Corporate Services 1 4 3

1 Grand Total 130 111 117

Graph 14: The number of PALS issues received.

Graph 15: The percentage of PALS issues resolved within five working days.

Compliments 117 Compliments were received between July and September 2014.

The following indicates how these were distributed between Divisions:

42 14

Allied Primary Care Services 22 Children's Health and Wellbeing 4 Corporate Services 4 Networked Nursing and Community Rehab 21 Barnet Community and Specialist Services 66 Totals: 117

Of the services receiving more than one compliment in the period July to September 2014, the following are noted:

Sexual Health Services 3 Primary Care Mental Health 6 Urgent Care / Walk In Centre 6 Health Visiting 3 Patient Safety Team 3 Community Neuro-Rehabilitation 9 District Nursing 2 Rehabilitation - Inpatient 3 Wheelchair Services 3 Continuing Care 11 Continence Care 3 District Nursing 3 Palliative Care (Inpatient) 3 Parkinson’s Service 4 Phlebotomy 2 MSK Physiotherapy 4 Podiatry 3 Rehabilitation - Inpatient 11 Respiratory / COPD 6

Of the compliments received, the most were about Clinical care (61) which saw a big increase from the 14 received last quarter. Compliments around staff attitude received the second highest amount (44).

Graph 16: The number of compliments received

43 15

3.0 Preventing Harm

3.1 Incidents CLCH is actively encouraging the reporting of all incidents; both through datix training and regular contact between the Patient Safety team and divisional staff. The total incidents reported, excluding rejected incidents, for Q2 July – Sept 2014 was 1,614. The graph below depicts rate of reporting by quarter since April 2013. The decrease in reporting seen in Q1 Apr – June 2014 has continued in Q2 July – Sept 2014. The Patient Safety Managers will explore possible reasons for the decrease in reporting with their divisions. The top 5 types of reported incident for Q2 July – Sept 2014 are: Medication (195); Pressure ulcers developed within CLCH(151); Slips, trips & falls (142); staffing issues (81); and problems with appointments (81).

Graph 17: Number of incidents reported 2013-14

3.2 Category of harm Severity of each incident is assessed at the time of reporting. The range of severity is “no harm/minor harm/moderate harm/major harm/catastrophic”. The table below depicts the total incidents by severity for Q2 July – September 2014. The major severity incidents were mostly pressure ulcers (52) and one adult safeguarding incident. (Note: This graph includes all reported incidents).

Graph 18: Number of incidents by severity

44 16

3.3 Incidents reported by Clinical Commissioning Group (CCG) The graph below depicts incidents reported by CCG. Barnet CCG has the highest at 585 incidents, with Central London CCG second with 498 incidents; then West London with 296 incidents and Hammersmith & Fulham with 207 incidents.

Graph 19: Incidents by CCG.

3.4 Serious Incidents Forty Five Serious Incidents were reported to North West London Commissioning Support Unit (NWL CSU) in Q 2 July - September 2014. All SI’s are managed via the SI process and the Board is informed of all SI’s via the monthly SI report. The graph below depicts the total reported serious incidents by category for Q 2 July - September 2014. Pressure ulcers grade 3 remain the highest category (23), with Pressure ulcers grade 4 next highest (18). The remaining categories had one of each type reported.

Graph 16: Categories of serious incidents 25

20

15

10

5

0 Pressure Ulcer Pressure Ulcer Adverse Media Slip/Trip/Fall Safeguarding Confidential Grade 3 Grade 4 of Vulnerable Information Adult Leak

45 17

Graph 20: Serious incidents by month and STEIS classification

Graph 21: External serious incidents by division and month

3.5 Timeliness of reporting serious incidents to North West London Commissioning Support Unit (NWLCSU)

Graph 22: STEIS reporting to NWLCSU against due date

46 18

3.6 Harm Free Care This metric determines the percentage of patients participating in the NHS safety thermometer survey day who did not have any of the harms being monitored. It includes harms which occurred within CLCH care (new harm) and those that occurred elsewhere. It should be noted that the vast majority of patients suffer no harm at all. It is important to differentiate between all harms and new harms. New harms are those which occurred when the patient was under CLCH care and exclude harms that the patient had already sustained when they arrived in our care, for example a patient discharged from an acute hospital to the district nursing service with a pressure ulcer. CLCH consistently meets the national target (96%), but has not yet achieved the local stretch target for the New Year (98%) in main due to the number of pressure ulcers. However, 97.5% of our patients do not sustain any harm under our care.

Graph 23: Proportion of care that was harm free (new and old - all harms) The proportion of patients who's care was harm free 100% 98% 96% 94% 92% 90%

Percentage 88% 86% Jan Feb Mar Apr May Jun Jul Aug Sep 2014-15

percentage threshold

Graph 24: Outliers

47 19

3.7 Patients free from venous thromboembolism (VTE) This metric counts the number of patients on the day of the survey who have a VTE such as a deep vein thrombosis (DVT). The Trust has an excellent record in this area, almost always having 100% of patients VTE free. The Trust continues to easily exceed its new stretch target.

3.8 Patients free from catheter associated urinary tract infections (CAUTIs) This category of harm counts the number of patients on the day of the survey who have a urinary tract infection associated with their catheter. This is another category where CLCH has excellent performance. For the whole of the last year more than 99% of patients were free from a CAUTI. The new stretch target, which exceeds national expectations, has also been met.

3.9 Patients free from pressure ulcers Our prevalence of pressure ulcers as measured by the NHS Safety Thermometer is 93.5% (all ulcers) and 99.3 % new ulcers in September.

Graph 25: Outliers – Pressure Ulcers

In relation to incidence of ulcers during September the grade 3 and 4 ulcers were in the following areas:

Grade Three Grade Four Total Athlone House Nursing Home 0 1 1 Jade Ward 1 1 2 Marjory Warren Ward 0 1 1 Princess Louise Nursing Home 0 1 1 Totals: 1 4 5

48 20

The Trust work on pressure ulcers was presented to the Quality Committee in September 2014.

Graph 26: Incidence of pressure ulcers

3.10 Patients who did not fall During the safety thermometer survey day the number of patients who fell whilst in CLCH care is counted. For the last year as a whole more than 98% of our patients did not fall. Both the national and local targets were exceeded. We have also improved this month for the number of patients who fell with harm (incidence).

Graph 27: The proportion of patients who did not fall.

49 21

Graph 28: NHS safety thermometer outlier chart for the prevalence patients who sustained harm from a fall July - September 2014

4.0 Smart, Effective Care

4.1 Satisfaction with wait for treatment

Graph 29: The percentage of patients who were satisfied with their wait for treatment

50 22

4.2 Goal attainment statement

Graph 30: Percentage of patients who reported a positive goal attainment score

5.0 Care Quality Commission (CQC)

5.1 Inspections CLCH have had one unannounced inspection in Q2 at Garside Nursing Home. On 7th August 2014, the CQC arrived at Garside Nursing Home unannounced. The inspection was not a routine inspection but in response to allegations raised of staffing issues on the unit, record keeping, management issues and claims of bullying. The Inspector spoke to a number of residents and staff on the unit and informally advised that they did not find any areas of non-compliance. However, they did request a number of documents to be sent on as evidence for review before a formal outcome of the visit could be given. The final report has been published and CLCH were found to be meeting the following standards:

Outcome 4 - Care and welfare of people who use services Outcome 16 - Assessing and monitoring the quality of service provision

5.2 Compliance Programme CLCH have refreshed the compliance programme in line with the new way CQC are inspecting community health services. The self-assessment templates are currently being reviewed. More detailed work is planned with the services on completing these templates and the outcomes will be shared in due course.

The Quality Inspection Teams (QITs), i.e. mock-CQC inspections are well underway, with positive feedback from the inspection teams. This is an ongoing programme of work and is being received well. In addition to these the Compliance team are actively attending various team meetings to discuss CQC compliance and how they can become involved in the inspections and to share the learning and key themes so far.

51 23

We have carried out 14 inspections, broken down as follows:

Bedded Rehab Unit 1 Children’s Community Nursing 2 Community Independence Service 1 Community Matrons 2 Community Rehab 2 District Nursing 1 Health Visiting 3 MSK 1 PCMH 1

Overall, Staff are proud of the work they do and would recommend their service to friends and family.

Some of the key themes arising from the inspections are as follows:

• Many staff are unaware of the management structure above their line manager • Some staff not sure of which CBU or division their service sits within • Some staff reported not receiving feedback following the logging of an incident on Datix • Mixed knowledge of emergency evacuation procedures and low knowledge of who the nominated fire wardens and first aiders are within their site

A Compliance Group to be chaired by the Chief Nurse is being formed and all key themes will be discussed and action plans put in place where required. The Group will also consider the best way in sharing the experience from these inspections across the whole organisation.

52

BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Integrated Finance and Performance Report

Agenda item number: 2.1

Report of: Director of Finance, Performance and Corporate Resources

Contact Officer: Divisional Director of Performance and Resources Performance Manager Relevant CLCH 14/15 Goal: This report relates to all Trust Goals for 2014/15

Freedom of Information Report can be made Public Status

Executive Summary:

This report provides the Board with an integrated view of performance, both financial and non- financial, for September 2014.

Assurance provided: This report is a standardised monthly report reflecting a series of pre-agreed performance indicators.

Report provenance: This paper is a summary report of the more detailed Performance & Finance Report presented on a monthly basis to the Finance, Resources and Investments Committee. It also contains the Quality of Care Balanced Scorecard which is also presented to the Quality Committee on a monthly basis.

Report for: Decision Discussion Information

53

1. Purpose

This report provides the Board with an integrated view of performance, both financial and non- financial, for September 2014. It is designed to provide Members with a monthly progress report on Key Performance Indicators and other key metrics.

2. Introduction

The report is in a new format from Month 6 and now continues to include a summary of the financial performance of the Trust and reports on a suite of KPIs aligned to each of the six strategic objectives for CLCH. The non-financial performance section now shows a series of graphs which show monthly performance for the current year, corresponding performance for 2013/14, the trajectory targets and the performance thresholds for each target. Where applicable each graph also shows a divisional RAG rating for each KPI.

Where KPI is reporting a red RAG rating at Trust level a separate exception report is included.

The report continues to include the Quality Information Balanced Scorecard.

3. Proposal

Members are asked to note the contents of this report

4. Quality Implications and Clinical Input

This report contains the Quality of Care Scorecard which reflects a number of Quality/Clinical issues. Comment regarding the performance of any indicators of a quality/clinical nature, and in particular any corrective action being taken, has been provided by the appropriate part of the Trust.

5. Equality Implications

There are no equality implications within this paper.

6. Comments of the Director of Finance, Performance & Corporate Resources

The Director of Finance, Performance & Corporate Resources is involved in the production of this report in addition to presenting the content at the monthly Finance, Resources and Investment Committee.

7. Risks and Mitigating Actions

54

Where corrective action is required in order to improve the performance of a particular indicator, this has been identified and provided. The Board will also be assured that considerable discussion regarding the data contained within this report has previously taken place at both the Finance, Resources and Investment Committee and the Quality Committee.

8. Consultation with Partner Organisations

No external consultation is required

9. Monitoring Performance

The contents of this report is subject to monthly performance monitoring

10. Recommendations

Members are asked to note the contents of this report.

55 Central London Community Healthcare NHS Trust

Contents Page

• Overview 2

• Trust KPIs 3 • Finance 14 • Key Financial Issues 15 INTEGRATED FINANCE & • Key Financial Risks 16 PERFORMANCE REPORT • Corporate and Service Transformation Summary 17 TO 30th September 2014

56 Overview – The Must Knows Finance Quality

I&E Performance: Trust surplus £1.2m YTD, favourable variance against plan of The Quality Scorecard presents some good progress across the Trust, but also a £26k. Forecasting £1.8m surplus due requiring £2.3m surplus on reserves, all of couple of areas for improvement that the Quality Committee has been sighted which is identified. The key issue impacting on the unadjusted YTD position is on: unachieved / unidentified QIPP (causing a £1.1m adverse variance) with usage of temporary staffing the other main concern. Friends & Family Test: There has been a reduction in the net promoter score in September with Red performance when using the national methodology and QIPP: Trust is currently under-achieving in QIPP YTD and forecast. P17 shows Amber when using CLCH methodology. The Quality Team are in the process of the significant efforts being made to develop the pipeline of alternative ideas undertaking a root cause analysis to ascertain the reasons for the slippage.

for bridging the gap in year. The residual challenge of non recurring solutions for 15/16 and beyond is being worked on.

Grade 2-4 Pressure Ulcer Incidents: The incidence of Pressure Ulcers has Cash: Cash balances are below plan to date primarily due to late recovery of increased this month to 52. The pressure ulcer group is reviewing this by area to WIC/UCC and LA income. note any issues relating to Septembers performance and the focus on training compliance continues, backed up by the Pressure Ulcer Policy in place across the Cap Ex: The Trust Cap Ex is ahead of plan and it is expected that the full Trust. The Percentage of Incidents Affecting Patients that did not Cause Harm allocation will be spent in year. has decreased this month due to this increase in grade 2 – 4 pressure ulcer incidents. Working Capital: Receivables >90 days 15%, Payables >90 days 9%. Workforce Performance

– Ratio of Bank to Agency Staff: Performance against a number of workforce The Trust is conduction a review of its activity – both year on year activity and targets has deteriorated this month. In particular, the ‘Bank to Agency’ ratio comparisons to contract commitments. Some services have seen activity reduce has slipped from Amber to Red. The exception report under Trust KPIs sets while others are over performing against contract and research is under way to out remedial actions. inform discussions with commissioners and avoid unanticipated capacity management issues. Staff from BME backgrounds at Band 7 and Above: Performance has slipped from Green to Amber due to increase in trend target while actual %age has remained consistent with previous months.

Staff Appraisal Rate: KPI has dropped from AMBER TO RED due to the use of a . new methodology for the calculation of the figures supporting this KPI. The exception report under Trust KPIs sets out remedial actions.

Note: = Trust KPI = Other Must Know 57 2 Central London Community Healthcare NHS Trust

Trust KPIs

58 September 2014 – Strategic KPIs (1)

Embody the best of the NHS for our patients

Red Friends and Family test - Net Promoter Score (National Methodology) Amber Friends and Family test - Net Promoter Score (CLCH Methodology) Amber Patients agreeing they were treated with dignity and respect

60 88 99% 86 56 97% 84 95% 52 82 93% 80

48 78 91%

76 89% 44 74 87%

40 72 85% April May June July Augus t Sept Oct Nov Dec Jan Feb March April May June July Augus t Sept Oct Nov Dec Jan Feb March

Actual 2014-15 Actual 2013-14 Target Trajectory Amber Threshold Actual 2014-15 Actual 2013-14 Target Trajectory Amber Threshold Actual 2014-15 Actual 2013-14 CLCH 2014 Target Amber Threshold

APCS NCNR SCNB CHD APCS NCNR SCNB CHD APCS NCNR SCNB CHD Lead Director: Louise Ashley Lead Director: Louise Ashley Lead Director: Louise Ashley The record count for this month is 1090. The record count for this month is 1090. The record count for this month is 1090. The Quality Team is in discussion with the Picker organisation regarding any potential data The Quality Team is in discussion with the Picker organisation regarding any potential data The Quality Team is in discussion with the Picker organisation regarding any potential data quality issues this month. The team is also investigating specific service areas to determine quality issues this month. The team is also investigating specific service areas to determine quality issues this month. The team is also investigating specific service areas to determine and address the root cause of any actual drop in performance. and address the root cause of any actual drop in performance. and address the root cause of any actual drop in performance.

Staff agreeing with the statement "I am satisfied with the care I give to Red Ratio of Bank to Agency Staff (Hours Based) patients/services users" (quarterly) Red

90 70

65 85

60 80

55 75 50

70 45

65 40 Q1 Q2 Q3 Q4 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov- 14 Dec-14 Ja n-15 Feb-15 Mar-15

Actual 2013-14 Actual 2014-15 Bank Actual Agency Actual Bank Target Target Amber Threshold APCS NCNR SCNB CHD Lead Director: Louise Ashley Lead Director: Steve Graham The performance figure is taken from the Pulse survey on a quarterly basis. The The Corporate Division (Corporate departments), also failed to achieve the target this figure for Q1 14-15 was 73.2%. The Q2 figures will be available in November. month, and was therefore RAG rated RED.

NB. RAG ratings are shown against Trajectory targets, not End of Year targets 59 Central London Community Healthcare NHS Trust 2 September 2014 – Strategic KPIs (2)

Support people safely out of hospital

Amber Proportion of Patients with No New Harms Recorded Green QGAF Score Green Hand Hygiene Audits

99% 5 100% 4.5 90% 98% 4 80% 3.5 70% 97% 3 60% 2.5 50% 96% 2 40% 95% 1.5 30% Amber Threshold = 88.2% 1 20% 94% 0.5 10% 0 0% Q1 Q2 Q3 Q4 Actual 2014-15 Actual 2013-14 Q1 Q2 Q3 Q4 CLCH target 2014-15 National Target 2014-15 Actual Target Amber Threshold Actual Target Amber Threshold

APCS NCNR SCNB CHD Lead Director: Louise Ashley Lead Director: Dr Jo Medhurst Lead Director: Louise Ashley The results of the external audit which took place during Q2 will be available in October 2014. Despite falling short of the Trusts 'stretch' target, this KPI is achieving the national target of There has been a slight deterioration in this KPI during September, however the 96%. There were no figures for the CHD Directorate this month. Trust is still meeting the monthly trajectory target.

Percentage of time bedded units achieving Green Green Statutory & Mandatory Training Red Grade 2-4 Pressure Ulcer Incidents - Monthly & Annual Targets minimum staffing each month

120% 100.0% 90.0% 400 100% 80.0% 70.0% 300 80% 60.0% 50.0% 60% 40.0% 200

40% 30.0% 20.0% 100 20% 10.0% 0.0% 0% 0 April May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov- 14 Dec-14 Ja n-15 Feb-15 Mar-15 Monthly Actual 2014-15 Monthly Actual 2013-14 Actual 2014-15 Actual 2013-14 Trajectory Target Cumulative 2014-15 Annual Target Monthly Value Trajectory Target Linear (Cumulative 2014-15)

APCS NCNR SCNB CHD APCS NCNR SCNB CHD Lead Director: Louise Ashley Lead Director: Steve Graham Lead Director: Louise Ashley Highest Value: 123% (Marjory Warren) This KPI continues to improve on a monthly basis. The Trust-wide figure for Lowest Value: 87% (Alexandra Rehab) September 2014 exceeds the monthly trajectory target, and is very close to the Please see attached Exception Report for further details. end of year target of 90%. The Corporate Directorate is rated Amber, with 87.19% compliance

NB. RAG ratings are shown against Trajectory targets, not End of Year targets except where stated 60

Central London Community Healthcare NHS Trust 3 NB. RAG ratings are shown against Trajectory targets, not End of September 2014 – Strategic KPIs (3) Year targets

Deliver better value than competitors in our selected markets

Not Net New Business Won Proportion of Services capturing Amber Red Percentage of incidents affecting patients that did not cause harm Rated Patients' Clinical Outcomes

65% 4 70.00% 60% 60.00% 2 55% 50.00% 0 50% 40.00% 45% -2 30.00% 40%

-4 20.00% 35%

10.00% 30% -6 YTD Value 25% 0.00% -8 20% End of Year April May June July Augus t Sept Oct Nov Dec Jan Feb Mar Target -10 YTD Value (Actual) Trajectory Target Amber Threshold Monthly Value 2014-15 Monthly Value 2013-14 Trajectory Target

Lead Director: Iain McMillan Lead Director: Jo Medhurst APCS NCNR SCNB CHD The adverse movement is due to the admin and Nursing support contract for OPD & DSU in Performance has improved substantially since last month, and is now Amber against the Lead Director: Louise Ashley Barnet being taken back by RFL as from Q4. A trajectory target is not applicable to this KPI trajectory target. Currently 66.2% of services have identified at least two outcome measures and several have indicated that they will be returning their third measure This performance figure relates to a total of 366 incidents, 132 of which were harm free. The definition this month. DDOs/ADQs will shortly receive a monthly progress report with the drop in performance during September is linked to the increase in pressure ulcers this status of their division and identified actions for outstanding responses. month.

Be responsive to our patients and partners needs

Red Complaints resolved within 25 days of receipt Green Complaints resolved within timescales agreed with the complainant Red Percentage of Appointments cancelled by CLCH

3.0% 120% 120%

2.5% 100% 100%

2.0% 80% 80%

1.5% 60% 60% 1.0% Monthly Value 40% 40% Trajectory Target 0.5% 20% Amber Threshold 20% 0.0% 0% Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov- 14 Dec-14 Ja n-15 Feb-15 Mar-15 April May June July Augus t Sept Oct Nov Dec Jan Feb March 0% April May June July Augus t Sept Oct Nov Dec Jan Feb Mar Monthly Value 2014-15 Monthly Value 2013-14 T arget Amber Threshold Monthly Value 2013-14 Monthly Value 2014-15 T arget APCS NCNR SCNB CHD APCS NCNR SCNB CHD APCS NCNR SCNB CHD Lead Director: Richard Milner Lead Director: Louise Ashley Lead Director: Louise Ashley The sample size for September was: 3699 cancellations out of 139,875 appointments. The drop in performance appears to be related to sickness/absence rates within the These figures relate to 8 out of a total of 13 complaints that were resolved within 25 days. Divisions leading to a lack of cover for clinics (linked to cost pressures), combined with an There have been delays in responses to complaints, as a result of which training for key increase in activity. The definition for this KPI needs to be reviewed, as the denominator divisional staff on good complaints management is being established. currently does not include DNA'd appointments. 61 Central London Community Healthcare NHS Trust 4 September 2014 – Strategic KPIs (4) NB. RAG ratings are shown against Trajectory targets, not End of Year targets except where stated

Employ only the best staff

Red Percentage of Staff that recommend CLCH as a place to work Red Staff Appraisal Rates Amber Sickness absence rate

6.00% 70% 100.00% 90.00% 5.00% 60% 80.00%

70.00% 4.00% 50% 60.00% 3.00% 40% 50.00% 40.00% 2.00% 30% Monthly Value 2014- 30.00% 15 1.00% 20.00% 20% Trajectory Target Amber Threshold 10.00% 0.00% 10% 0.00% Linear (Monthly Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov- 14 Dec-14 Ja n-15 Feb-15 Mar-15 Value 2014-15) 0% Actual 2014-15 Actual 2013-14 Trajectory Target Amber Threshold Actual 2013-14 Actual 2014-15 Trajectory Target Amber Threshold Q1 Q2 Q3 Q4

APCS NCNR SCNB CHD APCS NCNR SCNB CHD Lead Director: Lead Director: Steve Graham Lead Director: Steve Graham The performance figure is taken from the Pulse survey on a quarterly basis. The Q1 14-15 Monthly performance against target remains stable, while the YTD value dropped slightly figure was 40% with Divisional performance ranging from 30.3% to 72.7%. The Q2 figures An alternative methodology is being used to provide these figures with effect from September over last month. The figures include the Corporate Department, which achieved the target will be available next month. this year. Please see the KPI Exception Report for further details. this month, and is therefore RAG rated GREEN.

Red Vacancy Rates Amber Staff from BME Backgrounds at bands 7 and above

20.0% 35.00% 18.0% 16.0% 14.0% 30.00% 12.0% 10.0% 8.0% 6.0% 25.00% 4.0% 2.0% 0.0% 20.00% Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov- 14 Dec-14 Ja n-15 Feb-15 Mar-15 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov- 14 Dec-14 Ja n-15 Feb-15 Mar-15 Actual 2013-14 Actual 2014-15 Trajectory Target Amber Threshold Actual 2014-15 Trajectory Target Amber Threshold

APCS NCNR SCNB CHD APCS NCNR SCNB CHD Lead Director: Steve Graham Lead Director: Steve Graham This KPI has improved very slightly over last month, but is still not close to either the Performance against this KPI has slipped slightly this month, and is now just slightly below monthly or year end targets. The exception is the CHD Division with a vacancy rate of 9.65% the trajectory target, but within the amber threshold. Figures include the Corporate Division which meets both targets. Figures include the Corporate Department, which has the highest which failed to achieve the target this month, and is therefore RAG rated RED. vacancy rates in the Trust (24.9%). 62

Central London Community Healthcare NHS Trust 5 September 2014 – Strategic KPIs (5)

Be innovation and technology pioneers

Not The Innovation committee will see a number of projects each Red Recurrent QIPPS achieved % of total for the year Red Percentage of QIPP plans achieving the planned level of savings in-year Rated year, some of which will be taken forward as pilots

35 100.00% 100.00% 30

90.00% 25 90.00% 20 80.00% 15 80.00% 70.00% 10 5 70.00% 60.00% Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov- 14 Dec-14 Ja n-15 Feb-15 Mar-15 0 Projects Reviewed Projects taken forward

YTD Value Trajectory Target Amber Threshold YTD Value Trajectory Target Amber Threshold Actual End of Year Target

Lead Director: Richard Milner Lead Director: Ian Millar Lead Director: Jo Medhurst There has been a pause in this committee recently, although it has since There has been a slight fall in performance this month, continuing a declining trend in Please see the Finance Section for further information. been reconstituted, and the ToR redrafted. Due to this pause, there performance over a three month period. Please see the Finance Section for further have been no further changes to the KPI during the last month, and no information. further innovations have been taken forward. Not KPIs that are RAG rated GREEN on overall data quality confidence level. Not Rated Continuous improvement model in place and used across service lines 90% Rated 80% 70% 60% This KPI is under development: 50% As of the 31st September, there are no new successful completions as the first cohort of this year is still 40% 30% underway. Currently there are 11 participants, all of whom are due to complete successfully on the 23rd 20% 10% October. 0% Q1 Q2 Q3 Q4 Actual 2014-15 Trajectory Target The next cohort (Jan-15) will be expanded to accommodate 21 participants which should enable the KPI to Lead Director: Mike Fox be achieved. There is an open Risk on Datix (#1167) relating to this KPI. The DQAF meetings for Q2 2014-15 have not yet taken place, there are therefore no further updates to this KPI at this point in time. The meetings are due to take place during October.

NB. RAG ratings are shown against Trajectory targets, not End of Year targets except where stated 63 Central London Community Healthcare NHS Trust 6 Exception Report: Pressure Ulcer Incidence – September 2014

Monthly Performance 2014-15 v.2013-14 Review of Performance 60 In relation to incidence of ulcers during September the grade 3 and 4 ulcers were in the 50 following areas:

40

Grade Three Grade Four Total 30

Athlone House Nursing Home 0 1 1 20 Jade Ward 1 1 2 10 Marjory Warren Ward 0 1 1 0 Princess Louise Nursing Home 0 1 1

Totals: 1 4 5 Actual 2013-14 Actual 2014-15 Monthly Threshold The majority of PUs are in District Nursing and are grade 2 ulcers.

Cumulative Performance 2014-15 Proposed remedial actions Timescale 450 Status 400 350 The pressure ulcer group will review by area to note any On-going New 300 issues relating to Septembers performance. 250 200 150 The focus on training compliance continues. On-going New 100 50 0 April May June July Aug Sept Oct Nov Dec Jan Feb Mar A Pressure Ulcer Policy is now in place across the Trust. Complete Cumulative 2014-15 Cumulative Threshold Annual Threshold

Direction April May June July Aug Sept Oct Nov Dec Jan Feb Mar On Target of Travel Monthly Actual 2013-14 41 44 42 31 49 45 46 35 34 35 32 28 Monthly Actual 2014-15 46 45 48 46 38 52 Monthly Threshold 35 35 35 35 35 35 35 35 35 35 35 35 X ↓ Cumulative 2014-15 46 91 139 185 223 275 Cumulative Threshold 31.90 34.66 69.32 103.98 138.64 173.30 207.96 242.62 277.28 311.94 346.60 381.26 Annual Threshold 416 416 416 416 416 416 416 416 416 416 416 416 64 9 Exception Report: Staff Appraisal Rates – September 2014

Review of Performance Red Staff Appraisal Rates The appraisal rate is taken directly from the online appraisal system (e –PADR) used within the Trust. 100.00%

90.00% Following a data quality review it became apparent that the rates being reported were not 80.00% accurate.

70.00% During August investigations were carried out to identify a robust way of producing the 60.00% reports. This is now in place, but during this investigation it became apparent that several 50.00% staff and managers were not completing the online process to allow the system to register the appraisal. 40.00% 30.00% Proposed remedial actions Timescale 20.00% Status 10.00% Review process for running reports September 14 0.00% Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov- 14 Dec-14 Ja n-15 Feb-15 Mar-15

Actual 2014-15 Actual 2013-14 Trajectory Target Amber Threshold Inform managers and Staff of need to complete whole on October 14 line process APCS NCNR SCNB CHD The Corporate Division (Corporate departments) is included in these figures: the division also failed to achieve the target this month, and is therefore also RAG-rated RED on this KPI. Inform managers of revised appraisal rates October 14

Risk to achieving target Severity Mitigated Communicate to managers staff without an appraisal October 14 Engagement of managers and M staff

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 On Target Travel Actual 2013-14 83.30% 85.80% 89.10% 90.50% 85.80% 82.50% 83.00% 83.10% 82.80% 81.50% 81.00% 79.50% Actual 2014-15 78.85% 78.76% 81.9% 83.8% 60% Not reported X ↓ Trajectory Target 80% 85.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% Amber Threshold 71.6% 76.5% 81.0% 81.0% 81.0% 81.0% 81.0% 81.0% 81.0% 81.0% 81.0% 81.0% 65 10 Exception Report: Bank to Agency Ratio – September 2014

Red Ratio of Bank to Agency Staff (Hours Based) Review of Performance The bank: agency ratio has dropped off trajectory in the last month. 70 A review of the bank is currently underway. This review will provide metrics on the bank 65 workforce and compare it with the Trust requirements and also recommend improvements that can be made to deliver a more effective and efficient temporary workforce. 60 Work will continue with Divisions to understand their temporary staffing requirements and 55 drive their substantive recruitment.

50

45

40 Proposed remedial actions Timescale Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov- 14 Dec-14 Ja n-15 Feb-15 Mar-15 Status

Bank Actual Agency Actual Bank Target Review current bank workforce against Trust requirements October 14

APCS NCNR SCNB CHD Lead Director: Steve Graham The Corporate Division (Corporate departments), also failed to achieve the target this Review bank payment methods and rates October 14 month, and was therefore RAG rated RED.

Risk to achieving target Severity Mitigated Make recommendations on ways to increase numbers of bank October 14 staff available Number of staff registered to work with H bank Review use of agency in light of staff flow to identify more workers October 14 that can go through that system Incentives to work on the bank

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 No v - 1 4 Dec-14 Jan-15 Feb-15 Mar-15 On Target Travel Bank Actual 51 51.7 52.3 52.7 54.1 52.4 Bank Target 51 51 52.5 54 55.5 57 58.5 60 61.5 63 64.5 65 X ↓ Agency Actual 49 48.3 47.7 47.3 45.9 47.6 66 11 Exception Report: Vacancy Rates – September 2014

Red Vacancy Rates Review of Performance The Trust vacancy rate has historically been higher then the target of 11%. This year a 20.0% number of changes have been made within the recruitment to increase activity and 18.0% numbers of starters. This has shown some success, however over the last 3 months the 16.0% number of leavers has also increased reducing the impact of the increased starters. 14.0% Work continues within the recruitment team to increase the time to hire and raise the 12.0% profile and brand of the Trust. 10.0% Work is underway within the divisions to understand the reasons for leaving and create retention initiatives. This will be supported by a redesigned and robust Exit Interview 8.0% process 6.0% Consideration is being given to overseas recruitment 4.0% It is projected that the vacancy rate will be met by March 2015 2.0% 0.0% Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov- 14 Dec-14 Ja n-15 Feb-15 Mar-15 Proposed remedial actions Timescale Actual 2013-14 Actual 2014-15 Trajectory Target Amber Threshold Status

Invest in applicant management system to reduce time to hire December 14 APCS NCNR SCNB CHD Lead Director: Steve Graham This KPI has improved very slightly over last month, but is still not close to either the monthly or year end targets. The exception is the CHD Division with a vacancy rate of 9.65% Review opportunity for overseas recruitment December 14 which meets both targets. Figures include the Corporate Department, which has the highest vacancy rates in the Trust (24.9%). Review reasons of leaving, exit interview process November 14 Risk to achieving target Severity Mitigated Increased attendance at job fairs, schools and recruitment events On going Skills shortage means good candidates M are not available

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 On Target Travel Actual 2013-14 12.8% 14.1% 14.9% 14.7% 14.9% 14.9% 16.1% 16.7% 18.7% 15.8% 16.8% 16.9% 16.8% 17.3% 17.07% Actual 2014-15 X ↓ Trajectory Target 16.7% 15.90% 15.10% 14.30% 13.50% 12.70% 11.90% 11.10% 11.00% 11.00% 11.00% 11.00% Amber Threshold 15.9% 15.1% 14.3% 13.5% 12.7% 11.9% 11.1% 11.0% 11.0% 11.0% 11.0% 11.0%

67 12 Quality Scorecard – September 2014

Number This Month A Positive Patient Experience of End of Yr. Trajectory Records Target Target Ytd / Avg Sept 14 Patients' Experience 14-09 Mth

Proportion of patients who were treated with Respect and Dignity 1095 95% 95% 93% 94%

Patients who would recommend the service (National) 1103 58 54.5 47 52

Patients who would recommend the service (incl. "likely" Promoters) 1103 85 84 77 83

Proportion of patients whose care was explained in an 1063 90% 90% 91% 91% understandable way

Proportion of patients who were involved in planning their care 1026 80% 80% 76% 78%

Proportion of patients rating their overall experience as excellent or 1090 80% 80% 88% 91% good Number of PREMS responses is above threshold 1090 1424 1090

Patients' Complaints, Concerns and Compliments The number of compliments received this month 36 n/a n/a 36 33

56 80% 80% 71.4% 76% Proportion of patients' concerns (PALS) resolved within 1 week The number of complaints received this month 9 n/a n/a 9 7 Proportion of complaints responded to within 25 days 13 80% 80% 61.5% 64%

8 100% 100% 100% 100% Proportion of complaints responded to within agreed deadline

Preventing Harm Incidents & Risk

Proportion of Patient related Incidents that were Harm Free 366 49% 43% 36.1% 46%

10% reduction in incidents affecting Patients that caused harm 366 204 204 234 215

10% reduction in Pressure Ulcer Incidents 53 416 35 52 46 10% reduction in Medication Incidents that caused harm 43 13 13 12 18 10% reduction in Falls that caused Harm 35 13 15 9 15

Reported incidents affecting patients per 1000 OBDs (bedded units) 68 20 20 32 19

Proportion of external S.I.s with reports completed within deadline 20 100% 100% 95% 98%

Prevalence NHS Safety Thermometer) Proportion of Patients with Harm free care 1293 98% 98% 91.3% 92.1% Proportion of Patients who did not have a Pressure Ulcer 1293 98% 98% 93.5% 94.2%

Proportion of Patients who did not have a Catheter Associated UTI 1293 98% 98% 99.7% 99.2%

Proportion of Patients who did not have a Fall 1293 98% 98% 98.2% 98.6% Proportion of Patients who did not have a Veneous 1293 98% 98% 99.7% 99.7% Thromboembolism Proportion of Patients who did not have any NEW Harms 129 98% 98% 97.1% 97.1%

Smart, Effective Care Standardised Mortality Ratio in Bedded Units 0%

74 66% 66% 22% 20% Proportion of Services capturing Patients' Clinical Outcomes

1044 80% 80% 77.50% 76% Proportion of patients who were satisfied with the wait for treatment 68 13 283 90% 90% 90% 88% Proportion of Patients reporting a Positive Goal Attainment Score Central London Community Healthcare NHS Trust

Finance

69 Key Financial Issues

Income At Month 6, CLCH has achieved a £1,232k surplus (£1,046k surplus at Income and Expenditure Summary Expenditur Month 5); this represents a £26k favourable variance against plan. Year-to-Date (£'000) e Year to The Trust achieved an EBITDA margin of 3.7% as at the end of Month 6 Forecast Date which is broadly in line with plan. Income & Expenditure YTD Plan YTD Actual Variance Variance Income 96,617 97,400 783 1,838 I&E The Trust is forecasting a surplus of £1.8m which is in line with the Forecast annual plan. The forecast assumes an underspend of £2.3m (£1.9m at Pay Expenditure 68,361 68,980 -619 -2,531 Month 5) on reserves (all of which is identified). Non-Pay Expenditure 24,591 24,773 -182 534

Risks to the Trust achieving the financial plan for 2014/15 include: EBITDA 3,665 3,647 -17 -159 achieving CQUIN and SDIP in full and resolving the charging issue re. Depreciation 2,067 2,019 48 44 Pathology costs from Imperial. Dividend 417 430 -13 106 Interest Received 26 34 8 9 Quality, The QIPP target for 2014/15 is £12m. As at Month 6 the Trust has Innovation, identified QIPP schemes with the value of £11.6m and is reporting under- Surplus/(Deficit) 1,206 1,232 26 -0 Productivit achievement of £899k against a year to date plan of £4,994k (£577k at EBITDA Margin 3.8% 3.7% y and Month 5). Statement of Financial Position Prevention The Trust is currently forecasting achievement of £9.7m (£10.1m at Opening as Month 6 Forecast (QIPP) Month 5) of QIPP by the end of the financial year but once the at 01/04/14 Year end contingency reserve for QIPP achievement is factored in this reduces the £'000 £'000 £'000 gap to £0.2m. During 2014/15 £8.8m of the forecast QIPP will be Property, Plant and Equipment 39,444 39,506 42,646 achieved in year through recurrent schemes. Cas h 13,968 14,747 10,307 The recurrent value of the delivered QIPP is £10.3m meaning there is at Debtors 15,107 19,181 7,721 present a £1.6m recurrent gap. Total Assets 68,519 73,434 60,675

Balance At the end of Month 6 CLCH had a cash balance of £14.7m (11.9m at Total Liabilities -28,624 -32,307 -18,947 Sheet, Month 5). This is £0.7m higher than plan and is due to year to date Net Assets 39,895 41,127 41,728 Capital and redundancy payments being £0.6m lower than plan. This will reduce to Surplus(Deficit) 0 1,232 1,833 Cash £10.3m by the end of 2014/15. General Fund b/f 31,700 31,700 31,700 Revaluation Reserve 7,993 7,993 7,993 Total Capital Resource Limit for 2014/15 is £7.1m. As at Month 6, the Public Dividend Capital 202 202 202 Trust had capitalised £2.1m (£1.7m at Month 5) of expenditure. This is Total Reserves 39,895 41,127 41,728 £0.3m ahead of plan and will be subject to monthly monitoring through the Capital Investment Group. QIPP Plan Summary CIP Target Identified RAG Adj YTD Plan YTD Act YTD V ar FOT Var The %age of Trust payables over 90 days was 9% and receivables 15% Identified against against compared to a target of 5%. Plan Target £'000 £'000 £'000 £'000 £'000 £'000 £'000 CSRR The Trust would achieve a CSRR of 4 out of 4 under the new Monitor Total CIPs 2013/14 11,958 11,592 10,024 4,994 4,096 -899 -2,270 Risk Assessment Framework. 70 15 Key Financial Risks

Risk Description Value RAG £000s

QIPP: Directorates have identified plans to achieve £11.6m of the £12.0m CIP target for 2014/15. 1 The forecast CIP as at Month 6 is only £9.7m; once the £2m CIP contingency reserve is factored in the residual risk is 0 Green £0.3m. This shortfall will be offset by funds identified in reserves which are no longer required for their original purpose.

CQUIN: The Trust has agreed the total level of CQUIN income for 2014/15 (C.£3.0m). Although the Trust has a good track- 2 record for achieving this form of income there is an underlying risk given it is variable and dependant on achieving -1,000 Amber outcomes. The Trust has established a CQUIN monitoring group and funded bids to achieve agreed milestones

Service Development Implementation Plan: As part of the annual contracting negotiations the Trust agreed investments from commissioners linked to achieving certain IT developments and transformation initiatives which are yet to be 3 -1,000 Amber quantified and risk assessed. The Trust is confident of achieving these schemes however there is a risk given this income stream is dependant on achieving and evidencing improvements. Pathology Charges: CLCH has been invoiced £365k for 13/14 Pathology charges (credit notes have been received against some invoices raised hence the reduction from the £500k reported in month 5) and £195k for months 1- 5 14/15 charges. CLCH has not historically been funded for this and up until now invoices have not been received for this service. The DD 4 -850 Amber of Resources and Performance has written to Imperial disputing the charges and the invoices have also been formally disputed through the Q2 Agreement of Balances exercise. CLCH will need to raise with commissioners if a resolution cannot be reached with Imperial. Escorts and Bed watchers: HMPS have invoiced CLCH £180k for the month of June whereas the normal monthly charge is 5 0 Green £40k. The increase is linked to a disabled patient. NHSE have now agreed to pay this increased cost in full .

Note: A negative number = a potential negative impact on the forecast A positive number = a potential positive impact on the forecast

71 16 Corporate and Service Transformation Summary

M6 CIP/QIPP position: Operational Divisions

Plan Forecast Variation Plan vs. YE FY Change in- Plan vs. M5 YE M6 YE Comments re: in month changes Comments re: gap to YE target including Target month YE pipeline

Following the instruction by the Director of FPCR for all Services within the Directorate to identify additional CIP opportunities in order for action to be Corp Inclusion of additional CIPs in Estates and S&BD have improved the YE forecast taken to ameliorate the impact of the Estates under-delivery, £3,834 £2,807 £3,016 £209 £818 £122 Servs slightly. Directors/Heads of Service have developed new schemes. In addition to those already in delivery, new pipeline schemes are being worked up in HR, Estates and IM&T. Pipeline schemes have an in-year value of £696,000.

Timescale of Admin review has resulted in reduction of £130k. Workforce management reduction of £28k as post was double counted in Admin review. Home to Clinic schemes have decreased by £224k, following initial pilot review. Merge of Additional schemes to meet this gap are currently being explored, including NNCR £1,511 £1,144 £713 -£431 CIS and CRT has decreased as timescale will not allow for savings in current year, £798 £658 freezing vacant posts. The development schemes total value is £108,000 however a vacant post will be frozen to compensate.Procurement efficients have not identified savings , and Con Care Restructure will not offer savings due to timescale to implement and pay protection. This forecast gap includes the expected further non-delivery within CIP2, 5 CIP2, 5, 16 actual finance figures were amended to £0 for all months against cost and 16. There is also further slippage within CIP9. Change Requests are code AXX105, as no further savings can be identified. A change request to amend BCSS £2,473 £2,143 £1,870 -£273 £603 in progress to move expected gaps in CIP 2,4, 5 and 16 into a new CIP that £157 the value of these CIPS is in progress for inclusion in M7 report, and the gap will be will focus on 2% savings across all divisional pay and non-pay. The addressed in CIP23 and other schemes. development schemes total value is £223,000 in year.

CHD £2,181 £2,137 £2,137 £0 No Changes in month £44 £44 Change in position is due to the following: Extra schemes will be indentifed to cover -£7,000 required 20. Invoicing for dental out of area patients, the CIP was removed after further advise from NHSE 25. Extra income from WICs have increased to £128,000

APC S £1,958 £1,900 £1,951 £51 £7 £7

Total £11,957 £10,131 £9,687 -£444

% gap to plan 15% 19% £ gap to plan (excluding pipeline potential) £2,270 £ gap to plan if current pipeline potential is included £988

Positive movement/position Negative movement/position No change in movement/position

72 17

BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Monthly Nurse Staffing Report

Agenda item number: 2.2

Report of: Chief Nurse and Director of Quality Governance

Contact Officer: Director of Patient Safety / Deputy Chief Curse

Relevant CLCH 14/15 Goal: Embody the best of the NHS for our patients

Freedom of Information Report can be made public Status

Executive Summary: This report provided the monthly performance against our set staffing numbers for in-patient beds as per the joint guidance to Trusts on the delivery of the ‘Hard Truths’ commitments associated with publishing staffing data regarding nursing, midwifery and care staff levels.

The report also considers our quality indicators alongside the staffing of these wards and units.

Appendix 1 shows the staffing return Appendix 2 shows the no. on shift when a medication error or fall occurred.

Assurance provided: Continued monitoring of staffing in line with national guidance. Continued six monthly reviews considering our staffing against the most up to date guidance.

Report provenance: NA

Report for: Decision Discussion Information

73

1. Purpose 1.1 To provide the Trust Board with assurance that the Hard Truths Commitments are being appropriately actioned and that the Trust is managing minimum staffing levels appropriately.

2. Introduction 2.1 NHS England and the Care Quality Commission have issued joint guidance to Trusts on the delivery of the ‘Hard Truths’ commitments associated with publishing staffing data regarding nursing, midwifery and care staff levels. The Trust Board has, in line with the guidance, approved minimum staffing levels for all bedded units across the Trust (Appendix One) and has received the action plan outlining the Trust’s commitment to meeting the national requirements. In June 2014 the Trust Board received the first report on actual staffing levels against agreed minimum staffing levels.

2.2 This paper informs the Trust Board of the monthly staffing levels. The paper also seeks to provide assurance both for the Trust Board and the public that any issues related to ward staffing are taken very seriously both by front line staff and the organisation as a whole.

2.3 Assurance is also provided within this paper that the Trust has met all of its commitments as outlined in the the guidance issued by Jane Cummings, Chief Nursing Officer for England, and Professor Sir Mike Richards, Chief Inspector of Hospitals, Care Quality Commission and our staffing information submitted to NHS Choices and displayed on our website.

3. Report 3.1 Monthly Summary of Staffing Levels and Associated Quality Indicators 100% of the Trust’s in-patient units submitted complete data on time, which has been reported to the national database via UNIFY.

Overall the Trust average fill rate for nursing and care staff was as follows:

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3.1.1 Garside Nursing Home The continuing care homes are running on high vacancies with a high percentage of bank and agency, due to the recruitment and retention issues resulting from the divestment process. Bank and agency do not arrive on a number of occasions. If RN not available HCAs are over booked. Where there are additional nurses they are providing 1-1 care as agreed with commissioners and the continuing care assessment team due to the complexity of the resident’s needs.

Regular recruitment drives in place, which have been largely unsuccessful and our commissioners are aware; The CLCH recruitment team has been asked to approach Nurse Agencies regarding a guaranteed work for next 6 months for Band 5 and Band 6 nurses - this is a new initiative and progress will be reported back through the DMT.

3.1.2 Athlone Nursing Home See 3.1.1

75

3.1.3 Jade Ward Staffing shortfall relates to RN vacancies and subsequent bank staff availability; additional HCA rostered where possible to mitigate and ensure care needs met. Recruitment in progress.

3.1.4 Marjorie Warren Ward Some patients requiring 1-1 care due to falls risks.

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3.1.5 Pembridge Unit This is a small service, where occasional altered staffing levels impact upon total percentage.

3.1.6 Princess Louise Nursing Home See 3.1.1

77

3.1.7 Athlone Rehab / Alexandra Rehab. Vacancies within the units have been successfully recruited to, with new staff starting in October.

3.2 Conclusion The Trust has adjusted its staffing establishments to meet the required numbers and has a clear policy of approving all staffing requests related to minimum numbers of staff or quality of care. Inevitably at times it will be difficult to staff to the full levels particularly to cover short term sickness but this is quickly highlighted and risk assessed.

78

4. Quality Implications and Clinical Input The implications of staffing levels falling below minimum numbers for a prolonged amount of time are significant. Incidents are being reviewed, and actions plans agreed between the Quality team and the operational team.

5. Equality Implications The majority of patients using continuing care beds are elderly and frail, many with reduced mental capacity. The Trust therefore recognises the importance of ensuring staffing levels are maintained at least at minimum levels so as not to compromise the safety of these vulnerable patients.

6. Comments of the Director of Finance, Performance & Corporate Resources Financial implications have been raised with commissioners regarding the staffing issues as a result of the transfer of the continuing care beds and agreement has been reached to fund the extra staffing costs.

7. Risks and Mitigating Actions As described in section 3. The risk relating to poor retention of staff in the continuing care homes has been added to the Trust risk register.

8. Consultation with Partner Organisations This paper will be shared with the Trust’s commissioning CCGs and monthly mandatory returns have been submitted on time.

9. Monitoring Performance With the database designed in house, staffing levels can be checked daily by any staff member who is given authorisation to use the system. This includes all Directors and Board members.

10. Recommendations 10.1 The Board is asked to confirm assurance in relation to the action being taken against the Hard Truth Commitments.

10.2 The Board is asked to note the staffing levels for September.

79 Unit: Athlone House Reason Codes Month: September 1 Sickness Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue 2 Unfilled bank shift 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3 Escort Number of patients 20 18 18 18 18 18 18 18 18 18 19 21 21 21 20 20 20 20 20 20 20 20 20 20 21 21 21 21 21 22 4 Special Agreed RN 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 Unauthorised absence Regular RN 2 1 1 2 2 1 2 2 1 2 2 2 1 1 2 2 2 2 2 1 2 2 2 2 1 2 1 1 2 2 6 Vacancies Bank RN 1 1 1 1 1 1 1 1 1 1 7 Annual Leave Agency RN 8 Mandatory Training Total 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Variance -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 Reason 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 Early: Agreed HCA 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Regular HCA 2 3 3 3 2 3 3 3 3 4 3 4 4 4 4 3 4 3 3 4 2 2 3 2 3 2 2 2 2 2 Bank HCA 2 1 1 1 2 1 1 1 1 1 1 1 1 2 2 1 2 1 2 2 2 2 2 Agency HCA Total 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Reason

Number of patients 20 18 18 18 18 18 18 18 18 18 19 21 21 21 20 20 20 20 20 20 20 20 20 20 21 21 21 21 21 22 Agreed RN 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular RN 1 2 1 1 1 1 2 2 1 2 1 1 1 2 2 1 2 2 2 2 1 2 2 2 1 2 1 1 2 1 Bank RN 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Agency RN Total 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Reason Late Agreed HCA 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Regular HCA 2 2 2 2 2 3 3 2 2 2 3 2 3 3 3 4 3 2 3 2 2 3 3 2 3 2 2 2 2 2 Bank HCA 2 2 2 2 2 1 1 2 2 2 1 2 1 1 1 1 2 1 2 2 1 1 2 1 2 2 2 2 2 Agency HCA Total 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Variance 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Reason 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

Number of patients 20 18 18 18 18 18 18 18 18 18 19 21 21 21 20 20 20 20 20 20 20 20 20 20 20 21 21 21 22 22 Agreed RN 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular RN 2 1 2 2 2 2 1 1 1 2 2 1 1 2 2 2 1 1 2 1 1 2 2 1 2 2 1 1 1 1 Bank RN 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Agency RN Total 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Reason Night Agreed HCA 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular HCA 2 2 1 2 1 1 1 1 1 2 1 2 1 1 1 2 1 2 1 1 2 2 2 2 1 2 1 1 1 2 Bank HCA 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Agency HCA Total 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Reason

80 Unit: Athlone Rehab Reason Codes Month: September 1 Sickness Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue 2 Unfilled bank shift 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3 Escort Number of patients 21 21 22 22 19 19 19 20 20 21 21 22 22 22 22 22 22 22 22 22 22 22 21 20 19 17 17 17 17 16 4 Special Agreed RN 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 Unauthorised absence Regular RN 2 3 2 1 2 2 3 1 2 2 3 1 3 3 2 1 2 3 2 2 3 3 3 3 3 1 3 2 3 6 Vacancies Bank RN 1 2 2 1 1 1 1 1 7 Annual Leave Agency RN 1 8 Mandatory Training Total 3 3 2 3 2 2 2 3 3 2 2 3 2 3 3 2 2 2 3 2 2 3 3 3 3 3 2 3 3 3 Variance 0 0 -1 0 -1 -1 -1 0 0 -1 -1 0 -1 0 0 -1 -1 -1 0 -1 -1 0 0 0 0 0 -1 0 0 0 7 7 7 7 7 7 7 Early: Reason Agreed HCA 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Regular HCA 5 6 6 6 6 6 5 5 6 5 5 4 6 5 6 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 Bank HCA 1 1 1 1 1 Agency HCA Total 5 6 6 6 6 6 5 6 6 5 5 5 6 5 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 Variance 1 2 2 2 2 2 1 2 2 1 1 1 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Reason

Number of patients 21 21 22 22 19 19 19 20 20 21 21 22 22 22 22 22 22 22 22 22 22 21 20 19 19 17 17 17 16 19 Agreed RN 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular RN 1 1 1 1 1 3 2 2 1 1 1 2 2 1 2 2 2 2 2 1 1 2 2 2 1 2 1 2 Bank RN 2 1 1 1 1 1 1 1 1 1 1 1 1 1 Agency RN 1 1 Total 2 2 2 2 2 2 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Variance 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 7 7 Late Reason Agreed HCA 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Regular HCA 5 4 5 5 4 4 4 3 5 6 4 3 5 5 4 5 5 5 5 5 5 5 5 4 5 5 5 5 4 5 Bank HCA 1 1 1 2 1 1 1 1 Agency HCA Total 5 5 5 5 5 5 4 5 5 6 5 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 4 5 Variance 1 1 1 1 1 1 0 1 1 2 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 Reason

Number of patients 21 21 22 22 19 19 19 20 20 21 21 22 22 22 22 22 22 22 22 22 22 21 20 20 19 17 17 17 16 19 Agreed RN 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular RN 2 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 2 2 2 1 2 Bank RN 1 1 1 1 2 1 1 1 1 2 1 2 Agency RN 1 1 1 1 1 1 Total 2 2 2 2 2 2 2 1 2 2 2 1 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 1 2 Variance 0 0 0 0 0 0 0 -1 0 0 0 -1 0 0 0 0 0 0 0 0 0 -1 0 0 0 0 0 0 -1 0 2 2 1 2 Night Reason Agreed HCA 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular HCA 1 1 1 1 2 2 1 2 1 1 2 2 2 2 2 2 2 1 2 2 2 2 1 2 1 2 2 2 2 2 Bank HCA 1 1 1 1 1 1 1 1 1 1 Agency HCA Total 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Reason

Agreed RN 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 Regular RN 4 5 5 3 4 2 6 6 2 5 4 5 2 6 6 4 4 5 5 5 4 5 6 7 6 7 4 7 4 7 3 2 1 4 1 4 0 0 3 0 1 1 4 1 0 2 2 1 2 1 2 1 1 0 0 0 1 0 2 0 Day Total Bank RN Agency RN 0 0 0 0 1 0 1 0 2 1 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 Total 7 7 6 7 6 6 7 6 7 6 6 6 6 7 7 6 6 6 7 6 6 6 7 7 7 7 6 7 6 7 Variance 0 0 -1 0 -1 -1 0 -1 0 -1 -1 -1 -1 0 0 -1 -1 -1 0 -1 -1 -1 0 0 0 0 -1 0 -1 0

Agreed HCA 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 Regular HCA 11 11 12 12 12 12 10 10 12 12 11 9 13 12 12 12 12 11 13 13 13 13 12 12 12 13 13 13 12 13 1 2 1 1 1 1 1 3 1 1 1 2 0 0 1 1 1 2 0 0 0 0 1 1 1 0 0 0 0 0 Day Total Bank HCA Agency HCA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total 12 13 13 13 13 13 11 13 13 13 12 11 13 12 13 13 13 13 13 13 13 13 13 13 13 13 13 13 12 13 Variance 2 3 3 3 3 3 1 3 3 3 2 1 3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 3

Summary of key risks & challenges Corrective action plan

81 Unit: Garside House Reason Codes Month: September 1 Sickness Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue 2 Unfilled bank shift 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3 Escort Number of patients 38 38 37 36 36 35 35 35 35 35 35 35 35 35 35 36 37 37 37 37 37 37 37 37 37 37 37 37 38 38 4 Special Agreed RN 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 Unauthorised absence Regular RN 3 3 2 2 2 2 3 4 4 2 3 4 2 3 2 3 2 3 3 2 3 4 2 2 2 3 3 3 4 6 Vacancies Bank RN 1 1 2 1 1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 1 2 1 7 Annual Leave Agency RN 1 2 1 1 1 1 1 1 1 1 1 2 1 1 8 Mandatory Training Total 4 4 4 4 3 3 3 4 4 5 4 4 4 4 4 4 6 4 4 4 4 4 4 4 4 4 6 4 4 4 Variance 0 0 0 0 -1 -1 -1 0 0 1 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 2 0 0 0 2 2 1 4 4 Early: Reason Agreed HCA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 Regular HCA 2 5 5 2 3 4 4 4 4 6 3 4 4 4 3 4 4 3 2 3 1 2 3 3 3 4 3 3 4 Bank HCA 2 1 1 3 3 1 1 1 1 3 2 1 2 1 2 1 2 3 2 2 3 2 2 1 2 1 2 2 1 Agency HCA 2 1 1 1 1 1 1 1 1 1 1 4 2 2 1 1 1 1 1 1 1 1 2 1 Total 6 6 6 5 6 6 6 6 6 10 6 6 6 6 6 6 6 6 6 6 6 5 5 6 5 6 6 6 7 6 Variance 0 0 0 -1 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 -1 -1 0 -1 0 0 0 1 0 Reason 1 4 4 4 4 4 4 1 2

Number of patients 38 38 37 36 35 35 35 35 35 35 35 35 35 35 35 36 37 37 37 37 37 37 37 37 37 37 37 37 38 38 Agreed RN 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Regular RN 4 2 3 1 2 1 2 2 2 2 2 2 3 3 3 3 3 2 3 3 1 2 2 2 3 2 1 3 3 2 Bank RN 1 2 1 1 1 2 1 1 1 1 2 1 1 1 1 1 1 1 2 1 1 1 Agency RN 1 1 2 2 1 1 1 1 1 1 1 1 1 1 3 1 1 1 1 Total 4 3 4 4 4 4 4 4 4 3 4 4 4 4 4 4 6 4 4 4 4 4 3 4 4 4 4 4 4 3 Variance 1 0 1 1 1 1 1 1 1 0 1 1 1 1 1 1 3 1 1 1 1 1 0 1 1 1 1 1 1 0 1 4 Late Reason Agreed HCA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 Regular HCA 4 4 5 4 2 2 3 3 3 4 3 2 4 3 3 3 3 2 3 2 3 2 4 3 2 3 2 3 3 3 Bank HCA 1 1 1 3 1 2 2 2 2 3 3 1 3 3 1 1 4 3 2 3 4 1 2 2 2 2 3 3 1 Agency HCA 2 1 1 1 3 1 1 2 2 1 1 3 3 2 2 1 1 2 1 2 3 3 2 Total 6 6 6 6 6 6 6 6 7 8 6 6 6 6 6 7 7 6 6 6 6 8 6 6 6 6 6 9 9 6 Variance 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 1 1 0 0 0 0 2 0 0 0 0 0 3 3 0 Reason 4 4 4 4 4 4 2 2

Number of patients 38 38 37 36 35 35 35 35 35 35 35 35 35 35 35 36 37 37 37 37 37 37 37 37 37 37 37 37 38 38 Agreed RN 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Regular RN 2 1 1 1 1 1 2 2 1 2 2 1 2 2 2 2 2 2 2 2 2 1 2 2 2 2 1 2 2 1 Bank RN 1 1 2 2 1 1 1 2 1 1 1 1 Agency RN 1 2 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 Total 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Night Reason Agreed HCA 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Regular HCA 2 1 2 2 3 2 2 2 2 3 2 1 3 3 4 4 4 3 2 3 4 4 4 2 1 2 3 2 Bank HCA 1 2 1 3 2 2 2 1 2 2 3 3 3 3 2 1 1 2 1 1 1 1 1 3 3 1 2 Agency HCA 1 2 1 1 1 1 1 2 2 1 1 1 2 1 1 1 1 1 Total 4 5 4 5 5 4 5 4 5 5 5 5 5 5 5 5 5 5 5 5 5 4 5 5 5 4 5 5 5 5 Variance 0 1 0 1 1 0 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0 1 1 1 1 Reason 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Agreed RN 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 Regular RN 9 6 6 4 3 4 6 7 7 8 6 6 9 7 8 7 8 6 8 8 5 6 8 6 7 6 5 8 8 7 0 1 1 3 6 4 2 2 2 2 2 3 0 1 2 1 6 2 2 1 2 4 2 3 2 1 5 2 2 1 Day Total Bank RN Agency RN 2 3 4 4 1 2 2 2 2 1 3 2 2 3 1 3 1 3 1 3 3 1 0 2 2 4 3 1 1 2 Total 11 10 11 11 10 10 10 11 11 11 11 11 11 11 11 11 15 11 11 12 10 11 10 11 11 11 13 11 11 10 Variance 1 0 1 1 0 0 0 1 1 1 1 1 1 1 1 1 5 1 1 2 0 1 0 1 1 1 3 1 1 0

Agreed HCA 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 16 Regular HCA 8 10 12 8 8 8 9 9 9 13 8 7 8 7 9 10 7 10 10 7 8 6 10 10 9 8 7 8 9 9 3 4 3 7 8 4 5 4 5 7 8 7 6 7 7 3 3 4 7 4 7 8 4 5 4 5 6 8 6 4 Day Total Bank HCA Agency HCA 5 3 1 1 1 4 3 3 4 3 1 3 3 3 1 5 8 3 0 6 2 3 2 2 3 3 4 4 6 4 Total 16 17 16 16 17 16 17 16 18 23 17 17 17 17 17 18 18 17 17 17 17 17 16 17 16 16 17 20 21 17 Variance 0 1 0 0 1 0 1 0 2 7 1 1 1 1 1 2 2 1 1 1 1 1 0 1 0 0 1 4 5 1

Summary of key challenges and risks Corrective action plan

The continuing care homes are running on high vacancies with a high percentage of bank and agency, due to the recruitment and retention issues Regular recruitment drives in place, which have been largely unsuccessful; resulting from the divestment process. Bank and agency do not arrive on a commissioners aware; CLCH recruitment team asked to approach Nurse number of occasions. If RN not available (red) HCAs are over booked (yellow). Agencies regarding a guaranteed work for next 6 months for Band 5 and Band Where there are additional nurses they are providing 1-1 care as agreed with 6 nurses - this is a new initiative and progress will be reported back through the commissioners and the continuing care assessment team due to the complexity DMT. of the residents needs.

82 Unit: Princess Louise Reason Codes Month: September 1 Sickness Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue 2 Unfilled bank shift 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3 Escort Number of patients 42 42 42 42 43 43 42 42 42 42 42 42 42 42 42 43 45 45 44 44 44 44 44 43 43 43 44 44 44 43 4 Special Agreed RN 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Unauthorised absence Regular RN 2 3 4 3 3 2 1 4 3 3 3 4 1 1 4 3 3 3 2 2 2 3 2 3 3 2 2 2 2 3 6 Vacancies Bank RN 1 1 2 2 1 1 3 3 1 1 1 2 2 2 2 1 1 2 2 1 2 7 Annual Leave Agency RN 1 8 Mandatory Training Total 3 4 4 4 3 4 3 4 3 4 4 4 4 4 4 4 4 4 4 4 4 3 4 4 3 3 4 4 3 5 Variance -2 -1 -1 -1 -2 -1 -2 -1 -2 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -2 -1 -1 -2 -2 -1 -1 -2 0 7 6 7 7 7 6 6 6 2 2 2 2 6 6 2 2 2 2 2 6 6 2 8 2 2 6 6 6 6 Early: Reason Agreed HCA 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 Regular HCA 2 4 5 5 4 2 5 5 6 4 4 5 4 6 2 5 5 4 3 5 4 4 1 3 3 1 4 4 4 3 Bank HCA 5 2 4 3 5 6 5 5 4 5 5 4 3 2 8 4 5 5 6 4 5 5 8 6 7 6 3 3 5 6 Agency HCA 3 1 1 1 1 1 Total 10 7 9 9 9 8 10 10 10 9 9 9 8 8 10 9 10 9 9 9 9 9 9 9 10 7 8 8 9 9 Variance 2 -1 1 1 1 0 2 2 2 1 1 1 0 0 2 1 2 1 1 1 1 1 1 1 2 -1 0 0 1 1 Reason 6 6 4 4 4 6 4 4 4 4 4 4 5 4 4 3 4 4 4 4 4 4 2 3 4

Number of patients 42 42 42 42 43 43 42 42 42 42 42 42 42 42 42 43 45 45 44 44 44 44 44 43 43 43 44 44 44 43 Agreed RN 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Regular RN 1 2 3 2 2 1 1 2 1 2 2 2 2 2 2 2 2 1 2 2 2 2 1 1 3 2 2 Bank RN 2 2 1 3 2 1 2 1 4 1 2 2 1 1 1 1 2 2 1 2 4 3 2 4 1 1 2 Agency RN 1 1 1 Total 3 3 3 4 4 4 3 3 3 3 4 3 4 4 3 3 4 3 3 4 3 2 4 4 4 3 4 4 3 4 Variance -1 -1 -1 0 0 0 -1 -1 -1 -1 0 -1 0 0 -1 -1 0 -1 -1 0 -1 -2 0 0 0 -1 0 0 -1 0 6 6 2 6 2 2 2 2 2 2 2 2 2 2 6 1 Late Reason Agreed HCA 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 Regular HCA 2 2 3 4 5 3 3 2 6 5 5 4 3 2 4 7 2 6 4 6 3 2 2 1 4 3 4 4 3 3 Bank HCA 2 5 7 5 3 5 6 8 4 5 4 4 5 6 6 1 5 4 4 2 7 7 6 6 4 7 5 4 6 6 Agency HCA 5 Total 9 7 10 9 8 8 9 10 10 10 9 8 8 8 10 8 7 10 8 8 10 9 8 7 8 10 9 8 9 9 Variance 1 -1 2 1 0 0 1 2 2 2 1 0 0 0 2 0 -1 2 0 0 2 1 0 -1 0 2 1 0 1 1 Reason 4 6 4 4 6 4 4 4 4 4 2 4 4 4 2 4 4 4 4

Number of patients 42 42 42 42 43 43 42 42 42 42 42 42 42 42 42 43 45 45 44 44 44 44 44 43 43 43 44 44 44 Agreed RN 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular RN 2 2 1 1 1 2 2 2 1 1 1 2 2 1 1 1 1 2 1 2 2 1 1 1 1 2 2 1 1 Bank RN 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Agency RN 1 1 Total 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 2 2 2 2 2 2 2 2 2 2 2 2 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 Reason 2 Night Agreed HCA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 Regular HCA 5 4 5 3 5 6 5 4 3 6 6 5 2 3 5 5 4 4 4 5 4 6 5 5 4 4 3 3 4 4 Bank HCA 1 2 1 3 1 1 2 3 1 4 3 1 1 2 2 2 1 2 1 1 2 2 3 3 2 2 Agency HCA Total 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Reason

Agreed RN 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 Regular RN 5 7 8 6 6 5 4 8 5 6 4 8 5 4 7 6 6 7 4 6 6 6 4 4 5 4 4 7 5 6 3 0 0 4 2 5 4 1 3 3 6 1 5 6 2 3 3 3 5 4 3 1 5 6 4 4 6 3 3 5 Day Total Bank RN Agency RN 0 2 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 Total 8 9 9 10 9 10 8 9 8 9 10 9 10 10 9 9 10 10 9 10 9 7 10 10 9 8 10 10 8 11 Variance -3 -2 -2 -1 -2 -1 -3 -2 -3 -2 -1 -2 -1 -1 -2 -2 -1 -1 -2 -1 -2 -4 -1 -1 -2 -3 -1 -1 -3 0

Agreed HCA 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 Regular HCA 9 10 13 12 14 11 13 11 15 15 15 14 9 11 11 17 11 14 11 16 11 12 8 9 11 8 11 11 11 10 8 9 12 11 9 11 12 15 11 10 9 9 12 11 15 6 12 11 12 7 14 12 15 13 13 15 11 10 13 14 Day Total Bank HCA Agency HCA 8 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 Total 25 20 25 24 23 22 25 26 26 25 24 23 22 22 26 23 23 25 23 23 25 24 23 22 24 23 23 22 24 24 Variance 3 -2 3 2 1 0 3 4 4 3 2 1 0 0 4 1 1 3 1 1 3 2 1 0 2 1 1 0 2 2

Summary of key challenges & risks Corrective action plan

The continuing care homes are running on high vacancies with a high percentage of bank and agency, due to the recruitment and retention issues Regular recruitment drives in place, which have been largely unsuccessful; resulting from the divestment process. Bank and agency do not arrive on a commissioners aware; CLCH recruitment team asked to approach Nurse number of occasions. If RN not available (red) HCAs are over booked (yellow). Agencies regarding a guaranteed work for next 6 months for Band 5 and Band 6 Where there are additional nurses they are providing 1-1 care as agreed with nurses - this is a new initiative and progress will be reported back through the commissioners and the continuing care assessment team due to the complexity DMT. of the residents needs.

83 Unit: Princess Louise Rehab Reason Codes Month: September 1 Sickness Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue 2 Unfilled bank shift 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3 Escort Number of patients 7 6 6 8 9 8 8 7 7 7 6 6 6 6 6 6 5 5 7 7 7 7 9 10 10 9 9 9 9 9 4 Special Agreed RN 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 5 Unauthorised absence Regular RN 1 1 1 1 1 1 1 1 1 2 1 1 2 2 1 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 6 Vacancies Bank RN 7 Annual Leave Agency RN 8 Mandatory Training Total 1 1 1 1 1 1 1 1 1 2 1 1 2 2 1 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 Variance -1 -1 -1 -1 -1 -1 -1 -1 -1 0 -1 -1 0 0 -1 0 -1 -1 -1 -1 -1 0 -1 -1 -1 -1 -1 -1 -1 -1 Early: Reason Agreed HCA 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular HCA 1 1 1 2 1 1 1 1 1 1 2 1 1 2 1 2 1 1 1 1 1 2 2 1 1 Bank HCA 1 1 1 1 1 1 1 2 1 2 1 1 2 1 1 1 1 1 1 1 Agency HCA Total 2 2 2 2 2 2 2 2 2 1 2 2 2 1 1 1 2 2 2 2 2 1 2 2 2 1 2 2 2 2 Variance 0 0 0 0 0 0 0 0 0 -1 0 0 0 -1 -1 -1 0 0 0 0 0 -1 0 0 0 -1 0 0 0 0 Reason

Number of patients 6 6 8 9 8 8 8 7 7 7 6 6 6 6 6 5 5 7 7 7 7 7 10 10 9 9 9 9 9 9 Agreed RN 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Regular RN 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 Bank RN Agency RN Total 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 Variance 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 Late Reason Agreed HCA 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Regular HCA 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 1 Bank HCA 1 1 1 1 2 1 1 1 2 1 2 2 1 1 2 1 1 1 1 1 1 1 1 Agency HCA 1 Total 1 2 2 2 2 2 2 2 2 1 2 2 2 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 Variance 0 1 1 1 1 1 1 1 1 0 1 1 1 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 Reason

Number of patients 7 6 8 9 8 8 8 7 7 7 6 6 6 6 6 5 5 7 7 7 7 7 10 10 9 9 9 9 9 9 Agreed RN 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Regular RN 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Bank RN Agency RN Total 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Reason Night Agreed HCA 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular HCA 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Bank HCA 1 1 1 1 1 1 Agency HCA Total 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Variance -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 Reason

Agreed RN 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Regular RN 3 3 3 3 3 3 3 3 3 5 3 3 4 4 3 5 3 3 3 3 3 5 3 3 3 3 3 3 3 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Day Total Bank RN Agency RN 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total 3 3 3 3 3 3 3 3 3 5 3 3 4 4 3 5 3 3 3 3 3 5 3 3 3 3 3 3 3 3 Variance -1 -1 -1 -1 -1 -1 -1 -1 -1 1 -1 -1 0 0 -1 1 -1 -1 -1 -1 -1 1 -1 -1 -1 -1 -1 -1 -1 -1

Agreed HCA 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Regular HCA 2 3 3 4 2 3 3 3 1 3 3 1 3 3 1 2 3 3 1 4 3 2 2 2 2 1 5 5 4 3 2 2 2 1 3 2 2 2 4 0 2 4 2 0 2 1 1 2 4 1 2 2 3 3 3 2 0 0 1 2 Day Total Bank HCA Agency HCA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 Total 4 5 5 5 5 5 5 5 5 3 5 5 5 3 3 3 4 5 5 5 5 4 5 5 5 4 5 5 5 5 Variance -1 0 0 0 0 0 0 0 0 -2 0 0 0 -2 -2 -2 -1 0 0 0 0 -1 0 0 0 -1 0 0 0 0

Summary of key challenges & risks Corrective action plan

84 Unit: Jade Ward Reason Codes Month: September 1 Sickness Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue 2 Unfilled bank shift 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3 Escort Number of patients 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 4 Special Agreed RN 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 Unauthorised absence Regular RN 2 3 4 2 3 3 1 3 1 3 3 2 2 1 3 2 3 3 4 2 1 2 4 4 2 2 2 2 4 3 6 Vacancies Bank RN 1 2 1 1 1 1 1 1 1 2 1 1 7 Annual Leave Agency RN 2 2 2 1 1 2 3 1 1 1 2 2 1 8 Mandatory Training Total 4 4 4 4 4 4 4 3 3 3 4 4 4 4 3 3 4 3 4 4 3 2 4 4 4 4 4 4 4 4 9 Competency Training Variance 0 0 0 0 0 0 0 -1 -1 -1 0 0 0 0 -1 -1 0 -1 0 0 -1 -2 0 0 0 0 0 0 0 0 1 2 2 2 2 2 2 2 Early: Reason Agreed HCA 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Regular HCA 1 1 1 1 3 2 1 1 2 2 2 1 1 1 1 1 1 1 1 2 2 2 1 Bank HCA 2 2 1 1 1 1 2 1 1 1 2 1 2 1 1 2 1 1 1 1 1 1 Agency HCA 2 1 1 2 4 1 1 1 2 1 1 1 1 2 2 1 3 1 2 1 2 1 1 Total 3 3 3 3 4 3 3 5 3 2 3 4 3 2 4 3 3 3 3 3 4 3 3 4 3 3 3 3 3 3 Variance 0 0 0 0 1 0 0 2 0 -1 0 1 0 -1 1 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 Reason 3 3 2 3 2 3 3

Number of patients 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 Agreed RN 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Regular RN 1 2 3 2 2 1 1 3 1 1 1 2 1 3 2 2 2 2 2 2 2 1 3 1 2 1 1 Bank RN 1 1 1 1 1 1 1 1 1 Agency RN 1 1 1 1 1 2 2 1 2 1 1 1 1 1 1 1 2 2 1 2 Total 3 3 3 3 2 2 2 2 3 3 3 2 3 3 3 3 2 3 3 3 3 3 3 3 2 3 3 3 2 3 Variance 0 0 0 0 -1 -1 -1 -1 0 0 0 -1 0 0 0 0 -1 0 0 0 0 0 0 0 -1 0 0 0 -1 0 2 2 2 1 2 2 2 2 Late Reason Agreed HCA 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Regular HCA 2 2 1 2 1 1 1 1 1 2 3 2 2 2 3 2 1 2 2 2 1 2 Bank HCA 2 1 1 1 3 1 1 1 2 1 2 1 3 2 3 1 1 1 Agency HCA 1 1 2 1 1 2 1 2 1 2 1 1 3 1 1 1 1 1 1 1 1 Total 3 3 3 3 5 4 3 3 3 3 3 3 3 3 4 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Variance 0 0 0 0 2 1 0 0 0 0 0 0 0 0 1 -1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Reason 3 2 3 1

Number of patients 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 Agreed RN 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Regular RN 1 1 1 1 1 1 1 1 1 1 1 Bank RN 1 1 1 1 1 1 1 2 1 1 1 1 2 1 Agency RN 1 2 2 3 3 3 2 2 3 2 1 1 1 1 2 1 1 2 2 3 3 3 2 2 1 1 3 3 3 Total 2 3 2 3 3 3 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 Variance -1 0 -1 0 0 0 0 0 0 0 -1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1 0 0 0 2 2 2 2 Night Reason Agreed HCA 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular HCA 2 1 1 1 1 1 1 2 1 1 2 2 2 2 2 2 2 1 2 2 2 2 2 2 1 1 1 1 1 1 Bank HCA 1 1 1 1 1 1 1 1 1 1 1 1 Agency HCA 1 1 1 1 1 Total 2 2 2 2 2 2 2 2 2 2 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Variance 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Reason 2 4

Agreed RN 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 Regular RN 3 5 7 4 5 4 2 4 4 5 4 4 4 4 5 6 5 5 6 4 3 4 6 6 3 6 3 4 5 4 2 2 0 3 1 1 2 1 0 0 1 2 1 1 1 2 3 1 1 1 2 1 2 1 2 3 1 0 1 0 Day Total Bank RN Agency RN 4 3 2 3 3 4 5 3 5 4 4 3 5 5 3 1 1 3 3 5 4 3 2 3 4 1 5 6 3 6 Total 9 10 9 10 9 9 9 8 9 9 9 9 10 10 9 9 9 9 10 10 9 8 10 10 9 10 9 10 9 10 Variance -1 0 -1 0 -1 -1 -1 -2 -1 -1 -1 -1 0 0 -1 -1 -1 -1 0 0 -1 -2 0 0 -1 0 -1 0 -1 0

Agreed HCA 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 Regular HCA 3 3 4 3 2 6 4 2 2 2 4 4 6 5 6 4 4 2 5 6 3 3 3 5 3 3 5 5 4 4 2 3 4 3 5 2 3 2 4 2 4 1 0 2 1 1 2 0 0 1 3 3 5 1 3 2 1 3 3 2 Day Total Bank HCA Agency HCA 3 2 0 2 4 1 1 6 2 3 1 5 2 0 3 2 2 6 3 1 3 2 0 3 2 3 2 0 1 2 Total 8 8 8 8 11 9 8 10 8 7 9 10 8 7 10 7 8 8 8 8 9 8 8 9 8 8 8 8 8 8 Variance 0 0 0 0 3 1 0 2 0 -1 1 2 0 -1 2 -1 0 0 0 0 1 0 0 1 0 0 0 0 0 0

Summary of key challenges & risks Corrective actoin plan

RN VACANCIES ACTIVE RECRUITMENT IN PROGRESS

85 Unit: Marjory Warren Reason Codes Month: September 1 Sickness Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue 2 Unfilled bank shift 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3 Escort Number of patients 34 34 33 33 34 34 32 32 32 34 34 34 34 34 34 33 31 32 32 32 33 33 32 34 34 32 32 32 32 33 4 Special Agreed RN 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Unauthorised absence Regular RN 4 2 5 3 3 4 4 5 2 3 4 5 3 3 5 2 4 2 3 4 4 4 4 4 5 5 5 3 3 3 6 Vacancies Bank RN 1 1 1 1 7 Annual Leave Agency RN 2 1 1 1 2 2 2 1 1 1 1 1 1 1 1 1 2 8 Mandatory Training Total 4 4 5 4 4 5 5 7 4 5 5 5 5 4 5 3 5 4 4 4 4 4 4 5 5 5 5 4 4 5 9 Competency Training Variance -1 -1 0 -1 -1 0 0 2 -1 0 0 0 0 -1 0 -2 0 -1 -1 -1 -1 -1 -1 0 0 0 0 -1 -1 0 Reason 2 2 2 2 7 8 2 2 2 2 1 2 2 2 2 2 Early: Agreed HCA 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Regular HCA 2 3 3 2 1 3 3 3 3 2 2 2 2 3 2 3 2 1 2 3 3 2 1 4 2 4 3 Bank HCA 2 2 1 1 2 2 1 2 2 2 1 1 2 1 2 1 2 3 4 1 1 3 3 1 3 1 Agency HCA 2 1 2 1 1 1 1 1 1 1 2 1 4 2 1 2 1 2 2 1 Total 4 5 5 3 3 5 6 6 4 5 5 5 4 4 5 6 5 6 4 4 6 4 6 6 4 6 3 5 5 4 Variance 1 2 2 0 0 2 3 3 1 2 2 2 1 1 2 3 2 3 1 1 3 1 3 3 1 3 0 2 2 1 Reason 4 3 3 4 4 4 8 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Number of patients 34 34 34 33 33 32 32 32 34 34 34 34 34 34 31 33 32 32 33 33 33 32 34 34 32 32 32 33 33 Agreed RN 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Regular RN 4 2 3 4 3 3 3 3 3 3 2 3 3 3 2 2 2 3 2 3 4 3 4 4 3 4 3 3 4 3 Bank RN 1 1 1 1 Agency RN 1 1 1 1 2 1 1 1 1 1 1 1 2 1 1 1 1 Total 4 4 4 4 3 4 4 5 4 3 4 3 4 4 4 3 2 4 4 3 4 4 4 4 4 4 4 4 4 4 Variance 0 0 0 0 -1 0 0 1 0 -1 0 -1 0 0 0 -1 -2 0 0 -1 0 0 0 0 0 0 0 0 0 0 Reason 4 2 2 2 2 1 4 2 Late Agreed HCA 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Regular HCA 2 3 2 2 1 1 2 1 1 2 2 2 3 3 2 2 3 2 1 3 1 3 2 2 2 3 2 2 Bank HCA 2 1 1 1 1 3 2 2 3 3 3 1 1 1 1 1 2 1 1 4 5 1 3 1 2 2 2 1 2 2 Agency HCA 1 1 1 1 1 1 2 3 1 1 1 2 1 2 1 Total 4 4 3 3 3 5 5 4 4 5 6 4 4 4 5 4 5 5 4 7 6 4 6 4 4 4 4 4 5 4 Variance 1 1 0 0 0 2 2 1 1 2 3 1 1 1 2 1 2 2 1 4 3 1 3 1 1 1 1 1 2 1 Reason 4 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 4 4 4 4 4 4 4

Number of patients 34 33 33 34 34 32 32 32 34 34 34 34 34 34 33 31 33 32 32 33 33 33 34 34 34 32 32 32 33 33 Agreed RN 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 Regular RN 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 2 2 2 2 1 1 1 Bank RN 1 1 1 1 2 3 2 1 1 1 1 3 2 2 1 2 1 1 2 2 1 1 1 2 2 2 Agency RN 1 1 1 1 1 1 2 1 2 1 1 1 Total 3 3 3 2 2 3 3 3 3 3 3 3 2 3 3 2 2 3 3 4 3 3 3 3 3 3 3 3 3 3 Variance 0 0 0 -1 -1 0 0 0 0 0 0 0 -1 0 0 -1 -1 0 0 1 0 0 0 0 0 0 0 0 0 0 Reason 2 2 2 2 Night Agreed HCA 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular HCA 1 2 2 1 1 2 2 1 1 1 2 2 2 2 2 2 2 1 2 2 2 3 1 3 2 2 1 Bank HCA 1 3 2 1 1 1 2 3 3 1 2 4 5 3 3 3 2 3 3 3 1 1 1 2 2 Agency HCA 1 1 1 2 1 1 1 1 3 1 1 1 2 2 3 1 1 1 Total 3 2 2 4 3 4 4 4 4 4 5 4 4 5 4 5 5 5 6 5 5 5 7 5 6 3 5 4 3 3 Variance 1 0 0 2 1 2 2 2 2 2 3 2 2 3 2 3 3 3 4 3 3 3 5 3 4 1 3 2 1 1 Reason 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Agreed RN 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 12 Regular RN 10 5 9 8 7 8 7 9 6 7 7 9 7 6 8 5 6 7 6 8 9 7 9 10 10 11 10 7 8 7 1 2 1 0 2 2 3 2 1 1 2 0 2 3 3 0 2 2 2 1 1 2 2 1 0 1 1 2 3 3 Day Total Bank RN Agency RN 0 4 2 2 0 2 2 4 4 3 3 2 2 2 1 3 1 2 3 2 1 2 0 1 2 0 1 2 0 2 Total 11 11 12 10 9 12 12 15 11 11 12 11 11 11 12 8 9 11 11 11 11 11 11 12 12 12 12 11 11 12 Variance -1 -1 0 -2 -3 0 0 3 -1 -1 0 -1 -1 -1 0 -4 -3 -1 -1 -1 -1 -1 -1 0 0 0 0 -1 -1 0

Agreed HCA 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 Regular HCA 5 8 7 5 3 6 7 5 5 4 5 6 7 8 4 3 6 6 4 3 3 8 6 7 6 7 7 5 8 6 5 3 1 5 4 4 5 5 6 8 8 4 4 2 7 7 7 5 6 9 12 5 7 5 5 3 4 6 2 5 Day Total Bank HCA Agency HCA 1 0 2 0 2 4 3 4 1 2 3 3 1 3 3 5 2 5 4 4 2 0 6 3 3 3 1 2 3 0 Total 11 11 10 10 9 14 15 14 12 14 16 13 12 13 14 15 15 16 14 16 17 13 19 15 14 13 12 13 13 11 Variance 3 3 2 2 1 6 7 6 4 6 8 5 4 5 6 7 7 8 6 8 9 5 11 7 6 5 4 5 5 3

Summary of key challenges & risks Corrective action plan

Patients in room 23 and 39 are still one to one. High risk of fall patients, Rn Active recruitment for RN's in progress vacancies requests not filled by bank

86 Unit: Pembridge Reason Codes Month: September 1 Sickness Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue 2 Unfilled bank shift 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3 Escort Number of patients 9 10 10 9 8 6 7 7 5 5 6 7 8 8 8 6 6 6 8 8 6 7 7 8 8 10 10 11 9 10 4 Special Agreed RN 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 Unauthorised absence Regular RN 3 2 3 3 1 2 1 2 2 2 2 2 2 2 2 2 1 1 2 2 2 2 4 1 2 2 2 3 3 6 Vacancies Bank RN 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 7 Annual Leave Agency RN 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 1 1 2 1 2 1 1 1 1 8 Mandatory Training Total 4 4 4 3 3 3 3 3 3 4 4 3 4 3 3 4 3 4 4 4 4 4 4 4 4 2 4 4 4 4 Variance 0 0 0 -1 -1 -1 -1 -1 -1 0 0 -1 0 -1 -1 0 -1 0 0 0 0 0 0 0 0 -2 0 0 0 0 1 6 2 2 2 2 2 2 2 Early: Reason Agreed HCA 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular HCA 1 1 2 1 1 1 1 1 1 1 1 2 1 2 1 1 1 2 2 2 1 1 1 1 1 1 2 Bank HCA 1 1 2 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 Agency HCA 1 1 1 1 1 Total 2 2 2 2 3 3 2 2 3 2 2 2 2 3 3 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 Variance 0 0 0 0 1 1 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 -1 0 0 0 0 0 0 0 Reason 6 6 2 1 2

Number of patients 9 10 10 9 7 7 7 5 5 6 7 8 8 8 8 6 6 6 8 8 6 7 7 8 10 10 11 10 10 10 Agreed RN 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular RN 2 2 2 2 2 1 1 2 2 2 1 2 1 1 2 1 2 2 1 1 1 3 2 2 2 2 2 2 3 2 Bank RN 1 1 Agency RN 1 1 1 1 1 1 1 Total 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 2 2 2 2 2 2 3 2 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 6 6 Late Reason Agreed HCA 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular HCA 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 Bank HCA 1 1 2 1 1 2 2 1 2 1 1 1 1 1 2 1 1 1 1 1 2 1 2 1 1 1 Agency HCA Total 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 1 2 Variance 0 0 0 0 0 0 -1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -1 0 0 0 0 0 0 -1 0 Reason 2 6 6

Number of patients 9 9 8 9 6 7 7 5 5 6 7 8 8 1 8 6 6 6 8 8 6 7 6 8 10 10 11 11 10 9 Agreed RN 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Regular RN 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 Bank RN 1 1 1 1 1 1 1 1 1 1 2 2 2 Agency RN 1 1 1 1 1 1 1 Total 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Night Reason Agreed HCA 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Regular HCA 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Bank HCA 1 1 1 1 Agency HCA Total 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Variance 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Reason

Agreed RN 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 Regular RN 7 6 7 7 4 4 3 5 5 5 4 5 4 4 5 4 4 4 4 4 4 7 8 5 6 2 4 4 8 7 0 1 0 0 2 2 3 0 2 2 2 1 1 1 0 2 1 1 0 2 1 0 0 2 0 4 3 3 0 0 Day Total Bank RN Agency RN 1 1 1 0 1 1 1 2 0 1 2 1 3 2 2 2 2 3 4 2 3 2 0 1 2 0 1 1 1 1 Total 8 8 8 7 7 7 7 7 7 8 8 7 8 7 7 8 7 8 8 8 8 9 8 8 8 6 8 8 9 8 Variance 0 0 0 -1 -1 -1 -1 -1 -1 0 0 -1 0 -1 -1 0 -1 0 0 0 0 1 0 0 0 -2 0 0 1 0

Agreed HCA 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Regular HCA 2 2 0 3 3 2 3 2 4 3 2 3 4 3 4 2 2 3 3 4 5 3 2 2 3 2 3 3 3 4 3 3 5 2 2 3 1 3 1 2 3 2 1 2 1 3 3 2 2 1 0 1 2 3 2 3 2 2 1 1 Day Total Bank HCA Agency HCA 0 0 0 0 1 1 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total 5 5 5 5 6 6 4 5 6 5 5 5 5 6 6 5 5 5 5 5 5 4 4 5 5 5 5 5 4 5 Variance 0 0 0 0 1 1 -1 0 1 0 0 0 0 1 1 0 0 0 0 0 0 -1 -1 0 0 0 0 0 -1 0

Summary of key challenges & risks Corrective action plan

87 Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Agreed RN 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 62 Regular RN 44 37 44 37 34 32 35 42 33 46 36 39 37 40 44 41 38 38 41 39 35 45 49 45 42 44 35 39 44 42 Trust Total Bank RN 7 10 5 11 13 15 11 6 11 5 9 9 11 8 6 8 15 8 7 8 10 8 7 8 6 9 14 10 9 6 RN Agency RN 7 11 9 9 6 9 11 11 13 10 13 8 12 12 8 9 5 11 11 12 11 8 2 7 11 5 11 10 5 11 Total 58 58 58 57 53 56 57 59 57 61 58 56 60 60 58 58 58 57 59 59 56 61 58 60 59 58 60 59 58 59 Variance -4 -4 -4 -5 -9 -6 -5 -3 -5 -1 -4 -6 -2 -2 -4 -4 -4 -5 -3 -3 -6 -1 -4 -2 -3 -4 -2 -3 -4 -3

Agreed HCA 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 83 Regular HCA 46 54 57 54 49 55 56 48 54 60 55 52 58 57 55 59 53 56 54 60 52 54 51 53 53 48 56 55 56 55 Trust Total Bank HCA 28 29 32 33 37 30 32 38 36 32 38 31 27 26 36 23 31 29 34 26 42 34 39 35 34 34 29 34 31 32 HCA Agency HCA 17 6 3 4 8 10 7 13 8 8 5 11 7 7 8 12 12 14 7 11 7 5 8 8 8 10 8 7 10 6 Total 91 89 92 91 94 95 95 99 98 100 98 94 92 90 99 94 96 99 95 97 101 93 98 96 95 92 93 96 97 93 Variance 8 6 9 8 11 12 12 16 15 17 15 11 9 7 16 11 13 16 12 14 18 10 15 13 12 9 10 13 14 10

Early Census Total 191 189 188 188 187 183 181 181 179 182 183 187 188 188 187 186 186 187 190 190 189 190 190 192 192 189 190 191 190 191

Late Census Total 190 189 191 189 183 182 181 179 147 183 184 188 188 188 187 183 188 189 190 191 189 189 190 191 193 189 191 190 191 194

Night Census Total 191 187 188 190 183 182 181 179 181 183 184 188 188 181 186 183 188 189 190 191 189 189 191 192 192 189 191 191 192 150

Average Daily Census 191 188 189 189 184 182 181 180 169 183 184 188 188 186 187 184 187 188 190 191 189 189 190 192 192 189 191 191 191 178

88 Day Night Day Night Average fill rate registered- nurses (%) Average fill rate registered- nurses (%) Registered nurses Care Staff Registered nurses Care Staff Average fill rate care- (%) staff Average fill rate care- (%) staff

Total Total Total Total Total Total Total Total monthly monthly monthly monthly monthly monthly monthly monthly planned actual planned actual planned actual planned actual staff staff staff staff staff staff staff staff hours hours hours hours hours hours hours hours

Athlone House 1125 900 1575 1800 450 450 450 450 80% 114% 100% 100% Ahlone Rehab 1125 1035 1800 2415 450 420 450 450 92% 134% 93% 100% Garside 1575 1800 2700 2805 675 675 900 1080 114% 104% 100% 120% Princess Louise 2025 1620 3600 3967.5 450 457.5 1350 1350 80% 110% 102% 100% Alexandra Rehab (PLK) 675 510 675 810 225 225 450 225 76% 120% 100% 50% Jade 1575 1447.5 1350 1410 675 645 450 465 92% 104% 96% 103% Marjory Warren 2025 1875 1350 2070 675 645 450 960 93% 153% 96% 213% Pembridge 1350 1275 900 907.5 450 450 225 225 94% 101% 100% 100% Whole Trust 11475 10462.5 13950 16185 4050 3967.5 4725 5205 90% 118% 98% 111%

Percentage fill rates September 2014

Day Night RN HCA RN HCA Athlone House 80% 114% 100% 100% Ahlone Rehab 92% 134% 93% 100% Garside 114% 104% 100% 120% Princess Louise 80% 110% 102% 100% Alexandra Rehab (PLK) 76% 120% 100% 50% Jade 92% 104% 96% 103% Marjory Warren 93% 153% 96% 213% Pembridge 94% 101% 100% 100% Whole Trust 90% 118% 98% 111%

89 Staffing Staffing Status Actual no. on Unit Incident type Date Time Shift Status RN HCA shift RN/HCA Alexandra Unit (PLK) Falls 09-Sep 0005 Night 0 -1 1/1 Alexandra Unit (PLK) Medication Errors 10-Sep 1600 Late 1 0 2/1 Alexandra Unit (PLK) Falls 16-Sep 0615 Night 0 -1 1/1 Athlone House Nursing Home Fall 21-Sep 19:50 Late 0 1 2/4 Athlone Rehabilitation Falls 01-Sep 1838 Late 0 1 2/5 Athlone Rehabilitation Falls 05-Sep 0820 Early -1 2 2/6 Athlone Rehabilitation Falls 08-Sep 1220 Early 0 2 3/6 Athlone Rehabilitation Medication Errors 15-Sep 1100 Early 0 2 3/6 Athlone Rehabilitation Medication Errors 15-Sep 1230 Early 0 2 3/6 Athlone Rehabilitation Falls 16-Sep 0000 Night 0 0 2/2 Athlone Rehabilitation Medication Errors 17-Sep no time Early -1 2 2/6 Athlone Rehabilitation Medication Errors 17-Sep no time Late 0 1 2/5 Athlone Rehabilitation Medication Errors 17-Sep no time Night 0 0 2/2 Athlone Rehabilitation Falls 24-Sep 1700 Late 0 1 1/2 Athlone Rehabilitation Falls 26-Sep 0510 Night 0 -1 1/1 Garside Fall 02-Sep 14:00 Early 0 0 4/6 Garside Fall 02-Sep 14:00 Late 0 0 4/6 Garside Fall 03-Sep 11:30 Early 0 0 4/6 Garside Fall 17-Sep 15:30 Early 2 0 4/6 Garside Fall 17-Sep 15:30 Late 3 1 6/7 Garside Medication error 19-Sep no time Early 0 0 4/6 Garside Medication error 19-Sep no time Late 1 0 4/6 Garside Medication error 19-Sep no time Night 0 1 3/5 Jade Falls 01-Sep 0145 Night -1 0 2/2 Jade Falls 01-Sep 0400 Night -1 0 2/2 Jade Falls 07-Sep 1805 Late -1 0 2/3 Jade Medication error 09-Sep 0800 Early -1 0 3/3 Jade Medication error 15-Sep 1400 Early -1 1 3/4

90 Jade Medication error 15-Sep 1400 Late 0 1 3/4 Jade Falls 16-Sep 0915 Early -1 0 3/3 Jade Medication error 18-Sep 1620 Late 0 0 3/3 Jade Medication error 20-Sep 2030 Late 0 0 3/3 Marjory Warren Falls 02-Sep 2050 Late 0 1 4/4 Marjory Warren Falls 02-Sep 1400 Early -1 2 4/5 Marjory Warren Falls 02-Sep 1400 Late 0 1 4/4 Marjory Warren Medication Errors 05-Sep 1800 Late -1 0 3/3 Marjory Warren Falls 06-Sep 0330 Night -1 1 2/3 Marjory Warren Medication Errors 07-Sep 1800 Late 0 2 4/5 Marjory Warren Medication Errors 08-Sep no time Early 2 3 7/6 Marjory Warren Medication Errors 08-Sep no time Late 1 1 5/4 Marjory Warren Medication Errors 08-Sep no time Night 0 2 3/4 Marjory Warren Medication Errors 09-Sep no time Early -1 1 4/4 Marjory Warren Medication Errors 09-Sep no time Late 0 1 4/4 Marjory Warren Medication Errors 09-Sep no time Night 0 2 3/4 Marjory Warren Falls 12-Sep 2015 Late -1 1 3/4 Marjory Warren Medication Errors 13-Sep 2200 Night -1 2 2/4 Marjory Warren Medication Errors 18-Sep 1100 Early -1 3 4/6 Marjory Warren Falls 18-Sep 1030 Early -1 3 4/6 Marjory Warren Falls 24-Sep 2000 Late 0 1 4/4 Marjory Warren Medication Errors 24-Sep 1800 Late 0 1 4/4 Marjory Warren Medication Errors 26-Sep 1400 Early 0 3 5/6 Marjory Warren Medication Errors 26-Sep 1400 Late 0 1 4/4 Pembridge Medication Errors 02-Sep 0620 Night 0 0 2/1 Pembridge Medication Errors 06-Sep 1300 Early -1 1 3/3 Pembridge Medication Errors 06-Sep 1300 Late 0 0 2/2 Pembridge Medication Errors 22-Sep 1730 Late 1 -1 3/1 Pembridge Medication Errors 23-Sep 1625 Late 0 0 2/2 Pembridge Medication Errors 23-Sep 1130 Early 0 -1 4/1 Pembridge Medication Errors 24-Sep 1200 Early 0 0 4/2 Princess Louise Nursing Home Medication Errors 01-Sep 1400 Early -2 2 3/10 Princess Louise Nursing Home Medication Errors 01-Sep 1400 Late -1 1 3/9

91 Princess Louise Nursing Home Medication Errors 03-Sep 1130 Early -1 1 4/9 Princess Louise Nursing Home Falls 09-Sep 0005 Night 0 0 2/6 Princess Louise Nursing Home Falls 10-Sep 1230 Early -1 1 4/9 Princess Louise Nursing Home Falls 10-Sep 1230 Late -1 2 3/10 Princess Louise Nursing Home Medication Errors 10-Sep 1600 Late -1 2 3/10 Princess Louise Nursing Home Falls 12-Sep 0545 Night 0 0 2/6 Princess Louise Nursing Home Falls 16-Sep 0715 Night 0 0 2/6 Princess Louise Nursing Home Falls 16-Sep 0615 Night 0 0 2/6 Princess Louise Nursing Home Falls 20-Sep 1300 Early -1 1 4/9 Princess Louise Nursing Home Falls 20-Sep 1300 Late 0 0 4/8 Princess Louise Nursing Home Falls 24-Sep 1755 Late 0 -1 4/7

Staffing at Green Numbers in the staffing status columns are the variance against agreed staffing levels agreed level Staffing above Yellow agreed level Staffing below Red agreed level

92

BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Patient Safety – Serious Incident Report for cases to end September 2014

Agenda item number: 3.1

Report of: Chief Nurse and Director of Quality Governance

Contact Officer: Head of Patient Safety

Relevant CLCH 14/15 Goal 2: Support people safely out of hospital: providing safe, high quality value for money alternatives to hospital admissions

Executive Summary: Central London Community Healthcare NHS Trust (CLCH) is committed to creating and maintaining a culture of openness, learning from experience and fair blame. Whilst everything is done to ensure services and care given are of a high quality, at times mistakes do happen. The Trust has robust structures and processes in place to identify any errors at an early stage, thoroughly investigate in a transparent and honest way, identify how things may have been done differently and learn from those mistakes in order to improve care. The attached report contains information on External and Internal Serious Incidents which have occurred within the Trust together with lessons learned from those incidents, where the Root Cause Analysis investigation has been completed. The incidents have been anonymised in order to protect the identity of patients and staff.

The area of concern currently is the number of grade 3 and 4 pressure ulcer cases, attributable to CLCH. Although the total in June 2014 fell to 9, it increased again in July 2014 with a total of 21, and a total of 12 for August 2014 and September 2014. Currently the majority of cases are occurring in patients’ homes The management of pressure ulcers is monitored within the Pressure Ulcer Performance Review Group.

Assurance provided: The minutes of the Quality Committee meeting provide evidence of review of serious incidents.

Report provenance: Also presented to Trust Board and Patient Safety & Risk group

Report for: Decision Discussion Information

Serious Incident Report/Trust Board/Oct 2014 Page 1 of 35

93

1. Purpose of the Report

1.1 Central London Community Healthcare is committed to providing the highest quality services possible for the people we serve. Every week thousands of people are treated safely and successfully by CLCH staff. However, when incidents do happen, it is important that lessons are learned in order to prevent the same incident occurring again. This report contains highlights of learning from Serious Incidents (SIs) but is highly anonymised in order to protect patient and staff identity.

1.2 Benefits to Patient Safety quality domain are that the identification of the root causes and lessons learned will result in safer services.

1.3 Benefits to Clinical Effectiveness quality domain are that clinical policies and procedures are reinforced following a serious incident investigation.

1.4 Benefits to Patient Experience quality domain are that Being Open is an integral part of the serious incident management process, and contact is made with patients/families to share findings.

2. Introduction

2.1 Central London Community Healthcare has made a commitment to creating and maintaining a culture of being open and honest and takes seriously its duty of candour. Whilst the Trust deals with underperformance of staff in a fair and appropriate way through clear policies and procedures, it is also recognised that through genuine human error, mistakes do at times happen and it is therefore important to support staff to learn from those incidents and act to prevent recurrence.

2.2 CLCH Serious Incident panels are meeting regularly. The non-pressure ulcer cases are booked to individually planned panels chaired by an Executive Director. The pressure ulcer panels are chaired by the Deputy Chief Nurse, the Head of Patient Safety or an Associate Director of Quality. The investigator and representatives from each clinical team involved in a serious incident attend to review and discuss the investigation findings, to review the quality of the investigation report, to have an opportunity to reflect with senior management the issues which may have contributed to the event. These may include system failures, service failures, and external constraints on the service or human error.

2.3 The Trust has in place a clear procedure for managing serious incidents in a timely manner. A serious incident is one which has resulted in a serious or catastrophic outcome (severe harm (physical, clinical, reputational, financial), injury or death). Serious incidents are not necessarily an error in practice or process and may have been unavoidable but when a serious incident occurs, an investigation is immediately commenced in order to ascertain the root cause of the incident. North West London Commissioning Support Unit (NWLCSU) has responsibility for overseeing the

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management of the majority of serious incidents within CLCH. Some categories of serious incident are managed by NHS England directly. All externally reportable SIs are recorded on the NHS system ‘STEIS’. There is an obligation for the Trust to report the outcome of the investigation within a set timeframe (45 or 60 working days depending on the STEIS classification) to NWLCSU/NHSE.

2.4 From 1st October 2014 the NWLCSU ceased to exist. Future management of serious incidents will be overseen by Central London, West London, Hammersmith and Fulham, Hounslow and Ealing (CWHHE) Collaboration of Clinical Commissioning Groups.

2.5 A total of thirteen new serious incidents were declared to NWLCSU in September 2014. Details are presented in section 3 below.

2.6 During September 2014 a total of twenty three cases were reviewed by a serious incident panel, prior to submission of externally reportable reports to NWLCSU. Twenty of these were pressure ulcers cases, and one each of the following category: Slip, trip & fall, Safeguarding of a Vulnerable Adult and Allegation against a Healthcare Professional. Details of each case is included in sections 7 (external cases) and 9 (internal cases) below.

2.7 Twelve pressure ulcers were reported to NWLCSU during September 2014. Details are reported in Sections 3 and 4 below.

3. Newly Reported SIs

New SIs reported

3.1 There were thirteen new SIs reported to NWL CSU during September 2014. Twelve of these were pressure ulcers; Seven grade three and five grade four. The non-pressure ulcer case was a Confidential Information Leak incident, detailed in Table 1 below.

3.2 There have been some delays in reporting a number of pressure ulcer cases on to STEIS, explanation given in Table 3 below.

Table 1 – Newly Reported SIs in September 2014 No CCG ID Date of Date put Date Incident Description of Incident SI RCA Report Number Incident on Datix reported Category Due Date (STEIS) on STEIS (investigation) 1 NHS Central 2014/ 24/07/14 24/07/14 02/09/14 Pressure Ulcer Pressure Ulcer Grade 3. Late reporting 03/11/2014

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London CCG 28488 as initially graded incorrectly as a grade 2. When datix was changed by the DN team on 16/08/14 no notification was sent to the RCA/Datix inboxes. Found during quality check on 1 Sept. 2 NHS Barnet 2014/ 06/08/14 06/08/14 02/09/14 Pressure Ulcer Pressure Ulcer Grade 4. 03/11/2014 CCG 28498 Not declared when originally entered on datix. Found during quality check on 1 Sept 14. 3 NHS Barnet 2014/ 04/09/14 05/09/14 15/09/14 Pressure Ulcer Pressure Ulcer Grade 4. Delayed 14/11/2014 CCG 29928 reporting due to admin backlog. 4 NHS West 2014/ 27/08/14 12/09/14 15/09/14 Pressure Ulcer Pressure Ulcer Grade 4. Delayed 14/11/2014 London CCG 29917 reporting due to admin backlog. 5 NHS Barnet 2014/ 09/09/14 10/09/14 15/09/14 Pressure Ulcer Pressure Ulcer Grade 3. Delayed 14/11/2014 CCG 29921 reporting due to admin backlog. 6 NHS Barnet 2014/ 04/07/14 07/07/14 15/09/14 Pressure Ulcer Pressure Ulcer Grade 3. This incident 14/11/2014 CCG 29922 was initially incorrectly reported on datix as a non CLCH case. It was highlighted during preparation for a safeguarding conference. 7 NHS Barnet 2014/ 18/07/14 20/07/14 15/09/14 Pressure Ulcer Pressure Ulcer Grade 4. This incident 14/11/2014 CCG 29923 was initially incorrectly reported on datix as a non CLCH case. It was highlighted during preparation for a safeguarding conference. 8 NHS Barnet 2014/ 22/07/14 28/07/14 15/09/14 Pressure Ulcer Pressure Ulcer Grade 3. This incident 14/11/2014 CCG 29927 was initially incorrectly reported on datix as a non CLCH case. It was highlighted during preparation for a safeguarding conference.

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9 NHS Barnet 2014/ 15/08/14 29/08/14 17/09/14 Confidential A Hertfordshire HV team received an 17/11/2014 CCG 30156 Information A4 envelope via normal mail Leak containing a large number of A&E attendance slips from CLCH. The A&E slips contain confidential patient information. 10 of the referrals received were for children living in the London area not Hertfordshire. 10 NHS West 2014/ 19/09/14 19/09/14 19/09/14 Pressure Ulcer Pressure Ulcer Grade 3 18/11/2014 London CCG 30619 11 NHS Barnet 2014/ 16/09/14 16/09/14 19/09/14 Pressure Ulcer Pressure Ulcer Grade 3. Delayed 18/11/2014 CCG 30621 reporting due to admin backlog. 12 NHS Barnet 2014/ 01/09/14 16/09/14 19/09/14 Pressure Ulcer Pressure Ulcer Grade 4. Delayed 18/11/2014 CCG 30622 reporting due to admin backlog. 13 NHS 2014/ 15/09/14 15/09/14 19/09/14 Pressure Ulcer Pressure Ulcer Grade 3. Delayed 18/11/2014 Hammersmit 30623 reporting due to admin backlog. h & Fulham CCG

4. Pressure Ulcer Update

SI Pressure Ulcer update

4.1 Following national guidance, all grade 3 & 4 pressure ulcers, acquired within CLCH, are reported as SIs. Table 2 below shows the number initially reported, those cases subsequently de-escalated and the total cases attributable to CLCH, since April 2013.

Table 2 – Numbers of Pressure Ulcers reported to NWL CSU since April 2013

Newly Total attributable De-escalated following investigation reported cases to CLCH

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T April 2013 8 1 7 May 2013 21 2 19 June 2013 10 0 10 July 2013 9 0 9 Aug 2013 4 4 0 September 2013 10 2 8 October 2013 18 4 14 November 2013 11 3 8 December 2013 16 6 10 January 2014 9 3 6 February 2014 10 5 5

March 2014 14 6 8

April 2014 16 3 13

May 2014 21 2 19 4.2 Pressure Ulcer Trends June 2014 9 0 9 Graph 1: Standard Process Chart July 2014 21 3 (Awaiting decision on 1 more case) 18 since April 2013. August 2104 12 0 12 September 2014 12 0 12

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Pressure Ulcer Serious Incident Reported on STEIS since April 2013 to September 2014 30

25 20 15 10 10.39 5 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Referrals per month Referrals -5 -10

UCL LCL Average New Pressure Ulcer Serious Incidents Reported on STEIS per month

Graph 2: Line Graph with change in process

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Training PU Information Pressure Ulcer Serious Incidents CLCH enhanced on hub. 20 Poster OSCE commence. 18 circulated Dietetics rep for patients at risk 16

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10 Wound 8 Forms amended 6 Policy Revised. Training in App introduced 4 4 Nursing Stop the Homes Pressure 2 New PU Policy month 0 2013 04 2013 05 2013 06 2013 07 2013 08 2013 09 2013 10 2013 11 2013 12 2014 01 2014 02 2014 03 2014 04 2014 05 2014 06 2014 07 2014 08 2014 09

4.3 Breakdown of newly reported pressure ulcers by CCG/Location of Origin for September 2014, in table 3 below. Currently the majority of cases are occurring in patients’ homes.

Table 3 – Numbers of Pressure Ulcers by CCG & grade for September 2014 CCG Grade 3 Grade 4 Location of Origin Total Barnet 4 4 3: Patient’s Homes; 4: Other non-CLCH Residential Home; 1:FMH 8 H&F 1 0 Patient’s Home 1 West London 1 1 All Patient’s Homes 2 Central London 1 0 Patient’s Home 1

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4.4 CLCH is committed to reducing the number of pressure ulcers in the community and the Pressure Ulcer Performance Review Group is in place to take forward work to reduce the incidence and promote the healing of pressure ulcers. A trust wide action plan has been agreed.

4.5 Components of the Trust-wide pressure ulcer action plan include: 1. Monitoring the trend of reported pressure ulcer incidence 2. Implementation of Pressure Ulcer policy 3. Pressure ulcer training 4. Pressure Ulcer Link Nurses Forum 5. Pressure ulcer documentation including core care plan and wound assessment & evaluation 6. Pressure ulcer competency development and assessment 7. Delivery of innovative initiatives – e.g. Pressure Ulcer CQUIN 8. NICE Pressure Ulcer compliance audit 9. Strategic work across the health economy 10. Pressure Ulcer Quality Action Teams

5. SI Status Update

SI status update

5.1 All reports were submitted on time to NWLCSU in September 2014. Table 4 below depicts the cases due and sent.

Table 4 –SIs sent to NWLCSU September 2014 No CCG ID Number Incident Category SI RCA Report Due Date RCA sent to (STEIS) Date NWLCSU (investigation) 1 NHS West London 2014/21260 Pressure Ulcer Grade 4 02/09/2014 02/09/2014 CCG 2 NHS Central 2014/21261 Pressure Ulcer Grade 3 02/09/2014 02/09/2014 London CCG

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3 NHS Central 2014/21265 Pressure Ulcer Grade 4. Subsequently de-escalated 02/09/2014 02/09/2014 London CCG 4 NHS Central 2014/21272 Pressure Ulcer Grade 3 02/09/2014 02/09/2014 London CCG 5 NHS Central 2014/22189 Pressure Ulcer Grade 4 10/09/2014 08/09/2014 London CCG 6 NHS Central 2014/22199 Pressure Ulcer Grade 3 10/09/2014 08/09/2014 London CCG 7 NHS West London 2014/22203 Pressure Ulcer Grade 3 10/09/2014 10/09/2014 CCG 8 NHS West London 2014/22226 Pressure Ulcer Grade 3 10/09/2014 10/09/2014 CCG 9 NHS Barnet CCG 2014/22548 Slip/trip/fall 12/09/2014 12/09/2014 10 NHS Barnet CCG 2014/22549 Pressure Ulcer Grade 3 12/09/2014 12/09/2014 11 NHS Barnet CCG 2014/22551 Pressure Ulcer Grade 3 12/09/2014 12/09/2014 12 NHS Central 2014/22556 Pressure Ulcer Grade 3 12/09/2014 12/09/2014 London CCG 13 NHS Barnet CCG 2014/22909 Pressure Ulcer Grade 4 15/09/2014 12/09/2014 14 NHS Barnet CCG 2014/22910 Pressure Ulcer Grade 4 15/09/2014 12/09/2014 15 NHS Barnet CCG 2014/24532 Pressure Ulcer Grade 3 29/09/2014 12/09/2014 16 NHS Barnet CCG 2014/24533 Pressure Ulcer Grade 4 29/09/2014 25/09/2014 17 NHS Barnet CCG 2014/24535 Pressure Ulcer Grade 3. Subsequently de-escalated 29/09/2014 25/09/2014 18 NHS West London 2014/24537 Pressure Ulcer Grade 3 29/09/2014 10/09/2014 CCG 19 NHS Barnet CC 2014/24538 Pressure Ulcer Grade 3 29/09/2014 25/09/2014 20 NHS Barnet CCG 2014/24541 Pressure Ulcer Grade 4 29/09/2014 25/09/2014 21 NHS West London 2014/26059 Pressure Ulcer Grade 3 10/10/2014 30/09/2014 CCG 22 NHS West London 2014/26062 Pressure Ulcer Grade 4 10/10/2014 30/09/2014 CCG 23 NHS West London 2014/26066 Pressure Ulcer Grade 4 10/10/2014 30/09/2014

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CCG

6. Overdue SIs

SI reports Currently Overdue

6.1 There are no overdue reports at present.

7. De-escalation Requests

De-escalation requests

7.1 There were two request s for de-escalation during September 2014, shown in Table 5 below.

Table 5 –De-escalations requested in September 2014 No ID Number/ Date of Date Incident Comment Date De- CSU CCG Incident entered Category Rationale for de-escalation escalation decision onto STEIS requested 1 2014/21265 26/06/2014 01/07/2014 Pressure On review this was considered to be a blister not a 02/09/2014 Agreed Central Ulcer pressure ulcer. 10/09/2014 London 2 2014/24535 21/07/14 28/07/14 Pressure At SI panel it was clarified that the wound had developed 26/09/14 Agreed Barnet Ulcer as the patient walks on sides of feet causing pressure and 06/10/2014 had gone for a long walk for shopping on the day the ulcer deteriorated

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8. External Serious Incidents/Lessons Learned

External Serious Incidents/Lessons Learned

8.1 Learning from the Serious Incidents listed below is being taken forward across the Trust overseen by the Chief Nurse and Director of Quality Governance. The external cases presented to SI panel are described in table 6 below. All cases have agreed action plans, monitored via the SI process. The lessons learned are shared at CLIPS meeting, and for pressure ulcer cases at the Pressure Ulcer Working Group. Out of the pressure ulcer cases reviewed at SI panel sixteen were deemed to be unavoidable, with three avoidable. Details in the table below.

Table 6 – Completed investigation – Lessons Learnt STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/22548 A patient was found on the floor in his room in one of the bedded units, in a pool of Investigation completed , Slip. Trip & fall blood. It was not clear if he fell or collapsed. He was transferred to Barnet Hospital presented to SI panel and Barnet where a CT showed hemorrhagic contusions to both frontal lobes, a small approved on 3rd September parenchymal hemorrhage in the right cerebellum, and subdural blood but no bony 2014 injury. The patient was transferred to the neurosciences centre at The Royal London Hospital where he was managed conservatively. He was subsequently transferred back to CLCH where it became clear he had a neurological deficit and was transferred to a neurological rehab ward. Root Causes Whilst the investigation was unable to determine if the patient fell or collapsed, it concluded that the position he was found in, on his front with the right side of his face against the floor, suggests a collapse rather than a fall. Therefore there is no clear root cause for his fall. Lessons learned

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STEIS Reference/ Summary of Incident Update Classification/ CCG 1. Falls assessments need to be completed for all patients on admission. This has already been addressed with training programmes on the falls assessment 2. Mr X was a rehabilitation patient but was on a ward where rehabilitation skills and ethos have been diluted as a consequence of admitting other patients who do not have rehabilitation needs 3. Loss of clinical leadership at both nursing and therapy senior levels has been detrimental to the culture of learning and development of staff. This is already being addressed and interviews are in the pipeline / have taken place for these roles 4. There is a lack of continuity when operational managers change. This has been addressed with the appointment of a substantive operational manager at CBU level 5. Admission of patients late at night should only be undertaken when it is absolutely necessary 6. Inadequate assessments lead to poor clinical reasoning and treatments 7. A systematic process is required to capture patients who are admitted to acute trusts. This has already been addressed and is in process of being implemented. Recommendations, which have been made in to an action plan: 1. Training in falls assessments for all staff 2. All staff to have training in the rehabilitation process and the necessity for MDT working 3. Outcome of this investigation is fed back to staff as part of culture of learning from experience 4. Rehabilitation processes are put in place including: • MDT goal setting • Patient timetables for therapy 5. There is a review of assessments to include: • Clinical assessments to be discussed in supervision to ensure they are thorough, relevant and probe for sufficient information as a regular part of supervision process • Therapy staff use an assessment form 6. All therapy / nursing staff to have training in neurological assessments 7. Nursing and therapy staff are able to demonstrate they can conduct an assessment to the required standard 8. Training is given a high priority and includes: • cognitive and dementia training for all staff on ward

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STEIS Reference/ Summary of Incident Update Classification/ CCG • Dedicated time for regular MDT training with sufficient numbers of nursing staff on shift to allow for attendance • Dedicated time for regular uniprofessional training • Medical training 9. Supervision includes joint clinical sessions with junior staff 10. Appointment of senior clinical roles in nursing and therapy 11. Division considers whether rotation of band 6 therapy staff would be possible 12. Operational managers set out clearly what the processes are for late admissions, and for not accepting patients with no rehabilitation potential. Staff are supported in the decisions they make and are not pressured by either the acute trust or CLCH to accept patients with no rehabilitation potential 13. A process to be introduced for capturing information for patients transferred to acute trusts from CLCH bedded units 14. There is a monthly forum led by the CBU manager and AHP lead until all the senior therapy leadership is in place to discuss patients on ward in regard to rehabilitation needs STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/21260 Grade 4 Identified when a scab lifted from the patient’s toe Investigation completed , Pressure Ulcer Grade 4 presented to SI panel and West London CCG approved on 2nd September 2014 Root Causes 1 Poorly fitting footwear (supplied by family) 2 Peripheral neuropathy 3 Peripheral vascular disease 4 Previous history of ulceration and multiple predisposing factors Lessons learned No care or service delivery problems identified. No actions to take forward.

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STEIS Reference/ Summary of Incident Update Classification/ CCG

Conclusion Unavoidable pressure ulcer.

STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/21261 Grade 3 on both heels. Chronic medical history, with a history of pressure damage Investigation completed , Pressure Ulcer Grade 3 presented to SI panel and Central London CCG approved on 2nd September 2014 Root Causes 1. Previous history of pressure damage 2. Diabetic neuropathy 3. Declined appropriate equipment 4. Poor mobility and high BMI. Lessons learned No care or service delivery problems identified. No actions to take forward. Conclusion Unavoidable pressure ulcer. STEIS Reference/ Summary of Incident Update Classification/ CCG

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STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/21265 Grade 4 right heel. Chronic medical history. Investigation completed , Pressure Ulcer Grade 4 presented to SI panel and Central London CCG approved on 2nd September 2014 Root Causes Prolonged periods sitting and not elevating both legs, when mobilising patient not wearing appropriate foot wear. Blister arose from ill-fitting shoes Lessons learned No care or service delivery problems identified. No actions to take forward. Conclusion Unavoidable pressure ulcer. STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/21272 Grade 3 on the sacrum. The patient was completely bedbound with end of life Investigation completed , Pressure Ulcer Grade 3 terminal condition and was very frail and fragile. presented to SI panel and Central London CCG approved on 28th September 2014 Root Causes Resident factors associated with end of life care needs and moisture lesion as well as complex mobility issue. Recommendations, which have been made in to an action plan: 1. The nursing home manager to have a meeting with qualified nurses to do a reflective account and discuss this case at the next staff meeting. 2. All qualified nursing staff to do practical training/competency assessment

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STEIS Reference/ Summary of Incident Update Classification/ CCG

Conclusion Unavoidable pressure ulcer.

STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/22189 Grade 4 Right hip, chronic medical history Investigation completed , Pressure Ulcer Grade 4 presented to SI panel and Central London CCG approved on 8th September 2014 Root Causes 1. Did not always comply with pressure area care advice 2. Faulty equipment 3. Decreased mobility 4. Diagnosis of lung cancer /Increasing shortness of breath/decreased oxygen saturation (77% on room air) – lack of perfusion to pressure area 5. Nutritional status

Lessons learned No care or service delivery problems identified. No actions to take forward.

Conclusion Unavoidable pressure ulcer.

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STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/22199 Grade 3 on the sacrum Investigation completed , Pressure Ulcer Grade 3 presented to SI panel and Central London CCG approved on 3rd September 2014 Root Causes 1. Non-compliant with equipment 2. Immobility 3. Extremes of Age 4. Terminal Phase

Lessons learned No care or service delivery problems identified. No actions to take forward.

Conclusion Unavoidable pressure ulcer. STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/22203 Grade 3 on Sacrum, Left buttock and right buttock. Investigation completed , Pressure Ulcer Grade 3 presented to SI panel and West London CCG approved on 10th September 2014 Root Causes 1. Patient is now palliative with poor nutritional intact 2. Patient had previous history of pressure damage to sacral area in 2013. 3. Patient’s mobility has reduced and she is spending more time sitting in her chair 4. Patient declined pressure relieving equipment which had contributed to her developing pressure ulcers.

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STEIS Reference/ Summary of Incident Update Classification/ CCG

Lessons learned No care or service delivery problems identified. No actions to take forward.

Conclusion Unavoidable pressure ulcer.

STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/22226 Grade 3 Right stump (right knee amputee) Investigation completed , Pressure Ulcer Grade 3 presented to SI panel and West London CCG approved on 10th September 2014 Root Causes 1. Dementia 2. Chronic Long Term Condition – poor vascular supply 3. Poorly controlled diabetes due to compliance issues related to nutritional intake 4. Non-compliant with medication, food and fluids.

Lessons learned No care or service delivery problems identified which contributed to the development of the pressure ulcer Recommendations, which have been made in to an action plan: Ensure staff are up to date with supporting patients with diabetes with their nutritional intake

Conclusion

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STEIS Reference/ Summary of Incident Update Classification/ CCG Unavoidable pressure ulcer.

STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/22549 and Grade 3 right and left hip, chronic medical history Investigation completed , 2014/24532 Case conference held – outcome was that care home staff required additional presented to SI panel and Pressure Ulcer Grade 3 training. approved on 12th Barnet CCG September 2014 Root Causes 1. Frail elderly patient with fragile skin and history of pressure ulcers 2. Patient care dependent on care home staff

Lessons learned No care or service delivery problems identified which contributed to the development of the pressure ulcer Recommendations, which have been made in to an action plan: 1. Ongoing management by nurses who have current PU training and OSCE 2. All staff to be assessed as competent to manage patients who are at high risk of PU.

Conclusion Unavoidable pressure ulcer.

STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/22551 Grade 3 right buttock. Chronic medical history. Investigation completed ,

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STEIS Reference/ Summary of Incident Update Classification/ CCG Pressure Ulcer Grade 3 presented to SI panel and Barnet CCG approved on 12th September 2014 Root Causes 1. Very challenging patient environment and chaotic lifestyle 2. Patient non-compliant with advice

Lessons learned No care or service delivery problems identified which contributed to the development of the pressure ulcer

Recommendations, which have been made in to an action plan: A pathway is devised to ensure that in these situations, all the appropriate liaison with other professionals is undertaken

Conclusion Unavoidable pressure ulcer.

STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/22556 Grade 3 sacrum Investigation completed , Pressure Ulcer Grade 3 presented to SI panel and Central London CCG approved on 5th September 2014 Root Causes 1. Patient is incontinent of urine and has developed moisture lesion. 2. Patient spends long hours sitting in chair watching TV 3. Non-compliance with pressure relieving cushion/mattress- sent them back to mediquip when ordered although she initially agreed.

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STEIS Reference/ Summary of Incident Update Classification/ CCG 4. Patient will only use a repose cushion which is not appropriate for her.

Lessons learned No care or service delivery problems identified. No actions to take forward.

Conclusion Unavoidable pressure ulcer. STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/22909 Grade 4 sacrum Investigation completed , Pressure Ulcer Grade 4 presented to SI panel and Barnet CCG approved on 12th September 2014 Root Causes 1. Advanced age, diminished acuities, immobility and lack of capacity resulting in noncompliance (scratching site and removing dressings 2. Care of patient largely dependent on carers. ? knowledge and skills on Pressure ulcers, SSKIN bundle, turning charts etc. 3. Continued use of dressings identified as causing an allergic reaction 4. New staff in post without PU training. Inappropriate assessment by nurse on 8/7/14 5. Issues picked up by TVN relating to patient care not followed through by DN team. 6. Failure to follow pressure ulcer policy 7. Monitoring of carers by use of turning charts not evident in nursing record, to ensure turns are being done

Lessons learned 1. Advise by TVN not followed through 2. Staffing levels and skill mix of team: Little senior nurse availability through sickness and leave. Band 6 nurse also had to support the HAB service two mornings per week for a period of approximately 6 months. New starters in place without the correct knowledge and skill

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STEIS Reference/ Summary of Incident Update Classification/ CCG base. Recommendations, which have been made in to an action plan: 1. Nurses to work closely with carers to ensure care is achieved 2. Nurse doing joint visit with TVN to ensure advice and new instructions are followed through

Conclusion Avoidable pressure ulcer.

STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/22910 Grade 4 sacrum Investigation completed , Pressure Ulcer Grade 4 presented to SI panel and Barnet CCG approved on 12th September 2014 Root Causes 1. Irregular ongoing assessment of patient, until 27th June 2014 and from then until 11th July. 2. Staff attending to the patient without the appropriate training and skills, deterioration in PU and overall patient condition not recognized. 3. Senior Staff not reviewing 4. Frail elderly patient at end of life

Lessons learned 1. Poor ongoing assessment of patient needs from initial assessment in February 2013 until 27th June 2014. Challenges faced by the wider team in regard to nursing numbers and skill mix 2. over recent months 3. Little evidence of palliative care provision by DN team for patient, due to staffing challenges; lack of knowledge and skills of new staff.

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STEIS Reference/ Summary of Incident Update Classification/ CCG Recommendations, which have been made in to an action plan: 1. All team members are able to undertake a comprehensive assessment 2. All DN staff in Barnet to have current PU management training and OSCE.

Conclusion Avoidable pressure ulcer. STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/24533 Grade 4 Right heel Investigation completed , Pressure Ulcer Grade 4 Grade 3 Right foot presented to SI panel and Barnet CCG Complex health needs approved on 24th September 2014 Root Causes 1. Deteriorating general physical health 2. Patient is bed bound 3. Extremes of age

Lessons learned No care or service delivery problems identified. No actions to take forward.

Conclusion Unavoidable pressure ulcer.

STEIS Reference/ Summary of Incident Update Classification/ CCG

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STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/24537 Grade 3 left buttock, history of pressure damage Investigation completed , Pressure Ulcer Grade 3 presented to SI panel and West London CCG approved on 10th September 2014 Root Causes 1. Patient is now palliative and his appetite has decreased, which may lead to poor nutritional intake. 2. Patient had previous history of pressure damage to sacral area in 2013. 3. Patient’s mobility has reduced and he is spending more time sitting in his chair

Lessons learned No care or service delivery problems identified. No actions to take forward.

Conclusion Unavoidable pressure ulcer.

STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/24538 Grade 3 sacrum. Chronic medical history. Investigation completed , Pressure Ulcer Grade 3 presented to SI panel and Barnet CCG approved on 24th September 2014 Root Causes 1. Poor concordance of patient at times, by patient and carer, including refusal to have care staff and transferring technique used by patient which required further monitoring and advise. 2. Management of patient with end stage LTC on long term O2 – some aspects of patient care not addressed as quickly as needed – slide sheet not ordered at first assessment.

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STEIS Reference/ Summary of Incident Update Classification/ CCG

Lessons learned 1. Poor concordance of patient at times with advise. 2. Timely clinical assessments of DN team 3. Refusal to have care staff, wife is the main carer who also has health problems 4. Limited mobility 5. Transferring technique used by patient causing shearing

Recommendations, which have been made in to an action plan: 1. Some aspects of patient care delivery not acted on appropriately. Pressure ulcer documentation not completed fully 2. Little evidence of full holistic care of patient – focus on the PU, when LTC should also be addressed.

Conclusion Avoidable pressure ulcer.

STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/24541 Grade 4 left ear. History of pressure damage. Attends an acute trust several times a Investigation completed , Pressure Ulcer Grade 4 week for dialysis, no pressure relieving equipment available at that venue. presented to SI panel and Barnet CCG approved on 23rd September 2014 Root Causes 1. Prone to pressure sores due to his chronic condition. 2. Always turns to his left side.

Lessons learned

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STEIS Reference/ Summary of Incident Update Classification/ CCG No care or service delivery problems identified. Further follow up to be undertaken with the acute trust’s Safeguarding lead.

Conclusion Unavoidable pressure ulcer. STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/26059 Grade 3 sacrum Investigation completed , Pressure Ulcer Grade 3 presented to SI panel and West London CCG approved on 30th September 2014 Root Causes 1. Cancer diagnosis and radiotherapy treatment 2. Poor concordance with equipment, client did not want to use overlay mattress or dressings

Lessons learned 1. On the first assessment the category may have been a category 2 and not a moisture lesion but there were no pictures to verify this grade. 2. Lack of awareness about when to send a safeguarding referral and when it is not needed.

Recommendations, which have been made in to an action plan: 1. Reflection session to take place with the team to discuss: 2. Taking photographs; Grading/identification of sores/moisture lesions; Safeguarding referrals

Conclusion Unavoidable pressure ulcer.

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STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/26062 Grade 4 right ischial tuberosity. Complex history, underweight, history of pressure Investigation completed , Pressure Ulcer Grade 4 damage presented to SI panel and West London CCG approved on 30th September 2014 Root Causes High dependency and at high risk of developing pressure sores - Complexity of condition/disability, Underweight, Lack of mental capacity, change of environment (stayed at his parents’ house), previous skin breakdown.

Lessons learned No care or service delivery problems identified. No actions to take forward.

Conclusion Unavoidable pressure ulcer.

STEIS Reference/ Summary of Incident Update Classification/ CCG 2014/26066 Grade 4 Mid spine Investigation completed , Pressure Ulcer Grade 4 presented to SI panel and West London CCG approved on 30th September 2014 Root Causes 1. Patient is for palliative care and has poor nutritional intact. 2. Patient declined pressure relieving equipment for a long time but no mental capacity was recorded

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STEIS Reference/ Summary of Incident Update Classification/ CCG Lessons learned No care or service delivery problems identified. No actions to take forward.

Conclusion Unavoidable pressure ulcer.

9 Department of Health National Never Events

9.1 The DoH have published a list of twenty five Never Events which are incidents determined by the Department of Health (DH) as serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Commissioning organisations are required to monitor the occurrence of Never Events within the services they commission and publicly report them on an annual basis.

9.2 CLCH has had no incidents of national reportable Never Events since the list was published, in 2011.

10. Internal Serious Incidents

Internal Serious Incidents/Lessons Learned

10.1 CLCH has identified incidents, complaints and audit results which in themselves would not be considered externally reportable serious incidents, but might indicate poor quality of care, or be a cause for concern. This includes allegations of patients being left in soiled linen or clothing,

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safeguarding queries regarding staff, information governance issues, complaints unresolvable to satisfactory conclusion and safety alerts not actioned by deadline. Table 7 below summarises the cases for which an investigation is ongoing, or has had the RCA report presented to panel.

Table 7 – Internal Serious Incidents CCG Datix Classification Incident Date Summary of Incident /Progress of case NHS West Drug Incident 21/05/2014 When entering vaccination data following a BCG clinic, it was noted that a baby London (general)W23517 had already received the BCG vaccination in hospital prior to discharge. The BCG CCG given at the clinic was therefore a second dose. NHS Investigation ongoing. SI panel arranged. Central Safeguarding of Vulnerable 13/07/2014 Two Health Care Assistants reported to the Senior Staff Nurse that they had London Adult W24347 found a patient lying in urine and faeces when they had arrived to attend to the CCG patient. They reported that it appeared the patient had been soiled for a significant amount of time. The RCA was presented to SI panel but not accepted as more information was required. To be revised and reviewed again by SI panel members once changes are made. NHS Barnet Allegation against 08/08/2014 A patient reported to an OT on the ward that she had been roughly handled by a CCG Healthcare Professional member of staff a few nights previously. W24899 The RCA was presented to SI panel but not accepted as more information was required. To be revised and reviewed again by SI panel members once changes are made.

NHS Drug Incident 12/08/2014 A mother attended for her baby’s BCG vaccination. The mother said that the Hammersm (general)W25372 baby had not received the BCG in the hospital. The hospital discharge summary ith & stated that the BCG was refused by the mother. A few weeks later the mother Fulham informed the health visiting service that she had found the pink BCG notification CCG slip indicating that her baby had received the BCG before discharge home from the maternity unit.

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11. Management of Action Plans

111 During the review of the Incident Reporting and Serious Incident Policy the process for the closure of serious incident action plans was revised. The Standard Operating Procedure is described below.

Closure of Serious Incidents:

 Associate Director of Quality and Patient Safety Manager to monitor the completion of actions at monthly divisional governance meetings

 Once completed Head of Patient Safety to attend an SI Action Plan closure meeting with the Associate Director of Quality, CBU Manager, Patient Safety Manager and any other relevant member of staff to confirm actions are completed robustly and to update Datix notepad to confirm that all actions are completed and date of closure meeting

 Update on closure to be included in the divisional monthly report to PSRG

 Patient Safety Team to update the SI database once a case is closed

11.2 The table (8) below depicts the serious incident cases, reported from 1st April 2014, broken down by division, awaiting final closure. Each division is currently working on reviewing the evidence available, getting it uploaded on to datix before setting closure meetings with the Head of Patient Safety. Some cases have not reached the last action due date. As each new RCA is approved in future it will be added to the list.

Table 8 – current open serious incidents since April 2014. No ID Reference Classification Division Date Last Action Due EXTERNAL SIs 1 2014/20399 Confidential Information Leak Allied Primary Care Services 01/07/2015 EXTERNAL SIs 1 2014/17199 Confidential Information Leak Networked Nursing & Community Rehab 18/08/2014

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INTERNAL SIs 1 W24347 Safeguarding of Vulnerable Adult Networked Nursing & Community Rehab 31/12/2014 PRESSURE ULCERS 1 2014/10997 Pressure Ulcer Grade 4 Networked Nursing & Community Rehab 31/05/2014 2 2014/14703 Pressure Ulcer Grade 3 Networked Nursing & Community Rehab 31/07/2014 3 2014/11107 Pressure Ulcer Grade 3 Networked Nursing & Community Rehab 30/07/2014 4 2014/13102 Pressure Ulcer Grade 4 Networked Nursing & Community Rehab 30/06/2014 5 2014/14699 Pressure Ulcer Grade 3 Networked Nursing & Community Rehab 31/07/2014 6 2014/15625 Pressure Ulcer Grade 4 Networked Nursing & Community Rehab 06/06/2014 7 2014/16489 Pressure Ulcer Grade 3 Networked Nursing & Community Rehab 31/07/2014 8 2014/20388 Pressure Ulcer Grade 3 Networked Nursing & Community Rehab 31/08/2014 9 2014/20392 Pressure Ulcer Grade 3 Networked Nursing & Community Rehab 16/08/2014 10 2014/21261 Pressure Ulcer Grade 3 Networked Nursing & Community Rehab 12/09/2014 11 2014/22189 Pressure Ulcer Grade 4 Networked Nursing & Community Rehab 04/09/2014 12 2014/22203 Pressure Ulcer Grade 3 Networked Nursing & Community Rehab 20/09/2014 13 2014/22556 Pressure Ulcer Grade 3 Networked Nursing & Community Rehab 21/09/2014 14 2014/24537 Pressure Ulcer Grade 3 Networked Nursing & Community Rehab 30/09/2014 15 2014/26059 Pressure Ulcer Grade 3 Networked Nursing & Community Rehab 31/10/2014 16 2014/26062 Pressure Ulcer Grade 4 Networked Nursing & Community Rehab 10/10/2014 17 2014/26066 Pressure Ulcer Grade 4 Networked Nursing & Community Rehab 10/10/2014 EXTERNAL SIs 1 2014/12896 Confidential Information Leak Barnet Community & Specialist Services 30/06/2014 2 2014/14319 Adverse media coverage or public concern Barnet Community & Specialist Services 31/07/2014 about the organisation or the wider NHS 3 2014/16092 Confidential Information Leak Barnet Community & Specialist Services 01/01/2015 4 2014/22548 Slip/trip/fall Barnet Community & Specialist Services 28/02/2015 PRESSURE ULCERS 1 2014/11727 Pressure Ulcer Grade 4 Barnet Community & Specialist Services 30/06/2014 2 2014/18217 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 30/09/2014 3 2014/13114 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 30/06/2014 4 2014/14711 Pressure Ulcer Grade 4 Barnet Community & Specialist Services 31/07/2014

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5 2014/13124 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 31/05/2014 6 2014/13502 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 31/08/2014 7 2014/13507 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 31/08/2014 8 2014/13512 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 31/07/2014 9 2014/13971 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 31/07/2014 10 2014/15724 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 30/09/2014 11 2014/16105 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 31/07/2014 12 2014/15954 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 30/08/2014 13 2014/16106 Pressure Ulcer Grade 4 Barnet Community & Specialist Services 17/08/2014 14 2014/16763 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 01/09/2014 15 2014/16932 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 30/10/2014 16 2014/18234 Pressure Ulcer Grade 4 Barnet Community & Specialist Services 30/10/2014 17 2014/20376 Pressure Ulcer Grade 4 Barnet Community & Specialist Services 24/08/2014 18 2014/20389 Pressure Ulcer Grade 4 Barnet Community & Specialist Services 01/12/2014 19 2014/20397 Pressure Ulcer Grade 4 Barnet Community & Specialist Services 31/10/2014 20 2014/21272 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 30/11/2014 21 2014/22226 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 31/10/2014 22 2014/22549 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 30/11/2014 23 2014/22551 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 30/11/2014 24 2014/22909 Pressure Ulcer Grade 4 Barnet Community & Specialist Services 30/11/2014 25 2014/22910 Pressure Ulcer Grade 4 Barnet Community & Specialist Services 05/10/2014 26 2014/24532 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 30/11/2014 27 2014/24533 Pressure Ulcer Grade 4 Barnet Community & Specialist Services 30/11/2014 28 2014/24535 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 30/09/2014 29 2014/24538 Pressure Ulcer Grade 3 Barnet Community & Specialist Services 30/11/2014 30 2014/24541 Pressure Ulcer Grade 4 Barnet Community & Specialist Services 30/09/2014 12. Whistleblowing

12.1 There was a whistleblowing case in August 2014. The CQC visited one of the bedded unit as a result of a concern raised directly to CQC. The visit and subsequent report were positive. No further concerns were raised. The report is available on the CQC website.

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13. Child Deaths

13.1 There has been one expected child death since the last report.

14. Maternal Deaths

14.1 There have been no maternal death cases since the last report.

15. Quality Implications and Clinical Input

15.1 The Trust will continue to identify and investigate all serious incidents, from which themes and trends will be identified. Review of the root causes and the lessons learned enables the organisation to identify risks resulting from such incidents.

16. Equality Implications

16.1 The Complaints, Litigation, Incidents, PALS and Serious Incidents (CLIPS ) Group meetings review themes from complaints, litigation, incidents, PALS contacts and Serious Incidents and would highlight any access issues or communication barriers for patients if identified. By tracking information in these areas the organisation can help to demonstrate equality of service to all and recommend improvements where necessary.

17. Risks and Mitigating Actions

17.1 The main area of concern currently is the management and documentation of pressure ulcers, which continues to be the highest reported category of serious incident (grade 3 & 4), although the total reported pressure ulcer incidents has dropped to second highest category for quarter 2 July – September 2014. Management of pressure ulcers is represented on the risk register as Risk ID 435, and is currently being reviewed. This is monitored at Patient Safety & Risk Group.

18. Consultation with Partner Organisations

18.1 Serious Incident reports are sent to both Clinical Quality Review group meetings: Barnet and Tri-Borough 18.2 All serious incidents are sent to the Commissioning Support Unit.

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18.3 All external reporting requirements are met, for reporting serious incidents to North West London Commissioning Support Unit, NHS England and to the National Reporting & Learning System.

19. Monitoring Performance

19.1 NWLCSU monitors performance against achieving deadlines. 19.2 The achievement of the deadlines is monitored internally and reported to the Quality Committee quarterly.

20. Recommendations

20.1 The Board is asked to review the report and note the progress of the management of Serious Incidents across the Trust.

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BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Francis and other national reports – six month update

Agenda item number: 3.2

Report of: Chief Executive

Contact Officer: Trust Secretary

Relevant CLCH 14/15 Goal: 1 Embody the best of the NHS for our patients: delivering great results with compassion and thoughtfulness 2 Support people safely out of hospital: providing safe, high quality value for money alternatives to hospital admissions 4 Be responsive to our patients and partners’ needs: promoting integration and partnership by demonstrating our capacity, character and competence 5 Employ only the best staff: selecting staff who care and supporting them to go the extra mile for our patients Freedom of Information Report can be published Status

Executive Summary:

In January 2014, the Board welcomed the Government’s acceptance of the inquiry recommendations in support of high quality care and acknowledged its role in continuing to lead and promote an open culture of learning and improvement.

The Trust’s response included 15 key milestones, the majority of which are now business as usual. An update on outstanding actions at April 2014 are included in this report.

Assurance provided: Progress made against the Trust’s national report recommendations maturity matrix was reviewed throughout 2013/14, with a final report considered in April 2014. At that point it was agreed a report would be considered in 6 and 12 months to ensure that organisational governance arrangements remain compliant.

Report provenance: A paper (Francis 1-year on) was shared with the Board in April 2014. It was agreed that the high level action plan template prepared by the trust secretary would be used by the Board to monitor progress in October 2014 and April 2015.

Report for: Decision Discussion Information

Recommendation: To discuss the Trust’s position in relation to key national report recommendations and to highlight where any further assurance may be required.

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1 Purpose 1.1 To provide an update to the Board regarding the implementation of relevant Francis and related report recommendations (Berwick and Keogh).

2 Introduction 2.1 The final report of the public inquiry into Mid Staffordshire NHS Foundation Trust provided detailed and systematic analysis of what contributed to the failings in care at the trust. It identified how the extensive regulatory and oversight infrastructure failed to detect and act effectively to address the trust's problems for so long, even when the extent of the problems were known. The Trust’s position in relation to the Francis report and related reports is attached.

With regard to milestones set in 2013, the report in April 2014 confirmed that the majority of milestones had been met.

The outstanding milestones at that time were:

Milestone Position at April 2014 Current position

Reduction in paperwork for Work continued however SytmOne being implemented. front line staff (by a third), reductions in paperwork were creating time to care by not being realised. Electronic Mobile devices deployed to introducing electronic/ digital systems gradually being increase efficiency of solutions to reduce paperwork implemented slowly. community care workers – increasing patient visits by 10%. Deployment of e-fax solution to decrease paper load.

Interoperability will enable the receipt of referrals in Barnet and the receipt of notifications to Child Health from the Acute providers to be automated. Removing paper and releasing the time of Administrative staff.

Audit of recruitment processes Audit will be completed by Managers are advised to make to demonstrate values April. 2 of the 10 questions they ask questions asked and staff values based and are given survey to shows high levels of examples from which to understanding and choose. commitment to Trust values Audit of three files from each division demonstrated 100% compliance with this requirement.

Further work between October 2014 and March 2015 will be undertaken to audit the impact of those questions on recruiting decisions.

Audit of dementia, mental No plans in place. Under Plans and training now in place health and learning disability discussion - to be included in for both dementia care and care and of vulnerable adults work plans for 2014/15 but learning disabilities. These policy audits will not be achieved by areas will be audited in quarter 129 April 2014. 1, 2016 when they have been embedded into services. Care of vulnerable adults will be audited alongside the audit of safeguarding adults policy, in quarter 4.

3 Quality implications and clinical input 3.1 The Francis report and related reports are focused on providing high quality care.

3.2 The Medical Director and Chief Nurse have contributed to the production of this report.

4 Legal implications 4.1 Draft regulations have been published, including the duty of candour and the fit and proper persons test. The regulations were originally intended to be introduced for NHS Trusts from October; however this has been postponed to mid-November (at least). Similarly, the Care Quality Commission has been consulting on their proposed guidance for providers to help them meet the requirements of the regulations, and the proposed guidance on how the CQC will use their enforcement powers. This will lead to the replacement in its entirety, from April 2015, of CQC’s current Guidance about compliance and current enforcement policy. The consultation closes 17.10.14.

Note 1 - it has been proposed that the Remuneration Committee should consider practical steps to ensure / continuously review the ‘fitness’ of directors. Note 2 - it has been proposed that the Quality Committee should further consider the duty of candour, fundamental care standards and notifiable incidents.

5 Equality implications 5.1 The Francis report and related reports support the provision of equality of care.

6 Consultation with partner organisations 6.1 This paper will be shared with the CCG clinical quality review groups.

7 Monitoring performance 7.1 A further report will be provided in April 2015.

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This table provides the Trust’s summary position in relation to relevant Francis recommendations as at October 2014.

Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) Implementing the To hold listening events to discuss how Four listening events held in April 2013, feedback Chief nurse and recommendations safe, effective and compassionate care shared with all attendees in June 2013. director of quality (R11) can be delivered. An overarching engagement strategy was approved governance / by the Board in September 2014, including a medical director commitment to hold listening events in each of the four key boroughs, at least twice annually. Implementing the To consider the findings and Inquiry findings considered in March 2013, maturity All directors recommendations recommendations and to decide how to matrix updates provided to Quality Committee and (R1) apply them to their own work. Board quarterly to January 2014. This paper (for Board meeting in October 2014). Implementing the Publish a report at least annually, All papers considered by the Board in response to Chief executive / recommendations information regarding progress in Francis Inquiry and related reports are published on Chief nurse and (R1) relation to planned actions the CLCH website. The maturity matrix tracked director of quality progress against action planned - now business as governance usual. This report will be included with Board papers for 28.10.14 and shared with CCG clinical quality review groups. Implementing the To publish the Trusts response to the A position paper ‘Francis 1 year on’ was published in Chief executive recommendations recommendations on the website. January 2014. This report will be included with Board (R1) papers for 28.10.14 and shared with CCG clinical quality review groups. Implementing the Leadership to drive improvements in Chief nurse and recommendations safety, quality and compassionate care. director of quality (R1) governance / medical director CLCH has developed its own compassion in care project, linked to the national 6Cs (care, compassion, competence, communication, courage and commitment) initiative led by the Chief Nurse for

1 Recommendation / DH response number

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) England. Our project was developed in partnership with City University, building on their work on patient dignity and best practice in care for older people and quality of life in care homes. The project aimed to promote compassionate care with frontline staff across a number of areas of CLCH services including adult rehabilitation services, HMP Wormwood Scrubs and our Pembridge Palliative Care unit. Staff developed their own workstreams in consultation with patients and we are developing ways in which the positive impact of these can be measured.

The Compassion in care programme focuses in 2014/15 on End of Life Care and the development of the Leadership Strategy.

Separate to this programme ‘Clinical Fridays’ and ‘Back to the Floor’ have been implemented, with members of the senior team visiting clinical areas across the Trust.

A leadership strategy is being developed for implementation in 2015. Implementing the Central responsibility of the Board to The Board recognises its role in creating and leading Board of directors recommendations pay attention to the culture of their a culture of compassion and thoughtfulness. (R1) organisation, actively dealing with cultural risks and seeking improvements in their organisation’s culture. Clarity of values and NHS constitution as a central reference CLCH goals (embody the best of the NHS for our Board of directors principles (R3) point for all NHS staff and patients. patients, support people safely out of hospital, deliver better value than our competitors in our selected

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) markets, be responsive to our patients and partners’ needs, and employ only the best staff).

Values (quality, relationships, delivery and community) Clarity of values and Statutory duty of candour to be open Serious incident reports are published with Board Board of directors principles (R5) and and honest where there have been papers. R174 and R181 failings in care. Learning from experience team have a role in encouraging staff to report all incidents and promoting an open safety culture.

We have made a commitment to creating and maintaining a culture of being open and honest and our contractual arrangements include the duty of candour.

The Trust’s ‘being open’ policy has been re-written and launched and will be audited in Q1 of 2015/16.

Clarity of values and NHS staff should be required to enter No reference to NHS values and constitution in Director of finance, principles (R7) into an express commitment to abide by contracts of employment, however CLCH values are performance and the NHS values and the constitution, included in job descriptions and are core to the staff corporate resources both of which should be incorporated appraisal process. into the contracts of employment. Fundamental Healthcare professionals should be The clinical education and practice team lead this Chief nurse and standards of prepared to contribute to the work; staff are actively involved in the preparation of director of quality behaviour (R11) development of, and comply with, guidelines which are published on the intranet. governance standard procedures in the areas in which they work. Responsibility for, Suitability and competence of staff and Guidance issued by the National Quality Board, Chief nurse and and effectiveness of, related guidance published by the is being taken forward by the chief nurse and director director of quality healthcare National Quality Board How to ensure the of quality governance. governance

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) standards (R23) right people, with the right skills, are in the right place at the right time. This includes the expectation (1) that the “Board takes full Monthly and the six monthly staffing level reports are Board of directors responsibility for the quality of care provided to included with Board papers and published on the patients, and as a key determinant of quality, Trust’s web site and notice boards publicising the take full and collective responsibility for nursing, expected and actual daily staffing figures are at the midwifery and care staffing capacity and front of each bedded unit. capability. Board papers are accessible to patients and staff working at all levels, boards seek to involve There is also a Chief Nurse email and contact number staff at all levels and across different parts of the on the notice boards if patients, relatives or staff have organisation, facilitating a strong line of any concerns regarding staffing. communication from ward to Board, and Board to ward. Boards ensure their organisation is open and honest if they identify potentially unsafe staffing levels, and take steps to maintain patient safety”. Expectation 7 (openness and transparency) includes that “boards receive monthly updates on workforce information, and staffing capacity and capability is discussed at a public Board meeting at least every six months on the basis of a full nursing and midwifery establishment review. Boards receive monthly updates on workforce information, including the number of actual staff on duty during the previous month, compared to the planned staffing level, the reasons for any gaps, the actions being taken to address these and the impact on key quality and outcome measures. At least once every six months, nursing, midwifery and care staffing capacity and capability is reviewed (an establishment review) and is discussed at a public Board meeting. This information is therefore made public monthly and six monthly. This data will, in future, be part of CQC’s Intelligent Monitoring of NHS provider organisations. Use of information Co-ordinated collection of accurate An external review of the Trust’s performance Director of finance,

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) for effective information about the performance of management reporting processes was undertaken in performance and regulation (R36) organisations early 2014 and recommendations are being corporate resources implemented. Data quality remains a high priority and the Audit Committee will review the implementation of the Data Quality Strategy and seek assurance that the actions in the implementation plan achieve the strategy’s stated aims during 2014/15. Use of information Quality account to include a fair The quality directorate led the production of the Chief nurse and about compliance by representation of areas where 2013/14 quality account which was published in June director of quality regulator from compliance has not been achieved. 2014 in line with regulatory requirements and governance and quality accounts guidance. chief executive (R37) and Comparable quality Quality accounts should be comparable The Trust’s quality account is published on the accounts (R246) website and made available to all our stakeholders. and Accountability for Quality accounts should be shared with quality accounts commissioners, stakeholders and (R247, R248 and regulators R251) Independent audit of quality accounts. A retrospective audit of the 2012/13 quality account was been undertaken by KPMG. and R249 – R250) Certification by all directors that the The quality account includes a statement from the quality account is accurate chief executive that “the information contained in this document is an accurate reflection of our performance for the period covered by the report”. Use of information The requirement for the Trust to The learning from experience team co-ordinate and Chief nurse and about compliance by demonstrate that learning from serious support the incident reporting process. director of quality regulator from incidents has been successfully governance media (R44) implemented. The Trust has a regular CLIP (Complaints, litigation,

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) complaints (C), litigation (L), incidents (I) PALS (P) Serious Incidents (S) (CLIPS) newsletter for staff. By learning from experiences we will be better able to continually improve the safety and quality of the services that we provide. Need for Council of Governors - role, training A guide for governors is being prepared for agreement Chief executive constructive working and stakeholders by the quality stakeholder reference group and with other parts of approval by FT steering group. This guide will the system include the statutory duties of governors, together with (R75/76/77) the role of governors in support of quality and will reinforce their role in relation to both members and the wider public. Training and development of Governors will include the FTN (GovernWell) programme. Accountability of Compliance with code of conduct and fit All directors have self-certified that they are ‘fit and Chief executive providers’ directors and proper person test. proper persons’ within the current Monitor (R79/81) requirements; this is also included in executive board Disqualification of directors member job descriptions. The Board has also agreed and a code of conduct which is consistent with the Nolan principles.

Practical steps to ensure / continuously review the ‘fitness’ of all directors, under the proposed statutory regulations will be considered by the Remuneration Committee.

The constitution will be updated to include serious misconduct and incompetence in the list of director disqualification criteria.

Shared code of Common code of ethics Board members have all signed a code of conduct. ethics All staff receive a copy of the Trust’s customer care (R215) standards, confidentiality code of conduct, the code of

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) conduct for NHS manager and the conflict of interest policy.

Requirement for the FTs will have to have in place an The Board has a development programme which Chief executive and training of directors adequate programme for the training includes 360 degree feedback, structured induction Chairman (R86) and continued development of directors and individual appraisal.

Recent Board evaluation has included the board governance assurance framework and quality governance assurance framework.

The board development programme as an FT will be focused on CQC / Monitor Well-Led Framework. Health Protection Healthcare acquired infections The annual infection prevention and control report is Medical director Agency co- published with board papers. The medical director is ordination and the responsible officer, supported by the infection publication of prevention and control team. providers’ information (R106) Any new requirements will be included in future annual reports. Effective complaints Methods to comment or complain must The complaint policy has been updated to reflect Chief nurse and handling be readily accessible and easily findings from the 2013 report of handling complaints director of quality (R109/111/113/114/ understood. by NHS hospitals. Actions in response to the Clywd- governance 118) Hart review of complaints has been considered and implemented through the patient experience group.

The Trust has a Customer Service Team and do you have something to tell us about our services?” leaflets are available in all care settings and via the website.

In liaison with NHS England, the Trust has developed an iPad based App for people with learning disabilities

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) to be supported to answer the NHS Friends and Family Test. A short film about the Project has been produced for service users and families/carers - which will be available to be viewed on YouTube My Health, My Say films with captioning to increase accessibility.

Complaints received are escalated as appropriate having considered the risk to patient safety.

There is board led scrutiny of complaints and the executive team and chairman receive weekly information on all complaints.

The medical director, chief nurse and deputy chief nurse meet regularly to review complaints information and to consider whether there are any safety/clinical practice issues, for example staff repeatedly being named.

The Trust publishes an annual report on complaints management, and reports quarterly to Quality Committee and Board via the Quality Report. All Board members (NEDS and executive directors receive a weekly update on complaints. Restrictive ‘Gagging clauses’ or disparagement Should the Trust be required to enter into a Director of finance, contractual clauses clauses compromise agreement, it will be made clear that staff performance and (R179) signing the agreement may make a disclosure in the corporate resources public interest in accordance with the Public Interest Disclosure Act, regardless of what other clauses may be included in the agreement. Focus on culture System and standards of training, The Trust holds an annual awards ceremony to Director of finance, and caring (R185) including recognition of achievement, recognise the achievements and excellence of staff. performance and

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) comprehensive feedback on corporate resources performance and concerns, priority to All staff are required to have an annual appraisal. patient well-being. See also response to R1 – compassion in care and ‘Clinical Fridays’ and ‘Back to the Floor’ above. Recruitment for A regulatory (provider) requirement for The Trust has already agreed a goal “to employ only Chief nurse and values and the recruitment of qualified and the best staff”. director of quality commitment (R191) unqualified nursing staff should include governance and assessment of candidates’ values, In support of the delivery of the quality strategy, the director of finance, attitudes and behaviours towards the quality team and HR function will be initiating values performance and well-being of patients and their basic based recruitment. corporate resources care needs. Nurse leadership Ward nurse managers should operate A detailed paper was considered by the Board at their Chief nurse and (R195) in a supervisory capacity, and not be meeting in January 2014 regarding safer staffing. All director of quality office bound or expected to double up, ward leaders are supervisory and not included in governance except in emergencies as part of the minimum numbers. nursing provision on the ward. Nurse leadership Training and professional development See response to R23 – compassion in care above. Chief nurse and (R196) of nurses should include leadership Performance and development reviews (PADR) are director of quality training from student to director undertaken for all staff to identify potential leaders and governance / leadership development needs. medical director The learning and development team commission external training and provide in-house training as relevant to individual posts. The clinical supervision policy has been reviewed and a leadership strategy is being prepared. Measuring cultural The development of transparent See response to R1 – compassion in care above. Chief nurse and health (R198) measures of the cultural health of front- Separate to this programme ‘Clinical Fridays’ have director of quality line nursing been implemented, with members of the senior team governance visiting clinical areas across the Trust. The PADR process is directly linked to the Trust’s values. The staff survey is a formal measure of cultural health

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) and progress against the subsequent action plan is reported quarterly to the Board. Staff engagement is a high priority for 2014/15 – ‘fit for the future’ events are being rolled out across all clinical business units between September and November 2014. Key nurses (R199) Named key nurse for each shift to co- See response to R23 – compassion in care above. Chief nurse and ordinate the provision of care needs for The Trust’s bedded units are compliant. director of quality each allotted patient. governance Strengthening the The requirement for healthcare The chief nurse and director of quality governance is Chief executive / nursing professional providers to have at least one executive an executive director. One of our non-executive chairman voice (R204) director who is a registered nurse and directors was previously a nurse. The composition of to consider recruiting nurses as non- the Board in our constitution for FT includes that “one executive directors of the executive directors is to be a registered nurse or a registered midwife”. Strengthening the Commissioning arrangements should The chief nurse and director of quality governance Chief nurse and nursing professional require the boards of provider would be consulted on any major changes to the director of quality voice (R205) organisations to seek and record the nursing establishment. governance advice of its nursing director on the impact on the quality of care and The medical director and chief nurse lead the clinical patient safety of any proposed major assessment of all cost improvement proposals. change to nurse staffing arrangements or provision facilities, and to record A key action from the Compassion in Care programme whether they accepted or rejected the included publication of staffing levels, linked to quality advice, in the latter case recording its of care and patient experience (see also R23 above). reasons for doing so. Strengthening The need for a uniform description of Work has started in north west London (NWL) to Chief nurse and identification of healthcare support workers, with the develop the role of the healthcare support work in director of quality healthcare support relationship with currently registered collaboration with the local education and training governance workers and nurses nurses made clear by the title. board (LETB) and Buckinghamshire New University. (R207) Communication with Regular ward rounds and constructive See response to R1 – compassion in care above. Chief nurse and

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) and about patients interaction between nurses and patients director of quality (R238) ‘Clinical Fridays’ have been implemented, with governance members of the senior team visiting clinical areas across the Trust.

Provision of food Constant review and monitoring of best See response to R1 – compassion in care above Chief nurse and and drink (R241) practice for providing food and drink to which includes documentation / patient records. director of quality patients governance Medicines Process of the administration of The Trust has a medicines management team have Medical director administration medication needs to be overseen by ward clinical pharmacists who undertake daily checks (R242) the nurse in charge of the ward or their in liaison with the nurse in charge. nominated delegate, together with frequent checks that all patients have The Board receives an annual medicines received what they have been management report. prescribed and what they need There is an annual omitted doses audit all bedded units, including the prison and palliative care unity. Common Need for common information Patients that wish to gain access to their medical Director of finance, information practices, including patient access to record under the Data Protection Act 1998 are performance and practices, shared their records, system prompts and required to submit a request form which will include corporate resources data and electronic defaults in support of safe and effective consent to release the information. This process is records (R244) care, patient engagement in system managed by the IG Team and is logged on a central design. system to ensure the records are collated, reviewed and released as appropriate within the 40 calendar day statutory deadline.

Electronic data on our current clinical systems (RiO, Adastra) is not shared outside the organisation without explicit patient consent. Systems provided under the National Programme for IT contract prompt for justification when access is requested to a record outside the current caseload.

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s)

Deployment of TPP SystmOne will allow the establishment of robust information sharing arrangements between care providers, as well as allow patients to access their own electronic record Board accountability Board level member for information The director of finance, performance and corporate Director of finance, (R245) resources, is accountable for the business performance and intelligence, performance and analytics corporate resources function of the Trust. Quality accounts (R246-251) see R37 above Access to data (252) Appropriate steps must be taken to Although compliant with the Health and Social Care Director of finance, enable properly anonymised data to be Information Centre anonymisation standards further performance and used for managerial and regulatory work is underway to put in place systematic control to corporate resources purposes. strengthen our compliance.

Information governance training is mandatory for all CLCH staff.

The Trust has implemented a pseudonymisation tool which can be used to send data without identifying an individual. This is currently up and running with the Trusts Information team and a training programme is to be delivered to other corporate services to enable the use of the tool.

Using patients’ Results and analysis of patient Results from patient reported experience measures Chief nurse and feedback (R255) feedback need to be made available to (PREMS) and the friends and family test (FFT) are director of quality stakeholder in as ‘real time’ as possible available to both commissioners and Board members. governance Following up A proactive system for follow-up after The Trust has engaged Picker to undertake telephone Chief nurse and patients (R256) discharge surveys of patients in support of PREMS and gaining director of quality feedback on services provided. governance

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Section Recommendation / requirement CLCH position / sources of assurance (evidence) Board Lead(s) Enhancing the use, Systems to provide effective real-time The Trust has implemented QlikView, self-service Director of finance, analysis and information on performance of services access to up to date business intelligence and clinical performance and dissemination of dashboards for all staff. corporate resources healthcare information (R262)

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Keogh, 2013 Relevant CLCH position / sources of assurance (evidence) Board Lead(s) Ambitions for improvement To tackle some of the underlying causes of poor care

2 The boards and leadership of provider To content and presentation of data is a high priority Chief Nurse and and commissioning organisations will for the Trust. Funnel charts have been introduced Director of Quality be confidently and competently using (showing outliers) and the use of standard variation Governance with data and other intelligence for the charts (SVC) is being explored. Director of Finance, forensic pursuit of quality improvement. Performance and They, along with patients and the Corporate public, will have rapid access to Resources accurate, insightful and easy to use data about quality at service line level. 3 Patients, carers and members of the We have an agreed engagement strategy which Chief Nurse and public will increasingly feel like they are covers the engagement of patients, carers, the public, Director of Quality being treated as vital and equal members and stakeholders. Listening events are Governance partners in the design and assessment planned in every borough (twice annually). of their local NHS. They should also be confident that their feedback is being The most recent listening event was held on the day listened to and see how this is of the annual general meeting (18.09.14) impacting on their own care and the care of others. 4 Patients and clinicians will have A number of CLCH staff have participated in CQC Chief Nurse and confidence in the quality assessments inspections of other trusts. The Trust is piloting mock Director of Quality made by the Care Quality Commission, CQC inspections of its own sites. In the future these Governance not least because they will have been mock inspections will include our members. active participants in inspections.

6 Nurse staffing levels and skill mix will A monthly nurse staffing report is made to the Board, Chief Nurse and appropriately reflect the caseload and this is based on agreed, appropriate staffing levels for Director of Quality the severity of illness of the patients all areas. Governance

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they are caring for and be transparently reported by trust boards.

8 All NHS organisations will understand The Trust’s engagement strategy includes staff Director of finance, the positive impact that happy and engagement and staff engagement is a high priority performance and engaged staff have on patient for 2014/15. Fit for the future events commenced in corporate resources outcomes, including mortality rates, and September to support the direct engagement of staff. will be making this a key part of their quality improvement strategy.

Berwick, 2013 Relevant CLCH position / sources of assurance (evidence) Board Lead(s) A promise to learn, a commitment to act

1 The NHS should continually and forever The quality team have been instrumental in creating a Chief Nurse and reduce patient harm by embracing learning culture. The Trust has a regular CLIP Director of Quality wholeheartedly an ethic of learning. (Complaints, litigation, complaints (C), litigation (L), Governance incidents (I) PALS (P) Serious Incidents (S) (CLIPS) newsletter for staff. By learning from experiences we will be better able to continually improve the safety and quality of the services that we provide (see R44 above) 2 All leaders concerned with NHS Our values include “putting quality at the heart of Chief Nurse and healthcare – political, regulatory, everything we do”. Director of Quality governance, executive, clinical and Governance advocacy – should place quality of care We have established a quality team, associate in general, and patient safety in directors of quality and clinical directors are linked to particular, at the top of their priorities for every CBU / division. investment, inquiry, improvement, regular reporting, encouragement and support.

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3 Patients and their carers should be Our engagement strategy ensures each division and The Board present, powerful and involved at all CBU has a clear strategy for engaging staff, patients levels of healthcare organisations from and stakeholders. Board meetings are held in public. wards to the boards of Trusts. The quality stakeholder reference group (QSRG) feeds directly into the Quality Committee.

Members have been invited to participate in the 15 steps challenge and patient led assessments of the care environment (PLACE). 4 Government, Health Education England The Trust has been involved with the development of Chief Nurse and and NHS England should assure that community education provider networks (CEPNs) Director of Quality sufficient staff are available to meet the across all networks. The Chief Nurse works with Governance NHS’s needs now and in the future. Health Education England and we are contributing to Healthcare organisations should ensure the identification of workforce development / needs. that staff are present in appropriate numbers to provide safe care at all times and are well-supported.

5 Mastery of quality and patient safety The Trust has launched a continuous improvement Medical Director sciences and practices should be part education programme. of initial preparation and lifelong education of all health care professionals, including managers and executives.

6 The NHS should become a learning See 5 above and Francis R44 above. Medical Director organisation. Its leaders should create and support the capability for learning, Reflective time has been incorporated into the working and therefore change, at scale, within week for ELT (meeting without a planned agenda) and the NHS. this is being encouraged across the organisation.

7 Transparency should be complete, All 48 hour meetings discuss the duty of candour and Chief Nurse and

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timely and unequivocal. All data on unless there are very specific / exceptional Director of Quality quality and safety, whether assembled circumstances, the family / patient are informed of any Governance by government, organisations, or errors. professional societies, should be shared in a timely fashion with all Serious incident reports are published together with parties who want it, including, in the quality scorecard and other performance accessible form, with the public. information.

8 All organisations should seek out the The Trust collects up to 1500 patient reported Chief Nurse and patient and carer voice as an essential experience measure (PREMs) forms across the Director of Quality asset in monitoring the safety and organisation each month, together with patient stories Governance quality of care. and localised patient satisfaction data. This is analysed through the patient experience group lead by the director of patient experience. The Trust has appointed 4 new patient experience facilitators to work within each division to improve the uptake and analysis of patient data. This will enable the divisions to work on demonstrating direct improvements in care. 9 Supervisory and regulatory systems There is a clear management structure within the Deputy Chief should be simple and clear. They Trust. The new clinical business unity (CBU) structure Executive should avoid diffusion of responsibility. ensures that clinical staff are managed by clinical Director of Finance, They should be respectful of the staff. All staff have access to clinical supervision and Performance and goodwill and sound intention of the vast are actively encouraged to use this facility. Corporate majority of staff. All incentives should There are policies and procedures in place to support Resources point in the same direction. staff development and a very clear performance management strategy. Staff are rewarded in their day to day practice and at events such as the annual staff awards ceremony.

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BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Board governance memorandum – updated action plan

Agenda item number: 3.3

Report of: Chief Executive

Contact Officer: Trust Secretary

Relevant CLCH 14/15 Goal: 1 Embody the best of the NHS for our patients: delivering great results with compassion and thoughtfulness Freedom of Information Can be published Status

Executive Summary: Having agreed the board governance memorandum in July 2014, an action plan to achieve best practice was prepared and agreed at the Board meeting of 30.09.14. Since this date, the Trust has received the findings of the external assessment by Grant Thornton, including some 14 recommendations (5 high priority), attached. These actions have been incorporated into the action plan (shown in red text). Updates on the original action plan are also tracked (shown in blue text).

The action plan is aligned and referenced to the DH framework, thus there is some repetition which cannot be avoided.

A copy of Grant Thornton’s report has been circulated to members of the Board.

Key observations included in their report are listed below:

1. The board governance memorandum is thorough and generally supported by the four case studies and evidence provided by the Trust. Ratings in ten of the fifteen categories have been endorsed, five scores have however been reduced.

2. Overall, by far the most common rating is 'amber/green'. This characterises accurately the Trust's overall position, namely the great majority of good practice requirements are either present or planned to be implemented in the near future. From the work performed, the Trust appears to be on track with its FT application timetable and has time to address those areas where improvements are required.

3. Fourteen recommendations that relate to specific ways in which the Trust can adopt more of the good practices have been made.

4. There is a good balance of skills, experience and knowledge amongst board members, with the NEDs providing good challenge during board and committee discussions

5. Three of the six NED terms are due to end on 31 March 2015, and the chair is having ongoing discussions with the TDA to try and resolve this issue. To ensure board stability and prevent a

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significant loss of expertise, Grant Thornton believe it is important that this issue is fully resolved as soon as possible to prevent it impacting on the effectiveness of the board.

6. Feedback from the Trust's lead tri-borough commissioners indicates that, although there has been some improvement in the relationship over the last year, further work is required to further develop an effective and constructive relationship. The development of a clear stakeholder engagement plan and supporting key account plans is a recognised development action for the Trust, and as part of this process we would recommend that the board confirms with its key external stakeholders the best methods to ensure effective and constructive relationships.

7. The Trust's plans for future engagement with FT governors are consistent with its FT application timetable. The consideration of detailed plans relating to the future governors of the Trust post- authorisation as an NHSFT should be undertaken by the FT steering group in the coming months.

8. The Trust has spent time considering board performance reporting over the last year, and feedback from board member interviews indicates that the KPIs included in the integrated performance and finance report balanced scorecard enable the board to effectively measure performance against the Trust's six strategic goals. The Trust is planning further development of the integrated finance and performance report for reporting to the board and Finance, Resources and Investment Committee (FRIC) in October 2014 and in our view, as part of this development process, the board should reflect upon the effectiveness of the key performance indicators used to monitor performance against four of the six strategic goals.

The recommendation in relation to this final observation was contested by the Chief Executive and since receipt of the report; clarity regarding specific improvements that the Trust might consider has been requested.

Report provenance: Actions identified to achieve ‘good’ practice were included in the board governance memorandum approved by the Board on 31.07.14 and the initial action plan was agreed on 30.09.14. The updated action plan has been discussed with ELT and is shared for Board comment.

Report for: Decision Discussion Information

Recommendation: To discuss.

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Grant Thornton recommendations, ref 08.10.14

Section Recommendation Priority (High, Medium, Low) BGAF 1.1 The Trust should continue negotiating with the TDA over the staggering High and 2.3 of the three NED terms coming to an end on 31 March 2015. The Trust should consider what contingency actions it can take to prevent the risk of such an imbalance in board composition. BGAF 1.3 The Trust should review how the new arrangements to ensure regular Medium attendance by board members at board and committee meetings are working after six months. BGAF 2.1 The board should engage in a comprehensive, independent board Medium evaluation process in 2015. BGAF 2.1 The board should ensure that the current work to gather stakeholder High perspectives on the effectiveness of the board is given full consideration and acted upon. Stakeholder perspectives should then be gathered and analysed at regular intervals, moving through the foundation trust application process and beyond. BGAF 2.2 We recommend that a formal and long-term board development plan / Medium programme is put in place to ensure that the direction, workings and supporting governance arrangements of the board are appropriate both before and following foundation trust authorisation. BGAF 2.4 The Trust should put an action plan in place to ensure that when the Low time comes, governor involvement in the chairman's and NEDs' appraisal processes is fully considered. BGAF 3.1 As part of the Trust actions to improve the IPFR, the board should High reflect upon the effectiveness of the KPI used to monitor the performance against the following four strategic goals: ‒ deliver better value than competitors in our selected markets; ‒ be responsive to our patients' and partners' needs; ‒ employ only the best staff, and; ‒ be innovation and technology pioneers. BGAF 3.1 In further developing the form and content of the IPFR over the coming High months, the Trust should ensure: ‒ greater emphasis is placed on providing insightful explanations for adverse variances and trends and stating what actions have been taken to bring the variance back into line with plan; ‒ forecast outturn information is provided for non-financial KPIs; ‒ service line reporting information includes a quality perspective and is presented more clearly; and, ‒ comparable data (comparable organisations or between different service lines) is included. BGAF 3.1 We recommend that when committee chairs provide verbal updates to Medium the board, written updates are also provided or the minutes of board meetings note the key points made by the committee chairs. BGAF 3.2 In reporting CIP performance to the FRIC, we recommend that analysis Medium of major CIP schemes is provided to highlight where performance is not in line with plan. BGAF 4.1 We recommend that the chairman and chief executive meet with their High peers in the tri-borough commissioners to confirm the best method to ensure effective and constructive relationships; and follow

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this up with the development of key account plans. BGAF 4.2 The Trust should seek feedback from staff on the effectiveness of its Medium internal communication methods, particularly the impact of regular email communications and the effectiveness of the intranet hub, to ensure that they are appropriate and efficient. BGAF 4.3 The Trust should set up a process for monitoring attendance at key Medium external stakeholder events and meetings, in particular those that involve important commissioner meetings, and ensure regular attendance by key account owners. BGAF 4.4 The consideration of the roles, responsibilities, method of selection, Medium numbers and designations and all other matters relating to the future governors of the Trust post-authorisation as an NHSFT should be directed and overseen by the FT steering group once the Trust is within a year of its planned authorisation as an FT.

151 Board Governance Memorandum (BGM) Action Plan, v8 October 20141

The action plan, agreed by the Board on 30.09.14, has been updated as planned to reflect the findings of the independent review by Grant Thornton, 6 Oct 2014. It is confirmed that of the 15 categories, the self-assessment score for 5 has been reduced (2.4, 3.3, 4.1, 4.3 and 4.4) – see status below. These relate to areas where it is considered that evidence has not been provided to demonstrate good practice and action plans in place to achieve good practice. Two new sections have been added to the action plan in relation to 3.3 environmental and strategic focus and 4.3 Board profile and visibility.

Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

1.1 Board positions and size Amber / Green High turnover of Board Action 1.1, good practice P Chesters Open n/a membership in previous statement 2 We have had some significant turnover 2 years Board development programme of the Board in the previous 2 years. (red flag) supports rapid assimilation. The This has strengthened the Board by most recently appointed Board increasing the level of skill and members all have previous Board experience held by Directors to match experience. the requirements of foundation trust status.

A succession plan is in place for all Board positions. Where necessary, the Action 1.1, good practice P Chesters Open March 2015 appointment term of statement 7 The TDA advised in January 2014 that NEDs is staggered so The Chairman has brought this their NED development team were they are not all due for problem to the attention of looking at staggering end terms for re-appointment or leave Christine Beasley and the Head community trusts. the Board within a short of the TDA Appointments Section space of time. who have promised to review this In October, the TDA confirmed that phasing which is an issue Director for Delivery and Development affecting all community trusts. supports the re-appointments of the

1 Author – Jayne Walbridge, Trust Secretary

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152 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

three NEDs and have asked the Chairman for a recommendation on the length of terms (up to four years).

Grant Thornton BGAF An action in relation to this issue 1.1 and 2.3 has already been agreed. The Trust should continue negotiating with the TDA over the staggering of the three NED terms coming to an end on 31 March 2015. The Trust should consider what contingency actions it can take to prevent the risk of such an imbalance in board composition. 1.3 Board member commitment Amber / Green Board members have a Action 1.3, good practice J Reilly / Complete September good attendance record statement 1 L Ashley / Since August 2014, the Deputy CEO 2014 at all formal Board and This has been reviewed recently R Milner has attended each meeting and this Committee meetings and arrangements to ensure that arrangement has been confirmed, and at Board events ‘operational’ staff are routinely therefore no changes to the represented at the Quality membership will be required. Committee are will be confirmed. This will be reflected in the revised terms of reference for Board approval. Grant Thornton BGAF Committee and board attendance J Walbridge Open March 2015 1.3 to be reviewed to ensure regular Planned for February 2015. The Trust should review attendance by members. how the new

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153 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

arrangements to ensure regular attendance by board members at board and committee meetings are working after six months. 2 Effective Board level evaluation Amber / Red Formal evaluations of Action 2.1, good practice J Walbridge Open Tbc in liaison the Board and statement 1a / J Reilly / P The Code requirement is for the “board with TDA Committees have been The Quality Committee self- Chesters of directors should undertake a formal guidance. undertaken within the assessment in 2014 has been and rigorous annual evaluation of its previous 12 months deferred in order to arrange a consistent with the FT more comprehensive, facilitated, own performance and that of its Code of Governance. self-assessment with Stephen committees and individual directors”. The Board can clearly Ramsden, a former NHS CEO. Board and committee programmes identify a number of The output of this review will be include this requirement. External changes/improvements available in September. The evaluation of the Quality Committee has in Board and Committee Remuneration Committee self- now been received and the Charitable effectiveness as a result assessment is planned for Funds Committee have also concluded of the formal evaluations October 2014 and the Charitable their review. The People and that have been Funds Committee will be Remuneration Committee review is undertaken. concluded in September 2014. complete and will be reported to the Remuneration Committee on 22.10.14.

Committee chairs will consider whether June 2015 a more formal assessment process is required in 2015. The Board has not Action 2.1, good practice P Chesters/ Open June 2015 undertaken an statement 1b J Reilly Excellence in Leadership will be independent evaluation The Board’s current focus is on conducting a stakeholder survey of the of effectiveness within Development and the Unitary Board in early 2015. The outcome of the last 2 years. Board, independent evaluation of this will shape the next phase of the (red flag) effectiveness will be arranged in Board’s development programme. 2015.

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154 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

The need for independent evaluation of effectiveness has been discussed by ELT, it is concluded that this is integral to the work Excellence in Leadership and that any gaps, specific to effectiveness, should be considered after this work has been concluded.

Previous Board evaluation has included Deloitte and the TDA.

The Board has had an Action 2.1, good practice P Chesters Open Nov 2015 independent evaluation statement 2 This will be conducted towards the end of its effectiveness and To arrange further independent of 2015 when the work with Excellence committee structure evaluation of the Board (hard and in Leadership and the current internal within the last 2 years by soft dimensions) and committee review of Committees/Board work and a third party that has a structure during 2015 to ensure reporting has been embedded. good track record in that evaluation within the undertaking Board previous 12 months can be effectiveness demonstrated on application to evaluations Monitor. Grant Thornton BGAF Timing of independent evaluation J Reilly Guidance from the TDA on the timing April 2015 2.1 to be confirmed. and format of further Board evaluation, The board should including the status of the recent engage in a assessments by Grant Thornton and comprehensive, Niche Consultancy has been sought. independent board evaluation process in 2015. The perspectives of staff Action 2.1, good practice P Chesters / Open April 2015 and commissioners has statement 3 J Reilly Excellence in Leadership will be not informed Board As part of the Board’s conducting a stakeholder survey of the evaluation. development programme with Board in early 2015. The outcome of

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155 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

Excellence in Leadership, internal this will shape the next phase of the stakeholder perspectives will be Board’s development programme. obtained later in 2014 and external perspectives in 2015. Grant Thornton BGAF An action in relation to this issue I McMillan Open April 2015 2.1 has already been agreed. for I Millar The Board has agreed an engagement The board should strategy. ensure that the current work to gather The Board has discussed the stakeholder perspectives development of the commercial strategy on the effectiveness of which is due to be considered for the board is given full approval in November 2014. consideration and acted upon. Stakeholder Analysis of stakeholder feedback The Trust will use customer relations perspectives should then at regular intervals throughout the management (CRM) software to gather be gathered FT process and beyond to be and analyse information from and analysed at regular incorporated into stakeholder stakeholders. intervals, moving engagement plans. through the foundation trust application process and beyond. 2.2 Whole Board Development Programme Amber Green … understanding what Action 2.2, good practice L Ashley / Open November FT status means; statement 1 J Walbridge Reference to Well-led framework, 2014 development specific to The Board will consider the included in this action plan the Trust’s FT requirements of the ‘Well-led’ application… framework in support of future Well-led framework for governance Board evaluation plans reviews: As an FT the Trust will be expected (by Monitor) to commission an external review of governance arrangements J Walbridge every 3 years. The framework is built At along the lines of the existing quality authorisation governance framework and is intended

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156 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

as a guide for trusts and assessors in considering whether the processes and overall organisational culture in these areas are fit for purpose. It is proposed that between the external assessments, ie year 1 and 2, an internal review of 2 of the 4 domains is undertaken. This will inform the development programme for the Board.

A Board development programme specific to the FT curriculum / application process to be updated post April 2015 on completion of the P Chesters/ Excellence in Leadership plan. This will May 2015 J Reilly include how the Board discussion on how the Board will communicate and engage with governors and how governors will be involved in strategic development, service change and quality issues. Grant Thornton BGAF Development plan post April P Chesters/ Open April 2015 2.2 2015 (when Excellence in J Reilly/ To be discussed. We recommend that a Leadership plan concludes), to J Walbridge formal and long-term be prepared. Template from the Good Governance board development plan Institute sourced for long-term plan / / programme is put in programme. place to ensure that the direction, workings and supporting governance arrangements of the board are appropriate both before and following foundation trust

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157 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

authorisation. Members have an Action 2.2, good practice J Walbridge Open March 2015 appreciation of how they statement 2 Scheduled for December 2014 for report will be regulated as an A comparison with Monitor’s code in January 2015. FT and the role of the of governance will be repeated in board and NEDS in an 2014/15. FT environment. … The Board has been Action 2.2, good practice L Ashley / Open Quarterly engaged in the statement 3a J Walbridge BGAF action plan considered in review from development of the IBP Board to review progress against September and October 2014. September and LTFM and in self- QGF and BGAF quarterly. 2014 assessing the Trust’s The Board approved the QGAF in July QGAF 2014. The initial action plan was considered in September 2014.

Recommendations made by the external assessor (Niche) are expected to be received in October 2014. … The Board has been Action 2.2, good practice Iain Open January 2015 engaged in the statement 3b McMillan for A commercial strategy, including development of the IBP Implementation of the I Millar external (commissioner) engagement and LTFM and in self- commercial strategy (including will be developed in 2014. Proposal assessing the Trust’s external stakeholder considered at Board seminar on QGAF engagement) which is managed 30.09.14. Strategy to be considered for by the Director of strategy and agreement by Board on 27.11.14. business development. …. Whether the Board’s Action 2.2, good practice P Chesters / Open April 2015 Committees are statement 4 J Reilly / J This has been discussed at the Board operating effectively and As Board Committees have Walbridge seminar in July and a revised approach providing sufficient become much more effective in is being introduced, together with assurances to the Board. their role, the Board is actively refreshed reporting formats. Once considering how best to avoid established they will be reviewed in repetitive discussion with items 2015 to check the effectiveness and that are considered by the whether the revised arrangements have

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158 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

Committees. been appropriately embedded. The Board has Action 2.2, good practice P Chesters / Open n/a considered, at a high- statement 6 J Walbridge Development needs will be addressed level, the potential ‘First 100 days’ post FT through the Board’s development development needs of authorisation plan to be prepared programme. At the appropriate time, the the Board post and implemented in 2015/16 curriculum will include, for example the authorisation as an FT. FT regulatory regime and the role of governor.

When the authorisation date is known, the 100 day plan will be prepared by the Trust Secretary to ensure that at authorisation, necessary governance arrangements can be implemented immediately, for example confirmation of governors, the constitution and establishment of the council of governors nomination and remuneration committee. 2.3 Board induction, succession and contingency planning Amber / Green NED appointment terms Action 2.3 P Chesters Open n/a are not sufficient The second term for 3 of our In October, the TDA confirmed that staggered. NEDs will conclude at the same Director for Delivery and Development (red flag) time (April 2015). The Chairman supports the re-appointments of the has raised this formally with the three NEDs and have asked the TDA and also with the NEDs to Chairman for a recommendation on the advise that length of terms (up to four years). See 1.1 above. 2.4 Board member appraisal and personal development Green Amber / Green2 Grant Thornton 2.4 An action in relation to this issue The Trust should put an has already been agreed

2 GT assessment score, Oct 2014

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159 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

action plan in place to ensure that when the time comes, governor involvement in the chairman's and NEDs' appraisal processes is fully considered. 3.1 Board Performance Reporting Amber / Green The Board receives a Action 3.1, good practice Mike Fox for Open December fully integrated statement 1 and 2 I Millar The FRIC have discussed improved 2014 performance dashboard Internal performance priorities for reporting processes which will be which enables the Board 2014 include: implemented from October 2014. to consider the • Gaining a better performance of the Trust understanding of any outliers against a range of at clinical business unit metrics, including quality, (CBU) level and in some performance, activity and areas, team level finance and enables • More frequent forward links to be made, eg looking indicators financial variances are • More triangulation of key linked to activity. performance metrics Variances from plan are examining the impacts of clearly highlighted and change in workforce, activity, explained. quality and finance have on one another. Action 3.1, good practice C Sheldon Open November statement 2b for L Ashley The serious incident reporting policy 2014 Briefing to be prepared was updated in August 2014 and demonstrating how issues arising includes a clear escalation process from at the front line are identified and floor to Board. Whistleblowing for all escalated, building on funnel staff and further guidance for clinical charts and clinical business units. staff has been issued. A flow diagram is also being prepared showing all routes for whistleblowing (raising concerns

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160 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

about staff, clinicians and fraud). Action 3.1, good practice Mike Fox for Open November statement 2c I Millar A Tyler has been asked to prepare 2014 Survey of Qlikview usage to be report on usage for ELT to consider in arranged towards the end of late November. 2014.

Grant Thornton 3.1 Mike Fox for J Reilly has written to the Board to state November As part of the Trust I Millar that he has requested further 2014 actions to improve the clarification regarding Grant Thornton’s IPFR, the board should recommendations in relation to the reflect upon the integrated performance and finance effectiveness of the KPI report. used to monitor the performance against the following four strategic goals: ‒ deliver better value than competitors in our selected markets; ‒ be responsive to our patients' and partners' needs; ‒ employ only the best staff, and; ‒ be innovation and technology pioneers. Grant Thornton 3.1 Mike Fox for J Reilly has written to the Board to state November In further developing the I Millar that he has requested further 2014 form and content of the clarification regarding Grant Thornton’s IPFR over the coming recommendations in relation to the months, the Trust should integrated performance and finance ensure: report.

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161 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

‒ greater emphasis is placed on providing insightful explanations for adverse variances and trends and stating what actions have been taken to bring the variance back into line with plan; ‒ forecast outturn information is provided for non-financial KPIs; ‒ service line reporting information includes a quality perspective and is presented more clearly; and, ‒ comparable data (comparable organisations or between different service lines) is included. Grant Thornton 3.1 J Walbridge Open January 2015 When committee chairs with This process is now established for the provide verbal updates Committee Audit Committee and FRIC Committee. to the board, written Chairs With the exception of FRIC, J Walbridge updates are also to prepare draft for all Committee provided or the minutes Chairs. With the agreement of the Trust of board meetings note Chairman, such updates will be tabled if the key points made by necessary. the committee chairs. 3.2 Efficiency and Productivity Amber / Green

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162 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

The Board is assured Action 3.2, good practice L Ashley / Complete October 2014 that there is a robust statement 1 J Medhurst A more robust impact assessment process for prospectively New CIP review arrangements to process has been introduced. assessing the risks to discussed at Quality Committee. care quality and the Divisional directors of operations are potential knock-on involved in the agreement and impact of the wider monitoring of CIP plans. health and social care community of The Medical Director and Chief Nurse implementing CIPs. This have personally signed off all CIP quality process requires the impact assessments and review CIPs Medical, Nursing and with Divisions every two months. All Operations Directors to CIP risks are on the Trust’s risk register. all sign-off each major Action 3.2, good practice L Ashley / Open October CIP to ensure patient statement 1 J Medhurst It is planned that all corporate CIPs will 2014. safety is not Some corporate CIP quality be signed off by mid October 2014. compromised. impact assessments have not yet been received for assessment and are due to be considered in August 2014. The Board receives Action 3.2, good practice L Ashley / Open October 2014 information on all major statement 3a J Medhurst As above, the Medical Director and CIPs/QIPP plans on a The Quality Committee and FRIC Chief Nurse meet every two months with regular basis, including have agreed that post all Divisions to review quality key how other organisations implementation reviews should performance indicators for all schemes. in the local health be conducted on all significant economy are performing CIP schemes to ensure that they against QIPP. Schemes have not led to an unacceptable are allocated to lead level of increased risk to quality. Directors and are RAG Timetable for 2014/15 to be rated to highlight where prepared and agreed by the Chief performance is not in line Nurse and Medical Director. with plan. The risks to Action 3.2, good practice Mike Fox for Open October 2014 non-achievement of statement 3b I Millar The process to capture information on

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163 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

each major CIP is clearly To consider process to capture other organisations will be considered stated and contingency information on how other but it is likely that this level of detail will measures are organisations in the local health not be published – the resources to articulated. economy are performing against achieve will be considered against any their QIPP schemes. benefits. Grant Thornton BGAF ELT to consider the level of detail Mike Fox for Open Dec 2014 3.2 provided in report to FRIC. I Millar Exception reports to highlight where In reporting CIP performance is not in line with plan. performance to the FRIC, we recommend that analysis of major CIP schemes is provided to highlight where performance is not in line with plan. 3.3 Environmental and strategic focus Green Amber / Green3 Note4 - Grant Thornton An action in relation to this issue commented that, while has already been agreed. market opportunities and threats in relation to services provided have been considered, the commercial strategy and related stakeholder engagement plans are not yet confirmed. 3.4 Quality of Board papers and timeliness of information Amber / Green Board papers outline the Action 3.4, good practice R Milner Open February decisions or proposals statement 5 To be incorporated into the Board 2015 that Executive Directors To review the effectiveness of the development plan.

3 GT assessment score, Oct 2014 4 This was not a recommendation, but was a key finding

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164 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

have made or propose. new board writing guidance, This is supported, where specifically improvement in the appropriate, by: an assessment of alternatives and appraisal of the relevant the rationale for the proposed alternative options; the option. rationale for choosing the preferred option; and a clear outline of the process undertaken to arrive at the preferred option, include the degree of scrutiny that the paper has already been through. The Board is routinely Action 3.4, good practice Mike Fox for Open November provided with data statement 6 I Millar The agreed internal audit programme for 2014 quality updates (eg IG An independent review in 2014 2014/15 includes data quality. toolkit scores). These has informed the Board of the updates include external current status of assurance and The Audit Committee has a specific assurance reports that has generated action plans that objective (64) for a second year - “To data quality is being are being delivered through the continue to monitor progress against the upheld in practice and year. implementation of the Data Quality are underpinned by a Strategy to gain assurance on the programme of clinical - a single data warehouse ("one accuracy, timeliness and relevance of and/or internal audit to version of the truth") key performance data sets”. test the controls that are - automated report generation, in place. minimising manual intervention, At the Audit Committee in September to maintain that "one version of 2014 data quality in relation to all KPIs the truth" philosophy, was considered which was interesting The Board does not - easier access for managers to and helpful. Areas of concern have routinely receive dashboard information that allows been referred to the respective assurances in relation to them to good practice statement committees (FRIC, Quality and data quality any data issues early. Workforce). (red flag)

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165 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

A data quality forum has also been established and meets regularly to improve data quality. It provides reports for assurance to the Board through the Audit Committee, including the results of data audits scheduled through the year to test the quality of data.

New for 2014/15 an extra Board level KPI is also being developed that will be reviewed regularly at FRIC and Board tracking overall data quality confidence levels as measured by the data quality assurance framework. 4.1 External Stakeholders Amber / Green Amber / Red The Board has an Action 4.1, good practice Iain Open December external stakeholder statement 1 McMillan for At the seminar meeting on 30.09.14, the 2014 engagement plan that External stakeholder plans to be Ian Millar Board considered the development of clearly describes the reviewed and refreshed in 2014, the Trust’s commercial strategy – Trust’s key existing and including confirmation of leads for encompassing stakeholders, emerging external various stakeholder groups. partnerships, competition and stakeholders, their marketing. relative priority and the For inclusion in Board tailored methods used to programme, 2014/15. An external stakeholder engagement January 2015 involve each stakeholder plan specific to FT status is being group (stakeholders prepared for ELT to consider in include CCGs, LA and November 2014, longer term plans will Wellbeing Boards). be developed as part of the commercial

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166 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

strategy implementation. Note5 - Grant Thornton has commented that further work is required to further develop an effective and constructive relationship and that the development of a clear stakeholder engagement plan and supporting key account plans is required.

A variety of methods are Action 4.1, good practice L Ashley Open December used by the Trust to statement 2a The learning disability protocol is being 2014 enable the board and Implementation of the learning prepared and will be discussed at the senior management to disability protocol Quality Committee in October 2014. listen to the views of patients, carers, In liaison with NHS England, the Trust commissioners and the has developed an iPad based App for wider public, including people with learning disabilities to hard to reach groups like be supported to answer the non-English speakers NHS Friends and Family Test. A short and service users with a film about the Project has been learning disability. The produced for service users and Board has ensured that families/carers - which will be available various processes are in to be viewed on YouTube My Health, My place and effectively and Say films with captioning to increase efficiently respond to accessibility. these views and can Action 4.1, good practice Joe Mills for Complete April 2015

5 This was not a recommendation, but was a key finding

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167 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

provide evidence of statement 2b I Millar A summary IBP has not been prepared, these processes Summary IBP to be completed however, the two-year plan has been operating in practice. and distributed to stakeholders. published here. Relationship with CCGs J Reilly Open December The TDA have expressed a view Monthly chairs meetings 2014 that CCG relationships is the Improved quality meetings with biggest challenge to the Trust’s commissioners FT application. Board meetings with CCGs held where/when possible Further work is required to Commercial strategy in development for strengthen the confidence of approval in November. North West London CCG and a Whole systems work progressing to plan to strengthen relationships plan. will be prepared by ELT.

ELT will also fully engage and See also 4.1, above (external consult with commissioners and stakeholder plan). other key stakeholder in the production of the 2015/16 IBP, including key service developments. Grant Thornton 4.1 Chairman and Chief Executive to J Reilly / Open Tbc We recommend that the raise this issue at their meetings P Chesters Chairman and Chief Executive to chairman and chief with all commissioning discuss. executive meet with their equivalents, including those in peers in the tri-borough the tri-borough. commissioners to confirm the best method to ensure effective and constructive relationships; and follow this up with the development of key account plans.

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168 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

4.2 Internal Stakeholders Amber / Green A variety of methods are Action 4.2, good practice J Reilly Open December used by the Trust to statement 1a Staff engagement events commenced 2014 enable the Board and ELT to review staff engagement on 29.09.14. senior managers to listen plans and processes to further to the views of staff, develop wider and structured While a target date of December is including ‘hard to reach’ staff engagement opportunities. included, this work will be on-going. groups like night staff ELT will consider whether the and weekend workers. group commissioned to develop A report on the staff communications The Board has ensured the Trust’s leadership strategy and engagement was received by the that various processes can support staff engagement Board on 30.09.14 showing some are in place to effectively plans. progress. and efficiently respond to these views and can provide evidence of these processes operating in practice. Grant Thornton BGAF Effectiveness of internal L McGeehan Open February 4.2 communications to be tested. for I Millar To be discussed with Head of 2015 The Trust should seek Communications. feedback from staff on the effectiveness of its internal communication methods, particularly the impact of regular email communications and the effectiveness of the intranet hub, to ensure that they are appropriate and efficient. Action 4.2, good practice S Graham Open December statement 1b for I Millar To be discussed with Head of 2014 Staff engagement to be reviewed Communications to ensure that the views of ‘hard

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169 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

to reach’ groups are pro-actively sought. Divisional Directors of Operations to be consulted in identifying robust communication channels for staff who may only work at night and weekends. The Board can evidence Action 4.2, good practice Joe Mills for Complete / underway January 2015 how staff have been statement 2 I Millar The 2013/14 business planning process engaged in the Continued involvement of front- was used to inform the IBP, this development of their 5 line staff at CBU level in included discussion with divisional year strategy for the developing the IBP. teams, for example planning away days, Trust and provide and at the senior management forum. examples of where their views have been The Trust’s whole planning process for included and not 2015/16 will be built bottom-up by the included in the IBP. CBUs and each manager will have a planning document which will describe their future plans for the CBU. This information will be integral to the development of the IBP.

The Board has Action 4.2, good practice J Reilly Open December communicated a clear statement 5 A series of staff engagement events 2014 set of values/behaviours Improved communication and (CLCH Fit for the Future) have been and how staff that do not engagement with staff through scheduled across all divisions, led by behave consistent with the ‘Fit for the Future’ initiative. ELT between 29 September and 19 these values will be November 2014. The focus of these managed. Examples events is to share details of the Trust’s can be provided of how future strategy and listen to the views of management have staff about how teams can work together responded to staff that to ensure the trust is ‘Fit for the Future’. have not behaved consistent with the Trust’s stated

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170 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

values/behaviours. The Board can Action 4.2, good practice J Medhurst Complete November demonstrate that statement 7 New divisional structures include clinical 2014 clinicians play a key role Establishment of permanent part- directors in management and time Deputy Medical Director Assistant directors of quality identified decision making within post Medical director forum established and the Trust. Deputy Medical Director has been appointed and is now in post (October 2014).

4.3 Board profile and visibility Green Amber / Green6 Grant Thornton BGAF Implementation of CRM software I McMillan Open December 4.3 for I Millar The Trust will use CRM software to 2014 The Trust should set up capture and act upon commissioner a process for monitoring information. attendance at key external stakeholder events and meetings, in particular those that involve important commissioner meetings, and ensure regular attendance by key account owners. 4.4 Future engagement with FT Governors Amber / Green Amber / Red There are robust plans in Action 4.4, good practice J Walbridge Open June 2015 place to elect, induct and statement 3a P Chesters The election and communication plan February2015 develop governors once A communications plan will be (scoping our approach) for the Council

6 GT assessment score, Oct 2014

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171 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

the Trust is authorized. developed to support our election of Governors will be prepared for plan, including early identification consideration by the FT steering group of a wide range of members who in October 2014. might be interested in standing for election. The draft Governor handbook, including the role of Governors in the Chairman’s and NED’s appraisal will be prepared for consideration by the FT steering group in November 2014.

The draft Governor induction programme will be prepared for consideration by the FT steering group in December 2014.

We have commenced the identification April 2015 of governors and the FT team led engagement events in late autumn early 2015 will help us progress this initiative, particularly for staff governors.

Plans to recruit governors will include a promotional film, to be scoped before December; however filming will not commence until after April 2015. Action 4.4, good practice P Chesters Open Feb 2015 statement 3b The constitution includes details of our The Chairman will write to appointed members. stakeholders seeking confirmation of appointed A letter confirming the Trust’s progress governors in a timely fashion at in achieving FT status will be sent to the same time as we move organisations who have agreed to towards holding elections for appoint a governor in February 2015. elected members.

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172 Ref Good practice Action Lead(s) Position, status and comments Target date question / deadline and Grant Thornton recommendation

Action 4.4, good practice J Walbridge Open statement 3c The membership strategy will be Feb 2015 The Trust’s guide for governors updated in January 2015 and will and proposed governor include more up-to-date plans specific to development plan will be the elections and governor induction. prepared in 2014. We will ensure that governors have access to The handbook for governors will be February the Foundation Trust Network drafted in November 2014 and will be 2015 GovernWell national governor considered by the FT Steering group. training programme. See also 4.4, 3a above Grant Thornton BGAF . See 4.4, 3a above. February 4.4 2015 The consideration of the roles, responsibilities, method of selection, numbers and designations and all other matters relating to the future governors of the Trust post- authorisation as an NHSFT should be directed and overseen by the FT steering group once the Trust is within a year of its planned authorisation as an FT.

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TRUST BOARD PAPER October 2014

Report title: FT timeline update

Agenda item number: 3.4

Report of: Director of Finance, Performance and Corporate Resources

Contact Officer: Foundation Trust Project Manager Relevant CLCH 14/15 Goal: 1 Embody the best of the NHS for our patients: delivering great results with compassion and thoughtfulness 2 Support people safely out of hospital: providing safe, high quality value for money alternatives to hospital admissions 3 Deliver better value than competitors in our selected markets: securing our sustainability by providing effective and efficient services 4 Be responsive to our patients and partners’ needs: promoting integration and partnership by demonstrating our capacity, character and competence 5 Employ only the best staff: selecting staff who care and supporting them to go the extra mile for our patients 6 Be innovation and technology pioneers: leading transformation of out of hospital services to empower staff and improve patient health Freedom of Information No Status

Executive Summary: A foundation trust trajectory was agreed with the Trust Development Authority (TDA) in July 2014. In light of recent confirmation that the Care Quality Commission (CQC) inspection will take place in April 2015, rather than March (which was indicative only), dates in the TDA stage of the Trust’s application have been revised accordingly.

The result is that the timing of the TDA Board to Board meeting is likely to be affected with some knock-on effect of up to two months on sign-off of the TDA stage. Previously, it was indicated as July 2015 but will now move to either 20 August or 3 September. The earlier date is advisable given that it will avoid delays to the TDA Board sign-off and the beginning of the Monitor stage; however, the Trust Board will need to decide whether it would be preferable to hold the Board to Board in August or early September. It should be notes that the Board to Board will require a considerable amount of preparation by Board members in advance.

This report also highlights that the introduction of the new Independent Financial Review (IFR) is delayed and there is still no launch date. Before CLCH can proceed to the Readiness Review, an external financial assessment will need to have been completed. Consequently, the TDA has asked the Trust to carry the out the assessments under the old framework, HDD 1 and 2.

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Assurance provided: The timeline and trajectory for foundation trust (FT) authorisation are regularly reviewed by the FT Project Manager in conjunction with the TDA.

Report provenance: This paper has been seen by ELT.

Report for: Decision Discussion Information

Recommendation: The Board is asked to note the contents of this paper and, in addition, to decide whether August 20 or September 3 would be most suitable for the Board to Board meeting with the TDA.

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1. Purpose

1.1 This is a quarterly update report on the foundation trust (FT) timeline. The Board is asked to note its contents. 1.2 In addition, the Board needs to consider whether it wants the Board to Board (B2B) meeting with the TDA in August or September 2015.

2. Introduction

The TDA has issued a new draft timeline in light of recent confirmation that the Trust’s CQC inspection will take place in April 2015. This is one month later than in the previous version of the timeline (July 2014), however the timing was indicative only. Although only one month later, there is an impact on some of the key milestones, shown below:

• The Quality Summit (date is set by CQC) cannot take place until after the Chief Inspector of Hospitals’ draft report is issued • The meeting of the TDA Medical Director and CLCH Chief Nurse is flexible to an extent but must take place before the B2B • The B2B with the TDA can only take place after the Quality Summit, optional dates being August 20th or September 3rd. (B2B meetings are held either on the first or third Thursday of every month). By agreeing to go with the earlier date CLCH would minimise delays in the subsequent formal sign- off by the TDA Executive and (one month later) by the TDA Board, which meets every two months, although it may be possible to request earlier sign-off at an extraordinary Board meeting. The whole Board is required for the B2B meeting, therefore the possible impact of any annual leave dates will need to be taken into consideration. It must be emphasised that the B2B will require considerable preparation beforehand by executive and non-executive directors

IFR/HDD

There are continued delays to the introduction of the new IFR assessments, which will not now be introduced during the current calendar year as originally planned. However, the Trust will still need to undergo external financial assessments as it did for BGAF and QGF before the Readiness Review (May 2015) can take place. The TDA has asked CLCH to use the previous Historic Due Diligence (HDD) framework, parts 1 and 2. The Trust will not be required to carry out IFR when it is introduced, although a bridge between the two assessments may be required. In part, this will be fulfilled by the mock IFR assessment recently carried out by the Trust.

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3. Proposal

The draft timeline below revises the milestone dates in the remainder of the TDA stage of the Trust’s FT application.

4. Quality Implications and Clinical Input

There are no implications.

5. Equality Implications

There are no implications.

6. Comments of the Director of Finance, Performance & Corporate Resources

7. Risks and Mitigating Actions

Delays to key milestones in the timeline may result in a delay to the Trust becoming authorised as a FT. As mitigation, the FT Project Manager and Commercial Director review the timeline on a regular basis to ensure that all milestones are being met in a timely fashion. Close contact is maintained with the TDA to ensure the programme is on track.

8. Consultation with Partner Organisations

No consultation with partner organisations was required.

9. Monitoring Performance

The FT timeline is subject to change; however, it is regularly monitored by the FT Project Manager (in conjunction with the TDA) and the FT Working Group.

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Appendix 1: Draft FT trajectory

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BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Safeguarding Children and Adults Report

Agenda item number: 3.5

Report of: Chief Nurse Contact Officer: Head of Safeguarding

Relevant CLCH 14/15 Goal: 1 Embody the best of the NHS for our patients: delivering great results with compassion and thoughtfulness 2 Support people safely out of hospital: providing safe, high quality value for money alternatives to hospital admissions 3 Deliver better value than competitors in our selected markets: securing our sustainability by providing effective and efficient services 4 Be responsive to our patients and partners’ needs: promoting integration and partnership by demonstrating our capacity, character and competence 5 Employ only the best staff: selecting staff who care and supporting them to go the extra mile for our patients 6 Be innovation and technology pioneers: leading transformation of out of hospital services to empower staff and improve patient health Freedom of Information Report can be made public Status

Executive Summary: The CLCH Safeguarding Children and Adult Services continue to report on safeguarding activity quarterly internally to CLCH Safeguarding Committee and externally to commissioners. In addition the CLCH PSRG receives a Safeguarding report (last report September 2014). The post of CLCH Head of Safeguarding, Safeguarding Children and Adult professionals is now managed within the Quality Division. The Looked After Children Services remain within Children Health and Development Division. The target for safeguarding training compliance is now 90% however training compliance remains below this. CLCH does not have a Named Doctor for Child Protection although an interim arrangement is in place to offer some basic cover for this statutory role. CLCH continues to be well represented and an active partner at both the Local Safeguarding Children Board (LSCB) and Safeguarding Adults Board (SAB). Both the Children Section 11 Audit and the Safeguarding Adult Risk Tool (SART) have been submitted and accepted by the respective Safeguarding Boards.

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Assurance provided: Safeguarding Children & Adults Service risks / incidents reported to PSRG (quarterly) Quarterly reports received at the CLCH Safeguarding Committee and Quality Committee.

Report provenance: Safeguarding Reports & Declaration approved at CLCH Safeguarding Committee and Quality Committee.

Report for: Decision Discussion Information

Recommendation: The CLCH Board supports the development of a CLCH Named Doctor Child Protection. The CLCH Board monitors the CLCH Safeguarding training and progress to the 90% target.

1. Introduction:

1.1 This report seeks to provide a mid-year update to the CLCH Board on the performance and activities of the CLCH Safeguarding Children and Adults services. The annual report 13/14 has been received by the CLCH Board (July 2014). 1.2 This report will inform the CLCH Board of the following metrics in regard to safeguarding children; training, supervision, referrals to children’s social care (CSC) and partnership working (case conference and multi-agency panel attendance). 1.3 This report will inform the CLCH Board of the following metrics in regard to safeguarding adults; training including PREVENT and partnership working. 1.4 In addition the report will include an update on CLCH involvement in serious case reviews (SCR) and domestic homicide reviews (DHR). 1.5 Safeguarding Children and Safeguarding Adult Services are now managed within the Quality Division (1st August 2014). Looked after Children Services remain in the Children Health and Development Division.

2. Safeguarding Children Services

2.1 Safeguarding children training compliance (September 2014) is as follows: Level 1 85.6% Level 2 82.4% Level 3 89.7%. 2.2 All safeguarding children professionals are trained at level 4 and above and compliance is 100%. 2.3 The 2014/15 target set by commissioners is 90% and so at present training compliance is below target, however progress toward compliance with this target will be met through access to an e –learning module (level 1), bespoke level 2 training and to LSCB training (level 3). 2.4 Safeguarding supervision compliance across CLCH for health visitors and school

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nurses in Q1 exceeded 90% compliance however in Q2 compliance levels have dipped in Barnet (78%) and H&F (85%). This dip is attributable staffing issues – sickness, work pressures, work patterns and for one member of staff jury service. Where practitioners have not accessed safeguarding supervision in Q2 a session in early Q3 has been arranged. 2.5 Attendance at child protection conferences by CLCH practitioner (initial and review) in both Q1 and Q2 exceeds 90%. Where a CLCH practitioner has not attended a child protection conference in Q2 a report has been submitted. 2.6 Referrals to Children Social Care in Q2 by CLCH practitioners numbered 8. This is a slight decrease on Q1. 2.7 Children subject to a child protection plan in Q2 numbered 584 – Inner boroughs 362 and Barnet 222. The number of children reported subject to a child protection plan has not shown any significant change in Q1 and Q2. 2.8 CLCH participation in multi-agency panels Multi Agency Risk Assessment Conference (MARAC), Multi Agency Sexual Exploitation Panel (MASE) in Q1 and Q2 has been 100% compliance. In addition a Barnet Multi Agency Public protection Arrangements Panel (MAPPA) has been attended by the Barnet Named Nurse for Child Protection. 2.9 CLCH is represented at both the Local Safeguarding Children Boards (LSCB) and subgroups – 100% compliance attendance at LSCB Board meetings. 2.10CLCH is currently contributing to a Serious case Review (SCR) commissioned by the Tri Borough LSCB which has been presented to the LSCB and will be submitted to the DfE for approval. 2.11Improving the response of partner agencies to cases of child neglect is an objective of both the Barnet and Tri B LSCBs. Notably Harrow LSCB have released a video capturing the learning from a serious case review which focusses on how partner agencies can improve their understanding and response the issues of neglect. This is available on the CLCH Safeguarding Children team pages and is featured in CLCH bespoke training updates. 2.12Safeguarding Children Named Doctor Function the CBU transformation of Children Health and Development Division has not lead to the identification of a resource for this statutory post. At present CLCH has no Named Doctor function which is a weakness in regard to safeguarding arrangements. To mitigate this CLCH has in place is an arrangement with the Designate Doctor to provide as required advice and support on complex cases.

3. Safeguarding Adults Services

3.1 Safeguarding adult training compliance (September 2014) is as follows: Level 1 87% Level 2 88 %. 3.2 All CLCH Safeguarding Adult Champions (28) have received training at Level 3. 3.3 All Safeguarding Adult Professionals are trained at level 4 and above and compliance is 100%. 3.4 PREVENT training is part of the HM Government counter terrorism strategy and from April 2014 has been included in mandatory training for all staff. Prior to this (from 2012) this training was delivered as part of induction training to clinical staff and

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bespoke training to specific services. 3.5 PREVENT Q2 (July - September) 328 CLCH staff were trained. 3.6 The new updated version of PREVENT has been launched by the Home Office and this will be embedded in CLCH training by Q4. 3.7 The Safeguarding Adult Service is now producing a quarterly newsletter for staff and learning event for Safeguarding Champions. The learning event in Q2 focussed on domestic abuse and the learning from Domestic Homicide Reviews (DHRs). There are three DHRs in progress across Barnet and the Inner Boroughs. It should be noted that CLCH involvement with the victim was in all cases minimal and as such the CLCH DHR action plan is directed towards raising awareness and ensuring CLCH staff have access to information and support when managing case where domestic abuse is a feature. 3.8 The Safeguarding Adult at Risk Tool (SART) has been submitted to both Barnet and Tri Borough CCG Safeguarding Leads. 3.9 The CLCH Safeguarding Committee reviews the progress of the Winterbourne Plan. The Learning Disabilities Service have progressed an innovative technology – tablet devices - to help patients with learning disabilities give feedback on their experiences of NHS care and treatment.

4. Looked After Children Services Q1.

4.1 The CLCH Looked after Children Service (LAC) continues to deliver a high quality service exceeding national and local targets regard to Health Assessments (compliance with timeframes exceeds 90%). 4.2 The LAC team now have a LAC page on the CLCH intranet which will include a library of LAC Annual Reports and relevant documents and guidance. This page is linked to the Safeguarding pages and will continue to be managed and updated by Safeguarding. 4.3 ‘The Story So Far’ which a compilation stories, poems and pictures from LAC children and young people has been published. 4.4 The LAC team won a CLCH Award for ‘Team of the Year’ 2014. 4.5 Each Borough LAC team has been involved in an Achievement Event celebrating the successes of the LAC children and Young People. 4.6 A Domestic Homicide Review (DHR) has been published (Essex) relating to the death of a 17 year old female who was murdered by her boyfriend who was known to Leaving Care Services and attended a college with in a London Borough. The learning from this case has been discussed at the Tri B LSCB and the report is available on the CLCH Safeguarding Children Team pages. What is of note is the application of the amended definition of domestic abuse to include violence between young people 16 years and over who are in a relationship (2013) so leading to the commissioning of the DHR.

5. Safeguarding Risks 5.1 Safeguarding risks are reported on at the Patient Safety and Risk Group. Reported on in September 2014.

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6. Recommendations 6.1 The CLCH Board supports the development of a CLCH Named Doctor Child Protection. 6.2 CLCH Board receives updates on the progress towards meeting the safeguarding training target of 90%

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BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Medical Director’s Quarterly Report

Agenda item number: 3.6

Report of: Medical Director

Contact Officer: Deputy Medical Director

Relevant CLCH 14/15 Goal: 2. Support people safely out of hospital: providing safe, high quality value for money alternatives to hospital admissions 3. Deliver better value than competitors in our selected markets: securing our sustainability by providing effective and efficient services

4. Be responsive to our patients and partners’ needs: promoting integration and partnership by demonstrating our capacity, character and competence 5. Be innovation and technology pioneers: leading transformation of out of hospital services to empower staff and improve patient health Freedom of Information Yes Status

Executive Summary: This paper summarises some of the work occurring throughout the medical directorate. The paper includes updates on: • Ebola outbreak • Winter planning • Flu vaccination programme • Clinical Directors • Caldicott Guardian Update • Update on clinical framework • Update on infection prevention

Assurance provided: The paper provides assurance to the board for the integrated action being taken across the directorate to ensure engagement of staff, patients and key stakeholders.

Report provenance: None

Report for: Decision Discussion Information

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Ebola Virus

The Infection Prevention team continue to work with clinical teams to ensure that they are prepared for the possibility of contact with patients at risk of Ebola. A trust Ebola plan is being complied which will be available to all staff on the Hub. To date, three patients who meet the risk criteria for Ebola have been seen at CLCH walk in centres and urgent care centres. These patients were managed appropriately following the risk assessment algorithm and were transferred to the nearest acute trust. Ebola was ruled out in each case.

On October 7th 2014, the DH sent around a central alerting system email. The outbreak of Ebola virus disease (EVD) continues in three countries: Sierra Leone, Guinea, and Liberia. In addition to these countries which are experiencing widespread and intense transmission, other countries have experienced importation of cases (Nigeria, Senegal, USA), and limited local transmission has occurred (Nigeria and Spain). The outbreak became a Public Health Emergency of International Concern (PHEIC) on 8 August 2014.

Winter Planning

The Tri-borough Urgent Care Board undertook an analysis of the current provisions within INWL for intermediate care beds to support step down of acute patients and step up for community patients from the community which demonstrated a need for a non-acute provision. Using the knowledge gained from last year, the aim of the Intermediate Care Ward is to provide effective intermediate care in a ward environment outside an acute clinical model with strong pathways to other Community Independence Services.

Local partners believe the scheme will deliver benefits to acute, primary care and social care: - Reduction of Length of stays - Decreased DTOC for suitable cohort of patients - Reduced excess bed days

The model

Since the end of July we have been scoping the project with local partners including Imperial College Healthcare, Chelsea & Westminster Hospital, CWWH and Tri-Borough Adult & Social Care

The model was initially developed with findings identified in the Boundary less Patient Flow Programme (shortlisted for HSJ award – awaiting outcome) and Chelsea & Westminster Hospital data of care audit which identified 30% of patient in acute beds would better cared for in a non- acute environment.

This proposal aims to explore how the registered GP and a community unit can work in partnership to deliver effective care to this cohort of patients. The GP had a duty of care that spans the patent journey as set out in recent legislation. The medical director of CLCH has a responsibility for ensuring appropriate medical care for patients being treated for pathways defined in contracts between the commissioner and the provider. Jointly with partners we agreed three principles for the 18 bedded intermediate care clinical model: 1. Integrates clinical responsibility into the primary care environment 2. Re-balances step up and step down access

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3. To align to the thinking of whole systems early adopters to allow the GP/multi-disciplinary team to manage against the care plan more effectively.

Funding for the project was agreed on 27th August and since then CLCH’s Senior Clinical Working Group identified the following cohort of patients as medically suitable for an intermediate ward:

• Short term rehabilitation • Post insult e.g. post falls, post-acute recovery/IV therapy • Mobility or confusion related issues resulting in delaying discharge • Social care related delay in discharge • General frailty

These beds would be aligned with the Community Independence Service (CIS) which operates in each INWL CCG providing home-based intermediate health care and with integration (full or partial) with social care, and primary care under each CCG’s out of hospital care model. This would enable the intermediate care provision to become in future an embedded part of community services in line with the objectives of the SAHF programme.

Flu Vaccination

Flu season is now beginning and the CLCH seasonal flu campaign went live in October 2014. Health or social care worker are eligible for vaccination by NHS providers, (the target this year has been set at 75% of staff working in Healthcare).

Having reviewed national best practice the employee health team have worked with the medical directorate to redesign the local programme. This year, CLCH will be using a peer vaccination approach to staff immunisation – the idea is that this approach empowers staff to immunise each other and is better suited to our large geographic spread of staff.

There is an expectation that CBU managers will encourage staff to receive the seasonal influenza inoculation so that we ensure maximum protection of our patient groups and sickness due to influenza is reduced. Two weekly immunisation rates will be published at CBU level to encourage discussion and to drive wider uptake.

Clinical Directors

The four Divisions have either appointed or are looking to appoint a Clinical Director. They will be accountable to the Divisional Directors of Operations but have a professional accountability to the Medical Director. Duties will include:

• Clinical leadership within the divisions and support the development of medical staff • Acting as the professional lead for medical staff • Assisting the Medical Director into enquiries with respect to performance and conduct of medical staff • Ensuring appropriate systems are in place for the effective delivery of patient care • Being responsible for the integration of operational management with the clinical governance agenda.

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• Preparing strategic and annual plans for the division alongside the annual objectives.

Division of Allied Primary Care Service

There is a Clinical Director in post one day a week. He has been supporting the two GP practices in transition, helping recruit Bank GPs for the Finchley and Edgware Walk-In Centres and upcoming work includes the recruitment of a new doctors to areas within the directorate.

Division of Barnet Community &Specialist Nursing Service

This role will be advertised the week commencing 13th October 2014 and preliminary discussions are being held with GPs.

Division of Children’s Health & Development Service

This role is currently being designed. The work will focus around health prevention and will feature a large public health element.

Division of Networked Community Nursing &Rehab Service

This role is currently being advertised for recruitment. There is one day available within the adult specialist services and one day within the adult community services.

Caldicott Guardian update

1. Introduction

In early July 2014 the Caldicott Work plan was submitted to the Information Governance Group (IGG) detailing the work to be undertaking in line with the IG Toolkit. It was agreed that the Caldicott Guardian would work with the IG Team to ensure delivery of tasks by 31st March 2015. The Caldicott Work plan focuses on the following areas:

 Confidentiality  Data Protection Assurance  Guidance for staff on consent issues  Incident Management  Data Protection Audit compliance  Information Sharing agreements

2. Key Areas of Progress

Data Protection Assurance:

The Caldicott has remained a focal point for issues relating to confidentiality and gaining Data Protection assurances. The IG Team launched the data protection audit compliance programme which included the Caldicott with other Directors visiting sites unannounced. The results of the

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audits were encouraging with clear themes arising for most sites. The Caldicott has carried out work to raise the profile of ensuring that areas are kept secure and clinical conversations are discreetly managed to respect the privacy on the individuals. Due to the success of the audit programme it has been agreed that this will continue as an annual work programme.

Incident Management:

Incidents are managed via 48hr panel meetings which are chaired by Caldicott Guardian or SIRO. The IG team carried out a deep dive of incidents between 2012/13-2013/14 which demonstrated incident reported had increased Trust wide.

Incident Themes:

There have been 49 IG incidents since the beginning of April 2014. The following table provides the five highest categories and incident themes for the organisation between April 2014 – July 20141.

No. of Category Incident Themes incidents Actions reported

Accidental Email being sent to the wrong CLCH has rolled out a new encrypted disclosure of email address with patient email solution (Egress) and staff information information. awareness is now on the increase to ensure that patient identifiable Data (PID) is sent via encrypted means. Patient information being Where information is received into received in a non nhs.net the organisation via insecure methods account the sending organisation is notified by the IG Department and both parties are required to incident report.

Posting information to the wrong person 12 The IG Training materials have been revised with a focus on ensuring records are kept secure, ensuring Patient information left at home information is limited when sending visit via any medium, verifying the recipient and tracking records while posting or transferring to another site. Documents left on printers

The IG Team have launched unannounced data protection compliance audits on sites with

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Directors attending the visits. Recommendations are stipulated to the audited services with feedback being submitted to the Information Governance Group. Any urgent matter that arises during a site visit is rectified immediately.

Accidental loss Information not recorded not The Clinical Effectiveness team carry of information on RIO out clinical record keeping audits and online training has been mandated for clinical staff. A Records Management Records left in a non-secure Facilitator has now been recruited to environment aid services with safe records management and ensure that 11 processes are put in place to safeguard records and transfer them Records lost in transaction safely.

Breakdown in Records Keeping training materials for lines of non-clinical (admin) are currently communication being created to ensure that all staff are aware of their roles and Incorrect text messages sent to responsibilities for checking the patients accuracy of data and updating the systems at point of contact with the 6 patient. Incorrect phone numbers taken

from patients Services that have waiting areas are now putting up notices to remind patients to update their details if they have changed.

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Loss or theft of Rio cards lost outside the UK Once Smartcard is reported misplaced Smartcard or stolen the card is disabled and the member of staff must present Misplaced Rio card themselves to the Clinical systems 14 team to be authenticated before another Smartcard is provided.

Rio card stolen with other belongings

Records The newly appointed records unavailable management facilitator is working when needed with high risk areas as a priority to ensure that records are managed and Records not being filed correctly filed appropriately. There is an 6 Electronic Document Management System (EDMS) project running to Information missing from files move paper records that are at the stage to be archived and scan them to remove the risk of paper loss or mislaid records.

Grand total 49

Since April 2014 there has been 2 serious incidents (SI) reported externally to Hammersmith & Fulham CCG which related to Community health and Dental services which will have been previously reported to Board. (Reports relating to August and September and October will be available in November).

Guidance for staff on consent:

There has been an increase in consent queries Trust wide in particular from clinical services. The queries have arisen due to some services moving to SystmOne for integrated care allowing for one record for a patient between Community and GP.

It has been assessed that system functionality and clinical risk remain high on the agenda for the organisation with regard to SystmOne. The Caldicott is currently working with teams to ensure that the correct guidance is available to staff during this process and that clinical risk is minimised. This issue is monitored via the IGG and SystmOne Project Board.

3. Conclusion

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In summary IG remains high on the Trusts agenda with support from Director level to gain assurances of Data Protection and Confidentiality. There is an increase in reporting of incidents and queries for advice managed by the IG Team and supported by the Caldicott Guardian. The work undertaken to date has had a positive impact on services who have demonstrated more confidence in dealing with Caldicott issues. It is expected that the delivery of the IG Toolkit will be assessed as compliant at a minimum level 2 with a robust evidence base submitted.

Update on the clinical framework

The clinical framework has now been published on CLCH’s website under clinical policy and guidelines. The stakeholder reference group requested an easy read version which has now been designed and can be found at this site;

http://www.clch.nhs.uk/about-us/our-publications.aspx

Update on infection prevention

Eye infections

The infection prevention team have been alerted to five cases of eye infections on Marjory Warren ward. The first case presented on 16/09/14 with four subsequent cases presenting. Investigation indicates that transmission may be due to poor infection control practices and as a result the ward has been deep cleaned. The most recent hand hygiene audit also identifies a decrease in hand hygiene compliance and measures are being put in place to combat this. The local health protection team (PHE) have been made aware and are in agreement with action put in place.

Clostridium Difficile

There was one case of C difficile identified more than 72 hours after admission to Marjory Warren Ward in September. No lapses in care were identified.

Hand Hygiene

Hand hygiene compliance across the bedded areas is at 93.75% for quarter 2.

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BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Medicines Management Annual Report 2013/14

Agenda item number: 3.7

Report of: Medical Director

Contact Officer: Head of Medicines Management

Relevant CLCH 14/15 Goal: Embody the best of the NHS for our patients Supporting people safely out of hospital

Executive Summary: This report highlights the medicines management activities undertaken in CLCH during 2013/14, providing assurance that systems are in place for medicines management in line with CQC Regulations, Outcome 9 and Controlled Drugs Regulations 2013.

In 2013/14 the Medicines Management Team has supported CLCH by:

• Advising community health services staff on medicines related issues. • Ensuring all policies, protocol and procedures are current and up to date. • Ensuring all patient group directions and processes are current and up to date. • Undertaking clinical audit in key areas and highlighted areas for further work, e.g. omitted doses, cold chain and safe and secure handling. • Ensuring safer management and use of controlled drugs. • Ensuring all medicine incidents are reviewed at the Medicines Management Group (MMG) on a quarterly basis and the risk register updated. • Assessing and responding to 33 medicines alerts. • Providing information under Freedom of Information Act. • Providing education, training and health promotion to healthcare professionals. • Ensuring systems are in place to promote patient safety in relation to medicines, including bedded services. • Embedding the new in-house clinical pharmacy service post re-tendering of the three pharmacy SLAs.

2013/14 has seen a number of achievements in medicines management including:

• Increasing capacity of the team has allowed them to be more responsive to queries from CLCH staff e.g. same day responses to cold chain breaks allowing continuity of service and preventing loss of vaccines. • Re-tendering of the 3 pharmacy SLAs resulted in a review of the services, all clinical and community health services have been brought in-house thereby developing a greater intelligence and quality of service provided.

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• The medicines optimisation service which was developed as part of the NWL integrated care pilot and CLCH were the first provider to win a bid as part of the ‘out of hospital’ innovation funding, came to a conclusion in December 2013. It successfully demonstrated a viable business case for long-term commissioning. • Raised profile of the team as 4 members of the team were acknowledged in the CLCH recognition awards, with one winner for Patient safety- Preventing Harm and one highly commended for innovation for smart effective care from Medicines Optimisation Pharmacists (MOPs).

Assurance provided: The Medicines Management Annual Report provides assurance to the Board that there are systems in place to meet the requirements of CQC Regulations, Outcome 9 and Controlled Drugs Regulations 2013.

Report provenance: The Medicines Management Annual Report was discussed at the Medicines Management Group (MMG) in September. Comments raised have been incorporated and the report will be virtually ratified by the Medicines Management Group in October.

Report for: Decision Discussion X Information X

1. Purpose This report highlights the medicines management activities undertaken in CLCH during 2013/14, ensuring systems are in place for medicines management in line with CQC Regulations, Outcome 9 and Controlled Drugs Regulations 2013. The report supports the CLCH Clinical Framework 2014-2017.

2. Introduction 2.1 Medicines management optimises the use of medicines both by patients and the NHS, protecting against the risks associated with the unsafe use and handling of medicines. It supports safe, appropriate and cost-effective prescribing, as well as helping patients to have their medicines at the times they need them, in a safe way and have information about their medicines made available to them. Good medicines management can help reduce the likelihood of medication incidents and hence patient harm.

2.2 The CQC has identified the management of medicines as one of its core quality and safety standards (Outcome 9). The Medicines Management Team provided an effective and responsive service in 2013/14 to ensure medicines were handled safely, securely and appropriately; prescribed and given by staff safely and kept up to date with published guidance on medicines safety so that best practice is implemented within the Trust.

2.3 The Medicines Management Team supports the Controlled Drugs Accountable Officer (CDAO) to ensure compliance with the Controlled Drugs Regulations 2013.

3. Proposal

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Not applicable

4. Quality Implications and Clinical Input 4.1 The full Medicines Management annual report which underpins this Board report is available on request from the medicines management team. The key areas of work highlighted below provide an overview of achievements in 2013/14 and plans for 2014/15. 4.2 Key areas of work in 2013/14 have included: • Clinical audits, reported to the Clinical Effectiveness Steering Group and the Quality Committee, have been undertaken. These led to improvements in clinical practice and compliance with regulations, where required, in relation to prescribing and safe and secure handling of medicines. • Omitted Doses audit results showed 5% (850 out of 16861 doses) of omissions recorded compared to 9.6% in 2012/13. Of the 850 omitted doses, 170 were for critical list medicines (20%). 77% of the omitted doses had an omission code recorded, an improvement from last year's 66%. A high number of omissions (71%) were due to patient refusal. This area will be further investigated in the 2014/15 audit. Omitted doses remain an area of concern and Clinical pharmacists monitor these on a daily basis. • Antimicrobial audit showed areas of improvement were required in documentation of allergy status, clinical indication and review/stop date in patient notes. • Safe and secure handling of medicines audits were carried out by the SLA provider for the Inner boroughs until the end of September 2013 but the audit was rudimentary. A baseline audit of 11 Inner borough sites in December 2013 found many areas of poor practice. The tools and processes used by the SLA provider did not meet CQC Outcome 9 standards. No audits had been carried out in Barnet. To address the gaps, there was a fundamental review of the audit tool, audit process and the competences of the audit staff, who were TUPE-ed to CLCH. An audit programme commenced in June 2014 in all sites (Inner borough = 130, Barnet = 55) • Cold Chain audits conducted by the SLA provider as above did not provide assurance. The CLCH audits also look at cold chain management commenced in June 2014 (Inner boroughs = 42 sites, Barnet = 16). • Controlled Drugs audits were carried out quarterly at all bedded units and day surgery. Areas for improvement include appropriate use of controlled drugs registers, CD balance checks, security of keys and timely destruction of unwanted or expired CDs. A gap was identified in audits of non bedded services that used CDs. These were completed in September 2014. • There are 266 CLCH non-medical prescribers (NMPs) registered with the Prescription Pricing Division. The Medicines Management Team maintains a database of NMPs and monitors their prescribing quarterly. • The total drug expenditure for CLCH is £1.86m (FP10 budget held by CCGs on behalf of CLCH = £361k, NMP = £652k and SLA drugs = £849K). • There are 26 medicines related policies, protocols and procedures reviewed and approved by the MMG. Four were reviewed or approved in 2013/14. The MMG contribute to the development of 3 other Trust policies. All policies are up to date. • There are 101 Patient Group Directions (PGDs) managed by the Medicines management Team. All are up to date. • The MMG receives quarterly incident reports. There were 724 medicines related incidents reported on Datix in 2013/14 (compared to 587 in 2012/13). The rise in medicines incidents was mainly due to the increased presence of clinical pharmacists on the wards in Barnet who identified poor practice at the wards. Lessons learned and recommendations were discussed at the MMG. • There were 87 Datix incidents involving controlled drugs. Main areas identified were syringe driver equipment problems, missing or insufficient supply of CDs, poor management of patches, incorrect storage and dosage errors. Management of CD incidents occurs day to day and is reported

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quarterly to the MMG. • The CQC self-assessment tool score for CLCH was 73%; CQC's interpretation of this score is "Overall, your organisation's CD governance appears to be good but you may want to improve by looking at best practice". An area for improvement was the sharing of information with partners in the local intelligence network (LIN). There have been no LIN meetings held in the last 12months due to the restructuring of the NHS. However, quarterly occurrence reports sharing any unresolved CD incidents and/or matters of concerns were submitted to the London Area CD Accountable Officer at NHS England. • Medicines Management offers clinical pharmacy expertise to all bedded services. Each service has an agreed level of pharmacy input. As we move forward, there may be a need to explore the needs of a clinical pharmacy service versus technical pharmacy support to each of the bedded areas. • The Medicines Optimisation Service (MOPs), a pilot funded by the ICP concluded in December 2013. This service provided a full clinical medication review for housebound patients. The outcomes included 1799 interventions for 387 patients, 80% of pharmacist interventions accepted by GPs and potential £56k cost avoidance for non-elective hospital admissions. A full report is available on request. The Medicines Management Team has successfully bid for commissioning of this service. From April 2015, Medicines Management will provide a housebound MOPs service to patients from the West London Clinical Commissioning Group. • A second MOPs service in Care Homes commenced in December 2013. • A comprehensive training programme was delivered at training events, classroom induction, refresher and e-learning. • Effective risk management led to a number of risks being closed. There were 18 open risks on the medicines management risk register at the end of 2013/14. • The review and re-tendering of the pharmacy clinical and supply services posed a huge challenge as it involved changes to services that had been in place for close to 20 years. This transition has been successfully delivered.

4.3 2013/14 has seen a number of achievements in medicines management including: • Completion of the medicines optimisation service which was developed as part of the NWL integrated care pilot and CLCH were the first provider to win a bid as part of the ‘out of hospital’ innovation funding. • Raised profile of the team as 4 members of the team were acknowledged in the CLCH recognition awards, with one winner for Patient safety- Preventing Harm and one highly commended for innovation for smart effective care from Medicines Optimisation Pharmacists (MOPs).

4.4 Priorities identified for 2014/15: • Embed new in-house services to deliver a high quality, safe and effective patient care. • Support Controlled Drugs Accountable Officer to comply with Controlled Drugs (CD) Regulations 2013. • Close monitoring of the 2 new pharmacy contracts. • Processes to support NICE Technical Appraisals (TAs). • Ensuring robust processes in place to register non-medical prescribers and monitor their prescribing. • Exploring the benefits and mechanisms for having a CLCH drugs budget. • Ensuring robust and consistent audit of safe & secure handling of medicines across all 4 boroughs. • Develop a medicines management strategy • Build relationships with the newly formed CCGs to manage medicines across the interface

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No implications noted.

6. Comments of the Director of Finance, Performance & Corporate Resources Not applicable.

7. Risks and Mitigating Actions The medicines management annual report provides assurance to the Board that actions are being taken to reduce the likelihood of medication incidents and hence patient harm. Effective risk management led to a reduction in the number and ratings of medicines management risks by year end, as action plans were completed.

Currently there are 10 open risks on the medicines management risk register.

ID Description Current Rating 977 Development of transcribing policy 15 974 Inaccurate information on discharge summary 12 688 NMP financial risk of devolved budget 12 779 Cold chain 12 994 Discharge of patients from CLCH with inaccurate information 9 778 Omitted doses 9 980 Self-medication not being assessed 9 978 Risk of admitting patients with insufficient medicine supply 9 971 Numeracy e-learning package 9 956 Cost of Pharmacy SLA 8

8. Consultation with Partner Organisations 8.1 Collaborative working with the Medicines Management teams of local acute trusts, CCGs and Pharmacy networks continues to ensure greater understanding and response to medicines management and patient safety issues.

9. Monitoring Performance Quarterly reporting to the MMG: • Policy and PGD dashboards. • Controlled drugs and medicines incidents. • CD Occurrence reports. • Drugs and SLA expenditure.

10. Recommendations 10.1 The Board is asked to note the content of the report and the work being undertaken by the Medicines Management Team, along with CLCH staff and managers to protect patients from medicines related harm.

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BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Health and Safety Annual Report Update

Agenda item number: 3.8

Report of: Director of Finance, Performance and Corporate Resources

Contact Officer Fire, Health and Safety Manager

Relevant CLCH 14/15 Goal: • Be responsive to our patients and partners’ needs. • Embody the best of the NHS for our patients. • Support people safely out of Hospital. Freedom of Information Can be published Status

Executive Summary: This paper provides a summary of the following topics: • Key health and safety risks across the Trust and includes comments on aspects of the Workforce Survey relating to safety. • A list of Policies and an overview of actions, all of which have been and are being addressed as a work backlog project. • A snap-shop of Violence and Abuse across the Trust domain. • Health and safety objectives for 2014 were not formalised, this was in the main due to changes in H&S management. Consequently the recently appointed Fire, Health & Safety Manager is working towards Health and Safety Executive (HSE) requirements; achieving standards set in the Trust Health and Safety Policy; through compliance with the Health and Safety Committee Terms of Reference and through the governance arrangements whether through the Patient Safety Review Group and Quality Committee or directly to the Board.

Assurance provided: The information provided in this summary highlights the key H&S related risks across the Trust, and gives an outline of the proposals for improvement. It also is evidence of the work carried out to improve policy production since the arrival of the Trust Fire, Health and Safety Manager in June 2014. Finally it shows a reduction in the V&A incidents in the first two quarters of the 2014 reporting year compare with 2013.

Report provenance: The key H&S risks, V&A and Security issues were discussed at the 2nd June 2014 H&S Committee. The Policies were discussed at the 2nd October Health and Safety Committee Meeting and the initial report was presented to the Board in July 2014.

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Report for: Decision Discussion Information

1. Purpose 1.1 To advise Board members of the work being undertaken and respond to questions at the July Board meeting emanating from the Health and Safety quarterly update.

2. Introduction

This report updates the Board on the progress of Health & Safety matters over the first 6 months of 2014/15. This is the first such report since the Board agreed the new H&S reporting governance in July. Going forward the Board will receive a similar report on the activities of the Health & Safety Committee on a quarterly basis.

1. A summary of current Health and Safety risks. 2. Progress on Policy and review dates. 3. A review of Violence and Abuse Data, including Security issues.

3 Progress 3.1 A summary of current Health and Safety Risks. The following Health and Safety Risks are taken from the Health and Safety Risk Register Review to the PRG for 21st October 2014.

a. Telephony lines for security alarms, fire alarms and lift alarms for CLCH sites across are at risk of being disconnected by NWL Telephony team. Initial Risk Rating - 20; Current Risk Rating – 12. Estates Operational Managers are progressing this matter with NHS PS. Following a recent discussion NHS PS have agreed to not disconnect any lines without first conducting exhaustive communications with Trust E&F management.

b. Auto diallers (Ad) for the fire alarms at the following sites are not active. Parsons Green, Hammersmith Bridge Road, Falkland House, Stamford Brook and Richford Gate. Initial Risk Rating - 20; Current Risk Rating – 12. Activation of an Ad is a landlords decision, however such a decision can be overridden by the Trust if we feel such a provision is necessary. This will incur costs, which on balance are considered minimal in comparison to costs if we had to close services due to fire damage. • NHS PS have been instructed to activate the Ad at Parsons Green Centre. • The Practice Manager at Richford Gate is progressing the reconnection of the Ad on said premises. • We are still awaiting a response from the GP’s at Hammersmith Bridge Road. • Stamford Brook is an NHS PS property, they have decided it is not viable to reconnect the Ad, however as a Trust we believe the low cost of connecting the Ad far outweighs any adverse service, relocation or reputational impacts on the Trust, thus instructions to reconnect are being processed. • The Ad at Falkland House is not being reactivated because the premises are being vacated in early 2015 by the Trust.

c. Lack of documented workplace risk assessments in place. Initial Risk Rating - 20; Current Risk Rating – 9. The Trust is working on the premise of there being three categories of building from which we

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deliver services: • Category 1 are those buildings for which there is a freehold or leasehold. • Category 2 are those buildings where the tenure is such that a lease should be in place. • Category 3 are those buildings where there is need for a licence to deliver services.

To date all category 1 and 2 buildings have been assessed using a ‘Global Non-Compliance Assessment process. This work along with the recent awarding of the Category 3 premises assessments to ‘Oakleaf Group’, will lead to the creation of a consolidated set of Site information Packs to be uploaded on to ‘Technology Forge’ the Trusts Estates & Facilities database by the beginning of December 2014.

d. Lack of a robust system of Fire Risk Assessment, Resulting in lack of compliance of Regulatory Reform (Fire Safety) Order. Leading to a risk to life, property. Initial Risk Rating - 12; Current Risk Rating – 9. A comprehensive review and work plan of sites, Fire Risk Assessments and Fire Safety Action plans is being conducted by the Fire Health and Safety Team. A full report which will include a work programme and training requirements is being prepared for the December 2014 Health and Safety Committee and will be shared with the Board in January 2015.

e. There is a lack of Health and Safety Representatives across the Trust domain, thus H&S issues are generally only addressed after a visit from the FH&S Team. Initial Risk Rating - 20; Current Risk Rating – 12 The lack of Union Trained safety representatives across the Trust means there is extremely limited access to local advice and support on health and safety matters for staff. In a bid to reverse this problem the Fire, Health and Safety Manager (FH&SM) is proposing a campaign to encourage more involvement of Non-Union members in conjunction the ‘Consultation with Employees Regulations 1996’, the aim being to train volunteers either on a bespoke course or to use the Institute of Occupational Safety and Health (IOSH) Managing Safely Course as the basis for their training. The aim will be to run a course in the early months of 2015.

In addition to encouraging non-union members to become safety representatives, the FH&SM is proposing to run IOSH Managing Safely Courses that should be made available to Band 5, 6 and 7 Managers and E&F managers. This will ensure safety issues are identified and acted upon in a more timely and effective manner. Costs for the course will be kept to a minimum because the Trust will only need to fund registration, materials and certification, rather than trainers fees. The FH&SM is an approved provider of this training hence low costs of courses.

3.2 Progress on policies, documents and review dates

On first of June 2014, only six H&S related policies had been reviewed and approved in accordance with Trust policy since June 2013. Following the appointment of the FH&SM 3 policies have been ratified and posted on the HUB, a further 6 policies are awaiting approval by the PRG and 11 are either in production or under review. The breakdown is as follows, 4 policies produced by the FH&S Team have been given tacit approval by members of the H&SC subject to there only being minor amendments; 1 policy produced by HR has been given tacit approval by members of the H&SC subject to there only being minor amendments and 1 Policy by Occupational Health is currently with the Head of HR for comments before being sent to the H&SC for comments. Upon approval all policies will then be progressed through the PRG and subsequently launched on the HUB. The intention is to have all remaining policies adopted by 31st March 2015.

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Serial Document Introduced Review Date Owner Date a b c d e 1 Health and Safety General Policy. Dec 2013 Dec 2015 H&S 2 Water Safety and Quality Policy Oct 2014 AA* Oct 2016 H&S (including Potable water). 3 Electricity at Work Policy. Oct 2014 AA* Oct 2016 H&S 4 Personal Protective Equipment Policy. In production May 2014 H&S 5 Workplace Safety Policy. Oct 2014 AA* Oct 2016 H&S 6 Fire Policy. Oct 2014 AA* Oct 2016 H&S 7 Control of Substances Hazardous to In production Dec 2014 H&S Health Policy. 8 Display Screen Equipment Policy. Under review Dec 2014 H&S

9 Environmental Strategy. Jun 2014 Jun 2016 H&S/E&F 10 Control of Contractors Policy. Jul 2014 Jul 2016 H&S 11 Asbestos Policy. Jul 2014 Jul 2016 H&S AB 12 Occupational Health Policy. Oct 2014 AA* Oct 2014 Emp Hlth 13 First Aid Policy (May require input from Dec 2012 Dec 2014 Emp HR) Hlth/HR 14 Moving and Handling Policy, Dec 2012 Dec 2014 L&D/H&S incorporating LOLER and PUWER. 15 Ionising Radiation Policy. Under review Sep 2014 Resilience

16 Medical Devices Policy. Jan 2016 Jan 2016 Med Dev 17 General Waste Policy. Under review May 2016 E&F 18 Pest Control Policy. Under review Jun 2014 E&F 19 Transport Policy. Under review Sep 2014 E&F 20 Young Persons at Work Policy. Under review Sep 2014 HR 21 Violence and Aggression Policy. Dec 2013 Dec 2015 Resilience 22 Lone Workers Policy. Dec 2013 Dec 2015 Resilience 23 Maternity and New Parents Policy Oct 2014 AA* Oct 2106 HR 24 Food Hygiene Policy Under review Jan 2015 H&S

25 Stress Policy May 2014 Apr 2017 Emp Hlth 26 Risk Assessment Policy In Production Jan 2015 H&S 27 Noise at Work Policy In production Aug 2014 H&S 28 Infection, Prevention and Control Policy Jan 2014 Jan 2016 IP 29 Equality and Diversity May 2014 Apr 2017 HR 30 No Smoking Policy May 2014 Apr 2017 HR 31 Accident, Incident and RIDDOR Policy Under review Apr 2014 H&S/ Resilience 32 Patient and Non-Patient Slips, Trips & Nov 2011 Nov 2014 H&S/Q&A Falls Policies

The main proposal following this update report is to ‘develop clear access to centralised Health and Safety Policies using the HUB as the primary instrument for searches’. The priority of policy work is all ‘Amber’ rated policies in the table above. A quick glance at the table shows there is a significant volume of work to be carried out in the coming months. This matter has been addressed at the recent 2nd October 2014 H&S Committee meeting.

In support of key the H&S policies we are developing a series of ‘Aide memoires’ (one page précises) of document that will be downloadable to an iPad, Smart phone or printable to fit in a diary, they will advise and if necessary direct staff to the full versions of the respective policy. These will be easily accessible and can be carried by staff at all times.

3.3 Review of Violence and Abuse Incidents first 6 months 2014. The key point to note from the figures below is they represent the first 6 months of this years’ reporting evidence on Violence and Abuse issues in the Trust.

The bottom line figures in the table below are particularly encouraging, especially in terms of

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‘Minor’ and ‘Moderate’ incidents. The comparison of incidents to date shows numbers equating to less than half of those reported in the first 6 months of 2013, and which if the level of reporting remains on the same trajectory throughout 2014, to the end of the reporting year will be less than half of those reported last year.

The key area of concern relating to violence and abuse is that 41 incidents have been reported to date, 29 are ‘No Harm’ incidents, e.g. verbal abuse; 10 are ‘Minor’ in nature, e.g threats, being grabbed by clothing and limbs, there have also been 2 Moderate events, e.g. slapped or punched but with no injuries sustained.

To give staff greater confidence when entering domiciliary premises a lone worker communications device is being procured and will be in service imminently.

Twenty one of the violence and abuse incidents reported have occurred in bedded units and the Prison, this figure added to the 41 incidents in patients’ homes accounts for 62 of 97 incidents to date (63.9%).

Violence & Abuse by Site first 6 months of 2014 No Harm Minor Moderate Major Catastrophic Athlone House Nursing Home 2 0 0 0 0 Charing Cross Hospital 1 0 0 0 0 Diabetes Centre, 4b Maida Vale 2 0 0 0 0 Edgware Community Hospital 9 8 0 0 0 Farm Lane Nursing Home 1 0 0 0 0 Finchley Memorial Hospital 8 4 0 0 0 Hammersmith Bridge Road Surgery 0 1 0 0 0 Health @ The Stowe 6 1 0 0 0 HMP Wormwood Scrubs 5 4 2 0 0 Holbrook House 1 0 0 0 0 Lisson Grove Health Centre 1 0 0 0 0 Mill Hill Clinic 0 1 0 0 0 Other 11 3 1 0 0 Parsons Green Health Centre 4 1 0 0 0 Patient's Home 29 10 2 0 0 Princess Louise Nursing Home 1 0 1 0 0 Queens Park Health Centre 1 0 0 0 0 Richford Gate Health Centre 1 0 0 0 0 Soho Centre for Health and Care 3 3 0 0 0 St Charles Centre for Health and Wellbeing 5 3 0 0 0 Stamford Brook Centre 0 1 0 0 0 The Medical Centre, Woodfield Road 2 0 0 0 0 Vale Drive Clinic 1 0 0 0 0 Violet Melchett Clinic 1 1 0 0 0 Walmer Road Clinic 0 1 0 0 0 Worlds End Health Centre 2 1 0 0 0 Totals first 6 months 2014 97 43 6 0 0 Totals for 12 months 2013 168 202 25 2 1

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3. Quality Implications and Clinical Input The changes outlined in this report will not have any affect upon the clinical quality of services provided by the Trust. Indeed they will improve access to H&S Policies for ALL staff, thus reducing time spent in.

4. Equality Implications 4.1 There are limited implications of this change in terms of the equality impact.

5. Comments of the Director of Finance, Performance & Corporate Resources 5.1 The Divisional Director – Resources and Performance has reviewed this paper.

6. Risks and Mitigating Actions 6.1 The main risk of not having a full suite of policies or aide memoires is that staff could conduct unsafe activities and possibly suffer injuries or cause damage to Trust property because they have not been unable to access policies. 6.2 Unaddressed risks present hazards to staff, patients and visitors alike, they must therefore be adequately funded and properly managed.

7. Consultation with Partner Organisations 7.1 Consultation in respect of the Annual Health and Safety Report; Health and Safety Risks; and Violence, Aggression and Security is undertaken at the Health and Safety Committee, the meeting is attended by senior managers, CBU managers specialist advisors, staff side union representative and non-union staff safety representatives. 7.2 Overlap of Health & Safety and Infection Prevention issues is addressed by the Fire, Health and Safety Manager, and the Senior Infection Prevention Nurse attending the respective specialist committees. Additionally there is joint attendance at Strategic Estates & Facilities Meetings; Capital Project Groups and Joint Planning Meetings. Compliance reporting along with joint audits and inspections tie the two services neatly together, and where joint visits are not possible, the specialties share information and are committed to identifying issues related to both services.

8. Monitoring Performance 8.1 The issues identified by the Board at the July meeting are all regular agenda items at the Trust Health and Safety Committee.

9. Recommendations 9.1 The Board is asked to note the contents of this report. 9.2 To note that the FH&SM will liaise closely with each of the divisions and their heads or nominated leads on health and safety matters as a means of further enhancing their understanding and management of health and safety risks and thus improving all round health and safety compliance across the Trust .

203 A summary of Health and Safety Risks.

The following Health and Safety Risks are taken from the Health and Safety Risk Register Review to the PRG for 21st October 2014.

1. Telephoney lines for security alarms, fire alarms and lift alarms for CLCH sites across are at risk of being disconnected by NWL Telephony team.

Estates Operational Managers are progressing this matter with NHS PS. Following a recent discussion NHS PS have agreed to not disconnect any lines without first conducting exhaustive communications with Trust E&F management.

2. Auto diallers (Ad) for the fire alarms at the following sites are not active. Parsons Green, Hammersmith Bridge Road, Falkland House, Stamford Brook and Richford Gate.

NHS PS have been instructed to activate the Ad at Parsons Green Centre. The Practice Manager at Richford Gate is progressing the reconnection of the Ad on said premises. We are still awaiting a response from the GP’s at Hammersmith Bridge Road. Stamford Brook is an NHS PS property and they have decided it is not viable to reconnect the Ad, and finally the Ad at Falkland House is not being reactivated because the premises are being vacated imminently by the Trust.

3. Lack of a robust system of Fire Risk Assessment, Resulting in lack of compliance of RRO. Leading to a risk to life, property.

A comprehensive review and work plan of sites, Fire Risk Assessments and Fire Safety Action plans is being conducted by the Fire Health and Safety Team. A full report which will include a work programme and training requirements is being prepared for the December 2014 Health and Safety Committee and will be shared with the Board in January 2015

4. Lack of documented workplace risk assessments in place.

Work place risk assessments are being tendered for and contracts will be awarded by the end of October 2014. The contents of the reports being commissioned will be developed into an action plan and shall be linked to CQC compliance requirements.

5. There is a lack of Health and Safety Representatives across the Trust domain, thus H&S issues are generally only addressed after a visit from the FH&S Team.

The FH&S Manager is proposing to run Institute of Occupational Safety and Health (IOSH) Managing Safely Course that should be made available to Band 5, 6 and 7 Managers and E&F managers. This will ensure safety issues are identified and acted upon in a more timely and effective manner. Costs for the course will be kept to a minimum because the Trust will only need to fund registration, materials and certification, rather than trainers fees. The FH&SM is an approved provider of this training hence low costs of courses.

204 A list of H&S Related Policies and Review Dates.

The table below shows policies the Fire, Health and Safety Manager has identified as either being needed in, or that are available in the Trust. A quick glance at the table shows there is a significant volume of work to be carried out in the coming months. This matter has been addressed at the recent 2nd October 2014 H&S Committee meeting.

Since the appointment of the current FH&SM in June 2014 3 policies have been ratified; 4 policies produced by the FH&S Team have been given tacit approval by members of the H&SC subject to there only being minor amendments; 1 policy produced by HR has been passed been given tacit approval by members of the H&SC subject to there only being minor amendments and 1 Policy By Occupational Health is currently with the Head of HR for comments before being sent to the H&SC for comments. Upon approval all policies will then be progressed through the PRG and subsequently launched on the HUB.

An action plan for the remaining policies is being developed and will be sent virtually to all members of the H&SC for comments. Serial Policy Introduced Review Date Owner Date a b c d e 1 Health and Safety General Policy. Dec 2013 Dec 2015 AB 2 Water Safety and Quality Policy (including Oct 2013 AA* BC/AB Potable water).

3 Electricity at Work Policy. Oct 2013 AA* BC/AB

4 Personal Protective Equipment Policy. May 2014 BC/AB 5 Workplace Safety Policy. Oct 2013 AA* BC/AB 6 Fire Policy. Oct 2013 AA* BC/AB 7 Control of Substances Hazardous to Health Aug 2014 AB/+ Policy. 8 Display Screen Equipment Policy. Dec 2014 AB/+ 9 Environmental Policy. Dec 2013 AB/JC 10 Control of Contractors Policy. July 2014 ABB 11 Asbestos Policy. July 2014 AB

12 Occupational Health Policy. Oct 2014 AA* CH

13 First Aid Policy (May require input from HR) Dec 2014 CH/SG 14 Moving and Handling Policy, incorporating Dec 2014 MP/AB LOLER and PUWER. 15 Ionising Radiation Policy. Sep 2014 LW 16 Medical Devices Policy. Jan 2016 Jan 2016 JH/RGA 17 General Waste Policy. May 2016 LB/LC/JC 18 Pest Control Policy. Jun 2014 LB/LC/JC 19 Transport Policy. Sep 2014 LB/LC/JC

20 Young Persons at Work Policy. Sep 2014 SG

21 Violence and Aggression Policy. Dec 2015 TL 22 Lone Workers Policy. Dec 2015 TL 23 Maternity and New Parents Policy Oct 2014 AA* LL 24 Food Hygiene Policy Date not known Tbc 25 Stress Policy Apr 2014 Tbc 26 Risk Assessment Policy 27 Noise at Work Policy Aug 2014 AB/BC 28 Infection, Prevention and Control Policy Jan 2014 Jan 2016 JR 29 Disabled Persons Date not known 30 No Smoking Policy Apr 2014

31 Accident, Incident and RIDDOR Policy Apr 2014

32 Patient and Non-Patient Slips, Trips & Falls P Date not known

AA* = Awaiting Approval 205 Names Key:

Andrew Basham = AB Bill Cooke = BC Julie Chase = JC Christine Hunter = CH Martin Pendry = MP Laura Williams = LW Joanna Hill = JH Roveena Gata-Aura = RGA Lesley Burns = LB Lee Codrington = LC Steve Graham = SG Terry Leonard = TL Liz Lubbock = LL Joanne Rutter = JR

206 A Breakdown of Violence and Abuse issues by site

The key points to note out of the graphical evidence on Violence and Abuse issues in the Trust are:

1. The majority of incidents are occurring in bedded units, the prison setting, walk-in centres and patients’ homes. The Trust Local Security Management Specialist (LSMS) is visiting sites on a planned basis and where necessary will attend homes in support of staff. The main point to note when conducting domiciliary visits is that the LSMS has to be invited in by the resident or their family, he cannot force entry or take unnecessary intervention action with anything other than reasonable force. To mitigate against the risk of abduction and to assist staff when entering domiciliary settings the LSMS has secured funding for 600 ‘Sky Guard’, Lone Worker safety devices. They are GPS tracked, provide live contact with a controller and can be activated and deactivated on entering and exiting premises. The devices are due into service imminently. 2. Aside from domiciliary V&A statistics, all other ‘like for like’ Q1 and Q2, 2013 and 2014 figures are down, particularly in bedded units and walk-in centres. In respect of domiciliary statistics the figures are virtually the same after 2 quarters of reporting. 3. In respect of Security incidents there has been a significant turnaround at Parsons Green Centre, and a slight increase in sites classified as ‘Other’. The LSMS is producing detailed analysis of this date for the December 2014 H&S Committee Meeting, the information will be shared with the Board in the January 2015 Q3 report by the FH&SM

207 Violence & Abuse Incidents by Location 01/04/2013 - 31/03/2014 90

80

70

60

50

40

30 Data Mean 20

10

0

208 Violence & Abuse Incidents by Location 01/04/2014 - 30/09/2014 45

40

35

30

25

20

15 Data 10 Mean

5

0

209 Security Incidents by Location 01/04/2013 - 31/03/2014 60

50

40

30

20 Data Mean 10

0

210 Security Incidents by Location 01/04/2014 - 30/09/2014 16

14

12

10

8

6

4

2 Data 0 Mean Other In Transit Mill Hill Clinic West Hendon West Victoria Street Oak Lane Clinic Lane Oak 145 King Street Patient's Home Patient's Childs Hill Clinic Vale Drive Clinic School Premises Walmer Road Clinic Health @ The Stowe Violet Melchett Clinic Charing Cross Hospital Cross Charing Stamford Brook Centre Brook Stamford Abingdon Health Centre Health Abingdon HMP Wormwood Scrubs Wormwood HMP Connection at St Martins at St Connection Bessborough Street Clinic Worlds End Health Centre End Health Worlds South Westminster Centre South Westminster Milson Milson HealthRoad Centre Finchley Memorial Hospital Parsons Green Health Centre Garside House Nursing Home Nursing House Garside Edgware Community Hospital Community Edgware Athlone House Nursing Home Nursing House Athlone Princess Louise Nursing Home Torrington Park Health Centre Health Park Torrington DiabetesCentre, 4b Maida Vale Athlone House general - inside - Soho Centre for Health and Care and Health for Centre Soho Athlone House Rehab Unit - Cluster 4 Cluster - Unit Rehab House Athlone

St Charles Centre for Health and Wellbeing and Health for Centre Charles St

211

BOARD OF DIRECTORS 28 October 2014

Report title: Board self-certifications

Agenda item number: 3.9

Report of: Chief Executive Officer

Contact Officer: Trust Secretary

Relevant CLCH 14/15 Goal(s) 1. Embody the best of the NHS for our patients: delivering great results with compassion and thoughtfulness Freedom of Information Report can be made public Status

Executive Summary: In support of the NTDA phase of the application for FT process, the trust has been self-certifying against Monitor Provider Licence conditions and the board statements (included in the Monitor compliance framework for FTs, now superseded by Monitor’s Risk Assessment Framework which sets out Monitor’s approach to making sure foundation trusts are well run and can continue to provide good quality services for patients in the future).

Actions identified are now complete and the Trust is now compliant as far as possible with the licence conditions and board statements. Changes since the last return are tracked in red.

Assurance provided: Sources of evidence to support statements are included in the table.

Report provenance: The draft self-certifications are routinely circulated to Executive leads in advance, at the end of each month.

Report for: Decision Discussion Information

Recommendation: To approve the provider licence, board statements and governance rating for September 2014, for submission to the TDA.

212 Monitor Provider License Conditions and Board Statements – September 2014 data for Board review on 28.10.14 and submission later the same week.

License Conditions Condition Definition ( as per Monitor guidance) Responsible Trust position officer Condition G4 1. The Licensee shall ensure that no person who is an unfit person may become or J Walbridge Individual directors have all provided self- – Fit and continue as a Governor, except with the approval in writing of Monitor. for J Reilly certification as recommended by the People proper and Remuneration Committee to the Trust persons as 2. The Licensee shall not appoint as a Director any person who is an unfit person, except Board (now Remuneration Committee). with the approval in writing of Monitor. Governors and Directors 3. The Licensee shall ensure that its contracts of service with its Directors contain a Contracts have been updated to include a (also provision permitting summary termination in the event of a Director being or becoming an clause that gives the Trust the ability to applicable to unfit person. The Licensee shall ensure that it enforces that provision promptly upon dismiss ‘unfit persons’. those discovering any Director to be an unfit person, except with the approval in writing of performing Monitor. NOTE equivalent or The introduction of the Health and Social Care similar 4. If Monitor has given approval in relation to any person in accordance with paragraph 1, 2, Act 2008 (regulated activities) regulations 2014 functions) or 3 of this condition the Licensee shall notify Monitor promptly in writing of any material (implementation postponed from 1.10.14 to change in the role required of or performed by that person. mid-November for NHS Trusts) will require the 5. In this Condition an unfit person is: Trust to consider, separate, to the Monitor license conditions, new CQC requirements in (a) an individual; relation to new and existing directors, for (i) who has been adjudged bankrupt or whose estate has been sequestrated and (in either example “persons employed for the purposes case) has not been discharged; or of carrying on a regulated activity must – be of (ii) who has made a composition or arrangement with, or granted a trust deed for, his good character, have the qualifications, creditors and has not been discharged in respect of it; or competence, skill and experience”…… and (iii) who within the preceding five years has been convicted in the British Islands of any that recruitment procedures must be offence and a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him; or established and operated effectively to ensure (iv) who is subject to an unexpired disqualification order made under the Company that persons employed meet the conditions…. Directors’ Disqualification Act 1986; or This goes beyond the existing requirements (b) a body corporate, or a body corporate with a parent body corporate: and will include all directors, ie not just NED (i) where one or more of the Directors of the body corporate or of its parent body corporate and executive directors. is an unfit person under the provisions of sub-paragraph (a) of this paragraph, or (ii) in relation to which a voluntary arrangement is proposed under section 1 of the Insolvency Act 1986, or (iii) which has a receiver (including an administrative receiver within the meaning of section 29(2) of the 1986 Act) appointed for the whole or any material part of its assets or undertaking, or

213 Condition Definition ( as per Monitor guidance) Responsible Trust position officer (iv) which has an administrator appointed to manage its affairs, business and property in accordance with Schedule B1 to the 1986 Act, or (v) which passes any resolution for winding up, or (vi) Which becomes subject to an order of a Court for winding up.

Condition G5 1 Without prejudice to any obligations in other Conditions of this Licence, the Licensee shall I McMillan for This condition relates to the power of Monitor – Monitor at all times have regard to guidance issued by Monitor for any of the purposes set out in I Millar in setting regulations in relation to price, Guidance section 96(2) of the 2012 Act. configuration and continuation of services.

2 In any case where the Licensee decides not to follow the guidance referred to in At authorisation, Monitor guidance will be paragraph 1 or guidance issued under any other Conditions of this licence, it shall inform followed and the board will be provided with Monitor of the reasons for that decision. assurance of compliance.

Condition G7 1. The Licensee shall at all times be registered with the Care Quality Commission in so far L Ashley The Trust is registered with the CQC. – Registration as is necessary in order to be able lawfully to provide the services authorised to be with the Care provided by this Licence. The Board approved the revised statement of Quality purpose and the amendments to the Trust’s 2. The Licensee shall notify Monitor promptly of: Commission (a) any application it may make to the Care Quality Commission for the cancellation of its CQC registration, including the new locations registration by that Commission, or and regulated activities in October 2013. (b) the cancellation by the Care Quality Commission for any reason of its registration by that Commission. Note 3. A notification given by the Licensee for the purposes of paragraph 2 shall: The CQC’s consultation on guidance for (a) be made within 7 days of: providers on meeting the fundamental (i) the making of an application in the case of paragraph (a), or standards and CQC enforcement powers (ii) becoming aware of the cancellation in the case of paragraph (b), and ended on 17.10.14. (b) contain an explanation of the reasons (in so far as they are known to the Licensee) for: (i) the making of an application in the case of paragraph (a), or (ii) the cancellation in the case of paragraph (b). Condition G8 1. The Licensee shall: I McMillan for Eligibility criteria for all services (where this is – Patient (a) set transparent eligibility and selection criteria, I Millar available) now published on the web site at eligibility and (b) apply those criteria in a transparent way to persons who, having a choice of persons http://www.clch.nhs.uk/media/143682/eligibility selection from whom to receive health care services for the purposes of the NHS, choose to receive _criteria_for_services_-_clch_nj_dec_2013.pdf them from the Licensee, and criteria (c) Publish those criteria in such a manner as will make them readily accessible by any persons who could reasonably be regarded as likely to have an interest in them.

2. “Eligibility and selection criteria” means criteria for determining: (a) whether a person is eligible, or is to be selected, to receive health care services provided by the Licensee for the purposes of the NHS, and

214 Condition Definition ( as per Monitor guidance) Responsible Trust position officer (b) If the person is selected, the manner in which the services are provided to the person.

Condition P1 1. If required in writing by Monitor, and only in relation to periods from the date of that I Millar The Trust has maintained a system for – Recording requirement, the Licensee shall: identifying the cost and activity relating to the of (a) obtain, record and maintain sufficient information about the costs which it expends in the services provided. information course of providing services for the purposes of the NHS and other relevant information, and (b) establish, maintain and apply such systems and methods for the obtaining, recording Assurance is gained through the completions and maintaining of such information about those costs and other relevant information, on internal reports relating to activity and costs as are necessary to enable it to comply with the following paragraphs of this Condition. such as SLR and the completion of external reporting via monthly commissioner reports, 2. From the time of publication by Monitor of Approved Reporting Currencies the Licensee NTDA returns and annual reference costs. shall maintain records of its costs and of other relevant information broken down in accordance with those Currencies by allocating to a record for each such Currency all costs I Millar has reviewed license statement P1 expended by the Licensee in providing health care services for the purposes of the NHS (recording of information – patient costing). It within that Currency and by similarly treating other relevant information. has been confirmed that in reality most of the

Trust’s activity is non- payment by results and 3. In the allocation of costs and other relevant information to Approved Reporting Currencies in accordance with paragraph 2 the Licensee shall use the cost allocation reference costing for activity is maintained. methodology and procedures relating to other relevant information set out in the Approved Guidance.

4. If the Licensee uses sub-contractors in the provision of health care services for the purposes of the NHS, to the extent that it is required to do so in writing by Monitor the Licensee shall procure that each of those sub-contractors: (a) obtains, records and maintains information about the costs which it expends in the course of providing services as sub-contractor to the Licensee, and establishes, maintains and applies systems and methods for the obtaining, recording and maintaining of that information, in a manner that complies with paragraphs 2 and 3 of this Condition, and (b) Provides that information to Monitor in a timely manner.

5. Records required to be maintained by this Condition shall be kept for not less than six years.

6. In this condition:

“the Approved Guidance” – means such guidance on the obtaining and maintaining of information about costs and on the breaking down and allocation of cost by reference to Approved Reporting Currencies as may be published by Monitor;

“Approved Reporting Currencies” – means such categories of cost and other relevant

215 Condition Definition ( as per Monitor guidance) Responsible Trust position officer information as may be published by Monitor;

“other relevant information” – means such information, which may include quality and outcomes data, as may be required by Monitor for the purpose of its functions under Chapter 4 (Pricing) in Part 3 of the 2012 Act.

Condition P2 1. Subject to paragraph 3, and without prejudice to the generality of Condition G1, the I Millar Condition G1 is not included in the current list – Provision of Licensee shall furnish to Monitor such information and documents, and shall prepare or of conditions with which aspirant trusts must information procure and furnish to Monitor such reports, as Monitor may require for the purpose of comply, however at authorisation all performing its functions under Chapter 4 in Part 3 of the 2012 Act. information will be submitted to Monitor in the required format. 2. Information, documents and reports required to be furnished under this Condition shall be furnished in such manner, in such form, at such place and at such times as Monitor may require. The management team and board will take all reasonable steps to ensure that information is 3. In furnishing information documents and reports pursuant to paragraphs 1 and 2 the accurate, complete and not misleading. Licensee shall take all reasonable steps to ensure that: (a) in the case of information or a report, it is accurate, complete and not misleading; The Board of Directors have signed a code of (b) in the case of a document, it is a true copy of the document requested; and conduct consistent with the Nolan Principles which include the requirement to “be honest, 4. This Condition shall not require the Licensee to furnish any information, documents or reports which it could not be compelled to produce or give in evidence in civil proceedings and act with integrity and probity”. before a court because of legal professional privilege.

216 Condition Definition ( as per Monitor guidance) Responsible Trust position officer Condition P3 1. If required in writing by Monitor the Licensee shall, as soon as reasonably practicable, J Reilly Not currently applicable, however the trust is – Assurance obtain and submit to Monitor an assurance report in relation to a submission of the sort committed to meeting Monitor requirements as report on described in paragraph 2 which complies with the requirements of paragraph 3. an FT, including audit as required. submissions 2. The descriptions of submissions in relation to which a report may be required under to Monitor paragraph 1 are: (a) submissions of information furnished to Monitor pursuant to Condition P2, and (b) submissions of information to third parties designated by Monitor as persons from or through whom cost information may be obtained for the purposes of setting or verifying the National Tariff or of developing non-tariff pricing guidance.

3. An assurance report shall meet the requirements of this paragraph if all of the following conditions are met: (a) it is prepared by a person approved in writing by Monitor or qualified to act as auditor of an NHS foundation trust in accordance with paragraph 23(4) in Schedule 7 to the 2006 Act; (b) it expresses a view on whether the submission to which it relates: (i) is based on cost records which have been maintained in a manner which complies with paragraph 2 in Condition P1; (ii) is based on costs which have been analysed in a manner which complies with paragraph 3 in Condition P1, and (iii) provides a true and fair assessment of the information it contains. Condition P4 1. Except as approved in writing by Monitor, the Licensee shall only provide health care I Millar Majority of Trust services are provided under – Compliance services for the purpose of the NHS at prices which comply with, or are determined in block contract or locally agreed tariffs due to with the accordance with, the national tariff published by Monitor, in accordance with section 116 of lack of a national tariff. National the 2012 Act.

Tariff Source of assurance: Trust contracts update. 2. Without prejudice to the generality of paragraph 1, except as approved in writing by Monitor, the Licensee shall comply with the rules, and apply the methods, concerning charging for the provision of health care services for the purposes of the NHS contained in the national tariff published by Monitor in accordance with, section 116 of the 2012 Act, wherever applicable. Condition P5 The Licensee shall engage constructively with Commissioners, with a view to reaching I Millar The Trust engages with commissioners – agreement as provided in section 124 of the 2012 Act, in any case in which it is of the view regarding local tariff due to the nature of Trust Constructive that the price payable for the provision of a service for the purposes of the NHS in certain business being local tariff based and block engagement circumstances or areas should be the price determined in accordance with the national contracts. tariff for that service subject to modifications. concerning local tariff Source of assurance: Trust contract update. modifications

217 Condition Definition ( as per Monitor guidance) Responsible Trust position officer Condition C1 1. Subsequent to a person becoming a patient of the Licensee and for as long as he or she J Reilly Aside from carrying DH leaflets and posters – The right of remains such a patient, the Licensee shall ensure that at every point where that person has about patient choice, the trust does publish patients to a choice of provider under the NHS Constitution or a choice of provider conferred locally by information about patient choice. GPs and make choices Commissioners, he or she is notified of that choice and told where information about that commissioners have a primary role in patient choice can be found. choice. 2. Information and advice about patient choice of provider made available by the Licensee shall not be misleading. CLCH contracts with CCGs are based on the NHS standard contract which mandates that 3. Without prejudice to paragraph 2, information and advice about patient choice of provider we follow national guidance on patient choice. made available by the Licensee shall not unfairly favour one provider over another and shall be presented in a manner that, as far as reasonably practicable, assists patients in making well informed choices between providers of treatments or other health care The Trust has a policy on conflict of interests services. (including gifts and hospitality). The trust’s

induction programme includes the Bribery Act 4. In the conduct of any activities, and in the provision of any material, for the purpose of promoting itself as a provider of health care services for the purposes of the NHS the and there is an active counter fraud service. Licensee shall not offer or give gifts, benefits in kind, or pecuniary or other advantages to clinicians, other health professionals, Commissioners or their administrative or other staff as inducements to refer patients or commission services.

Condition C2 1. The Licensee shall not: I McMillan for The Board of Directors have signed a code of – Competition (a) enter into or maintain any agreement or other arrangement which has the object or I Millar conduct consistent with the Nolan Principles oversight. which has (or would be likely to have) the effect of preventing, restricting or distorting which include the requirement to “be honest, competition in the provision of health care services for the purposes of the NHS, or and act with integrity and probity”. (b) engage in any other conduct which has (or would be likely to have) the effect of preventing, restricting or distorting competition in the provision of health care services for The Trust is aware of laws prohibiting anti- the purposes of the NHS, to the extent that it is against the interests of people who use health care services. competitive behaviour (Competition Act 1998) and the Procurement, Choice and Competition Regulations 2013.

The trust understands that the Health and Social Care Act 2012 marks a major milestone for the NHS in England’s 20-year journey from a planned system to a competitive market for the supply of health care services.

The trust recognises that while it is the role of commissioners to decide if, and when, to use competition, Monitor polices the rules and makes sure that choice and competition

218 Condition Definition ( as per Monitor guidance) Responsible Trust position officer operate in the best interests of patients. In particular, to prevent anti-competitive behaviour by commissioners or providers where it is against patients’ interests. This is the role of Monitor’s co-operation and competition directorate.

Commercial and strategy managers will be attending a Monitor seminar on competition regulations

Condition IC1 1. The Licensee shall not do anything that reasonably would be regarded as against the R Milner The Trust works closely with its commissioners – Provision of interests of people who use health care services by being detrimental to enabling its and partners in social care. integrated provision of health care services for the purposes of the NHS to be integrated with the care provision of such services by others with a view to achieving one or more of the objectives As a member of Imperial College Partners, we referred to in paragraph 4. are committed to achieving population wide 2. The Licensee shall not do anything that reasonably would be regarded as against the health benefits in NW London and beyond interests of people who use health care services by being detrimental to enabling its through collaborative research and the more provision of health care services for the purposes of the NHS to be integrated with the systematic dissemination of proven provision of health-related services or social care services by others with a view to innovation and best practice (closing the gap achieving one or more of the objectives referred to in paragraph 4. between "what we know and what we do"). 3. The Licensee shall not do anything that reasonably would be regarded as against the The trust recognises that equality is key to interests of people who use health care services by being detrimental to enabling it to co- achieving our mission to provide the best operate with other providers of health care services for the purposes of the NHS with a view to achieving one or more of the objectives referred to in paragraph 4. healthcare for people in their homes and in their community. We work within a multi- 4. The objectives referred to in paragraphs 1, 2 and 3 are: cultural and diverse community and we are (a) improving the quality of health care services provided for the purposes of the NHS committed to ensure: that we treat all (including the outcomes that are achieved from their provision) or the efficiency of their individuals fairly, with dignity and respect; that provision, the healthcare we provide is open to all; that (b) reducing inequalities between persons with respect to their ability to access those we provide a safe, supportive and welcoming services, and environment - for patients and staff. (c) reducing inequalities between persons with respect to the outcomes achieved for them We were the only NHS Trust in London to be by the provision of those services. named as an Equality and Diversity Partner by 5. The Licensee shall have regard to such guidance as may have been issued by Monitor NHS Employers for 2011/12, and one of only from time to time concerning actions or behaviours that might reasonably be regarded as 17 NHS Trusts across England. against the interests of people who use health care services for the purposes of paragraphs 1, 2 or 3 of this Condition.

219

Board statements The Board Statements and self-certification requirements form part of the TDA phase of the application process. The following table sets out each of the Board statements against which the Trust must comply:

Where the Trust is not currently compliant, an explanation and timescales for achieving compliance must be given.

Board statement Responsible Compli Sources of assurance Explanation officer ant Y/N where non- compliant or at risk of non- compliance For Clinical Quality that: 1. The Board is satisfied that, to the best of its knowledge and L Ashley Y The Board has approved the using its own processes and having had regard to the TDA’s Quality Strategy and Quality oversight model (supported by Care Quality Commission Account and receives regular information, its own information on serious incidents, patterns of updates on performance and complaints, and including any further metrics it chooses to adopt), service improvements through the trust has, and will keep in place, effective arrangements for a monthly performance report the purpose of monitoring and continually improving the quality of and quarterly Quality Report. healthcare provided to its patients. The Quality Committee undertakes monthly monitoring of all issues related to quality. 2. The board is satisfied that plans in place are sufficient to L Ashley Y The Board approved the ensure on-going compliance with the Care Quality Commission’s revised statement of purpose registration requirements. and the amendments to the Trust’s CQC registration, including the new locations and regulated activities in October 2013. The Quality Committee and Audit Committee receive reports regarding CQC compliance; details of inspection visits are routinely included in the CEO

220 report to the Board. In August 2014, the Quality Committee received an update on the Trust’s statement of purpose. 3. The board is satisfied that processes and procedures are in J Medhurst Y Medical revalidation process place to ensure all medical practitioners providing care on behalf assured by the Medical of the trust have met the relevant registration and revalidation Director who reports regularly requirements. to the Board. Employment appointment checks undertaken at recruitment Medical appraisers group established (MAG) by the Medical director to ensure there are clear arrangements and support and that revalidation best practice is followed. The organisation submitted, on time, it's annual organisational audit (AOA), for 2013/14 to NHSE which reports on revalidation and appraisal

For Finance that: 4. The board is satisfied that the trust shall at all times remain a I Millar Y Finance report to board of going concern, as defined by the most up to date accounting directors standards in force from time to time. For Governance that: 6. All current key risks to compliance with the NTDA's J Walbridge for Y The process to identify and Accountability Framework have been identified (raised either J Reilly and manage risks has been internally or by external audit and assessment bodies) and I Millar reviewed. Risks are recorded addressed – or there are appropriate action plans in place to in either the board assurance address the issues in a timely manner. framework The Audit Committee reviews

221 all internal and external audit reports and action plans on behalf of the board. Audit Committee minutes are shared with the board. The board receives an annual report from the Audit Committee.

7. The board has considered all likely future risks to compliance J Walbridge for Y The process to identify future with the NTDA Accountability Framework and has reviewed J Reilly and risks has been reviewed as far appropriate evidence regarding the level of severity, likelihood of I Millar as possible. a breach occurring and the plans for mitigation of these risks to ensure continued compliance. 8. The necessary planning, performance management and I Millar Y The trust has an annual plan corporate and clinical risk management processes and mitigation and goals. There is an internal plans are in place to deliver the annual operating plan, including performance management that all audit committee recommendations accepted by the board system (with internal are implemented satisfactorily. challenge), the ELT and Board considers performance on a monthly basis. Board committees also consider performance reports, for example the quality KPI monthly report by the quality committee. 9. An Annual Governance Statement is in place, and the trust is J Walbridge for Y The statement is compiled in compliant with the risk management and assurance framework L Ashley line with most recent guidance requirements that support the Statement pursuant to the most up annually, agreed by the audit to date guidance from HM Treasury (www.hm-treasury.go committee and included in the annual report 10. The Board is satisfied that plans in place are sufficient to I Millar Y Trust integrated performance ensure on-going compliance with all existing targets as set out in report and balanced scorecard the NTDA oversight model; and a commitment to comply with all known targets going forward. The Board KPI report includes: • Milestones met for

222 developing and submitting IBP/LTFM ahead of key assessments (auditors, NTDA) • Milestones met for completion of action plans for external assessments by February 2014 – to be restated in line FT timeline 11. The trust has achieved a minimum of Level 2 performance I Millar Y Level 2 has been confirmed for against the requirements of the Information Governance Toolkit. 2013/14 Evidence – Annual report 2013/14 and IG toolkit submission / internal audit. 12. The board will ensure that the trust will at all times operate J Walbridge for Y Evidence - register of interests effectively. This includes maintaining its register of interests, J Reilly published on web site ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, or plans Board and Committee are in place to fill any vacancies. members are asked to declare any interests at the start of meetings – these are recorded in the minutes.

The Remuneration Committee consider succession planning arrangements for existing and future vacancies.

There are no Board vacancies. The NED vacancy has been filled; the successful applicant will join the Trust on 1 August 2014.

223 For GOVERNANCE, that Y This is included in the annual 13. The board is satisfied that all executive and non-executive J Reilly and P appraisal process for all directors have the appropriate qualifications, experience and Chesters directors. skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and Evidence – annual appraisal ensuring management capacity and capability. documentation

Executive directors appointed through a rigorous recruitment and selection process.

Annual board development plan.

BGAF self-assessment and validation.

A new NED appointment will be made in April 2014. For GOVERNANCE, that J Walbridge for Y The Remuneration Committee 14. The board is satisfied that: the management team has the J Reilly terms of reference include capacity, capability and experience necessary to deliver the approval review of annual annual operating plan; and the management structure in place is objectives for very senior adequate to deliver the annual operating plan. managers and monitoring performance against those objectives. It will provide input to the chief executive on the performance of other executive members of the board and will advise the chair on the chief executives annual appraisal.

Evidence – annual appraisal documentation

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BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Quality Committee terms of reference

Agenda item number: 3.10.1

Report of: Chief Executive

Contact Officer: Trust Secretary

Relevant CLCH 14/15 Goal: 1 Embody the best of the NHS for our patients: delivering great results with compassion and thoughtfulness Freedom of Information Report can be made public Status

Executive Summary: The annual review of the Quality Committee’s terms of reference was postponed from June to October 2014. This enabled the findings from the external assessment of the Committee’s effectiveness [reference Ramsden, Transforming Health Ltd, September 2014] to be considered.

Membership of the Committee has also been reviewed; no changes are proposed. Clinical leads are, however, welcome to attend as observers and there are a number of other regular attendees.

Proposed changes are shown tracked for the Board to approve, including for the first time, revalidation and monitoring the delivery of the Trust’s engagement plans.

The Committee’s role in relation to risk has been clarified to avoid confusion with the role of the Audit Committee (to review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), that supports the achievement of the organisation’s objectives). The risk categories are also updated in line with the Risk Management Strategy approved by the Trust Board on 30.09.14.

Following approval, a supporting annual programme will be prepared, commencing in January 2015. This will show how the Committee will deliver against each responsibility and will include the lead director and form of assurance to be provided.

Assurance provided: The terms of reference have been approved by the Board and compared to the 2nd edition of the foundations of good governance, compendium of best practice published by the Foundation Trust Network and DACbeachcroft in October 2013.

Report provenance: The Trust Board approved the terms of reference in June 2013 and the Quality Committee agreed proposed changes at the meeting of 22.10.14.

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Report for: Decision Discussion Information

Recommendation: For the Board to approvel.

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QUALITY COMMITTEE TERMS OF REFERENCE

Role The role of the Quality Committee is to focus on quality and risk issues including the clinical agenda to ensure that appropriate governance structures, systems and processes are in place across the Trust.

Definitions “the Trust” means Central London Community Healthcare NHS Trust “the committee” means the Quality Committee “the Directors” means the Trust’s Board of Directors.

1 Membership 1.1 Members of the committee shall be appointed by the Board of Directors. The committee shall be made up of 7 members. Non Executive Directors shall be in the majority. Members may appoint a deputy to represent them at a committee meeting. Members of the Quality Committee are as follows:  4 x Non-Executive Directors  Chief Nurse and Director of Quality Governance  Deputy Chief Executive (Operations)  Executive Medical Director

1.2 The Chief Executive shall attend at least quarterly. 1.3 Only members of the committee have the right to attend and vote at committee meetings. The committee may require other officers of the Trust and other individuals to attend all or any part of its meetings. 1.4 The chair of the committee will be an independent Non Executive Director. In the absence of the committee chair and/or an appointed deputy, the remaining members present shall elect another member who is a Non Executive Director to chair the meeting.

2 Secretary 2.1 The Trust Secretary or their nominee shall act as the secretary of the committee.

3 Quorum 3.1 The quorum necessary for the transaction of business shall be one Non Executive Director and one Executive Director. A duly convened meeting of the committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the committee.

4 Frequency of meetings and attendance requirements 4.1 The committee will normally meet ten times a year at appropriate times in the reporting cycle and otherwise as required; 4.2 Committee members should aim to attend all scheduled meetings but must attend a minimum of seven meetings unless otherwise agreed with the Chair. The Secretary of the committee shall maintain a register of attendance which will normally be published in the Trust’s annual report.

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5 Notice of meetings 5.1 Meetings of the committee may be called by the secretary of the committee at the request of any of its members. 5.2 Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed, shall be forwarded to each member of the committee, any other person required to attend and all other non-executive directors, no later than 5 working days before the date of the meeting. Supporting papers shall be sent to committee members and to other attendees as appropriate, at the same time.

6 Minutes of meetings 6.1 The secretary, or nominated deputy, shall minute the proceedings of all meetings of the committee, including recording the names of those present and in attendance. 6.2 Members and those present should state any conflicts of interest and the secretary should minute them accordingly. 6.3 Minutes of committee meetings should be circulated promptly to all members of the committee and, once agreed, to all members of the Board of Directors unless a conflict of interest exists.

7 Annual General Meeting 7.1 The chair of the committee will normally attend the Annual General Meeting prepared to respond to any questions on the committee’s activities.

8 Duties The committee should carry out the following duties for the Trust:

8.1 Quality

8.1.1 To review implementation of all elements of the quality strategy. In particular, obtaining assurance that the measures for success are implemented within the appropriate time scales. 8.1.2 To gain assurance over the full range of quality performance via the quality report, quality dashboard, minutes (including unconfirmed minutes if necessary) and summary reports from the quality stakeholder reference group and the quality campaign groups, namely the patient safety and risk, clinical effectiveness and patient experience and the provision of any other quality related information that the committee may request, including receipt of an annual report from each of these groups. 8.1.3 To receive reports as appropriate and as the committee may request from any of the work groups that feed into the quality campaign groups. 8.1.4 To monitor the production of the quality account; ensuring they are produced annually and in accordance with the relevant guidance.

8.1.5 To receive regular reports on delivery of annual objectives as defined within the quality account;

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PATIENT SAFETY AND RISK 8.2 Risk

8.2.1 To receive the quality committee sections of the corporate risk register at least quarterly –risk categories: clinical, environmental, fire, health and safety, information governance and workforce. To scrutinise and review risks rated 15 and above for the following risk categories: clinical, environmental and information governance.

8.2.2 To receive a regular update on new, removed and changes in scoring of risks on the added to the corporate risk register as they pertain to the above risk categories, for example risks added, taken off and movements in scoring . 8.2.3 To obtain assurance that risks are being managed appropriately and to escalate any particular concerns to the board or relevant directors. 8.2.4 To obtain assurance that the Trust has effective mechanisms for managing risk and improving service user safety, learning from incidents, and taking action to reduce risks.

8.3 Care Quality Commission (CQC) - Essential Standards

8.3.1 To monitor compliance against the CQC’s Essential Standards and obtain assurance that standards are being met and that improvement reviews are implemented.

A POSITIVE PATIENT EXPERIENCE

8.4 Involving and learning from service users

8.4.1 To obtain assurance that the experience of users, carers and voluntary groups are central to the Trust’s work. 8.4.2 To obtain assurance that the implementation and maintenance of programmes for measuring, monitoring and improving the experience of service users and carers is appropriate and relevant. 8.4.3 To obtain assurance that lessons learned learnt from involving service users are used to improve the quality of service provided. 8.4.4 To monitor the delivery of the Trust’s engagement plan, including the programme of listening events in each of our four key boroughs.

SMART EFFECTIVE CARE

8.5 Monitoring and improving clinical performance

8.5.1 To approve the annual programme of Trust-wide clinical audits. 8.5.2 To obtain assurance that clinical recommendations resulting from complaints investigated by the Parliamentary and Health Service Ombudsman; the implementation of NICE Guidelines and Technology Appraisals and recommendations for improving clinical performance resulting from national reviews and other external inquiries are appropriately managed.

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8.5.3 To receive, at least annually, the log in relation to Caldicott approval of requests for information. 8.5.4 To assure that the statutory duty of revalidation for doctors is delivered effectively and for other professionals as this is mandated.

8.6 Clinical Governance

8.6.1 To obtain assurance that appropriate clinical governance structures groups, systems, and processes are in place, and developed in line with national, regional and commissioning expectations.

9 Reporting responsibilities 9.1 The committee will report to the Board of Directors on its proceedings after each meeting. 9.2 The committee shall make whatever recommendations to the Board of Directors it deems appropriate on any area within its remit where action or improvement is needed. 9.3 The committee will produce an annual report to the Board of Directors. 9.4 To identify any control issues and bring these to the attention of the Audit Committee 9.5 To identify any new risks and issues arising during meetings and to agree action required.

See also 8.1.2 above.

10 Other matters The committee should: 10.1 have access to sufficient resources in order to carry out its duties, including access to the Trust secretariat for assistance as required; 10.2 be provided with appropriate and timely training, both in the form of an induction programme for new members and on an on-going basis for all members; 10.3 give due consideration to laws and regulations; 10.4 at least once a year, review its own performance and terms of reference to ensure it is operating at maximum effectiveness and recommend to the Board of Directors for approval, any changes it considers necessary.

11 Authority 11.1 The committee is a committee of the Board of Directors and has no powers, other than those specifically delegated in these Terms of Reference. The committee is authorised: 11.1.1 to seek any information it requires from any employee of the trust in order to perform its duties 11.1.2 to obtain, outside legal or other professional advice on any matter within its terms of reference via the Trust Secretary 11.1.3 to call any employee to be questioned at a meeting of the committee as and when required.

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12 Monitoring and Review: 12.1 The Board will monitor the effectiveness of the committee through receipt of the committee's minutes and such written or verbal reports that the chair of the committee might provide. 12.2 The secretary will assess agenda items to confirm they comply with the Committee’s responsibilities. 12.3 Terms of reference reviewed and considered by quality committee 20.10.14. 12.5 Terms of reference approved to be approved by trust board 28.10.14. 12.6 Date of next review September 2015.

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BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Update following Quality Committee meeting of 22.10.14

Agenda item number: 4.11.2

Report of: Quality Committee Chair

Contact Officer: Trust Secretary

Relevant CLCH 14/15 Goal: 1 Embody the best of the NHS for our patients: delivering great results with compassion and thoughtfulness Freedom of Information Report can be published Status

Executive Summary:

A summary of key issues discussed by the Committee is attached.

Report provenance: The Quality Committee discussed these issues in full on 22.10.14.

Report for: Decision Discussion Information

Recommendation: To note.

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Highlights:

QUALITY IMPROVEMENT 1 Quality report, Q2 1.1 It was confirmed that a cluster of outliers had been identified. Quality Action Teams will be appointed to work with the services/teams identified to help implement improvement plans.

1.2 A substantive complaints and claims manager is now in post and training for CBU staff has been planned to help resolve complaints in a more timely manner. A status update will be reported back to the Quality Committee in Q, 2015.

2 Care Quality Commission (CQC) 2.1 There has been positive feedback following the unannounced inspection at Garside Nursing Home.

2.2 The Chief Executive confirmed that the Trust’s CQC inspection is likely to take place in April 2015.

3 Quality governance assurance framework (QGAF) 3.1 Niche Consulting have provided verbal, positive feedback following the QGAF assessment. The summary and final report will be shared with the Board. Chair thanked and congratulated all involved.

4 Risk register review 4.1 The risk in relation to the nursing homes was discussed at length; delays in the transfer to Sanctuary Housing cited by commissioners included: TUPE and pension arrangements together with estate issues. Senior representatives from the current health service providers continue to press for an early transfer date; in the meantime NHS Trusts would continue to manage the risks to the provision of high quality care.

A new risk (1108) was added to the register with a scoring of 20 (although it is anticipated this will be lowered to 16 after the patient safety and risk group meeting on 27.10.14). Discussion took place as to how a risk can enter the register at such a high level without prior “sighting”.

A POSITIVE PATIENT EXPERIENCE 5 Achieving excellence together 5.1 Members welcomed a report on the ‘achieving excellence together’ campaign focussed on improving the quality of care and morale of staff within district nursing services, in partnership with New Buckinghamshire University. It was agreed that a quarterly update on this initiative would go to the Workforce Committee.

6 Quarterly waiting times report 6.1 Members discussed the waiting times report in detail, noting actions planned to consider the redirection of resources from services which were ‘over-performing’ against contract and more challenged services. The importance of contract negotiations for 2015/16 was recognised, including whether a move to activity or performance based contracts could be achieved. It was also agreed that greater insight into average versus static times would be beneficial. Importantly, the committee received assurance that any extended waiting times were not putting patients at risk.

7 Learning disability protocol 7.1 A draft protocol was considered and a number of helpful additions agreed to broaden and improve access to services for people with a learning disability.

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PREVENTING HARM 8 Patient safety – serious incident report 8.1 The Committee received assurance that as much as possible was being done to prevent and manage pressure ulcers. It was noted that the management of level 3 and 4 pressure ulcers remained a significant challenge, both locally and nationally.

See also 1.1 above regarding action in response to confirmed outliers.

9 Short record keeping audit 9.1 A report triangulating record keeping in relation to pressure ulcer assessments, falls, nutritional assessments and safeguarding had been prepared and shared with divisions. It was confirmed that the record keeping steering group would review the results and determine a specific action plan for improvement.

9.2 It was agreed that the full record keeping audit would be postponed from November to enable an improved process which is better understood by staff – for report to the Quality Committee in January 2015.

10 Child health information hub 10.1 The remedial action plan was noted to be progressing well. Executive directors were asked to confirm the process for electronic notifications and how these would continue to be accessible to staff.

SMART, EFFECTIVE CARE 11 Falls report 11.1 The comprehensive report, which had been well received by commissioners, comparing the number and severity of falls in each of the Trust’s bedded units (including those managed by Care UK for which the Trust provides therapy staff) was considered. It was noted that Pembridge had achieved a zero falls in September and was commended for having implemented actions to address the service challenges.

OTHER ITEMS 12 Quality Committee terms of reference 12.1 The revised terms of reference, which had been postponed to enable recommendations from the external assessment to be considered, were agreed for Board approval on 28.10.14.

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BOARD OF DIRECTORS 28 OCTOBER 2014

Report title: Update following Remuneration Committee meeting 22.10.14

Agenda item number: 3.10.3 Report of: Remuneration Committee Chair

Contact Officer: Trust Secretary Relevant CLCH 14/15 Goal: 1 Embody the best of the NHS for our patients: delivering great results with compassion and thoughtfulness Freedom of Information Report can be made public Status

Report provenance: The Remuneration Committee discussed these issues in full on 22.10.14, a copy of papers has been provided to all Non-Executive Directors.

Report for: Decision Discussion Information Recommendation: To note.

Highlights 1 Outstanding issues from the former people and remuneration committee It was agreed that a comprehensive interim usage report, governance arrangements for the appointment of interim staff and a table capturing the totality of temporary posts, highlighting those in excess of 6, 12 and 24 months would be provided to Workforce Committee members no later than the end of November.

2 Update on VSM remuneration and terms of service 2.1 Members were informed that the Medical Director had a temporary variation to contract, working 4 days per week for an approximately 8 week period and that a part- time, Deputy Medical Director (Dr Dharini Shanmugabavan) had been appointed.

2.2 J Reilly reported that the Head of Communications and External Relations had resigned.

3 People and Remuneration Committee – performance review 3.1 The findings of the former Committee’s performance review were noted – no specific recommendations had been made.

4 Remuneration Committee - programme 4.1 The programme was agreed, subject to the inclusion of pensions and a mid-year update on progress against VSM objectives. A copy of the programme will be included with Board papers for 27.11.14.

5 Remuneration Committee – terms of reference 5.1 The terms of reference were agreed, subject to inclusion of a mid-year review of VSM objectives and the attendance of the Director of HR (or equivalent), for Board approval on 27.11.14.

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Quality Committee Minutes of the meeting held on Tuesday 16 September 2014 In the Boardroom, Westminster City Hall, Victoria Street, London Present Louise Ashley Chief Nurse and Director of Quality Governance Julia Bond Non-Executive Director (Committee Chair) Pamela Chesters Non-Executive Director (Trust Chairman) (part) Carol Cole Non-Executive Director Joanne Medhurst Medical Director Richard Milner Deputy Chief Executive Officer David Sines Non-Executive Director

In attendance

Judith Barlow Associate Director of Quality (part) James Benson Divisional Director of Operations Nick Caley Grant Thornton LLP (observer) Jo Davis Clinical Specialist OT (observer) Steve Graham Head of HR and OD Clare Gray Clinical Lead Physiotherapist Learning Disabilities (observer) Joanne Howard NICHE Patient Safety (observer) Janet Lewis Divisional Director, Children’s Health and Development Jean Lewis Professional Lead Adult Nursing (part) Esther Palmer Clinical Lead Physiotherapist (observer) Sheila Pearce Head of Patient Safety Tony Pritchard Deputy Chief Nurse (Director of Patient Experience) James Reilly Chief Executive Sharon Slack Niche Health and Social Care Consulting (observer) Rachel Stoukas Committee Administrator Paul Thomas Head of Quality Improvement Jayne Walbridge Trust Secretary

QC/187/14 Welcome, Introduction and Apologies 187.1 All members were present. 187.2 J Bond welcomed C Cole to the committee.

QC/188/14 Declarations of Interest 188.1 There were no interests declared.

QC/189/14 Minutes of the meeting held on 7 August 2014 189.1 The minutes of the meeting held on the 7 August 2014 were agreed as an accurate record.

QC/190/14 Action Log 190.1 The action log was reviewed and it was agreed that all completed actions could be closed.

190.2 Action QC/11/14 (Quality Report) – L Ashley reported that the balanced scorecard was being migrated onto Qlikview and it was expected that by the end of September service levels would be able to view data quality sets, however there were currently some data quality issues. It was agreed a short update paper would be prepared for the next meeting.

Action QC/83/14 L Ashley

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It was agreed this action would be closed.

190.3 Action QC/60/14 (Terms of Reference Review) – J Bond reported she had received the report following the external committee review in August. It was agreed an action plan would be devised and presented to the Board in October.1 The report would also inform potential revisions to the Terms of Reference.

190.4 Action QC/76/14 (Dental recall audit NICE) - This action would be closed however it was agreed that R Milner would ask S Yadin to share the audit results with committee members. Action QC/84/14 R Milner

190.5 Action QC/81/14 (Statutory and Mandatory Training) - This action would be closed however it was agreed that an updated position by division would be circulated to the Board the following week. Action QC/85/14 L Ashley & T Pritchard

QC/191/14 Matters Arising 191.1 On reflection of the minutes of the meeting held on 7 August, J Bond queried if an action should have arose regarding encouraging staff to share their concerns via the internal Trust whistleblowing procedures (ref QC/170/14 / 170.4). J Reilly assured the committee that ‘Your Trust News’ and ‘CLCH Today’ have regular bulletins referencing the correct avenues for whistleblowing.

QC/192/14 Quality Presentation 192.1 J Lewis presented on the prevention and management of pressure ulcers highlighting that training for clinical staff throughout the Trust had developed to focus on prevention, classification, risk assessment and wound management for nursing and therapy staff. Competency assessments were also being undertaken. NHS safety thermometer data showed a reduction in incidence of CLCH acquired pressure ulcers from April to August.

192.2 A demonstration was provided about the educational smartphone and tablet app that had been developed for patients and carers. The committee were particularly impressed and it was agreed that J Medhurst would look into how the body of work being conducted by CLCH on pressure ulcers could be leveraged further through the Innovation committee. Action QC/86/14 J Medhurst

192.4 Members had a useful discussion regarding patient pathways and carer intervention. J Bond was particularly pleased to note the reduction in pressure ulcers and it was agreed J Reilly would discuss with L Ashley and J Medhurst the most appropriate forum to thank staff for their efforts.

Action QC/87/14 J Reilly/L Ashley/J Medhurst

192.3 J Bond stressed the importance of communicating this important work to the commissioners which L Ashley noted was routinely shared at the clinical quality groups.

192.4 Resolved Members thanked J Lewis for her excellent presentation and all the effort being undertaken to reduce the number of pressure ulcers affecting patients.

J Bond would consider the most appropriate route to ensure all non-executive colleagues were sighted on this important work.

1 Following the meeting it was decided the action plan would be presented to the Board on 30 September. 2 237

Action QC/88/14 J Bond

QC/193/14 Quality Improvement Plan – Sign up to Safety 193.1 L Ashley updated members on the Sign Up to Safety campaign highlighting the plan for the Trust was to focus on a safety programme related to organisational safety culture. Impressively CLCH was one of the first trusts and the first community trust to join the campaign.

193.2 Resolved Members noted the Sign up to Safety update and how it would work alongside existing initiatives.

QC/194/14 Quality balanced scorecard (August Performance) 194.1 Throughout August thirteen KPIs were RAG rated green, six amber and six red. The areas of concern remained the number of falls with harm and pressure ulcers.

194.2 The proportion of complaints responded to within 25 days Members discussed the year to date average of 64%. Concern was noted that the year-end target of 90% was now unachievable which was disappointing given the low volume of complaints received per month. T Pritchard sought to provide assurance that whilst not all complaints were resolved within 25 days, they were resolved within an agreed timeframe. It was anticipated there would be a significant improvement now that a permanent complaints manager was in post and culture change workshops were being held for staff.

194.3 10% reduction in falls that cause harm The year to date average was reported at 16. Whilst the decline in falls was acknowledged it was agreed a detailed falls analysis would be prepared for the next meeting highlighting the outliers and mitigations in place. Action QC/89/14 L Ashley

194.4 Proportion of services capturing clinical outcomes Although RAG rated red at the moment, J Medhurst assured the committee there would be a step change at the end of September as work had been intensified by the continuous improvement manager to work closely with services to record their clinical outcomes.

194.5 Resolved The Quality Balanced Scorecard was noted.

QC/195/14 Engagement Strategy 195.1 T Pritchard introduced the strategy highlighting the Trust’s plans for ensuring effective engagement with patients, the public and key stakeholders.

195.2 Members discussed the strategy in detail emphasising the importance of direct involvement with divisional directors and CBU managers. J Reilly noted that initial accountability for engaging stakeholders lies with CBUs and the current planning round included a focus on stakeholder engagement.

195.3 In response to members’ queries, T Pritchard confirmed further equality impact assessment work was being considered on how to include hard to reach groups and following further discussion agreed it would be useful to have more specific measurements in some areas of the strategy. For example metrics against what success looked like and how assurance could be provided.

195.4 It was also decided it would be important to evidence engagement of the Board of Directors and J Walbridge agreed to prepare a section for inclusion in the strategy.

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Action QC/90/14 J Walbridge

195.5 Resolved The committee endorsed approval of the Engagement Strategy by the Board subject to amendments. It was agreed the maturity matrix would be considered on a quarterly basis by the committee.

QC/196/14 Patient and Public engagement update 196.1 T Pritchard highlighted key updates on the patient and public engagement work streams through April to June 2014; • There were now four patient experience facilitators in post aligned to each division and a new permanent head of patient experience had been appointed • PREMS coverage had expanded to include a monthly walk around of services to collect data • Tablets and kiosks were being used in some bedded areas and wards • Divisional engagement plans had been drawn up • The 15 steps challenge had been implemented on Jade ward, Marjory Warren ward, the Pembridge Unit, Athlone House and Alexandra rehab unit.

196.2 Members were particularly pleased with the ‘you said / we did’ updates and L Ashley confirmed these were communicated back to the services on a regular basis as well as on a quarterly basis to the commissioners.

196.3 In response to P Chesters’ query, L Ashley explained it was important for the Qlikview data to be reviewed at a team level quarterly to enable progress against action plans.

196.4 Resolved The Patient and Public engagement update was noted. The committee welcomed the future plans to develop staff and carers stories and re-introduce ‘mystery shopping’ to follow the pathway of care / the patient journey.

QC/197/14 Volunteer Service Update 197.1 Members discussed the current volunteer services provided within the Trust noting the high number of volunteers in Barnet and the low numbers within the tri borough. A key aim for the remainder of 2014 was to expand the service within the inner boroughs with one idea focused around recruiting younger people with the aim of advancing to apprenticeships.

197.2 J Reilly highlighted the Charitable Funds Committee had discussed the volunteer service with a view to supporting plans to expand provisions. It was agreed it would be useful to have a proposal and discussion at the next Charitable Funds meeting.

Action QC/91/14 T Pritchard

197.3 Resolved Members noted the volunteer update and were supportive of the plans to increase the numbers. It was agreed J Medhurst would ensure there were robust systems in place with employee health regarding the immunisation status of current and future volunteers. Action QC/92/14 J Medhurst

QC/198/14 Patient safety – serious incident report 198.1 S Pearce reported on the serious incident cases to end of August 2014. Of concern there were twelve new pressure ulcer cases and five confidential information governance leaks.

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198.2 In response to concerns raised regarding the delays in reporting some pressure ulcer cases, S Pearce highlighted that although there were delays in reporting cases on STEIS due to staffing issues, there was no delay in the investigation of each case.

198.3 The table charting the number of pressure ulcers reported to NWL CSU since April 2013 was discussed in detail. Given the substantial range month on month, members queried if there were any particular themes / outliers and any correlation with the use of agency nurses / incidents occurring within patient’s homes. J Medhurst noted a standard variation chart would be a useful tool to capture this data and would arrange a meeting between S Pearce and J Ramazanoglu who would be able to assist. Action QC/93/14 J Medhurst

198.4 Resolved Members noted the Serious Incident Report and welcomed an update in the next report against the actions generated in the lessons learned section.

QC/199/14 Record Keeping Audit 199.1 J Barlow introduced the results of the short record keeping audit that took place in July 2014. An overall compliance rate of 76% was recorded. Whilst there was improvement around safeguarding, reporting on resuscitation and medication and care planning, there were several areas of concern where questions were poorly answered around pressure ulcer and falls risk assessments, nutritional assessments and medication deficits.

199.2 The audit findings were discussed and members acknowledged the effort needed to achieve the 90% target in the annual audit due to take place in November. J Barlow provided assurance that the Record Keeping Steering group were providing extra support to those services identified the previous year as having poor recording keeping performance. However members were still concerned regarding the percentage of non-compliant services. It was agreed that an update report would be prepared for the next meeting focusing on service outliers and their KPIs for falls, pressure ulcer management and safeguarding.

Action QC/94/14 J Barlow / L Ashley

199.3 In addition J Medhurst would review the audit questionnaire focusing on the issues around the questions that were not answered correctly.

Action QC/95/14 J Medhurst

199.4 Resolved The Record Keeping audit report was noted.

J Bond expressed her concern that the tone of the paper was more positive than suggested when looking at the detail.

QC/200/14 Quality Impact of Cost Improvement Programme update 200.1 L Ashley updated the committee on the quality impact assessments undertaken for the 2014 /15 cost improvement programme highlighting a more collaborative process with the divisions this year. Whilst no CIP schemes were declined, J Medhurst and L Ashley worked closely with services to revise proposed schemes and ensure robust quality assessments were in place. Full assurance was also given around all schemes as the full project plans including patient experience data were reviewed as part of the assessments.

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200.2 Resolved Members noted the report and were assured the CIPs were being appropriately managed and monitored to prevent adverse impact on the quality of service delivery.

QC/201/14 Update on progress with delivery of remedial action plans for Child Health Information Hub records management process 201.1 J Lewis informed members that the two satellite centres had been set up to deal with the backlog. This had ensured the CHIH could continue to run business as usual. All the red and amber rated notifications had been processed. L Ashley assured the committee that there were no children within the records that were of immediate safeguarding concern as these cases would have been dealt with at the time under the serious incident reporting process.

201.2 In response to queries, J Lewis suggested an estimated completion date of the end of November, however stressed there were currently problems with ensuring continuity of bank staff and recruitment processes. It was agreed J Lewis and S Graham would urgently discuss ways of recruiting to and sustaining bank admin staff. Action QC/96/14 J Lewis / S Graham

J Bond also stressed that appropriate financial resources / incentives should be allocated to ensure sustainability for the satellite centres.

201.3 Resolved Members noted the update on progress with delivery of the action plan for CHIH records management. It was suggested the next iteration of the report should sensibly manage expectations and include timeframes.

In response to J Bond’s suggestion of an external review, J Reilly recommended awaiting the findings of the internal investigation and internal audit to be picked up at the Audit Committee.

QC/202/14 Dementia Update 202.1 Resolved Members noted the update on initiatives to support the development of dementia care across the organisation in particular noting the e-learning specialist dementia training module that had been set up and the links with the End of Life strategy and Carer’s strategy.

QC/203/14 Committee effectiveness review 203.1 Resolved J Bond informed members she had received the feedback following the committees’ external assessment and shared some of the high level output. An action plan would be prepared by J Bond and L Ashley and shared with the Board.

QC/204/14 Risks and issues arising for which further assurance is required 204.1 A risk in relation to the non-compliance with the record keeping audit in particular pressure ulcer risk assessments and falls risk assessments was identified during the meeting and J Bond requested that a paper come back to the committee which cross-referenced these areas against other reporting metrics.

QC/205/14 Grid of all meeting dates 205.1 Members noted the list of meeting dates for groups reporting to the Quality Committee.

205.2 J Bond reiterated the need for consistency with the groups reporting to the committee and noted her disappointment that minutes were still not being received

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in a timely manner. She urged the Chairs of the groups to ensure minutes were provided emphasising draft minutes were acceptable. J Bond also suggested the Chairs of each group might want to review memberships to ensure more consistent attendance.

QC/206/14 Clinical Effectiveness Group Minutes 206.1 The minutes of the Clinical Effectiveness group held on 9 July 2014 were noted.

QC/207/14 Patient Safety and Risk Group Minutes 207.1 The minutes from the Patient Safety and Risk Group held on the 30 June 2014 and the 28 July 2014 were noted.

QC/208/14 Update of key issues from Clinical Commissioning Group Quality Meetings 208.1 Members noted updates from the Barnet CCG and combined inner London CCG following the meetings held in August 2014.

QC/209/14 Update on new regulation and guidance 209.1 Resolved The committee noted the update on regulation and guidance issued since July 2014.

QC/210/14 Any other business 210.1 L Ashley reported that the Achieving Excellence Together programme had been successful in receiving a bid with the value of £340,000 from LETB.

210.2 J Medhurst informed members that a Deputy Medical Director had been appointed and would take up post in October.

186.1 Date and time of next meeting 20 October 2014, 1400 Boardroom, Victoria Street

The meeting closed at 1655 hours.

Signed ………………………………………………….. Julia Bond, Committee Chair

Date ……………………………………………………..

7 242 Acronym Description Alphabetical by abbreviation A&E Accident & Emergency AHP Allied Health Professional ALB Arms Length Bodies AQP Any Qualified Provider BAU Business As Usual BGAF Board Governance Assurance Framework BGM Board Governance Memorandum CAS Central Alerting System CBU Clinical Business Unit CCG Clinical Commissioning Group CFT Community Foundation Trust CIO Chief Information Officer CIP Cost Improvement Programme CLCH Central London Community Healthcare NHS Trust COPD Chronic Obstructive Pulmonary Disorder CQC Care Quality Commission CQUIN Commissioning for Quality and Innovation CRG Clinical CSRR Continuity of Service Risk Rating CSU Commissioning Support Unit DH Department of Health DN District Nursing EBITDA Earnings Before Interest, Taxes, Depreciation and Amortisation ELT Executive Leadership Team ESR Electronic Staff Record FOI Freedom of Information FRR Financial Risk Rating FRIC Finance, Resources and Investment Committee FT Foundation Trust FTE Full Time Equivalent – see WTE GP General Practitioner GRR Governance risk rating HCA Health Care Assistant HDD Historical Due Diligence HR Human Resources HV Health Visiting IBP Integrated Business Plan ICO Information Commissioner’s Office (1) ICO Integrated Care Organisation (2) ICP Integrated Care Pathway IG Information Governance IM&T Information Management and Technology ITT Invitation to Tender KPI Key Performance Indicator KSF Knowledge and Skills Framework LA Local Authority

243 LETB London Education Training Board LTC Long Term Conditions MAU Medical Admissions Unit NHS National Health Service NHSLA National Health Service Litigation Authority NICE National Institute of Clinical Excellence NRLS National Reporting and Learning System NTDA NHS Trust Development Authority OBD Occupied bed days OD Organisational Development OOH ‘Out of Hospital’ agenda or Out of Hours ORSA Organisational Readiness Self-Assessment PASA Purchasing and Supply Agency PID Project Initiation Document PPE Patient and Public Engagement PST Patient Safety Thermometer PQQ Pre-Qualifying Questionnaire QGAF Quality Governance Assessment Framework QIPP Quality, Innovation, Productivity and Prevention RA Registration Authority R&D Research and Development RIO Is the name of a clinical system, it is not an abbreviation, it is a Spanish word which correlates to ‘flow of work’. RTT Referral to Treatment SDIP Service Development Improvement Plan SLR Service Line Reporting STEIS Strategic Executive Information System TAG Technology Appraisal Guidelines (NICE) TDA Trust Development Authority WTE Whole Time Equivalent – see FTE

244 KEY PERFORMANCE INDICATOR SCORECARD Embody the best of the NHS for our patients

Key Performance Indicator Description End of Yr Target Key Performance Indicator Calculation

This KPI is calculated in accordance with "The NHS Friends and Family Test: Publication Guidance". The calculation therefore reflects the proportion of respondents who reply "extremely likely" to the survey question 'How likely is it that you would recommend this service Friends and Family test - Net Promoter Score (National methodology) 58 to a friend or family if they needed it', minus those who would not recommend the service (response categories; "neither likely or unlikely", "unlikely" and "extremely unlikely"). The survey to generate the responses for this KPI is the monthly patient experience survey. The calculation of this KPI reflects the percentage of those respondents that gave either an "extremely likely" or "likely" response to the survey question 'How likely is it that you would recommend this service to a friend or family if they needed it', minus those who would not Friends and family test - Net Promoter Score (CLCH methodology) 85 recommend (response categories; "neither likely or unlikely", "unlikely" and "extremely unlikely"). The survey to generate the responses for this KPI is the monthly patient experience survey. This KPI is also taken from the monthly patient experience survey and reflects the percentage of Patients agreeing with the statement “I was treated with dignity and respect” 95% respondents choosing the 'Yes, definitely' category when answering the question "Did the staff treat you with dignity and respect?". This measure reflects the percentage of staff that respond 'strongly agree' or 'agree' when asked to what degree they agree with the statement "I am satisfied with quality of care I give to “I am satisfied with the care I give to patients/service users” (quarterly) 85% patients/service users". This question forms part of the National Staff Survey and is replicated internally in the Trusts quartely Pulse Survey. This represents the simple ratio of the total hours worked by the two categories of a) Bank staff The ratio of clinical bank : agency staff by hours worked 65:35 and b) Agency staff within the four clinical directorates.

Support people safely out of hospital

Key Performance Indicator Description End of Yr Target Key Performance Indicator Calculation This metric represents the percentage of patients where one of the four categories of Patient Safety Thermometer harms (Falls, Pressure Ulcers, Catheter Associated UTIs and Veneous Proportion of Patients with no NEW harms identified (PST monthly prevalence survey) 98% Thromboembolisms) did not occur within the current episode of care. The data is generated from a monthly survey of mandated services and clinical teams. This KPI reflects Monitors self assessment mechanism used in assessing the readiness for QGAF Score, to be tested quarterly 2.5 Foundation Trust status. It is assessed quarterly by the Quality Directorate. Monthly hand hygiene observations are carried out in bedded services by Infection Prevention Link Practitioners(IPLPs), and this KPI calculation reflects the number of observed hand hygiene Hand hygiene audit, to be measured quarterly 92% opportunities achieving an Overall Confidence Rating of 'Green' as a percentage of the total number of observed hand hygiene opportunities. The calculation of this KPI reflects the NHS England guidelines published in May 2014 and as such calculates a total 'fill rate' for Nursing and Care Assistant staff. The total hours worked by these Percentage of time bedded units achieve minimum staffing each month 100% staff is shown as a percentage of the total hours that should have been worked if minimum staffing levels were met. Statutory and mandatory training compliance 90% This KPI reflects the percentage completion rate for all 10 training elements. This measure is a straight count of the number of Grade 2 to Grade 4 Pressure Ulcers that Reduction in incidence of Grade 2-4 Pressure Ulcer (by 10% from the previous year). 416 develop or deteriorate whilst the patient is within a CLCH service.

Deliver better value than competitors in our selected markets

Key Performance Indicator Description End of Yr Target Key Performance Indicator Calculation This metric reflects the full-year effect (annualised) of changes to our revenue stream, both Net new business won - annualised figure of committed changes to income £3.1m positive and negative, from acquisition or loss of business. The figure will be a cumulative total for the year for all changes. This KPI represents the percentage of the 67 services within the Trust which have identified 3 Proportion of Services capturing Patients' Clinical Outcomes 66% clinicical outcomes and are able to collect and report the data electronically.

This measure is the count of the number of harm free incidents expressed as a percentage of the Percentage of incidents affecting patients that did not cause harm 49.0% total number of reported incidents. It reflects only those incidents directly related to patients.

Be responsive to our patients and partners needs

Key Performance Indicator Description End of Yr Target Key Performance Indicator Calculation This KPI reflects the number of Low/Moderate graded complaints (to which a 25 day completion Complaints resolved within 25 days of receipt 90% deadline applies) which are dealt with within 25 days. Formal complaints are administered using the Trusts Datix system.

245 This KPI applies to complaints which, due to their complexity fall outside of the 25 day completion deadline, and whose completion deadline is agreed with the complainant. The Complaints resolved within timescales agreed with the complainant 100% agreed completion date is recorded on the Datix system and the KPI reflects the percentage of complaints which were completed within the agreed timescale.

Data relating to both patient and service cancellations are collected on the Trusts Patient Percentage of Appointments cancelled by CLCH 2.1% Administration Systems. This KPI highlights the total number of appointments which were cancelled by a service as a percentage of the total number of planned contacts.

Employ only the best staff

Key Performance Indicator Description End of Yr Target Key Performance Indicator Calculation

This KPI is collected quarterly via the Trusts Pulse Survey for Q1, Q2 and Q4 with the national staff survey covering Q3. The measure reflects those staff who agree or strongly agree with the Percentage of Staff that recommend CLCH as a place to work 62% question asking staff whether they would recommend the Trust as a place to work. The percentage is calculated against total number of responses for that question.

This KPI shows the number of staff assignments appraised as a percentage of the number due for Staff appraisal rates 90% appraisal in the same period. The ESR and E-PADR systems provide this data. The measure simply reflects the number of hours recorded as being lost due to sickness absence Sickness absence rate 3.50% as a percentage of the total hours available in the same period. Data is taken from the ESR system and is reported one month in arrears. This KPI reflects the vacant full time equivalent (less frozen posts) divided by the budgeted Vacancy level 11% establishment. Data is taken from two sources namely the ESR system and the General Ledger. Taken from the Trusts ESR system, this KPI shows the percentage of all staff that self classify as Staff from BME backgrounds at bands 7 and above 34% BME. The denominator figure includes those staff whose classification is recorded as not known and not stated.

Be innovation and technology pioneers

Key Performance Indicator Description End of Yr Target Key Performance Indicator Calculation This KPI shows the forecast end of year recurrent QIPP position (including any contingency in Recurrent QIPPs achieved % of total for the year 100% reserve) as a percentage of the end of year QIPP target. This KPI reflects the financial position of the year to date 'actual' QIPPS achieved as a percentage Percentage of QIPP plans achieving the planned level of savings in-year 100% of the year to date planned position. The Innovation committee will see a number of projects each year, some of which will This measure reflects the number of projects presented to the Innovation committee and the 30 : 6 be taken forward as pilots number which are to be progressed. This KPI reflects the number of board KPIs which are assessed as having appropriate levels of KPIs that are RAG rated GREEN on overall data quality confidence level. 85% data quality. The assessment is carried out by the Data Quality Forum using a Data Quality Assessment Framework. This measure is currently under development but is expected to reflect the total number of staff Continuous improvement model in place and used across service lines 10% successfully undertaking the course.

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