Bundle Public Trust Board 6 April 2021

0 Apologies for absence - Jonathan Odum 0.1 Nolan Principles and Trust Values Lead Chair Action to note Nolan Principles of Public Life and Trust Values.docx 1 To receive declarations of interest from Directors and Officers Declarations 01.04.21pdf.pdf 2 10:00 - Minutes of the meeting of the Board of Directors held on 2 March 2021 **Action** To approve **Lead** Chair 3_minutes_Public_Trust_2 March 2021 v1.6 KW DL YH LT RE.docx 3 Matters arising and Board Action Points from the minutes of the meeting of the Board of Directors held on 2 March 2021 3_TB Board_Action_Point 6 April 2021 docx (1).docx Public Actions v 1 300321.docx 3.1 10:05 - Ockenden Report - verbal update (see Midwifery Services Report 7.7) Lead Director of Midwifery Action to note 3.2 10:10 - NHS National Staff Survey Results Lead Chief People Officer Action to note TB_2020 NHS Staff Results_March 21.docx 3.3 Memorandum of Understanding with Walsall Healthcare NHS Trust Lead Strategic Advisor to the Trust Board Action to note MOU Between RWT and WHT TB Mar 2021.pdf 3.4 Trust Board and Trust Board Committee Governance – Withdrawal of Interim Arrangements Lead Company Secretary Action to review and approve 0_1_Trust_Board_Front_Sheet_Covid Governance April 2021.docx Post Covid Wave 3 2021 Trust Board and Trust Board Committee Governance final v1.4 31.03.21 SF DL KW.docx 4 10:15 - Patient Story - A Dowling, Matron C Banks https://youtu.be/PeN4wrgM754 5 10:35 - Staff Voice - Cleaners and Porters T Ray - Domestic Supervisor M Bunt Domestic Senior - Supervisor 10:55 - Chief Executive and TMC Reports Lead Chief Executive Officer 6 Action to note Chief Executive's Report

6.1 TB CEO Report to Board 6 April 2021.doc 6.2 Chief Executive's Report of the TMC held on 27 March 2021 Chairs Report TMC TB Summary 6 April 2021 - 26 March 2021.docx 7 Governance, Risk and Regulatory 7.1 11:05 - Quality Governance Assurance Committee (QGAC) - Chair's Report QGAC chair's report March 2021WK4.docx 7.2 QGAC terms of reference Lead Chief Nursing Officer Action to approve Enc 11 - Draft Terms of Reference - QGAC.docx 7.3 11:10 - Chief Nurse's Nursing Report Lead Chief Nursing Officer Action to note 1. Part 1 CNO TB Report Feb 2021 - FINAL.pdf 2. Part 2 CNO TB Report Feb 2021 - FINAL.pdf 7.4 11:15 - Trust Board Assurance Framework and Trust Risk Register Heat Map Summary Lead Chief Nursing Officer Action to note April 2021 BAF TRR Heat Map TMC_Front_Sheet 31.03.21 Brief Public TB.docx TRR Heat Map Report TB draft Mar 21 06.04.21 for Public TB Brief.docx 7.5 11:20 - Director of Infection Prevention Report - Jo Macve Lead Chief Nursing Officer Action to note IPC Board report Apr 2021.pdf 7.6 11:25 - Infection Prevention & Control Board Assurance Framework (BAF) - J Macve K Corbett Lead Chief Nursing Officer Action to note IP BAF TMC report March 2021 v1.1.pdf BAF March 21 update.pdf 7.7 CQC Well-Led Inspection Activity and Improvement Plan Progress Update as at 28th February 2021 Final_Trust Board_CQC well Led update report_March 2021.pdf 7.8 11:30 - Midwifery Services Report Lead Director of Midwifery Action to note Part 1_TB midwifery report - April 2021.pdf Part 2_ TB midwifery report - combinedpdf.pdf 8 Patient Safety, Quality and Experience 8.1 12:00 - Learning from Deaths update Lead Chief Medical Director Action to note Learning From Deaths - Trust Board April 2021.pdf Learning from Deaths Update February 2021.pdf 8.2 12:05 - Safeguarding Adults and Children 6 Monthly update- C Hope Lead Chief Nursing Officer Action to note TB - Safeguarding 6 monthly update report March 2021 v1.2 - UPDATED comb.._.pdf 9 Finance and Performance 9.1 12:15 - Finance and Performance - Chair's Report 2.Report to Board - Chairs Report F+P 24.03.21.docx 9.2 12:20 - Report of the Chief Financial Officer - Month 11 Lead Chief Financial Officer Action to note Report of Chief Financial Officer M11.pdf 9.3 12:25 - Integrated Quality and Performance Report Lead Chief Nursing Officer/Chief Operating Officer Action to note Trust Board IQPR February 2021.pdf IQPR Reference Pack February 2021.pdf 10 Strategy, Business and Transformation 10.1 12:30 - Innovation, Integration and Research Director's Report Lead Chief Innovation, Integration and Research Officer Action to note Trust Board Chief Innovation Integration and Research Officers Report A....docx April Reference Pack FINAL.DOCX Appendix 1 - Outcomes Operating Framework Wolverhampton ICP v2.pdf 10.2 12:35 - Chairs’ Report – Charity Board meeting report Charity March 21.docx Royal Wolverhampton NHS Trust Charity Opportunities Review.pdf 10.3 12:40 - Trust Strategy Update/revision/progress Lead Chief Strategy Officer Action to note Strategy Board Front Sheet.docx Final Draft Trust Strategy 2021.22.pdf 10.4 12:45 - The Wolverhampton Pound – Development of the Anchor Network Lead Chief Strategy Officer Action to note The Wolverhampton Pound - Anchor Network TB Rep.pdf 11 People and Engagement 11.1 12:50 - Workforce & Organisational Development (WOD) Committee - Chair's Report Chairman's WOD Report - Mar 21.docx 11.2 People and Organisational Development Committee (PODC) terms of reference Lead Chief People Officer Action to approve PODC v2TORs 2021-2022.docx 11.3 12:55 - Executive Summary Workforce Report Lead Chief People Officer Action to note TB Exec Workforce Rpt 06 04 2021.pdf 11.4 13:00 - Education and Training Academy Report- L Nickell Lead Chief Medical Officer Action to note TB Education Report 6 April 21.docx 12 Items to Note 12.1 13:10 - Approved Minutes from Committees in respect of which the Chair's report have already been submitted to the Board 12.1.1 Finance and Performance Committee minutes 19 February 2021 Finance+Performance Minutes 9.02.21 Agreed.pdf 12.1.2 Trust Management Committee minutes 19 February 2021 Minutes_Trust_Management_Committee_of_the_Board_19_February_2021 v1.4 vKW SF.docx 12.1.3 Quality Governance Assurance Committee minutes 24 February 2021 Draft QGAC Minutes - February 2021.docx 12.1.4 WODC minutes 22nd January 2021 Mins 22 January 2021.doc 13 General Business 13.1 Any Other Business 13.2 Questions from members of the public and those in attendance 13.3 Date and time of the next meeting 4 May 2021 10 am 13.4 To consider passing a resolution that representatives of the press and other members of the public be excluded from the remainder of this meeting, having regard to the confidential nature of the business about to be transacted, publicity on which would be prejudical to the public interest 14 For reading/information 0.1 Nolan Principles and Trust Values 1 Nolan Principles of Public Life and Trust Values.docx

Nolan Principles of Public Life & Trust Values Committee on Standards in Public Life - Guidance The Seven Principles of Public Life Published 31 May 1995

The Seven Principles of Public Life (also known as the Nolan Principles) apply to anyone who works as a public office-holder. This includes all those who are elected or appointed to public office, nationally and locally, and all people appointed to work in the Civil Service, local government, the police, courts and probation services, non- departmental public bodies (NDPBs), and in the health, education, social and care services. All public office- holders are both servants of the public and stewards of public resources. The principles also apply to all those in other sectors delivering public services.

Principle I will show this by 1. Selflessness Holders of public office should act solely in terms of the public interest.

2. Integrity Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships.

3. Objectivity Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias.

4. Accountability Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this.

5. Openness Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing.

6. Honesty Holders of public office should be truthful.

7. Leadership Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs.

Kw 1/4/21 V1.0 Kw 1/4/21 V1.0 1 To receive declarations of interest from Directors and Officers 1 Declarations 01.04.21pdf.pdf RWT - Register of Declarations of Interest from Directors and Officers - April 2021

Employee Role Interest Type Provider Interest Description (Abbreviated)

Alan Duffell Chief People Officer Loyalty Interests Chartered Management Institute Member

CIPD (Chartered Institute for Personnel and Alan Duffell Chief People Officer Loyalty Interests Develovement) Member

UK and Ireland Healthcare Advisory Board for Alan Duffell Chief People Officer Loyalty Interests Allocate Software (Trust Supplier) Member (unpaid)

Anand Pandyan Associate Non Executive Director Outside Employment Digitimer Provided consultancy or received honorarium for Digitimer

Anand Pandyan Associate Non Executive Director Outside Employment Biometrics Limited Provided consultancy or received honorarium

Anand Pandyan Associate Non Executive Director Outside Employment Merz Provided consultancy or received honorarium

Anand Pandyan Associate Non Executive Director Outside Employment Ispen Provided consultancy or received honorarium

Anand Pandyan Associate Non Executive Director Outside Employment Allergan Provided consultancy or received honorarium

Anand Pandyan Associate Non Executive Director Loyalty Interests Biometrics Limited Obtained unrestricted educational support from Biometrics Limited

Anand Pandyan Associate Non Executive Director Loyalty Interests Allergan Obtained unrestricted educational support from Allergan

Anand Pandyan Associate Non Executive Director Loyalty Interests Merz Obtained unrestricted educational support from Merz

Developing a research project with a company called Aparito on an App Anand Pandyan Associate Non Executive Director Outside Employment Aparito Development for monitoring stroke patients in the community

Anand Pandyan Associate Non Executive Director Outside Employment Staffordshire University Visiting Professor

Has a PhD student working with University Hospital South Manchester and Anand Pandyan Associate Non Executive Director Loyalty Interests University Hospital South Manchester and OpCare OpCare

Anand Pandyan Associate Non Executive Director Outside Employment University of Keele Professor of Rehabilitation Received a research grant from the Stoke Association on Medcity to work with Vitrue to develop and App/system to monitor exercise performance Anand Pandyan Associate Non Executive Director Outside Employment Vitrue and compliance with the Community.

Shareholdings and other ownership Ann-Marie Cannaby Chief Nurse interests Ann-Marie Cannaby Ltd Director

Ann-Marie Cannaby Chief Nurse Loyalty Interests La Trobe University Victoria Australia Honorary Visiting Fellow

Ann-Marie Cannaby Chief Nurse Loyalty Interests Higher Education Academy Teaching (Fellow)

Ann-Marie Cannaby Chief Nurse Loyalty Interests Royal College of Nursing Member

Contracted for 1PA by PHE as West Midlands Endoscopy Professional Brian McKaig Acting Chief Medical Officer Outside Employment PHE Clinical Advisor for the Bowel Cancer Screening Programme

Brian McKaig Acting Chief Medical Officer Outside Employment Nuffield Hospital Private Practice

Professional Clinical Advisor for Endoscopy PHE role (1 PA) as clinical QA Brian McKaig Acting Chief Medical Officer Outside Employment West Midlands Bowel Cancer Screening Programme advisor to the West Midlands Bowel Cancer Screening Programme

Private Practice, Wolverhampton Nuffield Hospital Tue pm alternate weeks Brian McKaig Acting Chief Medical Officer Outside Employment Wolverhampton Nuffield Hospital Gastroenterology / Endoscopy MAC Member

Professional Clinical Advisor for Endoscopy PHE role (1 PA) as clinical QA Brian McKaig Acting Chief Medical Officer Outside Employment West Midlands Bowel Cancer Screening Programme advisor to the West Midlands Bowel Cancer Screening Programme

Private Practice, Wolverhampton Nuffield Hospital Tue pm alternate weeks Brian McKaig Acting Chief Medical Officer Outside Employment Wolverhampton Nuffield Hospital Gastroenterology / Endoscopy MAC Member

David Loughton Chief Executive Loyalty Interests National Institute for Health Research Member of Advisory Board

David Loughton Chief Executive Outside Employment West Midlands Cancer Alliance Chair

Gwen Nuttall Chief Operating Officer Loyalty Interests Calabar Vision 2020 Link Trustee of Funds.

John Dunn Non Executive Director Loyalty Interests Walsall Healthcare NHS Trust Non Executive Director Private out-patient consulting and general medical/hypertension and nephrological conditions at Wolverhampton Nuffield average time spent 1-2 Jonathan Odum Chief Medical Officer Outside Employment Wolverhampton Nuffield hours/week maximum

Junior Hemans Non Executive Director Outside Employment Wolverhampton University Visiting Lecturer

Junior Hemans Non Executive Director Outside Employment Kairos Experience Limited Company Secretary

Junior Hemans Non Executive Director Outside Employment Wolverhampton Cultural Resource Centre Chair of the Board

Junior Hemans Non Executive Director Outside Employment Tuntum Housing Assiciation (Nottingham) Chair of the Board

Junior Hemans Non Executive Director Outside Employment Libran Enterprises (2011) Ltd Director

Junior Hemans Non Executive Director Loyalty Interests Labour Party Member

Junior Hemans Non Executive Director Loyalty Interests Prince's Trust Business Mentor

Junior Hemans Non Executive Director Loyalty Interests Walsall Healthcare NHS Trust Non Executive Director

Kevin Stringer Chief Finance Officer Outside Employment Healthcare Financial Management Association Treasurer West Midlands Branch

Midlands and Lancashire Commissioning Support Kevin Stringer Chief Finance Officer Loyalty Interests Unit Brother-in-law is the Managing Director

Kevin Stringer Chief Finance Officer Loyalty Interests CIMA (Chartered Institute of Management Accounts) Member

Birmingham and Solihull Local Workforce Action Louise Toner Associate Non Executive Director Loyalty Interests Board and Education Reform Workforce Group Member

Associate Dean Faculty of Health, Education and Life Sciences at Birmingham Louise Toner Associate Non Executive Director Outside Employment Birmingham City University City University

Louise Toner Associate Non Executive Director Outside Employment Lovely Professional University India Visiting Professor/Advisory Board Member Louise Toner Associate Non Executive Director Outside Employment Birmingham Commonwealth Association Chair - Education Focus Group

Louise Toner Associate Non Executive Director Loyalty Interests Royal College of Nursing - UK Member

Greater Birmingham Chamber of Commerce Louise Toner Associate Non Executive Director Loyalty Interests Commonwealth Group Member

Louise Toner Associate Non Executive Director Outside Employment Higher Education Academy Teaching Fellow

Mary Martin Non Executive Director Outside Employment Midlands Art Centre Trustee/Director, Non Executive Member of the Board for the Charity

Mary Martin Non Executive Director Outside Employment Performance Birmingham Ltd Trustee/Director, Non Executive

Mary Martin Non Executive Director Outside Employment Martin Consulting (West Midlands) Ltd Director/Owner of Business

Friday Bridge Management Company Limited Mary Martin Non Executive Director Outside Employment (residential property management company) Residential property management company

Mary Martin Non Executive Director Outside Employment Extracare Charitable Trust Non Executive Director/Trustee

Mary Martin Non Executive Director Outside Employment Walsall Healthcare NHS Trust Non Executive Director

Mike Sharon Strategic Advisor to the Trust Board Loyalty Interests Liberal Democrat Party Member

Wife works as an independent trainer, coach and councillor. Some of this Mike Sharon Strategic Advisor to the Trust Board Loyalty Interests Wife work is for local NHS bodies (excluding RWT

North Salop Wheelers Ltd (Community Bus company) – Social services Roger Dunshea Non Executive Director Outside Employment North Salop Wheelers Ltd (contract with NHS) – bus driver

Roger Dunshea Non Executive Director Outside Employment Geological Society of London Chair of Audit Committee

Welsh Government Audit and Risk Committee for Roger Dunshea Non Executive Director Loyalty Interests Education and Public Services Independent Member

Daughter as an employee of Unite the Union takes part in union Rosi Edwards Non Executive Director Outside Employment Unite the Union campaigning, including on the NHS Birmingham Health Safety and Environment Rosi Edwards Non Executive Director Loyalty Interests Association President

Rosi Edwards Non Executive Director Outside Employment Care Quality Commission Inward Secondment undertaking the role of Executive Reviewer Italian National Government, the Autonomous Province of Trentino and Lombardy Regional OECD work Consultant advising on their systems for regulating Rosi Edwards Non Executive Director Outside Employment Government occupatioinal health and safety

Rosi Edwards Non Executive Director Loyalty Interests Labour Party Labour party member

Sally Evans Director of Communications and Engagement Nil Declaration

Simon Evans Chief Strategy Officer Nil Declaration

Steve Field Chairman Loyalty Interests University of Warwick Honorary Professor

Steve Field Chairman Loyalty Interests University of Birmingham Honorary Professor

Steve Field Chairman Loyalty Interests EJC Associates Director

Steve Field Chairman Loyalty Interests Nishkam Healthcare Trust Birmingham Trustee

Steve Field Chairman Outside Employment Pathway Healthcare for Homeless People Appointed as a Trustee for the Charity

Steve Field Chairman Loyalty Interests Walsall Healthcare NHS Trust Chair

Chief Innovation, Integration & Research Member of the Advisory Board for the Centre for Health and Social Care Sultan Mahmud Officer Loyalty Interests University of Birmingham Leadership, HSMC

Trustee and Director of Telford Christian Council Supported Housing (STAY), Susan Rawlings Non Executive Director Outside Employment Telford Christian Council Supported Housing (STAY) a charitable company.

Tracy Palmer Director of Midwifery Nil Declaration 2 Minutes of the meeting of the Board of Directors held on 2 March 2021 1 3_minutes_Public_Trust_2 March 2021 v1.6 KW DL YH LT RE.docx

The Royal Wolverhampton NHS Trust

Minutes of the meeting of the Board of Directors held on Tuesday 2 March 2021 at 10 am in the Conference Room C27 Hollybush House, New Cross Hospital, Wednesfield, Wolverhampton and virtually via Microsoft Teams (MT)

PRESENT: Prof. S Field CBE Chairman, in person Prof. D Loughton (v) CBE Chief Executive Officer Prof. S Mahmud Chief Innovation, Integration & Research Officer Mr S Evans Chief Strategy Officer Mr A Duffell Chief People Officer Ms R Edwards Non-Executive Director Ms S Rawlings Non-Executive Director Mr M Sharon Strategic Advisor to the Trust Board Mr K Stringer (v) Chief Financial Officer/Deputy Chief Executive Prof. L Toner Associate Non-Executive Director, in person Mr R Dunshea Non-Executive Director Dr J Odum (v) Chief Medical Officer Prof. A-M Cannaby (v) Acting Chief Operations Officer Prof. A Pandyan Associate Non-Executive Director Mr J Dunn Non-Executive Director Ms G Nuttall (v) Chief Operating Officer Ms S Evans Director of Communications and Engagement, RWT Ms M Martin Non-Executive Director - Deputy Chair (v) denotes voting Executive Directors.

IN ATTENDANCE: Mr K Wilshere Company Secretary, RWT, in person Ms S Banga Senior Administrator, RWT Ms Y Higgins Acting Chief Nurse, RWT Ms T Cresswell Healthwatch left at workforce summary report Ms S Thacker Deputy Head of Midwifery, RWT for Ockenden item Mr S Phipps Group Manager, RWT for Ockenden item Ms M Cole RWT for Patient Story item Ms K Lees RWT for Patient Story item Ms A Dowling RWT for Patient Story item Ms A Morgan RWT for Staff Story item Ms K Murphy RWT for Staff Story item Ms S Wilmhurst RWT for Staff Story item Ms S Fowles RWT for Staff Story item Ms L Abbiss RWT for Staff Story item Mr P Madeley Express and Star

APOLOGIES: Mr J Hemans Non-Executive Director

1 Part 1 – Open to the public

Prof. Field opened the meeting and welcomed all.

TB.8236: Apologies for absence Prof. Field welcomed the guests and observers. He confirmed that apologies had been received from Mr Hemans.

TB.8237: To receive declarations of interest from Directors and Officers Prof. Field confirmed that there were no changes or conflicts arising from or in addition to the list of declarations provided, reviewed and published in the Board papers.

TB.8238: Minutes of the meeting of the Board of Directors held on 2 February 2021 Prof. Field confirmed that there were no changes or amendments on the minutes of the meeting of the Board of Directors held on 2 February 2021.

Resolved: That the Minutes of the Board of Directors held on 2 February 2021 be approved as a true record.

TB.8239: Matters arising from the minutes of the meeting of the Board of Directors held on 2 February 2021

2 February 2021/TB.8189 Patient Story Action: “Ms Evans to gain patient’s consent to share the Patient Story video with West Midlands Ambulance Service colleagues.” Ms Evans confirmed this action had been completed. Action: it was agreed that this action be closed.

2 February 2021/TB.8191 Midwifery Service Report including Ockenden Review Action: “Ms Palmer to provide a fully-populated version of the assessment table and plan contained in the report to the Trust Board.” This action was noted as on the agenda. Action: it was agreed that this action be closed.

2 February 2021/TB.8198 Executive Summary Workforce Report Action “Mr Duffell to provide an update on the progress with staff Covid-19 vaccinations at the next Trust Board.” Mr Duffell confirmed he was to provide this in his report Action: it was agreed that this be closed.

2 February 2021/TB.8198 Learning from Deaths Update Action “That a demonstration be provided of the learning from deaths platform at the Board Development Session in April.” Prof. Field asked that this take place in a future Board development or NED Briefing session. Action: it was agreed that this action be closed

TB. 8240 Ockenden report – RWT Gap Analysis and Action Plan

2 Ms Thacker introduced herself and Mr S Phipps. She confirmed that the detail had been revised to include, in relation to the 7 immediate actions, action leads and timescales. Prof. Field said he and Prof. Toner were to visit the maternity ward following the Board meeting. Ms Higgins said the Trust had undertaken a ‘confirm and challenge’ meeting with the regional National Health Service England/Improvement (NHSEI) Midwife regarding the action plan. She said the meeting had confirmed the Trust’s ratings. She said there were further ‘confirm and challenge’ meetings planned with both the Regional Midwife and the Local Maternity and Neonatal System (LMNS) responsible officer in the next week. She said an internal ‘dashboard’ for maternity was being developed that included measures across Maternity and Neonatal Services.

Prof. Loughton said that following discussions with the Non-Executives, Tracy Palmer was to join the Board as Director of Midwifery. He believed that was an important part of the recommendations. Prof. Field agreed that this demonstrated how seriously the Board as a whole had taken Maternity services with regular updates to the Board.

Ms Edwards asked about page 5 on the maternity workforce planning and the reference to “undertake next round of consultant job planning”. She asked whether that included one of the points raised in the second Silverman Report and the Richard Kennedy Report of 12/2019 report regarding fairness of rotas including nights and weekend working. Prof. Loughton and Mr Phipps confirmed it was part of the action.

Prof. Cannaby said maternity reports had focussed on midwifery staffing and midwifery education. She asked for an update on staffing numbers and how the Trust assured itself that the numbers were correct including the competencies and training of the midwives. Ms Thacker said the Trust was undertaking a new birth rate plus review in year to provide assurance that the Trust had the correct staff in the right place. She said the Trust continued to recruit to any available hours. She said that the Trust Practice Development Midwives, with Trust Consultant colleagues, had produced at short notice online virtual training so the Trust had assurance that staff were safe to practice.

Mr Dunshea asked whether the timetable for the actions was realistic and achievable. He added that they also mentioned the requirement for audits to be undertaken. He asked about the nature of the audits and whether they were independent. He asked what process would be followed to check whether the actions had acted on the intended issues.

Mr Phipps said that the timescales reflected the importance of the issues being addressed. He said some of the timescales were challenging but that as a team, the service was confident it could meet the timescales. He asked if Mr Dunshea was referring to the audit on page 3 regarding complex pregnancies and Lead Consultants. Mr Dunshea confirmed that was what he was referring to. Mr Phipps said that audit that would be undertaken internally with the outputs shared with the LMNS and with the Board. He said he was confident that women with a complex pregnancy had a named Lead Consultant currently. He said there were issues with the EPR system being addressed with the supplier and further auditing to follow, the results of which would be shared.

Prof. Pandyan asked about page 4 of the report, and the mentioned of the need for additional equipment for foetal monitoring and applying for further funding. He asked whether that funding was in place and what guarantee there was that this equipment would be funded. Ms Thacker said the Trust’s Foetal Monitoring Lead had been supported by the LMNS but this secondment would end at the end of March 2021. She said support had been sought for a substantive post and that the Trust could support that internally during the next Birth Rate plus review. She said until the funding process was completed she could not give a definitive answer.

3 Prof. Toner asked what standards the staff had to achieve with the on-line and virtual training. She asked how it was made relevant to the development needs of individuals. Ms Thacker said it was a blanket training required of all the Trust’s Obstetricians and Midwives monitored as part of each staff members monitoring by the Trust Professional Development Midwives. She said every time a ‘skill drill’ was completed, the member of staff made a declaration to capture the learning.

Mr Dunn said he found the presented action plan very clear. He asked what the monitoring and control was as some of the due dates were imminent. Mr Phipps confirmed that there were a few dates in the plan to be completed and that the leadership team met regularly to review the progress against the plan and that this was reported in turn to the wider Directorate and Division.

Action: Prof. Field asked for the complete plan assurance to be provided to the next Trust Board.

Prof. Cannaby added that Ms Palmer provided her and the Chief Medical Officer with updates that were shared at Quality & Safety Intelligence Group (QSIG), Quality Governance Assurance Committee (QGAC) and the Board. Prof. Field reiterated the importance of the Ockenden report, the seriousness of the services addressed and that he had taken a person and lead interest for the next 12 months. Prof. Field thanked all for the report.

TB.8241: Patient Story Ms Higgins introduced the patient story and some of the Breast Care team in attendance. She summarised the story of a lady who in May 2020 had found a cyst on her breast. She was fast- tracked by her GP, subsequently had a mammogram which confirmed the presence of a cyst. She said this had also identified another breast abnormality that had led to a diagnosis of cancer. She said the patient talked about her journey of diagnosis and treatment and her interactions with various staff at all levels.

Ms Cole said that this lady had been the first patient to undertake the Self-Management Programme for the Trust’s Breast Care patients. She said they had learnt from colleagues in Stroke services experiences in forming this programme. She described how patients had the choice to, if they wished, self-manage their follow-up. She said that if the patient wished, they could re-enter the managed system and see a consultant or breast care nurse. She said it had allowed the patient to have autonomy with their 5 year follow-up and it had been really successful.

Ms Rawlings congratulated all the staff for being able to continue the work as they had done during the pandemic. She said to have made the patient feel comfortable during Covid was wonderful. She asked whether the pandemic had caused any issues in maintaining care and compassion within the department. Ms Cole said that with the Self-Management Programme she was not aware of any problems. She said there had been some difficulties in the referral process where patients had been concerned that they had not been seen quickly enough by a Consultant or had to wait for a mammogram. Ms Lees said despite this she felt that did not affect the good care that they had been given and how they had been treated.

Prof. Toner asked whether every patient undertook the self-management programme. Ms Cole said the patients’ potential suitability was first considered at a Multi-disciplinary Team review, then it was, depending on their results, procedures and condition, offered to the patient as a choice. She reiterated that a patient could opt-out at any time if they wanted to. Prof. Toner asked how many patients were on the Self-Management Care Programme Plan. Ms Lees said it commenced in September 2020 and there were approximately 55 at the present time. Prof. Toner congratulated the team on their work.

4 Ms Edwards said the patient had mentioned that she was very concerned about chemotherapy and she was delighted to be put on a trial to have radiotherapy. Ms Edwards asked for further information on the trial. Ms Cole said she did not have details of the trial with the lady as this was discussed with the oncologist and it would be managed through the clinical research team. Ms Edwards said it sounded like an interesting clinical trial.

Action: Prof. Field asked Ms Cole and Ms Lees to forward details of the treatment trial to the Company Secretary, Mr Wilshere, who would then forward it to the all the Board members.

Prof. Field said that breast cancer had affected him personally as he and his late wife lived with her breast cancer for over 20 years whilst she was a nurse and a cancer lead. He said he found patient story’s really difficult as the experience still had an impact on him but he felt this was an important example of progressive care. He said he had a particular interest in studies in breast cancer and that it had been a significant concern as to how Covid-19 had had an impact on breast cancer performance and restoration. Ms Nuttall said that there were a number of other Self-Management pathways in services across the Trust including learning from the Breast Self- care example.

Action: In response to a request from Prof. Field, Ms Nuttall confirmed that there was a Non- Executive Briefing arranged on Cancer Performance and recovery across all tumour site areas.

Ms Higgins said that despite the patient story being in the midst of the pandemic the Trust had not lost sight of the patient and the RWT ethos of being kind, caring and trying to exceed expectations. Prof. Field thanked all in attendance.

Resolved: that the Patient Story be received and noted.

TB.8242: Staff Voice - C26 Staff Prof. Field introduced the item by reiterating the importance of the patient and staff experience to the Board as indicators of where the Trust’s focus lay. He said that fulfilled happy motivated staff cared better for patients forming a virtuous circle. He said the Board was always interested in the contributions from staff. Mr Duffell introduced the attendees from C26 one of the Trust’s respiratory wards. Ms Wilmhurst, Dr Morgan, a Respiratory Consultant and Lead for Lung Cancer, Ms Murphy, Ms Fowles and Ms Evans introduced themselves.

Dr Morgan gave a summary description of the care the team had been undertaking including their recent move to one of the new Ward areas, providing care and Continuous Positive Airway Pressure (CPAP) support to patients. She said they had been able to successfully discharge many patients from the Ward without them requiring Intensive Care Unit input. Ms Murphy described her role as a Practice Education Facilitator. She praised her colleagues swift ability to adapt to the pandemic including staff who had never looked after CPAP supported patients before.

Ms Murphy described the journey of new nurses and redeployed staff being trained and the physically and mentally draining nature of caring for a continuous flow of very poorly and very acute patients. She said the staff had to adapt to CPAP trial and in her view they had provided excellent care. She recognised the high levels of motivation and caring, with support matrons and the extended workforce. She said the staff were rightly proud of what they had done and she asked that this was recognised. She said she had nominated the ward twice for an exceeding expectations award and hoped this might happen soon. Mr Duffell thanked Ms Murphy for her honest appraisal. He gave his and the Board’s thanks to her and all the staff team for the fabulous job they had done in the most challenging circumstances.

5 Ms Evans said all staff had undertaken further training in CPAP and Arterial Blood Gas (ABG). She said it had been difficult with a high number of end of life care patients and that the palliative team had been a great support together with the diabetic nurses. She said that the Army personnel had also been on the ward and had been fantastic, together with staff from B14 and the redeployed staff and students. She said the Ward had recently been awarded recognition in the Dignity of Care Award 2020. She outlined some of the teething issues and snagging in the new ward including problems with the sluice maceration unit. Ms Murphy said the new Ward had not included an area for relatives’ room and asked whether this could be considered.

Dr Odum said he felt that Ms Morgan had understated the amount of effort and the contribution of all the work on C26. He said it had been a fabulous team effort from all the consultants, all other medical staff, all the nursing staff, all the therapy staff all the palliative care staff. He said to have been able to support 27 CPAP beds, on top of the 44 beds that the Trust had open on the critical care unit, had enabled the Trust to cope at the time of greatest need. He said to develop the Ward from a standing start was amazing. He said many lives had been saved in the CPAP facility with the support of the wider teams and the critical care. He said the Board had heard the emotional impact of some of those patients who had not survived on staff and relatives. He contrasted the nature of the treatment on the Ward with CPAP patients remaining awake during their treatment and he did not doubt the impact of the loss of any patient in such circumstances.

Prof. Loughton apologised for problems with the ward that had been built in 9 weeks. He said the lack of a relative’s room would be resolved as would the other issues. He reiterated everything Dr Odum had said that the team had done a brilliant job under unbelievably difficult circumstances. Dr Murphy acknowledged the kind words of Dr Odum and Prof. Loughton. She said it had been a team effort and that it was important to retain the expertise developed in the respiratory unit.

Ms Rawlings thanked all the team and said all the Board were grateful for what they had done. She congratulated them on the dignity award. She asked whether they had been able to access the measures in place for staff support. Ms Murphy said staff had been allocated a buddy on the ward to enable them to share their stories, reflect on their experiences and provide support and guidance. She said staff had also accessed the sisters or matrons for help. She said they had always worked as a team and if one person was struggling they would go and help and support each other. Ms Evans said senior staff had skills in spotting signs of stress or upset. She said staff work placement was always considered in varying staff experience. She said many staff cried at work and staff had supported each other when needed.

Prof. Toner referred to the level of expertise that had been developed and the importance of retaining and using this in future. She said she recognised the experience referred to of caring for patients supported on CPAP and the requirement for psychological and emotional support especially when staff were physically and mentally drained. Ms Wilmhurst said that Linda Holland had been fantastic in facilitating support for the Team. She said psychological support sessions had been placed on the wards that had been easily accessible alongside support sessions via teams.

Prof. Loughton reflected on what was a very, very difficult year. He said he remembered the call he had received on a Sunday that he needed to be at the hospital as the Trust had the first death from Covid-19. He said the scale of death had not been envisaged and that no staff had entered their chosen profession to experience and deal with death on the scale that had been seen. He asked for a minutes silence to remember all those who had passed away, patients and colleagues alike, and on the great toll it had taken personally and professionally.

6 The Board observed a minutes silence in remembrance of those lost to Covid-19 and the experience of living through and caring for others through the pandemic. Prof. Field said recalled a call he and Prof. Loughton had with doctors from Italy and New York in December 2019 and early January 2020. He acknowledged the efforts of all involved from those designing and building the new Wards suitable for CPAP support. He felt that despite the financial risk taken, it had been the leadership and the commitment of the team at RWT that had saved lives in Wolverhampton and the Black County. He praised the skill, dedication and caring of the nurses and the doctors on the wards alongside the porters, the cleaners, the people selling the fruit, the staff shop that was created over WMI building and all of the those redeployed staff who made the numerous face protectors – it was all an incredible effort. He said it was important to remember those who had sadly passed and those who were alive because of what the Trust had achieved.

Resolved: that the Staff Voice be noted.

TB.8243: Chief Executive’s Report Prof. Field welcomed Ms Evans as Director of Communication and Stakeholder Engagement. Prof. Loughton introduced his report. He referred to his meeting with Colonel David Marshall and that he had been struck by the positive part that the military had played in supporting services in the Trust, particularly on Ward C26. He thanked them for their help. He referred to the lessons learned about the use of technology and, for example, the potential in future of remote consultations. He said it had made him realise the Trust had to change the way that it communicated with staff. He said the days of large meetings in person had to end. He had been struck by the far higher attendances at virtual meetings because of the ease of access and lack of travel involved. He said the Trust was further developing its facilities to enable such interactions in future.

Ms Edwards welcomed the new policy "safeguarding staff experiencing domestic abuse”. She felt this was a useful addition in relation to increased remote home working and she was pleased to see that the Trust had developed a policy. Prof. Loughton thanked her and the Trust had to be aware that for some people working from home may not be a safe option that had to be accommodated. Ms Martin said she was aware that Prof. Loughton attended weekly virtual meetings with Wolverhampton City Council. She said that this was important in maintaining the flow through the hospital. She asked Prof. Loughton for assurance regarding the working relationship with the Local Authority. Prof. Loughton said that working relationships were very positive with the Council and Director of Social Services, the leader of the City Council and Public Health colleagues. He said he was mindful of the stresses and strains on public health in delivering the vaccine programme.

Mr Dunshea asked Prof. Loughton for an update on the Wolverhampton Health Board Executive Steering Group. Prof. Mahmud briefly mentioned the development of the digital Wolverhampton agenda and the Trust’s relationship with the Primary Care Networks (PCNs) and the local Clinical Commissioning Groups (CCGs) that had been incredibly helpful in helping the Trust be the anchor organisation in the city. He referred to details regarding governance being finalised and that in his view RWT was in a really good place but with still much to do. Mr Evans said the Trust was working alongside 4 other organisations - the local authority, the University, Wolverhampton Homes and Wolverhampton College on a common shared purpose and the potential for working together and pooling collective resources. He outlined that the initial work was focussed on three areas – workforce, estates and procurement. He said a paper was to come to a near future Board. He also referred to an operational and outcomes framework to support The Place which linked in with work that Lucy Heath was doing with the Health Academy and the burgeoning ICS.

7 Dr Odum highlighted the consultant appointments in rheumatology, one of whom a senior clinical fellow and who had received their specialist registration through their training in the organisation that allowed them to be appointed as a Consultant. He said the Trust was seeing more and more consultants being appointed through the specialist registration careers process that sat alongside the formal training programme. Prof. Field said that was a point very well made as he had been impressed by the candidates' journeys.

Resolved: that the Chief Executive’s report be received and noted.

TB.8244: Chief Executive’s Report on Trust Management Committee (TMC) held on the 19 February 2021 Prof. Loughton introduced the report and asked that the contents be noted.

Resolved: that the Chief Executive’s report on TMC held on 19 February 2021 be received and noted.

TB.8245: Coronavirus Gold Command - Chief Executive’s Report Prof. Loughton introduced the report and asked that the contents be noted.

Resolved: that the Coronavirus Gold Command - Chief Executive’s Report was noted.

Finance and Performance

TB.8246: Chair’s Report of the Finance and Performance Committee (F&P) meeting Prof. Field pointed out the revised agenda order so as to let each Committee Chair provide their report first followed by the relevant Executive. He said this seemed to work well at the Walsall Healthcare Board and recognised and valued the work that the Non Executives in the Board Committees. Ms Martin introduced the report and that the Trust was on track to break even. She said that the changed financial regime still had some things to work through for year end. She said the Committee had increasingly focussed on 2021-2022 and the position with future cash flow for the year ahead.

She said there was still insufficient information available for ‘proper budgeting’ at present and it looked as if there would be block payments for the first 3 months. She said the Committee had noted that the waiting list was still high with 1447 people waiting over 52 weeks. She said the committee had asked what the governance arrangements were for reviewing and prioritising patients on that list. She said cancer performance was and remained challenging with work being completed looking at the future capacity and demand as the number of referrals had begun to increase.

Resolved: that the Chair’s Report of the Finance and Performance Committee be received and noted.

TB.8247: Finance and Performance Terms of Reference Ms Martin mentioned the Committee had refreshed their terms of reference which were for approval

Resolved: that the Finance and Performance Terms of Reference be approved.

8 TB.8248: Report of the Chief Financial Officer – Months 10 Mr Stringer introduced the report. He highlighted the capital position referred to in Ms Martin’s report. He said he had reported a number of risks regarding the funding of the ICCU, the Category 3 lab and the emergency Public Dividend Capital (PDC), all of which had now been resolved and that he expected to be transacted in March with an agreed CRL that funded all the agreed additional capacity opened in year. He said he was expecting a memorandum of understanding from the centre reflecting this and the Trust was relatively confident about achieving the CRL, working closely with the estates development teams to ensure that.

He spoke about the year-end revenue position for Audit Committee and the Finance Committee regarding the ways in which some things would be accounted for. He said that, for example, the Personal Protection Equipment (PPE) stock guidance was not yet received and could impact on the year end, along with annual leave accrual, as staff had unfortunately not been able to take all their annual leave in year. He said this backlog and carry-over would have to be accounted for. He said this might result in a technical deficit. Prof. Loughton congratulated Mr Stringer and Ms Martin for all their work.

Resolved: that the Month 10 Finance Reports be received and noted.

TB:8249: Audit Committee Chair's Report Mr Dunshea said the Committee had covered all the key assurances for the current year and all were on track. He echoed Mr Stringer in that there were a number of uncertainties to be clarified and resolved. He confirmed that the Internal Audit Plan was focussed on key red risks.

Resolved: that the Audit Committee Chair's Report be received and noted.

TB. 8250: Integrated Quality and Performance Report Prof. Cannaby introduced the Performance report. She highlighted the contrast between the beginning and end of January 2021. She said that in the first part the Trust had tried to maintain elective non-urgent activity as far as possible. She said it had become apparent in mid-January that the Trust needed to redeploy staff to ensure it could cover the increasing Covid-related emergency work. She said that as a result, the Trust had markedly reduced the elective work and redeployed staff from most areas into ICCU. She said the Trust was asked to double its bed base for people being cared for on a ventilator and that to achieve this, clinical staff had to be redeployed.

Prof. Cannaby highlighted the differences between the Covid ‘waves’ as in the most recent wave of the wards were full and remained full. As a result, she said the Trust needed to open additional medical beds to cope with the resulting demand. She said that performance across the Board had reduced including the emergency pathway, as processes had had to put in place to differentiate those with or without Covid, additional cleaning and the additional time required when dealing with patients with known and unknown Covid-status especially in relation to ambulance conveyances. She said the Trust cohorted patients so as to enable ambulance offloading.

Prof. Cannaby said that although ambulance attendance levels were not as high as previously, the patients being conveyed had been poorlier with a resulting increased admission rate with the process of testing, evaluating and monitoring before moves had taken more time with a deterioration in the A and E targets and flow. She said in later January and early February the Trust had concentrated on discharging patients with Local Authority and CCG partners to ensure the flow through the hospital which helped the emergency flow. She said the Trust had to pause some of its non-emergency non-elective work and that as a result some waiting times had increased.

9 Prof. Cannaby highlighted that the Trust had still done some elective operating work in the hospital and using private sector provision but at a much reduced rate as the anaesthetists, surgeons and operating were needed to staff the additional ICCU capacity. She said that more recently, clinical teams had been working to restore much of the cancer 2 week wait outpatient clinics screening. She said there had been high staff sickness where staff or family members were poorly so staff had to self-isolate. She said the combination of the emergency pathway with many very acutely sick patients and CPAP patients and with capacity in ICU doubled.

Ms Higgins referred to the quality section of the report. She highlighted that the Trust’s Caesarean Section (C-section) rate had risen in recent months with multi-faceted reasons and that the premature birth rates had doubled in January 2021. She said the same rise had been seen nationally and the Trust continued to closely monitor it. She said there were a number of transfers and high C-section rates in Covid-19 positive mothers, often due to their resulting poor physical health. She said the Trust’s birth to midwife ratio had improved to 1 to 30. She mentioned that the late observations had been improving. She referred to work ongoing to a standard operating procedure to enable improved recording against the key indicator. She said the Venous Thromboembolism (VTE) performance remained below 95% and the CQI team were supporting improvement work including use of an electronic reminder being piloted.

Ms Higgins referred to five C.difficile cases in January, with 2 of the same typing. She said the bed space decontamination unit had been reinstated and the impact was being evaluated.

Action: Prof. Field asked for a narrative about the C-section rate together with an overview of the outcome of the babies and mums with a commentary on what appeared to be triggering the early deliveries to be presented within subsequent maternity reports.

Resolved: that the Integrated Quality and Performance Report be received and noted.

TB:8251: Budget setting update for 2021/22 Mr Stringer introduced his report. He highlighted that NHSI/E, the Department of Health and the Treasury were in negotiation over the amount of money that the NHS required for 2021-2022. He outlined the significant factors in the debate including the level of funding for Covid-19 into Q1, the impact of the vaccination programme on staff and the national population. He said that the Trust would set a budget based on a roll-over of the arrangements for block top-up plus growth and inflation.

He said the Trust was continuing with its normal budget setting process with normal budget discussions on identified costs pressures, service developments with divisions and directorates and that the Trust would take that budget setting discussion into the Q1 to try and formulate the expenditure and run rate. He said the Trust would not have certainty on the income side until mid-March at which point he would set out the process and timescale in a high-level paper.

Resolved: that the Budget setting update for 2021/22 be received and noted.

10 Strategy, Business and Transformation

TB. 8252: Innovation and Research Adoption Committee - Chair's Report Mr Dunshea introduced the report and the exciting year ahead moving into the delivery of the Sensyne and Babylon schemes. He said the Committee would update the Board on progress along with the work on ‘Place’.

Resolved: that the Innovation and Research Adoption Committee - Chair's Report be received and noted.

TB. 8253: Chief Innovation, Integration and Research Officer’s Report Prof. Mahmud introduced his report highlighting the delivery in key areas including ‘Place’ through the Executive Steering Group chaired by the Prof. Loughton with the Chief Executives of Local Partners, the progress of the Integrated Care Partnership (ICP) and its initial hosting by the Trust. He said the Trust had secured some resource from the STP that would provide some management support and suitable partners were being sought. He said the NIHR was one of the best performing networks in the Country in urgent Covid 1A studies and were. He said the Trust had been renewed as host with the contract until 2024. He said the NIHR was prioritising recovery trials and recruitment was going well.

Resolved: that the Chief Innovation, Integration and Research Officer’s Report be received and noted.

TB:8254 The Institute of Health Innovation Prof. Mahmud introduced the paper that had the support of the Executive Team. He said it described bringing together the collective public and population health assets and partners with research colleagues to form a putative primary care academic unit similar to other organisations such as UHB. He said this would potentially generate ideas for evidence based transformation work with the local population and service providers.

Ms Edwards asked about the figure on page 6 of the report in relation to Governance: it looked as if the Director of Innovation would be reporting to both the Wolverhampton Health Board and the RWT Board. She asked how the demarcation between the two was going to work and felt it needed explanation. Prof. Mahmud said a paper explaining this was to follow including the details regarding governance.

Resolved: that the Institute of Health Innovation Report be received and noted.

TB:8255 The Green Plan Mr Stringer introduced the report. He said this portfolio was moving to Mr Evans who would be appointing a Head of Sustainability. He outlined the Plan’s journey to date through Board consultations and briefings. He said the Trust continued to pursue the solar farm as part of its response. Mr Evans said the Trust had advertised to recruit a Head of Sustainability that had generated international interest. He said he believed that the Trust was the only one in the Black Country with a Green Plan.

Resolved: that the Green Plan be approved.

11 People and Engagement

TB. 8256: Executive Summary Workforce Report Mr Duffell said that the Covid-19 staff vaccination position was changing daily. He summarised the three routes available to staff at RWT in the hospital hub, at Walsall as a hospital hub or via a PCN hub for community based staff. He said to date 68% of the Trust’s staff had been vaccinated along with some clinically vulnerable patients, contractors on site such as the security team and some social care staff.

He said in total the RWT hospital hub had vaccinated over 8600 since it commenced. He said that nationally was there was a move away from hospital hubs to primary care and larger community vaccination centres. He said the RWT hospital hub had started use of the AstraZeneca vaccine that was easier to store and for longer periods. He said 150 staff member had booked for their vaccination in the week ahead. He said the Trust had one dose but he did not know when the Trust would be receiving the next batch. He said many staff would be due for their second dose in 2 to 3 weeks’ time. He said the Trust was now in conversations with those who reused or were reluctant to have the vaccine.

Mr Duffell thanked Mr Dunshea for volunteering to be the Trust Well Being Guardian. He said the Workforce Organisational Development Committee (WODC) was soon to become the People Organisational Development Committee (PODC) with his role as an agenda item. He said the Trust staff retention rate remained high with expected turnover. He said included within the report was a national review of a future of what Human Resource (HR) and Organisational Development (OD) functions might look like. He said the recent recruiting campaigns increasing Trust bank staff had been successful.

Ms Edwards said this was positive and asked about the page 19 reference to “Consultant Job Plan Progress trend”. She said she was aware that the Trust was going to reset everything for a clean start. She said that previously she had asked for a breakdown of job plans and a narrative as to why people were having difficulties in achieving agreement. She asked if there were pockets of people who had greater difficulty discussing and progressing their job plans. She said this would be important for the new round in terms of focus and action.

Action: Mr Duffell to provide the data on job planning with a narrative of key areas and reasons for future focus.

Resolved: that the Executive Summary Workforce Report be received and noted.

Patient Safety, Quality and Experience

TB.8257: Learning from Deaths update Dr Odum introduced the report and a further reduction in the Summary Hospital-level Mortality Indicator (SHMI) 1.018. He said the crude mortality rate in January 2021 was not significantly higher given the number of deaths related to Covid-19 that had increased the crude mortality rate to 6.7%, higher than previously but in line with the national trend. He said Mr Dunshea had asked how that impacted upon the SHMI. He said that any diagnosis of death with Covid-19 within its diagnostic coding was currently excluded from the SHMI figure. He said he did not know how Covid-19 related death was ultimately going to be accounted for in relation to the SHMI at this moment in time.

Resolved: that the Learning from Deaths Report be received and noted.

12 Governance, Risk and Regulatory

TB.8258: Quality Governance Assurance Committee (QGAC) – Chair’s Report Ms Edwards introduced the report. She said cancer was discussed at the meeting and the Board had already heard about the problems and pressures. She said it was hoped that the Trust be able to secure some support from the other Trusts in the Black Country as it had in 2019 when there was similar problems. She said Ms Martin had already mentioned in her report the impact of Covid on the waiting list and there was an update on the improvement. She said Covid patient numbers were reducing with a positive impact on ICCU and CPAP so the demand and capacity project was underway developing a recovery plan to reduce the back logs for discussion at QGAC in March. She said the Committee had asked to look further into the potential harm and prioritisation of waiting patients from a quality perspective. She said the governance related to assurance of a transparent and fair process addressing any anxiety for patients regarding how this was done.

Ms Edwards spoke about the review of the proposed revised reporting of the Trust Risk Register (TRR) and Board Assurance Framework (BAF) to future public Board meetings in the format of a ‘heat map’. She said the Committee had reviewed and been impressed by the draft with final revisions underway and she looked forward to that being received for the first time at the next Board meeting. She said the Committee hoped it would make the overview more accessible than the one previously used and promote ‘good housekeeping’ of the Register and Framework in future. She said the Board had heard about the excellent cooperation between the Trust and other Services, whilst regarding Cancer performance a recovery plan was being formulated. She said the Committee thought that there were some good signs of things being managed well especially in relation to the difficult issues in the Emergency Department (ED) in how to achieve improved processes and pathways.

Resolved: that the QGAC Chair’s report be received and noted.

TB.8259: Chief Nursing Officer’s Nursing Report Ms Higgins highlighted the new style of report and the use of trend data with actions and analysis completed by the clinical leads. She said future reports would move to use Statistical Process Control (SPC) data charts for key indicators. She noted that recruitment was positive with vacancies for registered and unregistered nurses down to 9.3%. She said the recruitment campaign for unregistered staff continued. She said some of the additional capacity in medicine had now closed and that nursing sickness that was at 9.1% in January was now down to 6.29%. She said that falls and pressure ulcers had increased in month but not at the rates that were seen in the first wave. She said the Trust was conducting a themed analysis of incidents and introducing a new falls risk assessment together with a new pressure ulcer risk assessment during March that it was believed would further drive improvements.

Resolved: that the Chief Nursing Officer’s Nursing Report be noted.

TB.8260: Nursing System Framework (NSF) Milestone update and Annual Report 2020 Ms Higgins introduced the report against the previous Nursing System Framework. She said it detailed the successes in recruitment, staff culture, staff retention, training and education and patient satisfaction. She outlined that the new Framework was moving from a nursing systems framework to a clinical systems framework including Allied Health Professional (AHP) colleagues.

Prof. Cannaby said that the nursing staff had done remarkably well against the framework and that it was time to set new ambitions. She said the AHP’s were asked to join in a wider approach this time.

13 Mr Dunshea welcomed the inclusion of the Allied Health Professionals that he felt was a major step forward in light of Covid and shared work practices. He asked why Medical Staff were not part of this as part of the move to place based care and primary care. He asked how well the framework could support that process.

Ms Higgins said she was keen for the Trust to move toward a multi-professional framework over time. She said that primary care was involved within the development of the framework and there were some specific community aspects. She said the Trust would be working with colleagues across the system. Prof. Cannaby said there was much that was generic in nature and the plan could be applied flexibly depending on the setting including community nursing teams and community-based AHP’s. Prof. Mahmud said that multi professional co-operation was at the heart of future delivery development. He commended the approach as part of the ambition to move the Trust from good to outstanding. Prof. Cannaby said the draft was awaiting some data as it was underpinned by a tool kit, the implementation of which could form a research project.

Dr Odum mentioned the level of heightened degree attainment across the nursing workforce including first degrees, Masters and PHD’s and he asked what the future levels of attainment would look like. Prof. Cannaby said that the Clinical Fellowship Programme had enabled many nurses to either do top-up degrees or masters programmes. She said the space for staff to do this work was important for educational personal and analytical benefits. She said all were really important to nursing. She said that staff achieving something for themselves was assisting in staff retention.

Ms Higgins said when walking around wards it was positive to hear how many staff were undertaking masters or degree level study. She said a lot of staff members were coming forward and asking whether they could use quality improvement learning and involvement as part of their qualifications submissions. Prof. Toner said there were number of courses available with a pre-masters programme. She said the fact that the Trust supported the whole master’s programme was great.

Action; Prof. Field asked for this to be the focus of a future Briefing or Development Session. . Mr Wilshere to add to the Briefing or Development sessions programme.

Resolved: that the Nursing System Framework (NSF) Milestone update and Annual Report 2020 report be received and noted

TB.8261: Clinical Ethics Committee – Chairs Report Prof. Toner introduced the report and highlighted the recently formed Black Country and West Birmingham Systems Ethics Forum that aimed to consider clinical ethics from a wider population perspective. She confirmed that Dr Odum represented the Trust. She outlined the recent discussions of a number of documents from the Forum at the Trust Clinical Ethics Committee (CEC) - a decision making framework based on national guidance with the CEC views presented back to the Forum, a paper regarding the implications of staff not taking up to C-19 vaccine that concluded that it was in the best interests of staff and patients for staff to have the vaccine as part of the expectation of being safe to work. She said it was discussed as to whether this could be added to employment contracts. She said the potential of vaccine passports could potentially increase uptake. Prof. Loughton said that any contractual requirement would be dealt with at a national level and that the Trust had made representation. He reiterated that at this stage the Trust had to be very focused on encouraging its staff to have the vaccine. Prof. Field said the positive thing about having an ethics committee was there should be this type of debate and discussion.

Resolved: that the Clinical Ethics Committee Chair’s report be noted.

14 TB.8262: Finance and Performance minutes Wednesday 20th January 2021, TMC Minutes 22 January 2021, Audit Committee Minutes 8 December 2020

Resolved: Finance and Performance minutes Wednesday 20th January 2021, TMC Minutes 22 January 2021, and Audit Committee Minutes 8 December 2020 be noted.

TB.8263: Questions from the public Prof. Field confirmed that no questions had been raised. Mr Wilshere confirmed there had been no questions posted and that if anyone observing had questions after the meeting to email them to the Trust Board email address on the Trust website and he would respond.

TB.8264: Date and time of next meeting: Prof. Field said the next meeting was to take place on Tuesday 6 April 2021 via MS Teams.

TB.8265: To consider passing a resolution that representatives of the press and other members of the public be excluded from the remainder of this meeting, having regard to the confidential nature of the business about to be transacted, publicity on which would be prejudicial to the public interest.

Resolved; so to do. The meeting closed at 12:23 pm

15 3 Matters arising and Board Action Points from the minutes of the meeting of the Board of Directors held on 2 March 2021 1 3_TB Board_Action_Point 6 April 2021 docx (1).docx

The Royal Wolverhampton NHS Trust Trust Board Report Meeting Date: 6 April 2021 Title: Board Action Points Executive Summary: This report lists the outstanding actions from previous Board meetings, and timescales for completion. Action Requested: To note the actions taken, or still outstanding. Report of: Chief Executive Author: Keith Wilshere Contact Details: Tel 01902 694294 [email protected] Links to Trust N/A Strategic Objectives Resource None identified Implications: Risks: BAF/ TRR None identified (describe risk and current risk score) Public or Private: Public (with reasons if private) References: Minutes of previous Board meetings (eg from/to other committees) Appendices/ None References/Reading NHS Constitution: In determining this matter, the Board should have regard to the Core (How it impacts on any principles contained in the Constitution of: decision-making) Equality of treatment and access to services High standards of excellence and professionalism Service user preferences Cross community working Best Value Accountability through local influence and scrutiny

Recommendation The Board is recommended to note the Action Points listed below 1 Public Actions v 1 300321.docx

List of action items Agenda item Assigned to Deadline Status

Public Trust Board 02/03/2021 9.1 Executive Summary Workforce Report

89. Job Planning Duffell, Alan 06/04/2021 Pending

Explanation action item Mr Duffell to provide the data on job planning with a narrative of key areas and reasons for future focus.

Public Trust Board 02/03/2021 7.5 Integrated Quality and Performance Report

88. C-sections Higgins, Yvonne 16/03/2021 Completed

Explanation action item Prof. Field asked for a narrative about the C-section rate together with an overview of the outcome of the babies and mums with a commentary on what appeared to be triggering the early deliveries.

Explanation Higgins, Yvonne Response had been sent and further questions or clarification sort

Public Trust Board 02/03/2021 4 Patient Story - Michelle Cole, Kate Lees, Alison Dowling

84. Patient Story Higgins, Yvonne 06/04/2021 Completed Wilshere, Keith

Explanation action item Prof. Field asked Ms Cole and Ms Lees to forward details of the treatment trial to the Company Secretary, Mr Wilshere, who would then forward it to the all the Board members.

Explanation Higgins, Yvonne Response sent to K.Wilshire who had forwarded to NEDS

Explanation Wilshere, Keith Information provided to Non-executive Directors with additional information sought and provided by specialist.

87. BDS for Cancer Performance Wilshere, Keith 06/04/2021 Completed

Explanation action item In response to a request from Prof. Field, Ms Nuttall confirmed that there was a Non-Executive Briefing arranged on Cancer Performance and recovery across all tumour site areas

Explanation Wilshere, Keith Changes in cancer management during Covid, recovery – surgery and diagnostics, plans for networks (GN/Ray Matthew) scheduled for May 2021 Board Development Session

Public Trust Board 02/03/2021 11.3 Nursing System Framework (NSF) Milestone update and Annual Report 2020

85. Nursing System Framework (NSF) Milestone update Wilshere, Keith 06/04/2021 Completed and Annual Report 2020

Explanation action item To be added to as an agenda item for discussion at a Board Development Session

Explanation Wilshere, Keith Nursing/Clinical Systems Framework Report/Progress Update (YH) scheduled for August 2021 Board Development Session.

Public Trust Board 02/03/2021 3.1 Ockenden report – RWT Gap Analysis and Action Plan - Stacey Thacker, Steve Phipps

83. Ockenden Report Cannaby, Ann-Marie 06/04/2021 Completed Palmer, Tracy Explanation action item To be brought to the next Board in April to be discussed under matters rising

Explanation Palmer, Tracy Ockenden action plan and gap analysis will be presented at April Trust Board 3.2 NHS National Staff Survey Results 1 TB_2020 NHS Staff Results_March 21.docx

Trust Board Report Meeting Date: 6th April 2021 Title: 2020 NHS National Staff Survey Results Action Requested: To Note. For the attention of the Board Staff Engagement levels have remained consistent over the last three years (RWT score = 7.2; this is higher than the national average of 7.0). There has been a further increase in advocacy rates (Staff FFT questions):  Place to Work (75.5%)  Place for Care/Treatment (80.4%). Assure There were improvements in two of the theme areas, which have been reported as statistically significant:  Health and Wellbeing  Morale The key national message in relation to the 2020 survey was that the focus for the survey this year is very much on understanding the different experience of staff and learning from that experience, rather than on performance management or comparisons against other organisations, who may have had very different experiences of the Covid-19 pandemic.

The Median response rate across the 2020 benchmarking group (Acute and Advise Acute & Community Trusts) was 45%. The response rate for RWT is 34% (3,291 out of 9,770 staff responded to the survey); it should be noted that within RWT we ran the survey on a full census basis again whereby all ‘eligible’ staff in the Trust were invited to participate in the survey. Nationally, there has been a mixed approach in that many organisations will have run the survey on a sample of the workforce (ca. 10%). The summary benchmark report for the Trust is included in Attachment 1. Conversely, the Team Working theme is reported as statistically significantly lower for 2020. Alert Areas for suggested focus this year for Divisions have been indicated in the attached RAG rating - Appendix 1. Author + Contact Daniela Locke, Head of Workforce and Organisational Development Details: Tel 01902 695438 Email [email protected] Links to Trust Strategic 4. Attract, retain and develop our staff, and improve employee engagement Objectives Resource None Implications: CQC Domains Well-led Public or Private: Public Other formal People and Organisational Development Committee bodies involved: NHS In determining this matter, the Board should have regard to the Core principles contained in Constitution: the Constitution of:  Equality of treatment and access to services  High standards of excellence and professionalism  Service user preferences  Cross community working  Best Value  Accountability through local influence and scrutiny Trust Board Report 6th April 2021 2020 NHS National Staff Survey Results

Introduction

The 2020 NHS Staff Survey ran from mid-September to end of November 2020. Since reporting the early analysis to TMC in February, the confirmed benchmark reports have now been published on the NHS England website (11th March 2021).

The median response rate across the 2020 benchmarking group (Acute and Acute & Community Trusts) is 45%. The response rate for the Trust was 34% (a reduction from 37% in 2019); in terms of number of respondents to the survey this equates to 3,291 staff. It should be noted that within RWT we ran the survey on a full census basis again whereby all ‘eligible’ staff in the Trust were invited to participate in the survey. Nationally, there has been a mixed approach in that many organisations will have run the survey on a sample of the workforce (ca. 10%).

Of note is that the personal development section was replaced with a section focussing on working through the COVID-19 pandemic; with questions about staff experience during this pandemic, including working on Covid-19 specific wards or areas, redeployment, remote working, shielding and two qualitative questions about lessons learnt and what worked well during Covid-19.

Survey Results

There has been a further and notable increase in both the Trust recommender rates: Place to Work (75.5%), and Place for Care/Treatment (80.4%).

The extract table below shows a comparison between 2019 and 2020 results for each of the 10 survey themes. Themes are on a 0-10 point scale, where 10 is the best score attainable. Please note that the ‘Appraisals’ theme was removed due to the focus on the COVID-19 as highlighted in the Introduction section above.

There were improvements in two of the themed areas, which have been reported as statistically significant; these are Health and Wellbeing and Morale.

Conversely, the Team Working theme is reported as statistically significantly lower for 2020. It should also be noted that there has been a decline in the scores for Equality, Diversity and Inclusion and for Staff Engagement (- 0.1), however these have not been regarded as a statistically significant change.

Daniela Locke – TB 06.04.21 Page 2 of 6 Staff Engagement

The graph below provides a comparison for each year from 2014 to 2020 and against the best, average and worst scores for the benchmark group. Of positive note is that Staff engagement levels within RWT have remained fairly consistent over the last three years.

Staff Engagement 2014-2020 8

7.5

7 RWT

6.5 Best Average 6 Worst

5.5

5 2014 2015 2016 2017 2018 2019 2020

The Staff Engagement Theme is measured through the following categories and questions:

1. Motivation

Statement RWT 2020 RWT 2019 Average 2020 Best 2020 % % % % I look forward to going to work 62.5 62.7 58.5 67.8 I am enthusiastic about my job 74.3 76.3 73.1 79.7 Time passes quickly when I am 76.1 77.2 76.0 81.1 working

2. Ability to contribute to improvements

Statement RWT 2020 RWT 2019 Average 2020 Best 2020 % % % % There are frequent opportunities 73.1 73.8 71.9 78.1 for me to show initiative in my role I am able to make suggestions to 73.1 75.0 73.0 81.7 improve the work of my team / department I am able to make improvements 56.6 57.9 55.4 63.5 happen in my area of work

3. Recommendation of the organisation as a place to work/receive treatment

Statement RWT 2020 RWT 2019 Average 2020 Best 2020 % % % % Care of patients / service users is 82.9 83.3 79.4 90.7 my organisation’s top priority I would recommend my 75.5 72.3 66.9 84.0 organisation as a place to work If a friend or relative needed 80.4 78.2 74.3 91.7 treatment I would be happy with the standard of care provided by this organisation

Daniela Locke – TB 06.04.21 Page 3 of 6 Whilst the overall staff engagement theme score has remained fairly steady, it should be noted that there has been a decline compared to 2019 in the % of respondents agreeing with the statements within the first two theme sub-sections (Motivation and Ability to contribute to improvements) and the first statement in table 3. However, RWT compares favourably against the average comparator benchmark group.

The COVID-19 Pandemic

This year’s survey results include reporting the theme results by Covid-19 classification breakdown. This section, whilst providing information in terms of proportion of staff (who have participated in this survey) responding to yes or no, should not be taken in isolation to the rest of the report. The four questions in this section are:

a. Have you worked on a Covid-19 specific ward or area at any time? b. Have you been redeployed due to the Covid-19 pandemic at any time? c. Have you been required to work remotely/from home due to the Covid-19 pandemic? d. Have you been shielding? (for self or for a member of household)

The copy of the staff engagement chart shows that there were slightly higher levels of engagement recorded by staff required to work remotely and shielding staff. (9% of respondents were shielding, 34% working on Covid wards and 19% redeployed due to pandemic during the 8 month period in 2020.)

Parental/Caring Responsibilities

There were two new questions in the ‘Background information’ section about Parental/caring responsibilities:

 39% confirmed that they have caring responsibilities for children up to the age of 17.  35% confirmed that they look after, or give support to family members, friends, neighbours or others because of either: long-term physical or mental ill health/disability, or problems related to old age.

Daniela Locke – TB 06.04.21 Page 4 of 6 Divisional Results

The tables included in Appendix 1 and 2 display the divisional and directorate group results by theme with a RAG rating and highlight in particular where scores fall below the national average and RWT scores.

The theme that particularly stands out across all Divisions, except for Corporate services, is Team Working.

Across the Divisions, the three Divisions with the most areas marked as red are BCPS (apart from Safe Environment), Division 2 (E,D&I, Safe Environment and Team Working), then Division 3 (Safe Environment – Bullying & Harassment, Staff Engagement and Team Working) and Estates & Facilities (Safety Culture and Team Working). Division 3 has the most number of themes marked as Amber.

Conclusion/Next Steps

 Trust Board members are asked to note and consider the contents of this report.

 Results and Trust level plans will also be reported to the following groups and committees: Equality, Diversity and Inclusion Steering Group, People and Organisational Development Committee.

 The Staff Survey Oversight Group is to recommence in April to agree responses and actions.

* * * * * *

Daniela Locke – TB 06.04.21 Page 5 of 6 Appendix 1 – Key Themes by Division

Key Themes for RWT 2020 by Division

Worse than national and worse than RWT Worse than national and better / same as than RWT Better than / same as national and worse than RWT Better than / same as national and RWT

r e e g e

r p 8 7 r

v 0 e 9 1 2 3 s s o 1 1 o

& t A a 2 1

c e

c 0 0 e n n n a i l e s 0 S s 0 r s r 2 2

t

o o o a a e 2 m i 2 P

t i i i t

o

l t e T T d n s s s s i C Themes s T h T i i i p e a c e o r H H T e r B t

v v v i f a i i i h s t W W o o w F

W W g E a . D D D R C R i o R R o N L H N

% % % 3,291 3381 3141 3275

Responses 5 8 0 45% 50% 39% 26% 26% 37% 4 2 8 (34%) (37%) (38%) (40%) Equality, Diversity and Inclusion 9.2 8.3 9.6 9.1 9.2 9.1 9.1 9.1 9.5 9.4 9.1 8.9 9.1 1

Health & Wellbeing 6 5.2 6.7 6.4 6.2 6.1 6.1 5.9 7 7.2 6.1 6.3 6.1 1

Immediate Managers 6.9 6.5 7.5 7 7 6.9 6.8 6.1 7.7 6.7 7 7 7 2

Morale 6.2 5.7 6.8 6.5 6.4 6.3 N/A 5.6 6.8 6.8 6.6 6.6 6.3 1

Quality of Care 7.5 7.1 8 7.8 7.8 7.6 7.7 7.4 7.7 7.6 7.8 7.9 7.6 1 Safe Environment - Bullying & 8.2 7.5 8.6 8.2 8.3 8.2 8.2 8.8 9.1 9 7.9 7.8 8 3 Harrassment Safe Environment - Violence 9.5 9.3 9.7 9.6 9.6 9.5 9.5 9.9 9.9 9.7 9.5 9.2 9.6 1

Safety Culture 6.8 6.2 7.4 6.9 6.9 6.8 6.6 6.6 7.1 6.6 7 6.8 6.9 2

Staff Engagement 7.1 6.5 7.6 7.2 7.2 7.2 7.1 6.5 7.5 7.1 7.2 7.3 7 2

Team Working 6.7 6.2 7.3 6.6 6.7 6.6 6.6 6.2 7.3 6.1 6.5 6.3 6.5 5

No. of Themes worse than the national average & 19 worse than RWT 7 0 3 2 4 3 3.3 Memorandum of Understanding with Walsall Healthcare NHS Trust 1 MOU Between RWT and WHT TB Mar 2021.pdf

Trust Board Report Meeting Date: 2 March 2021 Title: Memorandum of Understanding (MOU) between The Royal Wolverhampton NHS Trust and Walsall Healthcare NHS Trust

Action Requested: Approval

For the attention of the Board • This Memorandum sets out the principles on which the Strategic Collaboration Assure between the two Trusts will be taken forward Advise • The MOU does not have legal force Alert • None Author + Contact [email protected] and [email protected] Details: Links to Trust 1. Create a culture of compassion, safety and quality Strategic 2. Proactively seek opportunities to develop our services 3. To have an effective and well integrated local health and care system that operates efficiently Objectives 4. Attract, retain and develop our staff, and improve employee engagement 5. Maintain financial health – Appropriate investment in patient services 6. Be in the top 25% of all key performance indicators Resource None at this stage Implications:

Report Data Caveats CQC Domains Safe: Effective: Caring: Responsive: Well-led: Equality and None identified Diversity Impact Risks: BAF/ TRR Risk: Appetite Public or Private: Public Other formal Walsall Healthcare HS Trust bodies involved: References NHS Constitution: In determining this matter, the Board should have regard to the Core principles contained in the Constitution of: • Equality of treatment and access to services • High standards of excellence and professionalism • Service user preferences • Cross community working • Best Value • Accountability through local influence and scrutiny

Brief/Executive Report Details Brief/Executive Summary Title: Memorandum of Understanding (MOU) between The Royal Wolverhampton NHS Trust and Walsall Healthcare NHS Trust Item/paragraph This Memorandum sets out the principles on which the Strategic Collaboration 1.0 between the two Trusts will be taken forward. It builds on the previously approved Strategic Collaboration proposal and sets out how the collaboration will be governed.

The duration of the MOU is for 12 months and is expected to be reviewed and renewed

Memorandum of Understanding

1. The Agreement

1.1 The purpose of this agreement (herein referred to as the ‘MoU’) is to set out the proposed joint approach that Royal Wolverhampton NHS Trust (‘RWT’), and Walsall Healthcare NHS Trust (WHT) have agreed to in respect of a strategic collaboration

1.2 The aim of the strategic collaboration between RWT and WHT is to significantly improve the quality of care for the populations we serve, standardise clinical best practice and provide a safe, skilled and sustainable workforce.

1.3 The Parties acknowledge that this MoU is not legally binding. It provides a framework that will underpin the strategic collaboration.

1.4 This MoU reflects the Strategic Collaboration arrangements which both Trust Boards formally approved at their respective public Board meetings in December 2020.

1.5 This MoU does not aim to change organisational form or undermine the sovereign obligations of each respective Trust; or replace (either in full or in part) any existing contractual arrangements.

2. Term

2.1 This MoU will be effective from 1 March 2021

2.2 The MoU will terminate on 28 February 2022

3. Background

3.1 The shared ambition across the Black Country and West Birmingham system, ultimately, is to deepen Trust collaboration on and between acute services.

3.2 The strategic collaboration between RWT and WHT is a precursor to the view of both Trust Boards with regard to the formation of a Group structure across the four Black Country acute hospital Trusts.

4. Principles of the Collaboration

The Parties agree that the following ‘high level’ principles will form the basis of this MoU:

4.1 Improve access to safe high-quality care for all services users across our respective health economies and shared areas of clinical co-operation

4.2 Deliver improved outcomes for all patients - minimising unwarranted variation and reducing inequity in access and outcomes

4.3 Ensure Executive leadership in each “place” with clarity of accountability to minimise the risk of destabilising each Trust

4.4 Support and encourage our staff to make best use of shared professional development and research opportunities

4.5 Combine our employer power to benefit employment opportunities in our local economies as anchor institutions

4.6 Standardised quality and corporate governance processes in line with best practice and minimise bureaucracy, such as additional structures and meetings

4.7 Be sensitive to local needs and differences to ensure the populations we serve are at the heart of our decision making

4.8 Agree mutually beneficial areas to plan, agree and deliver change across our Trusts

4.9 The parties already work closely together in a number of clinical areas and will develop a separate agreement(s) where appropriate, in respect further areas and specialties / services for future development and collaboration. in respect of further areas of future service development and collaboration.

5. Governance

5.1 Each Trust will remain as sovereign organisations, in line with the National Health Service Act 20061 and each Trust Establishment Order 2,3

5.2 The parties recognise that Non-Executive Directors may be appointed by the Secretary of State (through NHSEI) on a joint basis between the parties, in accordance with law.

5.3 The parties agree that the Remuneration Committees of the parties shall appoint Chief Executive Officer or Officers in line with The National Health Service Trusts (Membership and Procedure) Regulations 1990 s174

5.4 The parties agree that the Remuneration Committees of the parties may, on a case- by-case basis, agree to appoint an individual to an Executive Director role on a joint basis between the parties5. The parties shall agree the various financial and other consequential matters in respect of each such joint appointment.

5.5 The parties agree that where employees from either party are required to undertake regular or ad-hoc work on behalf of the other party, an honorary contract will be established. Issuing an Honorary Contract does not imply the creation of an employer/employee relationship and is for the purpose of granting licence to an individual to conduct certain activities, access to necessary information and use certain Trust facilities. The respective confidentiality of both organisations will be preserved and respected.

5.6 Any information made available to holders of Honorary Contracts are expected to treat the information in confidence and to maintain the integrity of the sovereign body. Any information gained under these arrangements will not be shared outside of the two Trusts without prior explicit written consent from the originating organisation.

1 2006 c.41 2 The Royal Wolverhampton Hospitals National Health Service Trust (Establishment) Amendment Order 2012 3 The Walsall Hospitals National Health Service Trust (Establishment) Amendment Order 2011 4 https://www.legislation.gov.uk/uksi/1990/2024/part/III/made 5 The National Health Service Trusts (Membership and Procedure) Regulations 1990 (s18)

2

5.7 The joint Chair will ensure complementarity of strategic direction of both organisations, ensuring the approval of a common approach and under pinning plan for closer collaboration.

5.8 The joint Chair will hold each Chief Executive Officer to account for the progress of delivery against the collaboration plan.

6. Termination

6.1 It is unlikely that this overarching MoU will require termination, but if at any time either Trust does wish to end the MoU then it can be terminated with 1 month written notice.

6.2 For individual service collaborations, the termination arrangements will be determined by the specific arrangements between the Trusts in each case.

7. Review

8.1 This MoU will be refreshed annually by agreement by the respective Boards.

3

3.4 Trust Board and Trust Board Committee Governance – Withdrawal of Interim Arrangements 1 0_1_Trust_Board_Front_Sheet_Covid Governance April 2021.docx

Trust Board Report Meeting Date: 6th April 2021 Title: Trust Board and Trust Board Committee Governance – Withdrawal of Interim Arrangements Action Approval Requested: For the attention of the Board  The interim arrangements during Covid-19 3rd Wave were agreed and have been in operation from 11th January 2021.  Covid-19 admission rates have reduced along with Covid-related Assure operational pressures to a point where the Interim Arrangements are no longer required.  When agreed, it was in the knowledge that the Interim Arrangements would be subject to regular review.  The Trust Board and Committees of the Board will return to their pre-Interim arrangements.  The Trust Board and Board Committees will remain on-line and virtual until such time as regular access to the New Cross Site is restored. Covid-19 requirements will be observed at all times where Board or Advise  Committee members are together – socially distanced, wearing masks at all times when with others and in public areas and observing all hand washing and sanitising requirements.  The Board and Board Committees will resume meeting in person as soon as it is judged safe and appropriate to do so.  The Board and Board Committees will resume their range of reporting, assurance and depth of scrutiny in meetings as previously.  The Board will monitor any issues in the recovery period bearing in mind the impact on all staff of the pandemic and aftermath. Alert  The Board will allow for flexible approaches to be taken where capacity and staffing issues remain.  The Board will consider and outline arrangements for the acceptable continued use of flexible and remote attendance arrangements at Board and Board Committees in line with the Trust approach to flexible working. Author + Contact Tel 01902 694294 Email [email protected] Details: Links to Trust 1. Create a culture of compassion, safety and quality Strategic Objectives Resource None Implications: CQC Domains Safe: Effective: Caring: Responsive: Well-led: Equality and The use of continued remote attendances potentially extend access to and the Diversity Impact option to attend to a wider range of people. Risks: BAF/ TRR BAF Risk SR14 Covid-19 Public or Private: Public NHS In determining this matter, the Board should have regard to the Core principles Constitution: contained in the Constitution of:  Equality of treatment and access to services  High standards of excellence and professionalism  Service user preferences  Cross community working  Best Value  Accountability through local influence and scrutiny 1 Post Covid Wave 3 2021 Trust Board and Trust Board Committee Governance final v1.4 31.03.21 SF DL KW.docx Trust Board and Trust Board Committee Governance – Withdrawal of Interim Arrangements Report (from 11th January 2021 to 6th April 2021)

1 SUMMARY

1.1 Introduction With the recent Government Road-map to restoration, the reduction in the hospitalisation of Covid-19 cases and the gradual easing of the national lockdown means the Trust Board is in a position to review whether the Interim Arrangements introduced from 11/01/21 are still required.

1.2 Trust Board It is proposed that the Trust Board resume its former length and scrutiny including scheduled quarterly, half yearly and annual reports. The cycle of business will be used in full.

1.3 Board Committees It is proposed that Board committees resume former reporting, timings and levels of scrutiny and that each cycle of business is implemented in full.

1.4 Reporting & Attendance options – capacity post-Covid, flexible working, accessibility and carbon reduction (*depending on Committee) It is proposed that the Trust Board approved a continued flexible approach to reporting where capacity and staffing issues remain.

It is proposed that the Trust Board and Board Committees will remain on-line and virtual until such time as regular access to the New Cross Site is restored. Covid-19 requirements will be observed at all times where Board or Committee members are together – socially distanced, wearing masks at all times when with others and in public areas and observing all hand washing and sanitising requirements.

The Board and Board Committees will resume meeting in person as soon as it is judged safe and appropriate to do so. It is proposed that the Board outline and approve arrangements for the acceptable continued use of flexible and remote attendance arrangements at Board and Board Committees in line with the Trust approach to flexible working.

This will potentially improve accessibility for some, be in line with the Trust approach to flexible working, and prevent or reduce additional travel for some.

Such hybrid working arrangements will be subject to further detailed description and operational requirements and restrictions.

Keith Wilshere Prof. Steve Field Prof. David Loughton Trust Company Secretary Chairman CEO

6th April 2021 6.1 Chief Executive's Report 1 TB CEO Report to Board 6 April 2021.doc

Trust Board Report Meeting Date: 6 April 2021

Title: Chief Executive’s Report

Action Receive and note Requested: For the attention of the Board Assure  Assurance relating to the appropriate activity of the Chief Executive Officer. Advise  None in this report. Alert  None in this report. Author + Tel 01902 695950 Email [email protected] Contact Details: Links to Trust 1. Create a culture of compassion, safety and quality Strategic 2. Proactively seek opportunities to develop our services 3. To have an effective and well integrated local health and care system that operates efficiently Objectives 4. Attract, retain and develop our staff, and improve employee engagement 5. Maintain financial health – Appropriate investment to patient services 6. Be in the top 25% of all key performance indicators Resource None Implications: CQC Domains Responsive: Well-led: Equality and None in this report. Diversity Impact Risks: BAF/ TRR None in this report. Public or Public Private: Other formal As detailed in the report. bodies involved: NHS In determining this matter, the Board should have regard to the Core principles Constitution: contained in the Constitution of:  Equality of treatment and access to services  High standards of excellence and professionalism  Service user preferences  Cross community working  Best Value  Accountability through local influence and scrutiny Chief Executive Report to Board 1.0 Review This report indicates my involvement in local, regional and national meetings of significance and interest to the Board.

2.0 Consultants There has been four Consultant Appointments since I last reported:

Trauma and Orthopaedics Dr Dip Chakrabati

Respiratory Dr Alison Stockbridge

Hepatology Dr Sarah Townsend

3.0 Policies and Strategies  Policies, Procedures, Guidelines and Strategies update  IP06 - Prevention and Control of Clostridium Difficile Diarrhoea Policy  OP110 - PREVENT Policy  CP58 - Prevention and Treatment of Venous Thromboembolism Policy  Consultation and Negotiation Arrangements in Partnership Framework  Job Planning Procedure  New - Guideline for the management of In-patients with Parkinson's Disease

4.0 Visits and Events  Since the last Board meeting I have undertaken a range of duties, meetings and contacts locally and nationally including:  Since Monday 27 March 2020 I have participated in the following virtual calls:  Since Friday 27 March 2020 I have participated in weekly calls with Chief Executives, led by Dale Bywater, Regional Director – Midlands – NHS Improvement/ England  Since Friday 27 March 2020 I put into action Gold Command – Coronavirus which virtually meets as required  Since 24 April 2020 I have held monthly with the Chair, Vice Chair and Scrutiny Officer of the Health Scrutiny Panel Committee meetings virtually  Since Monday 3 August 2020 I have participated in weekly calls with the Black Country and West Birmingham Strategic Transformation Partnership (STP) on the co-ordination of a collective Birmingham and the Black Country restoration and recovery plan and COVID-19 regional update  Since 9 October 2020 I have participated in daily STP Gold Command – Coronavirus meetings  Since 6 August 2020 I have participated in bi-weekly Cancer Strategy Rapid Review – Executive Reference Group meetings virtually  Since 4 January 2021 – held weekly virtual meeting with Wolverhampton City Council on discharge planning for patients  19 February 2021 – participated in the virtual Senior Medical Committee meeting  23 February 2021 – undertook a Non-Executive Directors virtual briefing and undertook the filming for the Staff Exceeding Expectation Awards– I announced the following awards: Trudi Law - Partnering Families Team Practitioner, Hayley Powis - Healthcare Assistant on the COVID Virtual Ward and COVID-19 Pandemic Study ISARIC Team  24 February 2021 – undertook a live interview with BBC Radio Wolverhampton  25 February 2021 – chaired in the Trust’s Senior Leaders Forum and participated in the virtual STP Healthier Future Partnership Board  26 February 2021 – participated in the Getting Right First Time (GIRFT) webinar - Guidance for improving the management of adult COVID-19 patients and participated in the Regional Cancer Board meeting

Page 2 of 3  1 March 2021 – participated in the STP Development session on Equality and Diversity  2 March 2021 – held a virtual Board to Board meeting with the Black Country Partnership Trust Board  3 March 2021 - participated in the Strategic Transformation and Recovery (STaR) NHS Improvement Board meeting  4 March 2021 – participated in the West Midlands Combined Authority (WMCA) Health of the Region – Black, Asian and Minority Ethnic (BAME) roundtable discussion, undertook an interview with Free Radio and held a virtual support meeting with Compton Hospice  5 March 2021 – undertook an interview with the Express and Star and was a Panel Member of the West Midlands Combined Authority (WMCA) Media briefing  8 March 2021 – chaired the virtual Wolverhampton Health Board Executive Steering Group  10 March 2021 – held a virtual joint meeting with Executive Directors of The Royal Wolverhampton NHS Trust (RWT) and Walsall Healthcare NHS Trust (WHT)  11 March 2021 – participated in the Wolverhampton Accountability meeting  12 March 2021 - was a Panel Member of the West Midlands Combined Authority (WMCA) Media briefing  15 March 2021 – participated in the Wolverhampton City Council, Wolverhampton Clinical Commissioning Group and The Royal Wolverhampton NHS Trust partnership meeting  16 March 2021 – participated in the NHS Providers Chair and Chief Executives virtual Network meeting  17 March 2021 - participated in the Strategic Transformation and Recovery (STaR) NHS Improvement – Safe Restoration and Recovery of Services Group meeting  18 March 2021 – chaired the virtual visit with staff from Angela Rayner, Deputy Leader – Labour Party and chaired the Trust’s Senior Leadership Forum  19 March 2021 - was a Panel Member of the West Midlands Combined Authority (WMCA) Media briefing

5.0 Board Matters There are no Board Matters to report on this month.

Page 3 of 3 6.2 Chief Executive's Report of the TMC held on 27 March 2021 1 Chairs Report TMC TB Summary 6 April 2021 - 26 March 2021.docx

Trust Board Report Meeting Date: 6 April 2021 Title: Chair’s report of the Trust Management Committee (TMC) held on 26 March 2021 – to note this was a virtual meeting Action Receive and note Requested: For the attention of the Board

Assure None in this report Advise Matters discussed and reviewed at the most recent TMC Alert None in this report Author + Contact Tel 01902 695950 Email [email protected] Details: Links to Trust 1. Create a culture of compassion, safety and quality Strategic 2. Proactively seek opportunities to develop our services 3. To have an effective and well integrated local health and care system that operates Objectives efficiently 4. Attract, retain and develop our staff, and improve employee engagement 5. Maintain financial health – Appropriate investment to patient services 6. Be in the top 25% of all key performance indicators Resource As per Agenda Item Implications: Report Data The meeting reviews standard reports that use the previous month’s data. Caveats This data may be subject to cleansing and revision. CQC Domains Safe: Effective: Caring: Responsive: Well-led: Equality and None identified Diversity Impact Risks: BAF/ TRR None identified Public or Private: Public Other formal Directors Meeting, Senior Managers Briefing bodies involved: References As per item. NHS In determining this matter, the Board should have regard to the Core Constitution: principles contained in the Constitution of:  Equality of treatment and access to services  High standards of excellence and professionalism  Service user preferences  Cross community working  Best Value  Accountability through local influence and scrutiny Brief/Executive Report Details 1 Key Current Issues/Topic Areas:  There were none this month.

2 Innovation Items:  There were none this month. 3 Exception Reports  There were none this month.

4 Items to Note – all of the following reports were reviewed and noted in the meeting  Integrated Quality and Performance Report  Division 1 Quality, Governance and Nursing Report  Division 2 Quality, Governance and Nursing Report  Division 3 Quality, Governance and Nursing Report  Executive Workforce Summary Report  Chief Nursing Officer (CNO) Report  Maternity Update Report  Trust Risk Register and Board Assurance Framework Heat Map Summary Report  Learning from Deaths Report  Finance Position Report  Capital Programme Update Report  Innovation, Integration and Research Report  Care Quality Commission (CQC) Well-Led Inspection Activity and Improvement Plan Progress Update as at 28 February 2021 Report  Financial Recovery Board Update Report  Operational Finance Group Minutes

5 Items to be Noted or Approved - Statutory or Mandated Reports (1/4, 6 monthly and Annual) – all of the following reports were reviewed, discussed* and noted in the meeting.  Health and Safety 6 Monthly Update Report  NHS National Staff Survey Results Report  Education and Training Academy Report  Safeguarding Adults and Children 6 Monthly Ypdate Report  Annual Audit of Risk Management Strategy Report  Infection Prevention and Control Board Assurance Framework (BAF) Report

6 Business Cases approved - Division 1  Business Case for the installation of Sound Proof Booths for Hearing Tests at West Park Hospital  Business Case for the Replacement of Three Ultrasound Machines within the Women’s and Neonatal Directorate  Business Case for the Replacement of the Opthamology Confocal Microscope  Business Case for the Replacement of one of the Neonatal Cerebral Function Monitors  Business Case for the Replacement of one of the Breast Navigation Wireless Angled Probes for the Diagnosis and Management of Breast Cancer

7 Business Cases approved - Division 2  There were none this month.

8 Business Cases approved - Division 3  There were none this month.

9 Business Cases – Corporate  There were none this month. 10 Outline/proposals for change  There were none this month.

Page 2 of 3 11 Policies approved  Policies, Procedures, Guidelines and Strategies Update Report  IP06 - Prevention and Control of Clostridium Difficile Diarrhoea Policy  OP110 - PREVENT Policy  CP58 - Prevention and Treatment of Venous Thromboembolism Policy  Consultation and Negotiation Arrangements in Partnership Framework policy  Job Planning Procedure  New - Guideline for the management of In-patients with Parkinson's Disease

12 Other items discussed:  There were none this month.

Page 3 of 3 7.1 Quality Governance Assurance Committee (QGAC) - Chair's Report 1 QGAC chair's report March 2021WK4.docx

Trust Board Committee Chairs Assurance Report

Name of Committee: Quality Governance Assurance Committee

Date(s) of Committee 31 March 2021 - virtual Meetings since last Board meeting: Chair of Committee: Rosi Edwards

Date of Report: 31 March 2021

ALERT Black Country Pathology Service Matters of concerns, gaps in Microbiology at Wolverhampton has had its UKAS accreditation suspended assurance or key risks to escalate following a virtual inspection which identified some significant issues including to the Board slippage of the audit plan. The assessment report has been received and action plans have already been drawn up, though the formal letter is awaited. An on-site reassessment is expected in May. Given the existing TRR risk on the quality system, QGAC suggests cultural and quality issues be covered in greater depth at a board development session.

Clinical Audit Audit activity was suspended across the Trust for Q1 and 2 2020/21 due to the COVID19 pandemic and again in January 2021 to end of 2020/21. On 16 March 2020 NHSE confirmed that national audits and some national registries were also suspended.

Division 1 has 196 audits on plan (including 79 national audits). Adjusted completion rate 56%. Division 2 has 118 audits on plan (including 69 national audits) with an adjusted completion rate of 37%. Division 3 has 94 audits on plan (including 17 national audits) with an adjusted completion rate of 35%. Clinical audit plans for 2021/22 remain under discussion and will be an item at the QGAC meeting in April 2021.

Never Event One reported in February: unintentional connection of a patient requiring oxygen to an air flowmeter. Actions taken include a reminder and short video sent to all matrons relating to the three barriers that reduce the risk of oxygen tubing being connected to air flow meters and an immediate review of all areas to ensure air flow meters are not in-situ unless explicitly required.

Cancer Failure of 8 out of 9 indicators predicted for February. However clinics which had been reduced during the current Covid period have now been restored and waiting times are reducing. Fast track clinics have increased during February and are now in line with normal levels.

Breast referral numbers remain the biggest concern, with bookings at day 28 and 170 patients waiting over 14 days. Additional sessions are being held to work through the backlog of patients. The trust has reached out for mutual aid to other neighbouring trusts but some are in a similar position; one trust has offered limited support. QGAC Chair April 2020 Page 1 of 5 ALERT (continued) Covid impact on waiting list: Matters of concerns, gaps in Referral to Treatment (Incomplete) - The number of patients waiting over 18 assurance or key risks to escalate weeks deteriorated during February, reaching 42,235 (target is below 40,000) to the Board due to the impact of Covid-related cancellations of routine elective inpatients and outpatient clinics. 2,054 patients have breached the 52+ weeks at month end - this figure is likely to grow since the large demand and capacity project gives priority to shorter waiters with higher clinical need. Referral numbers are not yet back to pre-Covid numbers - currently at around 65% of normal numbers.

ADVISE Cancer - 104 day harm report Area’s that continue to be There have been expected delays in treatment pathways due to Covid but no reported on and/or where some directly attributable harm. One case highlighted as potential harm relates to a assurance has been noted/further assurance sought Head & Neck patient where there was a delay in follow up for 18months, though this delay was not associated with Covid. Discussions are taking place with Head & Neck Clinical Director around assurances that other patients have not been similarly lost to follow up. This case will be raised as an incident.

C sections Emergency C. sections decreased in month to 23.9% from 28% in January, due to reduction in the number of women with Covid needing induction. The combined rate has reduced to 34.8%. Work is currently underway looking at the breakdown of C section rates in terms of number of women who had C section for physical health reasons, early presentations, and stage of presentation aligned with the outcome for the babies.

VTE compliance QGAC heard that VTE assessments remained stubbornly below target, as evidenced by QSIG chair’s report and minutes. There will be a focus on CQI projects in 3 key areas including ED. One includes combining data from several sources (VitalPac, PAS, EPMA) gathering information on missed assessments and missed doses or where there is no anti-coagulant prescription and present this to clinicians in an easy to digest format with the aim of improving assessment and prescribing.

Infection Prevention & Control Two post 48hr MRSA bacteraemia allocated to RWT during Quarter 3. The source for both was unclear.

CPE acquisitions are reduced to 15 (end of Q3 compared with 56 in 2019/20), possibly due to reduced international travel and elective activity.

C-difficile has no external trajectory for 2020/21. RWT with 31 cases at Q3 is above last year’s trajectory of 30.

Bed space equipment decontamination unit has been re-installed in an empty ward space – a previous trial appeared to reduce C difficile numbers.

Planned expansion of the IP team now achieved.

QGAC agreed that a report on outbreaks would be included in IQPR later in the year to include Covid but also Flu and other types of outbreak.

QGAC Chair April 2020 Page 2 of 5 ASSURE Falls Prevention Group Positive assurances & There has been an 18% decrease in falls from June to December 2020. Falls highlights of note for the Board rate per 100,000 bed days decreased from 4.48 in June to 2.151 in December 2020. The national benchmark of 5.6 falls per 1000 bed days is unchanged. There were 5 falls with harm during the same period.

CQI projects and education are ongoing. A new form for completion by Medical Staff is currently being piloted in AMU (supported by the CQI team). Polypharmacy contributing to falls is also being captured. From January 2021 all no harm falls will be followed up by the nursing Quality Team. In March 2021 there will be a trust wide launch of a new Nursing risk assessment booklet incorporating a more detail multifactorial falls risk assessment.

More services to support care at home: admission avoidance and early supportive discharges: QGAC noted the successful introduction of schemes to enable patients to be treated at home, avoiding admission or enabling earlier discharge through setting down including the COVID-19 Oximetry@home service, the COVID virtual ward service and a successful funding bid for a digital first remote monitoring solution from NHSX for 15 months which should expand the scope for the services with a potential roll out to respiratory patients post COVID.

QGAC received a note about the Tekihealth pilot which allows remote consultations to take place in care homes. The pilot care home and the GPs involved considered it a success, though there are issues of integration with other innovative services as well as benefit to patients which need further scrutiny. QGAC has passed follow up of this to the Innovation Committee.

Recommendation(s) to the • To agree the QGAC TOR - reviewed but not revised at this stage. Board

QGAC Chair April 2020 Page 3 of 5 Changes to BAF Risk(s) & BAF Strategic Risks TRR Risk(s) agreed QGAC noted the extensive updates to both risks and accepted the updates and agreed the ratings. • BAF SR13 - cancer services: QGAC asked for an update to cover support sought and obtained from other providers for breast 2 week waits, as this had been subject to STP level agreement in 2019 that access should be equal across the STP, and how difficulties in providing equal access were being overcome. Given the Phase 4 Recovery Planning Guidance QGAC expected to see more sharing of waiting lists. • BAF SR14 - Covid and recovery of services

TRR Heat Map QGAC discussed the verbal update to the Heat Map which took into account directorate assessments of whether the risk was under control and whether the measures listed would reduce the risk. QGAC decided that the questions would need reformulating to focus on assurance, e.g. on whether the existing measures were mitigating the risk and whether the further measures would reduce it.

The Heat Map which comes to the board will be followed by further modification with new questions for the risk holders and for QGAC. QGAC NEDs agreed comment by email on the red risks, the new risk, and the risk reduced from red to amber, to assist with developing a further iteration of the Heat Map.

TRR Risks 3 new risks: 5582 - CPAP beds on C26 (COO): QGAC asked how risk identified would be progressed now it was on divisional register - risk had been swiftly downgraded to divisional level as the demand pressures had reduced and the service wanted to review their needs. 5595 - Cancellation of elective surgery during COVID pandemic (COO) 5596 - Patient Safety Improvement (CNO)

3 red risks: 4661 - Lack of robust system for review and communication of test results (MD) 5182 - Lack of Network support for Vascular Services at RWT (MD) 5246 - Lack of Consultant cover within Cancer Services (COO)

Red reduced to amber 5388: mental capacity assessment. QGAC questioned this reduction, given the low compliance rates despite the excellent training rates and were told there are areas of really good practice as well as areas where compliance needs improvement.

ACTIONS • QGAC propose to follow up the trust’s response to the Radiotherapy Significant follow up action Audit on behalf of the Audit Committee commissioned (including discussions with other Board • QGAC will pass follow-up of the Tekihealth pilot to the Innovation Committees, changes to Work Committee who will be able to consider how it integrates with other Plan) schemes currently underway or planned.

QGAC Chair April 2020 Page 4 of 5 ACTIVITY SUMMARY • IQPR Presentations/Reports of note • TRR received including those • BAF Approved • BAF and Trust Risk Register Heat Maps • QSIG Chair’s report • COG Chair’s report • Internal Audit Report: Radiography within Radiotherapy Department • QGAC TOR

ACTIVITY QGAC discussed the IQPR, BAF and TRR. SUMMARY Major QGAC had a verbal report on the prioritisation of patients on waiting lists and agenda items how to reduce these in a fair and clinically justified way. There is a nationally discussed including agreed approach, using criteria from the Royal College of Surgeons. QGAC those asked that these criteria be made public in an easy-to-understand way. QGAC Approved was also concerned that those who chose not to go ahead with a procedure might be more vulnerable patients, less able to balance the risk from Covid with the risk of not proceeding, and sought assurance that they did receive sufficient advice, and that an analysis would be carried out to see if such groups disproportionately declined treatment.

QGAC discussed the test questions in the BAF/TRR Heat Map and considered how the assurance section questions should be formulated to enable QGAC to assess the level of assurance.

QGAC discussed the Internal Audit report on Radiography in the Radiotherapy Department, which had been to Audit Committee in December 2020. A report drawing together the 3 strands of governance, clinical and HR reports will come to QGAC in April or May.

QGAC reviewed its TOR and decided no change was needed at present. Change may be required later in the year when COG and QSIG merge and the TOR will be reviewed again then. Matters Cancer Recovery Plan, report for February 2021 presented for QSIG Minutes 25 February 2021 information or COG Minutes 11 February 2021 noting Self- Virtual meeting for 2 hours. It overran by 9 minutes, but there were comments evaluation/ that the discussions had been useful in clarifying the way forward, e.g. on the Terms of Heat Map, cultural issues post-Covid. Reference/ Future Work The meeting was observed by the Company Secretary for Walsall Healthcare Plan NHS Trust.

Items for None Reference Pack

QGAC Chair April 2020 Page 5 of 5 7.2 QGAC terms of reference 1 Enc 11 - Draft Terms of Reference - QGAC.docx

QUALITY GOVERNANCE ASSURANCE COMMITTEE TERMS OF REFERENCE Trust Strategic 1. Create a culture of compassion, safety and quality. Objectives 6. To be in the top quartile for all performance indicators. 3. To have an effective and well integrated organisation that operates efficiently. 4. Attract, retain and develop our staff and improve employee engagement.

Meeting To provide assurance to the Board that patient care is of the highest Purpose/Remit achievable standard and in accordance with all statutory and regulatory requirements. To provide assurance of proactive management and early detection of risks across the Trust. Responsibilities 1. To review all relevant indicators of patient experience/satisfaction, patient care and patient safety and to assure itself that good practice is being disseminated and that any deficiencies are put right. 2. Promote continuous quality improvement through a culture which encourages open and honest reporting and an educative and supportive approach to the management of risk. 3. To approve the Terms of Reference and membership of its reporting subgroups (and oversee the work of the sub-groups, receiving reports for consideration and action as necessary. 4. Co-ordinate the monitoring of risks utilising the Board Assurance Framework (BAF)/Trust Risk register framework (TRR) to assess the effectiveness of controls, assurances/gaps in assurance and further action. 5. To manage specific BAF risks delegated to the committee, providing assurance updates to Trust Board. 6. Utilise the assurance reporting processes to inform the Audit Committee and Trust Board on the management of risk and proposed internal audit work. 7. To oversee the Risk Management Assurance Strategy delivery (along with Risk management policies OP10) across the Trust. 8. To review the Annual Governance Statement together with any accompanying Head of Internal audit statement, external audit opinion or other appropriate independent assurances, prior to endorsement by the Board. To support this process, the Audit Committee will meet annually with the Quality Governance Assurance Committee. 9. To receive the Clinical Audit annual report and annual Clinical Audit plan ensuring it is consistent with the audit priorities of the Trust. 10. To examine any relevant matters referred to it by the Board of Directors or Audit Committee. 11. To monitor and report on quality and safety performance to the Trust Board. 12. To review a report on themes from incidents, claims, complaints and related areas, to inform risk management or improvement actions. Authority & The Quality Governance Assurance Committee is established to evaluate Accountabilities and report on quality and safety performance and the operation of risk management systems and controls to the Trust Board. The Committee is authorised by the Trust Board to investigate any activity within its terms of reference obtaining independent advice if necessary. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee shall transact its business in accordance with national/local policy and in conformity with the principles and values of public service (GP01). Reporting The Committee will function in line with the Board Assurance and Arrangements Escalation framework detailed in the Risk Management Assurance Strategy. The Minutes of each Committee meetings shall be provided to the Board. The Chairman of the Committee shall provide a report of each meeting drawing to the attention of the Board any issues that require disclosure to the full Board, or require executive action. Membership NED members x 3 Chief Nursing Officer Medical Director COO CEO Head of Governance Attendance As indicated by the Committee Chair NED Chair Quorum 4 members must be present consisting of 2 Executive Directors and 2 NED members. No tabled papers except with chairman approval. Frequency of Monthly meetings Administrative The Governance Department will provide administrative support. Agenda support and papers will be circulated one week prior to the meeting. Standards NHS Improvement Single Oversight Framework (to include Quality Governance and Well led guidance) H&SC Act Fundamental Standards of Care CQC Provider guidance on meeting the Fundamental Standards NHS Resolution (NHSR) Litigation triggers Annual Governance Statement CQC Well Led Inspection Framework Standard Agenda • BAF and TRR • Subgroup reports • Compliance/Performance (via Integrated Quality and Performance report, Compliance reports) • Themed review items • Committee action log Subgroups • Compliance Oversight Group (COG) • Quality and Safety Intelligence Group (QSIG)

Page 2 of 4 Date Approved March 2019 Date Review March 2020

Page 3 of 4 Appendix 2 Quality Safety reporting structure

Trust Board

QGAC TMC

Proposed Current

A. Quality and B. Compliance PSIG QSAG Safety Intelligence Oversight

DAA reporting on A. Performance B. Oversight reports Performance, Finance, Strategic Objectives and priorities (quarterly)

Division Division Division 1 2 3

PSIG IPG, MMG, POCT, Nutrition, Org Donation, Pleural, Swan, **IPG, MMG, POCT, Thrombosis, Hospital Transfusion, Nutrition, Org Resus, falls, CBP, Medical Devices, Donation, Pleural, Patient Exp forum Swan, Thrombosis, QSAG Hospital Transfusion, NICE, HSSG, CAG, IG, SVA/JHSC, Resus, falls, CBP, Rad Protection. Medical Devices, Patient Exp forum NICE, HSSG, CAG, IG, SVA/JHSC, Rad Protection.

**Subgroups will provide Action reports to Divisions and Compliance reports to Compliance Oversight group.

Page 4 of 4 7.3 Chief Nurse's Nursing Report 1 1. Part 1 CNO TB Report Feb 2021 - FINAL.pdf

Trust Board Report Meeting Date: 6th April 2021

Title: Chief Nursing Officer Report

Comprising: Right staff, right place, right time, Nurse Education Faculty, excellence in care, patient experience, communication and research. Purpose of the Regular report to advise members on updates from the CNO for assurance. Report: Action required: Receive for information and assurance • Registered Nurse/Midwife vacancies and unregistered vacancies have further decreased. • Falls have decreased in month from 120 in January to 59 approved to date in Assure February. • Combined sickness rate has improved from 9.19% in January to 6.44% in February. • Cardiac arrest numbers decreased from 19 in January to 5 in February. • NHSE/I workforce initiative to decrease HCA vacancies to zero by 31st March Advise 2021 is progressing.

• Clostridium difficile cases are above trajectory in year. • Mandatory training has remained fairly static at 88.6% in January and 89% in Alert February. • Pressure Ulcers have increased in month from 25 to 30.

QGAC Clinical Policy Group implications and Workforce Group view Matrons, Senior Nurses, Midwifes and Health Visitors Group Deteriorating Patient Committee Patient, carer, Council of Members Group public impact and views Author + Contact Vanessa Whatley and Yvonne Higgins– Deputy Chief Nurses Details: Tel 01902 695968 (85968) Email [email protected] and [email protected] CQC Domains Safe: patients, staff and the public are protected from abuse and avoidable harm. Effective: care, treatment and support achieves good outcomes, helping people maintain quality of life and is based on the best available evidence. Caring: Staff involve and treat everyone with compassion, kindness, dignity and respect. Responsive: services are organised so that they meet people’s needs. Well-led: the leadership, management and governance of the organisation make sure it’s providing high-quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. Trust Strategic 1. Create a culture of compassion, safety and quality Objectives 2. Proactively seek opportunities to develop our services 3. To have an effective and well integrated local health and care system that operates efficiently 4. Attract, retain and develop our staff, and improve employee engagement 5. Maintain financial health – Appropriate investment to patient services 6. Be in the top 25% of all key performance indicators Resource None Implications: TMC Report Report Data This is a standard report using the previous month’s data. It may be subject to Caveats cleansing and revision. Equality and No negative impact. Diversity Impact Risks: None Risk register N/A reference: Other formal As above bodies involved: References A variety of references apply to the topics outlined in this report.

Brief/Executive Report Details Brief/Executive Summary Title: Chief Nursing Officer Report

1.0 Key points from the report include: • There has been a decrease in the number of registered nurse/midwife/ and unregistered vacancies to an overall Trust total of 14.38wte in February 2020. The improvement in the registered nurse vacancies is predominantly as a result of a cohort of International recruits. There will however be a few months delay before these staff can sit their OSCE exam due to the availability of slots at the National test centres, hence they will not be able to function as registered nurses until then. Also additional beds remain open to support Covid-19 cases. The staffing for these areas is not captured in this overall total. • The Ockenden Assurance and assessment tool with the 7 immediate actions has been completed and submitted to the national team as requested from NHSE/I in February. The local action plan was presented to Trust Board in March. The DoM has met with the regional Chief Midwife for Midlands NHSE/I to discuss the submitted assessment and assurance tool. Trusts have been RAG rated and will receive a trust level report at the end of March. • Combined sickness rates have decreased in February to 6.44% • DOLs applications have decreased in February. A rate is being calculated for future months to reflect bed occupancy which will account for shorter months. During March, there will be a repeat audit undertaken relating to completion of MCA/DoLS and DNA/CPR procedures • Clostridium difficile cases are over trajectory year to date. • Pressure Ulcers have increased in month from 25 to 30. The trust is engaging in a retrospective research project to explore Covid skin changes over typical pressure points.

Page 2 of 2 1 2. Part 2 CNO TB Report Feb 2021 - FINAL.pdf

Reference Pack – Report Details Chief Nursing Officer Report 06/04/2021 NURSING QUALITY DATA The Nursing Quality Dashboard (Appendix 1) provides an ‘at a glance’ view of ward/department/service performance with regards to structure, process and outcomes and is provided for information. Trust level quality metrics are now provided as trend charts with key actions and mitigations outlined by the subject matter experts. Key points from this month’s trust level nursing quality metrics are highlighted below.

Key points from the February 2021 Trust Action/Mitigation level nursing quality metrics Leavers and data analysis The number of registered nurse/midwife and Recruitment is ongoing to all wards/depts. with unregistered vacancies in the wards and vacancies. 40wte third year students have opted in to departments included on the dashboard has paid placements for 12 weeks. A good proportion of decreased to -51.33wte. The actual total these have been placed in the hot spot areas with the number of registered and unregistered nurse intention that a proportion of them will convert to vacancies across the Trust is 14.38wte (this substantive positions on qualification later in the year. includes departments currently not included on the dashboard but excludes business case funding which is only included once staff are in post). The improvement in the registered nurse vacancies is as a result predominantly of a cohort of International recruits. However there will be a few months delay before these staff can sit OSCE exam due to availability of slots at the test centres, hence they will not be able to function as registered nurses until then. The Trust also has additional bed capacity open in excess of budgeted establishment. Hot spot areas: Critical care as they continue to show vacancies based on pre- business case budgeted establishment; if the revised establishment was included their vacancy position would be higher. Community services also have 19.72wte vacancies at end of February this is a slight improvement on last month. Combined sickness rates have decreased to Sickness rates continue to be closely monitored. 6.44% in February from 9.19% in January. Complaints have increased slightly from 33 to ED and AMU have been identified as areas with 36 increased complaints. A themed review of these complaints will be undertaken and actions to drive improvement identified. The percentage of friends and family test The Patient Experience Team continue to identify responses who would recommend has and work with key departments to improve remained static at 90% in February. recommendation rates and effective use of real time feedback. Clostridium difficile cases have remained at 5 Clostridium difficile ward rounds continue. A bed in February. space equipment decontamination unit has been re- instated for medical wards– a previous trial appeared to reduce C difficile numbers in the trial wards. Falls have decreased from 120 in January to A new falls risk assessment will be launched in 59 approved to date in February. March, along with new grip slipper socks. Themes and trends continue to be analysed.

1

Timely observations have remained static The CQI project in relation to improving with 95.2% in January and 95.4% in ‘observations on time’ continues and work has February. commenced on pilot wards. There has been a reduction in cardiac arrests Following a successful trial a business case for from 19 in January to 5 in February. sealed cardiac arrest trays is being developed. This supports patient safety by ensuring all emergency equipment is always available when required. Pressure Ulcers have increased in month A strategy to reduce category 2 incidents is being from 25 in January to 30 in February. There devised. The new risk assessment document and has been a reduction in all categories of intervention chart will be launched in March. The trust community pressure ulcers. is engaging in a retrospective research project to explore Covid skin changes over typical pressure points.

Trend Data For Nursing And Midwifery Quality Metrics

February 2021

2

There were to date 59 approved incidents of patient falls during February 2021.

Inpatient areas have reported a rise in A strategy to reduce the category 2 incidents is category 2 incidents but low numbers of being devised. The new risk assessment document category 3, 4 and unstageable incidents. and intervention chart will be launched in March. Community has reported a reduction of The Trust is engaging in a retrospective research all incidents below the mean line. project to explore Covid skin changes over typical pressure points.

3

4

5

There has been a reduction in vacancies in month. However the included budgeted establishment within this report does not include the additional ward capacity which has been opened in response to COVID.

Exception Reports Education

HEE • Following HEE and the NMC announcement of emergency standards, in response to the latest pressures on Health services, we now have 40 3rd year student nurses on paid placements until 7th of May 2021. • HEE Clinical Placement Expansion Programme (CPEP). RWT used the £50K award to create 2 secondments to support the new students. These posts cease on 31/3/21. The Trust has met all targets within organisational control and have reported to HEE those outside of its control namely that University of Wolverhampton have recruited 65 students less than our Adult Nursing target for the spring cohort. This risk was reported to HEE at the start of the programme.

University of Wolverhampton (UoW) • We have approached UoW to request University led allocation of Nursing and Midwifery students and they will consider this and the resources required.

Staffordshire University • We have approached Staffordshire University to request University led allocation of Nursing and Midwifery students and this is now in place. Keele University • We have agreed to partner with Keele University for the development and delivery of their new MSc Paramedic Science Degree, including providing clinical placements.

RWT • Classroom space - The Nurse Education portfolio has outgrown the current space on offer to support the student workforce expansion and the OSCE boot camp capacity increase for the lead recruiter programme. The current West Park accommodation capacity limit remains on our risk register. There are plans to expedite the transformation of Building 12 in support of this as we are currently using external venues to support our portfolio. • HCAs - In response to the NHSI/E initiative to recruit Health Care Support Workers, Nurse Education has developed a whole week induction for those who are new to care.

QUALITY AND SAFETY EXCEPTION REPORTS Maternity Update • Ockenden Assurance and assessment tool with the 7 immediate actions has been completed and submitted to the national team as requested from NHSE/I in February. The local action plan was presented to Trust Board in March. The DoM has met with the regional Chief Midwife for Midlands NHSE/I to discuss the submitted assessment and assurance tool; Trusts have been RAG rated and will receive a trust level report at the end of March. 6

• A Birth Rate + review full assessment has been commissioned for early spring. Presently midwifery workforce is in line with 2018 BR+ review. • Maternity service is still on track to be fully compliant with SBLCBv2 by end of March 2021 in line with the national Maternity transformational programme. • Maternity CNST Incentive scheme – the directorate continues to work towards full compliance with 10 safety actions. • Continuity of Care (COfC) – work continues to restore COfC care teams following the requirement to redeploy COfC teams into community and intrapartum areas due to the pandemic.

Safeguarding Team • The number of DoLS submitted during February was 27, down from 35 in December and January. A rate is being calculated for future months to reflect bed occupancy and shorter months. During March, there will be a repeat audit undertaken relating to completion of MCA/DoLS and DNA/CPR procedures. • In line with legislation, there is a new 16/17 year old MCA/DoLS assessment process. Trust training will be rolled out. • Section 42 (Safeguarding issues raised against the Trust) – there was one case in January, which was unfounded and closed. There were no cases escalated during February. There has been a 48% decrease for safeguards made against the Trust over the last 12 months. Summary paper with lessons learned has been collated for discussion at the Trust Safeguarding Operation Group in April. • The Prevent Policy, Domestic Abuse Policy and Children Supervision Policy have been completed and presented to the Trust Policy Group. • The 20-50 mile ‘out of area’ review health assessments for Wolverhampton children and young people in care have recommenced and will be fully established over a six month period in discussion with commissioners. • The LD team have reported an escalation in contacts with vulnerable patients during January and February. A Trust LD policy is to be written during 2021. LD and Autism training will be rolled out from April 2021. • There has been IT issues within Wolverhampton Local Authority which have had an impact on our service areas. This has been escalated to the Wolverhampton Safeguarding Together Board.

The following page is Appendix 1 – Executive Level Nursing Quality Dashboard.

7

30

8

Trust Board Report Key to Dashboard Green Amber Red Budget Total nursing and HCSW funded establishment for clinical location - Band 2-7 Not applicable Total Vacancies The total vacancies at the time of report = number recruited added with open vacancies wte = whole time ncies: trend arrow v. previous month: bar graph % over v. under recr Number in recruitment All known appointments made through recruitment - these staff are not yet in post equivalents 0-3 wte 3-5 wte >5 wte Combined Absence Combined absence average per ward area <3.85% 3.86 - 4.23% >4.24% CHHD An equation for the cost of patient care per (total hours of care delivery/bed occupied) >6 5-6 <5 Mandatory Training Percentage of all training mandatory requirements completed for each clinical location >95% 90% - 95% <90% FFT - Recommendations Friends and Family Test - from the patient response rates, how many would recommend care at RWT >90% 80% - 90% <80% Complaints Total number of complaint received for the clinical location/ward (Formal & Pals) 0 Not applicable ≥1 Pressure Ulcers Number of pressure injuries as reported on Datix (sample date - circa 10th day of new month) 0 Not applicable ≥1 Falls Number of falls as reported on Datix (sample date - circa 10th day of new month) 0 - 1 2 ≥3 KEY Medication Administration Errors Number of Administration errors reported on Datix (sample data - circa 10th of new month) 0 Not applicable >1 Missed dose % of all medications given % of missed doses during a month <5% Not applicable >5% Late Observations % of observations completed from Care Flow Vitals <5% Not applicable >5% Cardiac Arrests Total number of cardiac arrest calls to clinical location: not including other 2222 calls for non-cardiac arrest 0 Not applicable ≥1 C-diff Number of clostridium difficile incidences (as reported by Infection Prevention) 0 Not applicable ≥1 MRSA Number of MRSA acquisitions per month (as reported by Infection Prevention) 0 Not applicable ≥1

Page 9 of 9 7.4 Trust Board Assurance Framework and Trust Risk Register Heat Map Summary 1 April 2021 BAF TRR Heat Map TMC_Front_Sheet 31.03.21 Brief Public TB.docx

Trust Board Report Meeting Date: 6 April 2021 Title: Board Assurance Framework (BAF) and Trust Risk Register (TRR) Heat Map Summary Purpose of the The report provides a snapshot overview of the collective BAF and TRR Risks. Report: Action required: Receive and note  The entries on the BAF and TRR are regularly reviewed and attended to. Assure  Three Risks have been closed – see summary.  A number of risks have clear linkage to relevant BAF Risks – SR1 (2 Risks), SR13 (5 Risks) and SR14 (5 Risks).  The Governance Team, CNO Office and Company Secretary have developed a revised presentation of the BAF and TRR Risks as a Heat Map for use at the Public Trust Board.  QGAC will continue to review the TRR Risks in detail and make an Assurance determination in each case that will be added to the report Advise before presentation at Public Board in future. This is still under development.  The full BAF Risks will continue to be reviewed by each of the relevant Board Committees in detail as will the full and detailed Risk register at the Quality Governance Assurance Committee (QGAC).  The above will be reviewed in 6 months’ time.  2 of 3 BAF Risks remain red– Cancer Recovery and Covid-19 impact. Alert  There are a number of Risks that have been on the TRR for some time. Author + Contact Ann-Marie Cannaby – CNO, Yvonne Higgins – DCNO, Maria Arthur – Head of Details: Governance, Keith Wilshere – Company Secretary CQC Domains Safe: Effective: Caring: Responsive: Well-led. Trust Strategic 1. Create a culture of compassion, safety and quality Objectives Resource None Implications: Risks: No new or changed risks are highlighted as a result of this report. Other formal bodies QGAC, Trust Board involved: References TRR, BAF. 1 TRR Heat Map Report TB draft Mar 21 06.04.21 for Public TB Brief.docx Executive Summary – Board Assurance Framework & Trust Risk Register

1. The Trust’s Approach to Risk: The Trust operates three levels of risk register in order to manage risks, these are:  the Board Assurance Framework (BAF) (reported in detail separately),  the Trust Risk Register (TRR – Summary Reported herein, reported in detail separately) and  local Risk Registers (held at Division and Directorate level, reported in detail separately).

The BAF is the Trust Board’s prospective strategic risk tool focused on potential risks that might prevent or disrupt the achievement of the Trust Strategic Objectives and aims. The TRR is the corporate record of high level and includes operational risks escalated from service areas, risks identified from Director Portfolios or delegated from the strategic objectives. The TRR provides the link between local risk management activity and Board level review of operational risk. This summary of the TRR includes all approved risks scoring 12 and above using the categorisation matrix. All risks include a grade assessment, mitigating controls, positive/negative assurance updates and improvement actions. Risk register updates occur at Directorate and Divisional levels to inform the Trust Risk register.

2. BAF Risk Summary: The BAF risks are regularly reviewed and updated by the lead Chief Officer and reviewed in detail at the Board Committee’s, Audit Committee and Trust Board. In this report there are no new BAF Risks confirmed and there are no proposed closures of any BAF Risks. Risk SR1 remains below the target level and is proposed to be considered for closure at the next People and Organisational Development Committee (PODC).

3. TRR New Risks, Closed Risks:  New Risks opened since last report = 3 o Closed Risks since last report = 3 - 5466, 5542, 5574.  BAF related Risks: o 5246, 5315, 4661, 5182.

4. Board-Committee Summaries: The Quality Governance Assurance Committee review the detailed content of the full Trust Risk Register alongside the heat map summary. QGAC confirm and/or challenge the summary assurance rating to be reported to the Board. The heat maps summarize by Division all risks existing in the Trust Risk Register that score 12+ with month to month movement, current and target grades, and an assessment of the assurance level and rating. Target grade dates are not currently captured on Datix and will feature in future reports. The Committee challenge and view is then reflected in the QGAC Assure column in the heat map associated table using the Key below.

5. Action required: That the Committee/Board review, confirm and note the heat map report

Assurance Ratings Keys:

TBC/QGAC Assurance questions and ratings - To be confirmed for future publication

Symbols Key  New Risks since the previous report are marked *  Risks closed since last report are marked #  Assurance = + (positive assurance)/ - (negative assurance/gap in assurance/gap in control)  TRR Risks impacting BAF ~ Movement

Same as previous month

Score has increased since previous month

Score has reduced since previous month Board Assurance Framework (BAF) ‘Heat-map’ Summary Symbols Key New Risks since the previous report are marked * Risks closed since last report are marked # High Risks Weighting of assurance +/- Controls, TRR Risks impacting BAF ~ Mitigations Date BAF Risk Rating Brief Gaps, Target Start Movement L1 L2 L3 last Number score Headline Neg A. score date update 5 Cancer Perform- 17/03/ Mar SR13 4x5 + 6 + 5 + 8 -7 4x4 ance 2021 2019 Recovery SR13 4 SR14 Covid 23/03/ Apr SR14 4x5 impact and + 16 + 15 + 2 -7 2x3 2021 recovery 2020

3 Medium Risks Controls,

Consequence Mitigations Date BAF Risk Rating Brief Gaps, Target Start Movement L1 L2 L3 last 2 SR1 Number score Headline Neg A. score date update

Insufficient 26/03/ May SR1 2x4 staff + 2 + 5 +1 -5 3x4 2021 recruited 2015 1 Dates for risk target grades are to be established for all risks. 1) SR1 Initial score was 3 x 5 = 15. It has 2 associated TRR Risks – 5246 and 5315. There are 6 positive assurances noted. 2) SR13 Initial score was 4 x 5 = 20. It has 2 associated TRR Risks - 5246 and 5395. There are 6 positive assurances noted. 1 2 3 4 5 3) SR14 Initial score 5 x 5 = 20. It has 2 associated TRR Risks – 4661 and 5182. There are 11 positive assurances noted.

The following risks have been noted but as yet the nature and potential strategic risk and impact cannot be confirmed: Likelihood 1) Potential future financial Impact of changed contracting model (F&P) 2) Potential future reputational and financial impact of unsuccessful acute collaboration (QGAC/F&P/PODC) TRR ‘Heat-map’ Summary: Division 1 Symbols Key New Risks since the previous report are marked * Risks closed since last report are marked # High Risks Weighting of assurance +/- Assurances TRR Risks impacting BAF ~ Date Risk Rating Brief Target Target Movement L1 L2 L3 last Number score Headline score date update Vascular 5 5182~ 4x4 26/02/21 2x2 Services

Medium Risks 4903 Assurances 4 5182~ 5466# Date Risk Rating Brief Target Target Movement L1 L2 L3 last Number score Headline score date 4596 update Gallstone 31/12/ 5058 4596 3x4 - 11/02/21 2x2 5315~ Disease 21 3 5316 30/03/ 5058 3x4 BCPS QMS 04/03/21 3x2 5488 22 5031 Consultant

Consequence 5595* 5315~ 3x4 Microbiologist 27/01/21 3x1 Shortage

2 5316 3x4 RTT Breaches - 26/01/21 2x3 Cardiothoracic 5488 3x4 - 27/01/21 2x2 surgical list Screening 31/12/ 5031 3x4 - 05/03/21 3x2 Standards 21 1 Thoracic 4903 4x3 Service - 26/02/21 3x1 Specification Cancellation of 1 2 3 4 5 5595 3x3 elective 12/03/21 2x2 surgery

Likelihood Dates for risk target grades are to be established for all risks. 1) Risk 4596 – Date of Origin 9/8/16. 2) Risk 4903 – Date of Origin 16/11/17 3) Risk 5182 – No Positive assurance noted (Date of Origin 11/3/19). TRR ‘Heat-map’ Summary: Division 2 Symbols Key New Risks since the previous report are marked * Risks closed since last report are marked # High Risks Weighting of assurance +/- Assurances TRR Risks impacting BAF ~ Date Risk Rating Brief Target Target Movement L1 L2 L3 last Number score Headline score date update 5 Cancer 5246~ 4x4 Consultant 10/02/21 4x2 Cover

4472 Medium Risks 4 5246~ 5582* Assurances Date Risk Rating Brief Target Target Movement L1 L2 L3 last Number score Headline score date update ED Timely 30/09/ 3 4472 4x3 9/03/21 4x1 Assessment 21

5582 4X3 CPAP beds 4/03/21 3x2 Consequence

2 Dates for risk target grades are to be established for all risks. 1) Risk 4472 – Date of Origin 24/2/16.

1

1 2 3 4 5

Likelihood TRR ‘Heat-map’ Summary: Division 3 Symbols Key New Risks since the previous report are marked * Risks closed since last report are marked # High Risks Weighting of assurance +/- Assurances TRR Risks impacting BAF ~ Date Risk Rating Brief Target Target Movement L1 L2 L3 last Number score Headline score date update 5

Medium Risks 4 Assurances Date Risk Rating Brief Target Target Movement L1 L2 L3 last Number score Headline score date update 5083 Dysphagia 3 5284 5083 3x4 care - 10/02/21 2x2 5448 Management

Consequence 5284 3x4 EPMA System 09/03/21 3x1

CQC 2 5448 3x4 Medicines 11/03/21 3x2 31/12/2021 Report

Dates for risk target grades are to be established for all risks. 1) Risk 5083 – Requires update on assurance re compliance with all Safety alert actions. Last assurance update in Oct 20 identified monitoring of a few remaining local actions (Date of origin Aug 18). 1

1 2 3 4 5

Likelihood TRR ‘Heat-map’ Summary: Corporate Symbols Key New Risks since the previous report are marked * Risks closed since last report are marked # High Risks Weighting of assurance +/- Assurances TRR Risks impacting BAF ~ Date Risk Rating Brief Target Target Movement L1 L2 L3 last Number score Headline score date update 5 Review Test 4661~ 4x4 16/10/20 3x3 Results

Medium Risks 4812 4 4661~ 5542# Assurances Date Risk Rating Brief Target Target Movement L1 L2 L3 last Number score Headline score date 5045 update 5574# 3 5045 3x4 Sepsis 10/02/21 3x3 5596* 5388 Mental 5388 4x3 Capacity, DoLs 26/02/21 2x3 Consequence Assessment Patient Safety 5596 4x3 + 07/03/21 3x2 2 Improvement Children & 31/12/ 4812 4x3 - 04/03/21 2x1 Young People 21

1 Dates for risk target grades are to be established for all risks. 1) Risk 4661 – Level 1 assurances largely relate to the creation of Policy/SOPs, results filing performance and the switching off of TD Web and launch of ICE system for all Histology, Microbiology and Blood Science reporting. Updates on audit of local procedures in Radiology, Pathology and Operational areas to be requested for future update (Date of Origin and escalation 1 2 3 4 5 to TRR is 17/11/16). 2) Risk 4812 – Date of Origin 17/7/17 3) Risk 5045 – L1 Assurances were last updated Nov 20 (Date of Origin June 18) Likelihood TRR ‘Heat-map’ Summary: Estates & Facilities Symbols Key New Risks since the previous report are marked * Risks closed since last report are marked # High Risks Weighting of assurance +/- Assurances TRR Risks impacting BAF ~ Date Risk Rating Brief Target Target Movement L1 L2 L3 last Number score Headline score date update 5

Medium Risks 4 4382 Assurances Date Risk Rating Brief Target Target Movement L1 L2 L3 last Number score Headline score date update NX55 Fire 4382 4x3 15/03/21 2x2 20/06/21 3 Safety

Dates for risk target grades are to be established for all risks. Consequence 1) Risk 4382 – Dates required against the positive assurance for Fire alarm upgrade (Date of Origin 19/12/2015).

2

1

1 2 3 4 5

Likelihood 7.5 Director of Infection Prevention Report - Jo Macve 1 IPC Board report Apr 2021.pdf

Trust Board Report Meeting Date: 6th April 2021

Title: Infection Prevention and Control Report

Executive The report gives an overview of healthcare associated infection related Summary: data 2020-21, with a focus on January and February 2021, and reference to external and internal targets. The Board need to be aware of successes and challenges in healthcare associated infection, with particular reference to the challenge posed by the ongoing COVID 19 pandemic, with associated outbreaks among patients and staff. Healthcare associated infection rates are monitored monthly at Infection Prevention and Control Group. This report will be submitted for review by Trust Management Committee on 26th March 2021. Action required: Receive and note

For the attention of • Ongoing COVID-19 pandemic with rates and admissions falling after a the Board surge in January • Two RWT-attributed MRSA bacteraemias in 2020-21 to end of Februrary 2021. • 41 cases of toxin positive Clostridium difficile (externally attributable) to end of February 2021. The 2019-20 target for this point was 36; no target was set for 2020-21. • 24 RWT-attributable MSSA bacteraemia against a target of 22 for end of February 2021. • 49 MRSA acquisitions at the end of February 2021, which is an improvement on the previous 2 years • 66 DRHABs at the end of February 2021, above our internal target (44) • In 2020-21 season 74.5% of RWT staff received the influenza vaccine. • Compliance with mandatory training is below 95% for Infection Prevention, Antimicrobial Prescribing and Hand Hygiene competency. Meeting internal C. difficile target, and although above trajectory when compared to last year’s external C. difficile objective, when compared with external objective prior to change in definitions of attribution, no increase in cases. Assure Improving picture of MRSA acquisition, with fewer compared with the previous two years. CPE screening continues to pick up patients and reduce the risk of spread. Reduction in COVID-19 outbreaks and hospital-acquired cases in February Higher numbers of DRHABs this year than seen in recent years. No external C. difficile annual objective advised this year. There have been two Trust-attributable MRSA bacteraemias in the year to end of February 2021. The national objective is zero. Advise Compliance with infection prevention-related mandatory training below 95% (90% for IP mandatory training, 91% for Antimicrobial Prescribing, 87% for Hand Hygiene). A total of 116 probable or definite healthcare-associated COVID19 cases in Trust Board Report January 2021, and a further 16 cases in February 2021.Compliance with infection prevention-related mandatory training below 95% (92% for IP mandatory training, 93% for Antimicrobial Prescribing, 88% for Hand Hygiene). None Alert

Clinical Monthly data and detailed actions discussed at The Infection Prevention implications and and Control Group. Scrutiny of all DRHABs ongoing to look for themes and view areas for action. Patient, carer, MRSA bacteraemia, Clostridium difficile and E Coli bacteraemia available public impact and publically via Pubic Health England views Author + Contact Dr Joanna Macve Ext 88259 Email [email protected] Details: CQC Domains Safe: patients, staff and the public are protected from abuse and avoidable harm. Effective: care, treatment and support achieves good outcomes, helping people maintain quality of life and is based on the best available evidence. Responsive: services are organised so that they meet people’s needs. Well-led: the leadership, management and governance of the organisation make sure it's providing high-quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. Trust Strategic 1. Create a culture of compassion, safety and quality Objectives 2. Proactively seek opportunities to develop our services 3. To have an effective and well integrated local health and care system that operates efficiently 5. Maintain financial health – Appropriate investment to patient services 6. Be in the top 25% of all key performance indicators Links to None Assurances Resource None Implications:

Report Data The previous month’s data may be subject to change following scrutiny of Caveats RCAs.

Equality and None Diversity Impact

Risks: Trust reputational risk if infections increase, financial consequences of not meeting external targets Risk register None reference: Other formal CCG, Public Health contract IP services from RWT bodies involved: References The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (2015)

Report Details 1 Clostridium difficile Infection Due to the COVID-19 pandemic, no annual objective for Clostridium difficile toxin positive cases has been advised this year; last year the annual objective was 40. To the end of February 2021 there were 41 cases against a trajectory of 36 based on last year’s objective (see appendix 1). PCR (non-toxin) cases are also monitored as patient outcomes can be just as harmful to patient safety. At the end of February 2021 there had been 87

Page 2 of 8 Trust Board Report PCR positive cases against our internal target of 99 for this period (see appendix 1).

MRSA Bacteraemia The national objective for MRSA bacteraemia is zero for all NHS organisations. In Q4 so far there have not been any MRSA bacteraemias.

Monthly totals and number externally attributable to RWT Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 19-20 0 0 1 0 0 0 0 2 0 1 0 0 (RWT) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) 20-21 0 1 0 0 2 0 1 1 0 0 0

(RWT) (0) (0) (0) (0) (1) (0) (0) (1) (0) (0) (0)

MSSA bacteraemia MSSA is externally monitored by PHE but targets are set internally. MSSA bacteraemia is a good proxy for MRSA bacteraemia and may be avoidable therefore a local target is applied and cases investigated. In the first two months of Q4 there were 4 internally- attributable cases against a target of 4.

Monthly totals and number internally attributable to RWT Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 18-19 5 8 9 12 5 1 4 11 4 3 10 9 (RWT) (5) (4) (4) (3) (0) (0) (2) (3) (1) (1) (1) (5) 19-20 8 4 7 2 14 7 3 11 6 5 7 7 (RWT) (1) (3) (0) (1) (3) (2) (3) (4) (3) (1) (2) (3) 20-21 3 6 4 8 7 7 7 8 1 7 4 (RWT) (0) (2) (1) (2) (4) (3) (4) (4) (0) (1) (3)

MRSA Acquisitions There have been 49 MRSA acquisitions to the end of February 2021, which is lower at this point in the previous two years (see Appendix 1).

DRHABS Bacteraemia (any organism) related to a medical device is surveyed and acted upon. So far there have been 66 DRHABs against an internal target of 4 cases/month (48 per year, see Appendix 1); there has been an increase both in intravenous line related and urinary catheter related bacteraemias; additionally we are seeing ventilator associated pneumonias in long-stay COVID patients.

Gram negative bacteraemias Gram negative bacteraemias include a number of organisms and there was a national ambition to reduce E. coli bacteraemias by 50% by 2021, which has been revised to 25%. To the end of February 2021 there were 46 RWT-attributable E. coli bacteraemias, 7 fewer than in the same period last year.

Page 3 of 8 Trust Board Report Carbapenemase producing Enterobacteriaceae These multi-antibiotic resistant organisms have caused large outbreaks in UK Trusts, putting patients at risk and causing organisational disruption. In May 2019 a new, more sensitive molecular screening method was introduced, improving detection of cases. To the end of February 2021, seventeen new patients were found to be carrying a CPE, twelve of these were by rectal screening. The reduced number of positive patients compared with previous years may be due partly to reduced travel as a consequence of the pandemic, and partly to reduced screening due to reduced elective activity.

Blood culture contaminants The blood culture contamination rate has increased slightly compared with previous years however it remains below the recommended maximum rate of 3%, with the average rate to the end of February being 2.27%, with effective use of the phlebotomy service when available.

Outbreaks and Incidents

C. difficile Periods of Increased Incidence (PIIs) and Serious incidents (SIs) Three wards had PIIs in the first two months of 2021; forward C41 typing indicated that there had been transmission between patients and this was raised as SI, with remedial actions taken as appropriate. The other clusters were on Deanesly ward and Fairoak ward; typing of the isolates revealed no evidence of spread between patients.

MRSA PII An MRSA PII was identified on the Stroke Unit, with remedial actions taken as appropriate. The ward is now under increased surveillance with screening of patients for MRSA on discharge.

VRE PII An increase incidence of Vancomycin Resistant Enterococcus was noted on ward A12. Enhanced cleaning was done where possible with hydrogen peroxide vapour or Ultraviolet light. Other actions were taken as appropriate. Typing for the two patients indicated there had not been spread between patients.

COVID-19 Outbreaks and PII In January 2021 there were 19 Outbreaks and 6 PII, of which 10 involved patients (see appendix). In February 2021 this fell to 3 outbreaks and 2 PIIs, of which 2 involved patients. These have been both in clinical and non-clinical areas. In January 2021 there were 116 probable or definite cases of hospital acquired COVID-19; this fell to 16 cases in February 2021 (see appendix). Patients are screened for COVID-19 on admission, day 3 and day 5 after admission, and prior to discharge to care homes. There have also been outbreaks and cases in local care homes and RWT infection prevention, however at the time of writing there are no current care home outbreaks in Wolverhampton.

COVID-19 Pandemic This is ongoing, following a brief period in August with no active inpatient cases, there was a steady increase in admissions (including to critical care) in Q3, with a surge in cases in at the beginning of 2021. Cases in the Trust have been falling in recent weeks, with 44 positive inpatients at the time of writing. The local case rate in Wolverhampton has decreased significantly in recent weeks, with 61.1 cases per 100,000 population at the time of writing, having passed 1000 per 100,000 in January; the country remains in lockdown.

Page 4 of 8 Trust Board Report

Seasonal flu plan (supplied by Julie Sharp, Occupational Health) The final figures for the 2020/21 campaign were: 74.5% all staff vaccinated and 71% front line staff vaccinated.

2021/22 plan: • March 2021 – Flu De brief of Campaign 2020/21 • April 2021 – 1st Planning Meeting (Campaign 2021/22) • May 2021 – Peer Vaccinator Recruitment • June 2021 – Peer Vaccinator shortlisting and Kite Training to commence • July 2021 – Flu update & training for peer vaccinators . Flu comms to start Trust wide . 1st Draft of timetable . Weekly planning meetings to commence • August 2021 – Final Draft of timetable • September 2021 – Start Campaign . Weekly Flu meetings . Weekly reporting

To date there have been no identified cases of influenza in Wolverhampton in 2020-21; two of the COVID-19 testing platforms in use at RWT incorporate influenza testing.

Objectives for 2020/21 CDI – no objective (40 cases last year) CDI WCCG - no objective (48 cases last year) MRSA bacteraemia - 0 Flu vaccination – 100% ambition E. coli bacteraemia – no target has been advised, national ambition to reduce Gram negative bacteraemias by 25% by 2021.

At the time of writing we have not yet been informed of objectives for 2021/22.

Page 5 of 8 Trust Board Report

Appendices

1 Appendix 1 – Illustrative charts of Infection data

C. difficile Toxin Positives and External Targets 2020 - 21 80

70

60

50 RWT RWT Target 40 Wolves CCG CCG Target Number 30

20

10

0 Jul-20 Apr-20 Oct-20 Jun-20 Jan-21 Mar-21 Feb-21 Nov-20 Dec-20 Aug-20 Sep-20 May-20

Cumulative RWT-attributable C. difficile positives 180

160

140

120 2014-15 2015-16 100 2016-17 2017-18 80 2018-19 2019-20 2020-21 60 Target 40

20

0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Page 6 of 8 Trust Board Report

Cumulative RWHT-Attributable MSSA Bacteraemias from April 2013 40 35 2013-14 30 2014-15 25 2015-16 20 2016-17

Number 15 2017-18 10 2018-19 5 2019-20 2020-21 0 1 2 3 4 5 6 7 8 9 10 11 12

Cumulative Device Related Hospital Acquired Bacteraemias (DRHABs) from April 2012 120

100 2012-13

80 2013-14 2014-15 60 2015-16 Number 2016-17 40 2017-18

20 2018-19 2019-20 0 2020-21

Page 7 of 8 Trust Board Report

Number of new patients colonised with CPE identified (hospital and community). The three most common types of CPE enzymes are New Delhi Metallo- betalactamase (NDM), OXA-48, and Klebsiella pneumoniae carbapenemase (KPC). Some patients may have more than one enzyme.

Healthcare associated COVID summary table

Summary of outbreaks and PII, and Healthcare acquired cases of COVID 19 in Q3 2020-21. Includes probable healthcare acquired (>8 days from admission) and definite healthcare acquired (>14 days)

Total Outbreaks/PII Total HCAI Covid Outbreaks/PI involving patients cases I Mar 20 0 0 134 in Mar-Apr Apr 20 0 0 May 20 0 0 6 June 20 1 0 0 July 20 0 0 0 Aug 20 0 0 0 Sept 20 3 1 0 Oct 20 7 2 3 Nov 20 14 8 70 Dec 20 10 + 3 PII 7 + 2 PII 79 Jan 21 19 + 6 PII 10 116 Feb 21 3 + 2 PII 2 16

Page 8 of 8 7.6 Infection Prevention & Control Board Assurance Framework (BAF) - Jo Macve Kim Corbett 1 IP BAF TMC report March 2021 v1.1.pdf

Trust Board Report Meeting Date: 6 April 2021

Title: Infection Prevention & Control Board Assurance Framework (BAF)

Purpose of the To present the framework that assesses the Trust against NHS guidance. Report: Summary: The Framework is intended to be a useful document to provide internal assurance against the guidance that quality standards are being maintained. It is in place to protect service users and staff from avoidable harm and is structured around the existing 10 criteria set out in the Code of Practice on the prevention and control of infection which links directly to Regulation 12 of the Health and Social Care Act 2008 and Health and Safety at Work Act 1974. Robust risk assessments processes are central and where this is not possible the risk must be mitigated to provide safe systems of work.

Recommendation: Accept report

Action required: Receive for assurance

Overall compliance with the IP BAF Assure

Sections of non-compliance that the Trust are working towards Advise

Sections that will remain non-compliant Alert

Clinical implications and view Author + Contact Tel Ext 88755 Email [email protected] Details: CQC Domains Safe: patients, staff and the public are protected from abuse and avoidable harm. Effective: care, treatment and support achieves good outcomes, helping people maintain quality of life and is based on the best available evidence. Responsive: services are organised so that they meet people’s needs. Well-led: the leadership, management and governance of the organisation make sure it's providing high-quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. Trust Strategic 1. Create a culture of compassion, safety and quality Objectives 2. Proactively seek opportunities to develop our services 3. To have an effective and well integrated local health and care system that operates efficiently 5. Maintain financial health – Appropriate investment to patient services 6. Be in the top 25% of all key performance indicators Links to None Assurances

Resource Revenue: None Implications:

Report Data None Caveats

Equality and None Diversity Impact

Risks: Trust reputational risk if non-compliant with IP BAF Risk register None reference: Other formal bodies involved: References The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance (2015)

Report Details Gaps identified within the IP BAF 1. Implementation of twice weekly lateral flow testing – LAMP test is currently being rolled out to all RWT staff. 2. Robust IPC risk assessment processes and practices are in place for non COVID- 19 infections and pathogens – environment scores are low in some areas 3. Ensure Trust Board has oversight of ongoing outbreaks and action plans – Infection Prevention and Control report to include numbers of COVID cases, outbreaks and lessons learnt. 4. Mandatory reporting requirements are adhered to and boards continue to maintain oversight – antimicrobial audit results need to be included in the DIPC report 5. Infection status is communicated to the receiving organisation or department when a possible or confirmed COVID-19 patient needs to be moved – A discharge summary review group is in place. A discharge summary audit will be completed by IP in April 2021. 6. Monitoring of inpatients compliance with wearing face masks particularly when moving around the ward (if clinically ok to do so) – This has been discussed and compliance data for patients wearing masks is difficult to monitor as there are many variables. Some patients are exempt or their condition prevents them from wearing them. It is not compulsory. 7. That sites with high nosocomial rates should consider testing COVID negative patients daily – however with lab capacity this is limited.

This document is updated and presented at IPCG monthly to ensure compliance with NHS Guidance

..\..\COVID-19\BAF\March 21\11 - BAF March 21 update.xlsx

Resource/legal/financial/reputation implications Reputation of the organisation if BAF is not achieved Link to BAF/Key risks IP Risk Register Proposals BAF agreed

Page 2 of 2 1 BAF March 21 update.pdf

Infection Prevention and Control board assurance framework V1.6 February 12th 2021

1. Systems are in place to manage and monitor the prevention and control of infection. These systems use risk assessments and consider the susceptibility of service users and any risks posed by their environment and other service users

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and processes are in place to ensure:

Admission screening of all emergencies: ED, Maternity, Cardiac & Haem/Oncology Assurance required from Infection Prevention Team Infection risk is assessed at the front door and this is documented in patient notes Documentation audit Jun-20 GP practice triage patients remotely documentation (IPT)

Infection Prevention and Capacity work together to ensure patients are placed in appropriate beds/wards on admission. There are pathways in place which support minimal or avoid patient bed/ward transfers for Deputy COOs, Capacity Team, Flowcharts developed. Capacity report is Nil Nil Feb-21 duration of admission unless clinically imperative IPT graded RAG to ensure staff are aware of pathways. Electives are nursed in a separate building away from emergencies

Chlorine (Sochlor) used for decontamination. There are bed cleaning teams across the Trust That on occasions when it is necessary to cohort COVID or non-COVID patients, reliable and are working within zoneS. In COVID areas application of IPC measures are implemented and that any vacated areas are cleaned as Nil Nil IPT, Hotel Services Feb-21 Chlorine is used daily, with touch points x 3 per guidance daily. Chlorine and HPV clean to vacate bays/wards

Monitoring of IPC practices, ensuring resources are in place to enable compliance with IPC PPE, Hand Hygiene and Environment audits are practice - staff performed monthly by ward staff and quarterly Wards tasked with clearing staff adherence to hand hygiene - by IP Team. This is all recorded on Health Several staff rooms have no windows rooms and Hepa filter units have IPT Apr-21 staff social distancing across the workplace - staff Assure. Notices on staff rooms, offices, and are cluttered been purchased and will be installed adherence to wearing fluid resistant surgical facemasks (FRSM) in a) clinical meeting rooms to instruct staff how many b) non-clinical allowed in room for social distancing IP Link practitioners and IP Champions are identified in all clinical areas. Monthly PPE Monitoring of staff compliance with wearing appropriate PPE, within the clinical setting audits by ward teams and ad hoc by IPT are Nil Nil Ward/Department Managers Nov-20 completed and uploaded to Health Assure monthly

Lateral flow tests offered to all RWT staff Staff PCR testing completed during Implementation of twice weekly lateral flow antigen testing for NHS patient facing staff, Trust communications sent out to although not all staff have taken the option. outbreaks for all staff linked with the Occupational Health Apr-21 which include organisational systems in place to monitor results and staff test and trace offer staff LAMP testing LAMP testing commenced February 2021 area

Additional targeted testing of all NHS staff, if your Trust has a high nosocomial rate, as During outbreak incidents all staff linked to the Nil Nil Occupational Health Feb-21 recommended by local and regional infection prevention and control/Public Health team clinical area are screened using PCR test Trust Induction and Mandatory training IP Training in IPC standard infection control and transmission based precautions are provided training packages are available on the Intranet. Infection Prevention Team Nil Nil Nov-20 to all staff Reports of compliance is discussed at IPCG (IPT) monthly

IPC measures in relation to COVID-19 should be included in all staff induction and Slides have been included in all induction and Infection Prevention Team Nil Nil Dec-20 mandatory training mandatory training packages (IPT) Links to PHE PPE guidance on the intranet. Poster developed using ABCD categories. PPE group has now been disbanded and all PPE escalation to Silver/Gold Command Continue x 3 weekly review of stock RWT made visors National push strategy of PPE does levels against clinical area usage for All staff (clinical and non - clinical) are trained in putting on and removing PPE; know what Sourcing PPE out-with NHS supply. GPs access not offer medium term assurance of predicted requirements.Source Procurement Team/Infection PPE they should wear for each setting and context; and have access to the PPE that PPE independently, (during Covid via CCG and stock levels Nov-20 alternative suppliers. Risk Prevention Team protects them for the appropriate setting and context as per national guidance RWT process) assessments completed regarding RWT PCN are supplied with PPE from RWT and PPE and Respirators CCG. PHE poster laminated and displayed in practices. Videos available on the Intranet regarding donning and doffing and using a respirator

There are visual reminders displayed communicating the importance of wearing face National guidance Hands , Face, Space posters masks, compliance with hand hygiene and maintaining physical distance both in and out of Nil Nil Communications Team Nov-20 are located around the Trust the workplace Updates included in all user emails and daily Coronavirus update via Comms. Team. IP Team have signed up for daily update e mails from National IPC guidance is regularly checked for updates and any changes are effectively Gov.uk Nil Nil IPT/Communications Team Jun-20 communicated to staff in a timely way

Emergency Preparedness Team update the Executives and forward on any communications. Updates included in all user emails and daily Changes to guidance are brought to the attention of boards and any risks and mitigating Coronavirus update via Comms. Team. IP Team Nil Nil Emergency Preparedness/IPT Jun-20 actions are highlighted have signed up for daily update e mails from Gov.uk

COVID risks on Trust BAF Risks are on Trust Risk Register and Head of Nursing Corporate Risks are reflected in risk registers and the Board Assurance Framework where appropriate Nil Nil Jun-20 reviewed/updated monthly Support Services

All in place Low scoring areas are discussed at IP Policies (CPE, MRSA, Clostridium difficile, environment group to identify if Robust IPC risk assessment processes and practices are in place for non COVID-19 Norovirus, Flu and other alert organisms) Some environmental audits are immediate fixes are adequate. Head of Hotel Services Apr-21 infections and pathogens Monthly Environment, Hand Hygiene and PPE missed or score low Capital & Estates development area audits. included in TOR. Areas that do not improve are escalated to IPCG That Trust Chief Executive, the Medical Director or the Chief Nurse approves and Email generated from Silver personally signs off, all daily data submissions via the daily nosocomial sitrep. This will Dashboard/Information Team indicating Nil Nil IPT/DIPC Nov-20 ensure the correct and accurate measurement and testing of patient protocols are positive swabs in last 24hours and length of activated in a timely manner stay. Signed off by DIPC. This Board Assurance Framework is reviewed, and evidence of assessments are made This BAF is included in the Trust BAF and is Nil Nil IPT/Trust Secretary Feb-21 available and discussed at Trust Board discussed quarterly CNO Report presented monthly including Numbers of outbreaks or learning Senior Matron Infection Ensure Trust Board has oversight of ongoing outbreaks and action plans CNO Report to be reviewed Apr-21 inpatients numbers identified is not curently included Prevention/DIPC Executive/ Senior leadership complete There are check and challenge opportunities by the Executive/senior leadership teams in Unable to evidence that this is walkabouts across RWT for check and Nil Executives/Senior Leadership Apr-21 both clinical and non-clinical areas occuring challenge opportunities

2. Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and processes are in place to ensure:

GPs triaging patients remotely Positive/Possible/Contact/Green wards in the acute setting with designated teams including Fit testing for all staff Designated teams with appropriate training are assigned to care for and treat patients in IPNs and IP Champions supporting local Nil Nil Jun-20 COVID-19 isolation or cohort areas practice RWT PCN have identified an isolation room in each practice in the rare event patients presents with symptoms of COVID having penetrated the pre screening questions.

Apart from Warstones Surgery, GP practices in RWT PCN have contracts As above. with private cleaning companies who Hotel Services staff all trained including Fit continue to clean daily. All clinicians testing for all staff. There is a dedicated group clean rooms including equipement Scope cleaning services in each Designated cleaning teams with appropriate training in required techniques and use of of staff who clean COVID areas across the Trust between patients using clinell wipes. practice and health centres and Practice Managers of Vis Aug-20 PPE, are assigned to COVID-19 isolation or cohort areas. Including ED. Evidence is available of names of In the event of having a patient identify any gaps these staff. There are 97 housekeepers who attending with symptoms, the room are Fit tested would be cleansed as directed and ventilated.

Apart from Warstones Surgery, GP practices in RWT PCN have contracts with private cleaning companies who continue to clean daily. All clinicians Chlorine (Sochlor) used for decontamination. clean rooms including equipement Scope cleaning services in each Decontamination and terminal decontamination of isolation rooms or cohort areas is There are bed cleaning teams across the Trust between patients using clinell wipes. practice and health centres and Practice Managers of Vis 21st August 2020 carried out in line with PHE and other national guidance and are working within zones In the event of having a patient identify any gaps attending with symptoms, the room would be cleansed as directed and ventilated. Apart from Warstones Surgery, GP practices in RWT PCN have contracts Housekeeping is following the national with private cleaning companies who specification document on frequency of continue to clean daily. All clinicians toilet/bathroom cleaning. Specifically, 2 x full clean rooms including equipement clean and 1 x spot clean daily for high risk Identify level of cleaning required Increased frequency, at least twice daily, of cleaning in areas that have higher between patients using clinell wipes. (wards) and 1 x full clean and 1 x spot clean for and what happens in GPs and Health Practice Managers of Vis Aug-20 environmental contamination rates as set out in the PHE and other national guidance In the event of having a patient significant risk (clinics) daily centres attending with symptoms, the room Daily Chlorine (Sochlor) clean on all positive would be cleansed as directed and wards. ventilated.

Apart from Warstones Surgery, GP The Trust COVID decontamination is classed as practices in RWT PCN have contracts an 'Amber' clean with private cleaning companies who Evidence in RAG poster and increased continue to clean daily. All clinicians Cleaning is carried out with neutral detergent, a chlorine-based disinfectant in the form of quantities of Chlorine (Sochlor) ordered. clean rooms including equipement a solution at a minimum strength of 1,000ppm available chlorine, as per national guidance. Housekeeping is following the national between patients using clinell wipes. Scope cleaning services in each If an alternative disinfectant is used, the local specification document on frequency of In the event of having a patient practice and health centres and Practice Managers of Vis Aug-20 infection prevention should be consulted on this to ensure that this is effective against toilet/bathroom cleaning. Specifically, 2 x full attending with symptoms, the room identify any gaps enveloped viruses clean and 1 x spot clean daily for high risk would be cleansed as directed and (wards) and 1 x full clean and 1 x spot clean for ventilated. significant risk (clinics) da Toilets in GP surgeries are closed to patients and members of the public as cannot be cleaned after each use

Scope cleaning services in each Manufacturers' guidance and recommended product "contact time" must be followed for Initial and refresher training logs/documents External Contractors practice and health centres and Practice Managers of Vis Aug-20 all cleaning/disinfectant solutions/products identify any gaps

As per national guidance frequently touched’ surfaces, e.g. door/toilet handles, patient call bells, over bed tables and bed rails, should be decontaminated at least twice daily On the wards, this is part of the daily Griffiths Drive Surgery, Warstones Scope cleaning services in each and when known to be contaminated with secretions, specification. In communal areas, our re- comply. practice and health centres and Practice Managers of Vis Aug-20 excretions or body fluids deployed staff have been used to clean identify any gaps touchpoints throughout the day.

Apart from Warstones Surgery, GP practices in RWT PCN have contracts with private cleaning companies who This activity is performed by individual staff in As per national guidance electronic equipment, eg mobile continue to clean daily. All clinicians departments it is part of the cleaning strategy, phones, desk phones, tablets, clean rooms including equipement assured through monthly environment audits. Checklists to be implemented for this Ward/Department Managers Jul-20 desktops and keyboards cleaned at least twice daily between patients using clinell wipes. purpose In the event of having a patient attending with symptoms, the room would be cleansed as directed and ventilated.. Does not coincide with shift change overs and PPE removed in between If scores are low then feedback to Areas are cleaned as per the national these times team is undertaken and any gaps in specification document. Dirty Utilities are training/service provision discussed. Rooms/areas where PPE is removed must be decontaminated, timed to Hotel Services Manager Jun-20 cleaned twice daily. Assured through technical If any technical audits score below Low scoring areas are discussed at coincide with periods immediately after PPE removal by groups of staff(at least twice cleaning audit then the 98% threshold the Environment Group and any that daily) frequency of re-audit is increased require escalation are raise to IPCG.

All linen is treated as infectious and is in red alginate bags. Policy updated Nil Nil IPT Jun-20 Linen from possible and confirmed COVID-19 patients is managed in line with PHE and other national guidance and the appropriate precautions are taken Sessional use of PPE as per PHE Guidance No reprocessing of single use items, Single use items are used, where possible, and according to Single Use Policy Nil Nil Ward/Department Managers Jun-20

Equipment is decontaminated using disinfectant (Clinell green), Chlorine (Chlorox) Reusable equipment is appropriately decontaminated in line with local and PHE and other wipes or Chlorine 1000ppm. On site sterile Nil Nil Ward/Department Managers Jun-20 national policy services for reprocessing items required to be sterile – any non –conformities are reported and monitored 3 monthly at IPCG and bi- monthly at Decontamination Group.

Non-clinical areas are cleaned daily. Posters are No evidence recorded. Staff must Regular communication Trustwide Head of Hotel Ensure cleaning standards and frequencies are monitored in non-clinical areas with actions in place ensuring that staff are cleaning their take responsibility for own work regarding maintaining cleaning Services/Communication Nov-20 in place to resolve issues in maintaining a clean environment work surfaces and equipment at the start and space standards and Team/ Office Managers end of their shift

Social distancing measures have been Ventilation installed to guidance at the time of Project required to survey general implemented in areas. construction which includes a mix of natural ventilation in admission and waiting and mechanically ventilated systems. Some areas across the Organisation as part Reception staff should wear a face Head of Estates areas may have low levels of ventilation of the fresh air survey already being mask – PPE Guidance available. Ensure the dilution of air with good ventilation e.g. open windows, in admission and Development/Head of particularly where areas have been created in undertaken by estates Some outpatient areas have Jun-20 waiting areas to assist the dilution of air Estates/Health and Safety corridors and areas have been converted to developments. Ventilation Risk introduced screens Officers waiting facilities. Waiting areas not assessment to be added to Segregation in ED. encouraged however thoses that are have ward/department COVID RA and Windows to be opened for 5 - 10 social distancing practices in place. stored on Sharepoint minutes every hour

Environmental audits completed monthly by Audits scores and non-compliance Monitor adherence environmental decontamination with actions in place to mitigate any Ward/Department clinical teams and uploaded to Health Assure. reviewed at monthly Environment IPT complete peer audits Feb-21 indentified risk Managers/IPT Technical audits completed by Hotel Services Group

Environmental audits completed monthly by Audits scores and non-compliance Monitor adherence to the decontamination of shared equipment with actions in place to clinical teams and uploaded to Health Assure. Ward/Department reviewed at monthly Environment IPT complete peer audits Feb-21 mitigate any identified risk Technical audits completed by Hotel Services. Managers/IPT Group Commode audits completed ad hoc by IPT

3. Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and process are in place to ensure: Pharmacists are continuing to screen prescriptions to check that antimicrobial Arrangements around antimicrobial stewardship are maintained prescribing is appropriate, including COVID-19 Nil Nil Antimicrobial pharmacist Jul-20 positive patients. Audis completed and presented routinely through IPCG

Microbiology and Pharmacy have worked closely with ICCU and AMU to ensure antimicrobial guidelines are appropriate, and use of bacterial infection markers such as Procalcitonin are used to aid antimicrobial Audit data to be included in the DIPC Audit of antibiotic prescribing for all Antimicrobial pharmacist Apr-21 stewardship. An audit is planned to review report patients presented at IPCG Quarterly antibiotics prescribed in COVID-19 positive patients, to review practice across the Trust. Mandatory reporting requirements are adhered to and boards continue to maintain DATIX reports are completed when oversight appropriate.

4. Provide suitable accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/ medical care in a timely fashion

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and processes are in place to ensure:

Visiting was suspended at midnight on 14th March 2020, this remains under regular review through the Senior Nurses and Midwives Group. OP04 Appendix 3 No local guidance for compassionate Implementation of national guidance on visiting patients in a care setting states how to re-introduce visiting. Nil Executives/Senior Leadership Apr-21 visiting Compassionate visiting national guidance is NHSE/I Reference 001559 RWT PCN patients are encouraged to attend alone unless need extra support.

Posters are outside of Critical care and respiratory ward where AGPs take place Areas in which suspected or confirmed COVID-19 patients are where possible being treated Ward/Department Posters are in place in GPs and Health Centres Nil Nil Jun-20 in areas clearly marked with appropriate signage and have restricted access Managers/IPT

Information is available Easy read information available through Information and guidance on COVID-19 is available on all Trust websites with easy read Mencap e link and communicated via comms Nil Nil Communications Team Jun-20 versions 17 March ‘20

Teletracking/SafeHands records the infection Explore method to collect this data status of the patients for internal use. Discharge summary documentation Infection status is communicated to the receiving organisation or department when a COVID Screening Audits are taking The transfer (SBARD) document is completed is being reviewed but is sent out Matrons Apr-21 possible or confirmed COVID-19 patient needs to be moved place regarding transfers to care between ward/hospital moves electronically to all GPs on discharge homes. Discharge summary is completed and sent to GP’s electronically. The D2A form includes infection status. Datix of non-compliances are encouraged There is clearly displayed and written information available to prompt patients' visitors and Posters are located throughout the Trust both Nil Nil Communications Team Nov-20 staff to comply with hands, face, space advice inside and outside. Information has been added to all correspondence to patients

5. Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and processes are in place to ensure:

Temperature checks and triage Screening and triaging of all patients as per IPC and NICE guidance within all health and Risk assessment in ED and AMU, Maternity. Nil Nil Ward/Department Managers Nov-20 other care facilities must be undertaken to enable early recognition of COVID-19 cases ED stream patients and waiting room segregation for respiratory symptom patients GPs triage patients remotely

Temperature checks and triage front door areas have appropriate triaging arrangements in place to cohort patients with Emergency Risk assessment in ED and AMU, Maternity. possible or confirmed COVID-19 symptoms and to segregate them from non COVID-19 Nil Nil Portals/ward/Department Nov-20 ED stream patients and waiting room cases to minimise the risk of cross infection as per national guidance Managers segregation for respiratory symptom patients GPs triage patients remotely

Emergency All emergency portals are aware of the agreed Staff are aware of agreed template for triage questions to ask Nil Nil Portals/ward/Department Nov-20 template and is used for all patients and Managers updated as guidance changes Emergency Triage undertaken by clinical staff who are trained and competent in the clinical case All emergency portals are aware of the agreed Nil Nil Portals/ward/Department Nov-20 definition and patient is allocated appropriate pathway as soon as possible template and is used for all patients Managers Security are manning stands at entrances ensuring staff and visitors wear face coverings. Some patients are unable to comply Staff wear PPE and maintain 2 metre Face coverings are used by all outpatients and visitors Ward/Department Managers Nov-20 OPD are informing staff through due to medical condition distance wherever possible. correspondence

Staff wear PPE and maintain 2 metre Some patients are unable to comply distance wherever possible. Patients Face masks are available for all patients and they are always advised to wear them due to medical condition. No are encouraged to wear face masks Ward/Department Managers Apr-21 compliance data available when moving around the ward and if Wards have a supply of surgical face masks. they are able to during the day. Communication has been diseminated

Provide clear advice to patients on use of face masks to encourage use of surgical Some patients are unable to comply Staff wear PPE and maintain 2 metre facemasks by all inpatients in medium and high risk pathways if this can be tolerated and due to medical condition. No distance wherever possible. Patients Senior Sisters/Charge Nurses Apr-21 does not compromise their clinical care Communications are sent out through compliance data available are encouraged to wear face masks Coronavirus updates to inform staff to when moving around the ward and if encourage inpatients to wear a facemask they are able to during the day.

This has been discussed and Monitoring of inpatients compliance with wearing face masks particularly when moving Some patients are unable to comply compliance data for patients wearing around the ward (if clinically ok to do so) due to medical condition masks will be difficult to monitor No compliance data available IPT Mar-21 Reception staff should wear a face mask – PPE Guidance available. All areas that have requested screen Some outpatient areas have introduced have had them fitted, additional Ideally segregation should be with separate spaces, but there is potential to use screens, Nil Head of Estates Jun-20 screens screens can be fitted at request to e.g. to protect reception staff Segregation in ED the estates helpline. Patient segregation in RWT Primary Care.

No evidence available but IPNs walk Inpatients areas are encouraged to sit the Matron/ Senior Sister/Charge To ensure 2 metre social and physical distancing in all patient care areas around wards to check on a regular Ward staff to monitor compliance Nov-20 patients on opposite sides of beds to ensure Nurse basis that 2 metre distancing is maintained

Screenings are taken in ED or in ward areas if patients become symptomatic. Rapid testing is available in ED for patients who are being transferred to ICCU, Stroke Unit and Trauma for a quick decision on where to place patients. For patients with new-onset symptoms, isolation, testing and instigation of contact tracing COO/Deputy COO/Capacity Nil Flowcharts developed Nov-20 is achieved until proven negative A ward is available for patients who are Team deemed possible COVID with several side rooms available. A surge plan is in place. IP and Capacity work closely together to place patients in appropriate beds. IP Team moved to co-locate with Capacity team RWT PCN sign post symptomatic paients to 111 Patients that test negative but display or go on to develop symptoms of COVID-19 are Senior Sisters/Charge Nil Nil Nov-20 segregated and promptly re-tested and contacts traced promptly As above Nurses/Capacity There is evidence of compliance with routine patient testing protocols in line with key Compliance data is reported to IPCG on a Senior Matron Infection Nil Nil Nov-20 actions:infection prevention and control and testing document monthly basis Prevention/DIPC

Each directorate to complete Trust guidelines developed and being piloted West Park OPD, CCH NRU and assessments and review at local for Outpatient areas which includes guidance Patients that attend for routine appointments who display symptoms of COVID-19 are Neurophysiology and Maternity governance meetings on possible Covid-19 patients. Directorate Managers Jul-20 managed appropriately comply. All OPD areas have RA's in Gaps to be risk assessed and place considered by Divisional governance Compliance framework developed for local completion and subsequent risk assessment

6. Systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and processes are in place to ensure:

Elective patients are nursed in D Block, Beynon Separation of patient pathways and staff flow to minimise contact between pathways. For and Cannock Chase Hospital. One way systems COO/Deputy COO/Capacity example, this could include provision of separate entrances/exits (if available) or use of one- Nil Nil Nov-20 available in outpatients. Chairs have been Team way entrance/exit sytems, clear signage, and restricted access to communal areas removed from waiting rooms to ensure 2 metre distance. All main entrances have barriers to maintain entrance and exit routes Links to PHE Guidance on the intranet. Daily Coronavirus Communication e mails sent to all users.

Infection Prevention Team, IP Champions and Nurse Education Team are visiting areas daily All staff (clinical and non- clinical) have appropriate training, in line with latest PHE and to keep staff informed. Nil Nil IPT/Nurse Education Jun-20 other guidance, to ensure their personal safety and working environment is safe Training hub within Clinical Skills Hubs set up across Trust for Fit testing Training records available for Fit testing Extensive education with ICU/C19 where patients received CPAP/NIV/ventilation. PPE in RWT Primary Care worn, no need for FFP 3 masks , nursing staff have undergone the testing. As above plus PPE posters, videos including 3M respirator use All staff providing patient care and working within the clinical environment are trained in Fit testing has continued throughout and the selection and use of PPE appropriate for the clinical situation and on how to safely don Nil Nil IPT/Nurse Education Jun-20 central register of Fit tested staff held and doff it corporately

Fit testing recorded centrally and available A record of staff training is maintained locally. Training records held for Hand Hygiene Nil Nil Clinical Skills Jun-20 Competency and IP Mandatory Training. FFP3 Training database is stored on Sharepoint

Weekly/monthly ward audit of PPE use Adherence to PHE national guidance on the use of PPE is regularly audited with actions in recorded on Health Assure (5 observations per Nil Nil Senior Sister/Charge Nurse Jun-20 place to mitigate any identified risk week) Adverse findings feedback to Department leader and revisit takes place

Hygiene facilities (IPC measures) and messaging are available for all patients/individuals, staff and visitors to minimise COVID-19 transmission such as - hand hygiene facilities including instructional posters - good respiratory hygiene measures Information available on the Intranet, external - staff maintaining physical distancing of 2 metres wherever possible unless wearing PPE as internet, Social Media, posters across the part of direct care - staff Organisation, regular COVID updates through e Nil Nil Communications Team Nov-20 maintain social distancing (2m+) when travelling to work (including car sharing) and remind mails for staff. Posters around the Trust Hands, staff to follow public health guidance outside of workplace Face, Space - frequent decontamination of equipment and environment in both clinical and non-clinical areas - clear visually displayed advice on use of face coverings and facemasks by patients/individuals, visitors and by staff in non-patient facing areas

5 Moments of Hand Hygiene audits are completed monthly at ward level and also by IPT if required Senior Sister/Charge Staff regularly undertake hand hygiene and observe standard infection control precautions Glowbox is available in clinical areas to observe Nil Nil Jun-20 Nurse/IPT hand hygiene competence The use of Hand air dryers should be avoided in all clinical areas. Hands should be dried Housekeeping Manager, All clinical rooms and patient WCs in clinical Survey where hand driers are in all with soft, absorbent, disposable paper towels from a dispenser which is located close to No hand dryers in any clinically Primary care manager and areas have paper hand towels in hospital. settings and Trust position to be Jun-20 the sink but beyond the risk of splash contamination, as per national guidance settings Head of Estates where service Some public WCs and staff WCs have either or. agreed outsourced

Posters displayed and hand washing Hotel Services Guidance on hand hygiene, including drying, should be clearly displayed in all public toilet instructions on the back board or near to soap Nil Nil Manager/Communications Jun-20 areas as well as staff dispensers Team Trust Dress Code Policy on the intranet Staff understand the requirements for uniform laundering where this is not provided for on Re-iterated in Communication e mails to all No formal evidence of staff Communications Team/All Nil planned Jun-20 site users and also by Chief Nurse comprehension RWT Staff

Occupational Health and Wellbeing guidance on intranet Advice phone lines available. Staff have been informed via trust communications that if they develop symptoms or self- isolating in view of All staff understand the symptoms of COVID-19 and take appropriate action (even if symptomatic household contact they must No formal evidence of staff Communications Team/All experiencing mild symptoms) in line with PHE and other national guidance if they or a Nil planned Jun-20 inform the OH service via the COVID helpline at comprehension RWT Staff member of their household display any of the symptoms. which point they will be referred for testing if they fit the criteria which includes new persistent cough, temperature, loss of taste/smell.

Local authority and Public Health attend Silver A rapid and continued response through ongoing surveillance of rates of infection Command to update the Organisation on rates transmission within local propulation and for hospital/organisation onset cases (staff and Nil Nil Public Health/Wolves CCG Jun-20 of transmission. HCAI monitored and reported patients/individuals) through Datix

Outbreak process in place. IIMarch documents Positive cases identified after admission who fit the criteria for investigation should trigger completed and meetings arranged. Electronic a case investigation. Two or more positive case linked in time and place trigger an outbreak system introduced by NHSE/I which replaced Nil Nil IPT Nov-20 investigation and are reported the IIMarch forms HCAI process in place. Datix and scrutiny

All IP policies have been reviewed and COVID Robust policies and procedures are in place for the identification of and management of included where necessary. Also a COVID policy Nil Nil IPT/Trust Secretary Nov-20 outbreaks of infection. This inclues the documented recording of outbreak meetings has been developed to ensure all information is located in one place

7. Provide or secure adequate isolation facilities

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and processes are in place to ensure:

Restricted access between pathways if possible (depending on size of the facility, Elective patients are nursed in D Block, Beynon COO/Deputy COO/Capacity Nil Nil Nov-20 prevalence/incidence ratelow/high) by other patients/individuals, visitors or staff and Cannock Chase Hospital.Red/Amber/Green Team wards are identified. Areas/wards are clearly signposted, using physical barriers as appropriate to Matrons/Senior Sister/Charge Nil Nil Nov-20 patients/individuals and staff understand the different risk areas Posters are in place for all closed wards. Nurse Cohort wards in use AMU have a process to segregate patients on Patients with suspected or confirmed COVID-19 are isolated in appropriate facilities or transfer from ED designated areas where appropriate Side rooms are available across the Trust for Nil Nil Capacity Team/IPT Jun-20 positive patients in specialist areas ICCU have designated areas for COVID and non COVID

Two new wards with negative Areas used to cohort patients with suspected or confirmed COVID-19 are compliant with Monthly environment audits are completed by No ante rooms and very few negative pressure ability on line in next 3 Senior Sister/Charge Nurse Jun-20 the environmental requirements set out in the current PHE national guidance ward staff and IPT complete them as required pressure rooms months. These wards are now fully open

Patients with resistant/alert organisms are managed according to local IPC guidance, Senior Sister/Charge Nil Nil Jun-20 including ensuring appropriate patient placement IP suite of policies are available on the Intranet Nurse/IPT

8. Secure adequate access to laboratory support as appropriate

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG There are systems and processes in place to ensure:

Process of completing a competency document on COVID testing is currently being developed.

Competency documents for all methods are available within the department. BMS staff are No competency documents for staff Infection Prevention Team Testing is undertaken by competent and trained individuals HCPC registered. The micro management team Competency Document ratified Jun-20 obtaining swabs from patients (IPT) does not roster staff in an area where they have not been competency assessed and keep an up to date record of all assessments. The department is UKAS accredited, although COVID 19 testing is not currently within this scope as it is such a new test.

Time for in-house testing is 24 hours. An outstanding worklist is completed twice a day to ensure that there are no issues, any Patient and staff COVID-19 testing is undertaken promptly and in line with PHE and other Matrons/Department requests exceeding the 24hours are Nil Nil Nov-20 national guidance Managers investigated and resolved. POCT now in place in ED and operational. Staff have are using Lateral Flow/LAMP Testing Regular monitoring and reporting of the testing turnaround times with focus on the time Nil Nil IPT/Microbiology Nov-20 taken from the patient to time result is available This is reported at Silver Command if required Regular monitoring and reporting that identified cases have been tested and reported in Protocols in place in the Lab Nil Nil Lab Manager line with the testing protocols (correctly recorded data) Jun-20 Testing taking place in all emergency portals. OH Well Being process in place. MRSA screening is monitored monthly and fed back to areas via IPCG Education/Reminder e CPE Screening is monitored quarterly and fed MRSA Screening is below expectation mails/Mandatory training raising back to areas via IPCG Screening for other potential infections takes place - Screening compliance is improving awareness on importance of IPT Jun-20 month on month screening and risk assessing patients All routine microbiology continues, with the for CPE on admission exception of urine microscopy, h. pylori faecal antigen and crypto/giardia faecal screening. Continues as per IP policies.

All patients through any Emergency Portal has Senior Matron Infection That all emergency patients are tested for COVID-19 on admission a POCT and PCR test. Compliance data is Nil Nil Feb-21 Prevention/DIPC reported to IPCG monthly That those inpatients who go on to develop symptoms of COVID-19 after admission are Screening takes place in all ward areas if Nil Nil Senior Sister/Charge Nurse Feb-21 retested at the point symptoms arise patients become symptomatic All patients have Day 3 and Day 5 screens post Senior Sister/Charge That those emergency admissions who test negative on admission are retested on Day 3 of admission unless known positive. Compliance Nil Nil Nurse/Senior Matron Feb-21 admission, and again between 5 - 7 days post admission data is reported to IPCG monthly Infection Prevention/DIPC Contact patients are screened That sites with high nosocomial rates should consider testing COVID negative patients daily Not acheivable due to lab capacity regularly at Day 0, 7 and 12 That those being discharged to a care home are being tested for COVID-19 48hrs prior to All patients discharged to a care home have a discharge (unless they have tested positive within th eprevious 90 days) and result is COVID swab. Care homes refuse transfer if no No compliance data Nil Senior Sister/Charge Nurse Feb-21 communicated to receiving organisation prior to discharge recent result That those being discharged to a care facility within their 14 day isolation period should be Designated settings identified as Atholl House discharged to a designated care setting, where they should complete their remaining Nil Nil Discharge Co-ordinators Feb-21 and Bradley Resource isolation Swabbing hub in place. All information is That all Elective patients are tested 3 days prior to admission and are asked to self-isolate stored and all results are relayed to Nil Nil Senior Sister Swabbing Hub Feb-21 from the day of their test until day of admission appropriate people and patients are informed of their results

9. Have and adhere to policies designed for the individual’s care and provider organisations that will help to prevent and control infections

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and processes are in place to ensure that: IP Team are allocated to all areas to support and educate wards IP Ambassadors identified locally Nil Staff are supported in adhering to all IPC policies, including those for other alert organisms IP Ambassadors re-deployed to support IP team corporately. Nil Matrons/IPT Jun-20 PHE guidance links on intranet. Communication e mail daily if any updates Nil Any changes to the PHE national guidance on PPE are quickly identified and effectively issues communicated to staff Nil IPT Jun-20

Compliant. Waste Manager responsible Waste guidance posters around organisation Nil All clinical waste and linen/laundry related to confirmed or suspected COVID-19 cases is handled, stored and managed in accordance with current national guidance Nil Senior Sister/Charge Nurse Jun-20 PPE is allocated by Procurement team and PPEG depending on local daily usage. On line e request form completed by clinical Nil areas for their PPE requirements. Stored appropriately PPE stock is appropriately stored and accessible to staff who require it Nil Senior Sister/Charge Nurse Jun-20 10. Have a system in place to manage the occupational health needs and obligations of staff in relation to infection

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Appropriate systems and processes are in place to ensure:

Individual risk assessment template devised taking into account vulnerable, shielding, pregnant and BAME groups. Line managers responsible for working with employee for completion of assessment Staff in ‘at-risk’ groups are identified and managed appropriately including ensuring their Matrons/Senior Sister/Charge HR redeployment register devised (HR can Nil Nil Jun-20 physical and psychological wellbeing is supported Nurse provide figures indicating how many redeployed). Health & Wellbeing lead employed, bi-weekly steering group set up, psychological referral pathway for staff to access support set up between OH and HR.

That risk assessment(s) is (are) undertaken and documented for any staff members in an at All risk assessments are completed for all RWT Risk assessments are reviewed Matrons/Senior Sister/Charge risk or shielding groups, including Black, Asian and Minority Ethnic (BAME) and pregnant Nil Jun-20 staff and are stored on ESR regularly as the Pandemic changes Nurse staff Video available on the intranet for each type of Directorate/Department Managers to respirator. Compliance data stored on keep a record of evidence Staff required to wear FFP reusable respirators undergo training that is compliant with PHE Directorate/Department Sharepoint Nil retrospectively and prospectively. On Jul-20 national guidance and a record of this training is maintained Managers call managers also have access to this list Clinical Skills Team and a group of staff across Staff who carry out fit test training are trained and competent to do so Nil Nil Clinical Skills/Nurse Education Jun-20 RWT are recognised Fit Testers All staff required to wear an FFP respirator have been fit tested for the model being used Fit testing takes place on all FFP3 masks that Nil Nil Clinical Skills/Nurse Education Jun-20 and this should be repeated each time a different model is used are available in the Trust A record of the fit test and result is given to and kept by the trainee and centrally within The results are recorded on ESR and report Nil Nil Clinical Skills/Nurse Education Jun-20 the organisation available for on call managers on a central file

For those who fail a fit test, there is a record given to and held by trainee and centrally The results are recorded on ESR and report Nil Nil Clinical Skills/Nurse Education Jun-20 within the organisation of repeating testing on alternative respirators and hoods centrally available for

For members of staff who fail to be adequately fit tested a discussion should be had, Redeployment opportunities are available regarding redeployment opportunities and options commensurate with the staff members Nil Nil Matrons Jun-20 within RWT skills and experience and in line with nationally agreed algorithm A documented record of this discussion should be available for the staff member and held These are held in personal files. There is no Only the Line Manager is aware of centrally within the organisation, as part of employment record including Occupational Nil Matrons Apr-21 central repository and not sent to OH issues Health Several different respirators are available Following consideration of reasonable adjustments e.g. respiratory hoods, personal re- across the Trust and are kept in CERL. They are useable FFP3, staff who are unable to pass a fit test for an FFP respirator are redeployed asset traced and recorded on Teletracking. This Nil Nil Senior Sister/Charge Nurse Jun-20 using the nationally agreed algorithm and a record kept in staff members personal record information is stored on ESR and personal files and occupational health service record but no central repository an not sent to OH Boards have a system in place that demonstrates how, regarding of fit testing, the organisation maintains staff safety and provides safe care across all care settings. This The results are recorded on ESR and a report is Nil Nil Jun-20 system should include a centrally held record of results which is regularly reviewed by the stored on a central file for on call managers Board

Housekeeping staff have allocated areas for cleaning. Housekeeping have consolidated Consistency in staff allocation is maintained, with reductions in the movement of staff their specialist teams that were site-side (ie between different areas and the cross-over of care pathways between planned and Matrons/Hptel Services bed team, barrier team, afternoon toilet elective care pathways and urgent and emergency care pathways, as per national Nil Nil Manager/Senior Sister/Charge Jun-20 cleaners) into one team segregated into guidance Nurse allocated zones to minimise staff movement between areas. This can be evidenced by staff rota's

All staff should adhere to national guidance on social distancing (2 metres) wherever Trust Guidance is now available Nil Nil Directorates Jun-20 possible, particularly if not wearing a facemask and in non-clinical areas Health and care settings are COVID-19 secure workplaces as far as practical, that is, that PPE is available for all staff. Risk assessments Nil Nil Directorates Jun-20 any workplace risk(s) are mitigated maximally for everyone are completed for all areas. Communications are sent out through all user e mails and Coronavirus twice weekly updates Nil Nil Communications Team Jun-20 Staff are aware of the need to wear facemask when moving through COVID-19 secure to inform staff to wear a facemask at all times areas

Staff managed as per HR policy and supported Staff absence and well-being are monitored and staff who are self-isolating are supported by Local manager and OH. Data reported at and able to access testing Silver Command meetings Nil Nil HR Manager Jun-20

Workforce has monitoring system in place. Testing has been available since 06/04/20 and OH helpline in place to support this and co- ordinate referrals for testing.

Algorithm agreed by consultant microbiologist Staff who test positive have adequate information and support to aid their recovery and to ensure risk to vulnerable patients/staff Nil Nil Occupational Health Jun-20 return to work. reduced and staff member returns to a low risk area until negative result achieved, OH helpline team inform staff member of result, phased return to work etc. can be supported if necessary due to long term effects such as fatigue. 1. Systems are in place to manage and monitor the prevention and control of infection. These systems use risk assessments and consider the susceptibility of service users and any risks posed by their environment and other service users

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and processes are in place to ensure:

Lateral flow tests offered to all RWT staff Staff PCR testing completed during Implementation of twice weekly lateral flow antigen testing for NHS patient facing staff, Trust communications sent out to although not all staff have taken the option. outbreaks for all staff linked with the Occupational Health Apr-21 which include organisational systems in place to monitor results and staff test and trace offer staff LAMP testing LAMP testing commenced February 2021 area

All in place Low scoring areas are discussed at IP Policies (CPE, MRSA, Clostridium difficile, environment group to identify if Robust IPC risk assessment processes and practices are in place for non COVID-19 Norovirus, Flu and other alert organisms) Some environmental audits are immediate fixes are adequate. Head of Hotel Services Apr-21 infections and pathogens Monthly Environment, Hand Hygiene and PPE missed or score low Capital & Estates development area audits. included in TOR. Areas that do not improve are escalated to IPCG

CNO Report presented monthly including Numbers of outbreaks or learning Senior Matron Infection Ensure Trust Board has oversight of ongoing outbreaks and action plans CNO Report to be reviewed Apr-21 inpatients numbers identified is not curently included Prevention/DIPC

Executive/ Senior leadership complete There are check and challenge opportunities by the Executive/senior leadership teams in Unable to evidence that this is walkabouts across RWT for check and Nil Executives/Senior Leadership Apr-21 both clinical and non-clinical areas occuring challenge opportunities

3. Ensure appropriate antimicrobial use to optimise patient outcomes and to reduce the risk of adverse events and antimicrobial resistance

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and process are in place to ensure: Microbiology and Pharmacy have worked closely with ICCU and AMU to ensure antimicrobial guidelines are appropriate, and use of bacterial infection markers such as Mandatory reporting requirements are adhered to and boards continue to maintain Procalcitonin are used to aid antimicrobial Audit data to be included in the DIPC Audit of antibiotic prescribing for all Antimicrobial pharmacist Apr-21 oversight stewardship. An audit is planned to review report patients presented at IPCG Quarterly antibiotics prescribed in COVID-19 positive patients, to review practice across the Trust. DATIX reports are completed when appropriate.

4. Provide suitable accurate information on infections to service users, their visitors and any person concerned with providing further support or nursing/ medical care in a timely fashion

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and processes are in place to ensure:

Visiting was suspended at midnight on 14th March 2020, this remains under regular review through the Senior Nurses and Midwives Group. OP04 Appendix 3 No local guidance for compassionate SOPs available for visiting including Implementation of national guidance on visiting patients in a care setting states how to re-introduce visiting. Executives/Senior Leadership Apr-21 visiting compassionate visiting Compassionate visiting national guidance is NHSE/I Reference 001559 RWT PCN patients are encouraged to attend alone unless need extra support. Teletracking/SafeHands records the infection Explore method to collect this data status of the patients for internal use. Discharge summary documentation is Infection status is communicated to the receiving organisation or department when a COVID Screening Audits are taking The transfer (SBARD) document is completed being reviewed but is sent out Matrons Apr-21 possible or confirmed COVID-19 patient needs to be moved place regarding transfers to care between ward/hospital moves electronically to all GPs on discharge homes. Discharge summary is completed and sent to GP’s electronically. The D2A form includes infection status. Datix of non-compliances are encouraged

5. Ensure prompt identification of people who have or are at risk of developing an infection so that they receive timely and appropriate treatment to reduce the risk of transmitting infection to other people

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Systems and processes are in place to ensure:

Staff wear PPE and maintain 2 metre Some patients are unable to comply distance wherever possible. Patients Face masks are available for all patients and they are always advised to wear them due to medical condition. No are encouraged to wear face masks Ward/Department Managers Apr-21 compliance data available when moving around the ward and if Wards have a supply of surgical face masks. they are able to during the day. Communication has been diseminated

Staff wear PPE and maintain 2 metre Provide clear advice to patients on use of face masks to encourage use of surgical Some patients are unable to comply distance wherever possible. Patients facemasks by all inpatients in medium and high risk pathways if this can be tolerated and due to medical condition. No are encouraged to wear face masks Senior Sisters/Charge Nurses Apr-21 does not compromise their clinical care Communications are sent out through compliance data available when moving around the ward and if Coronavirus updates to inform staff to they are able to during the day. encourage inpatients to wear a facemask

This has been discussed and Monitoring of inpatients compliance with wearing face masks particularly when moving Some patients are unable to comply compliance data for patients wearing IPT/Ward Staff around the ward (if clinically ok to do so) due to medical condition masks will be difficult to monitor No compliance data available Mar-21 8. Secure adequate access to laboratory support as appropriate Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG There are systems and processes in place to ensure: Contact patients are screened That sites with high nosocomial rates should consider testing COVID negative patients daily Not acheivable due to lab capacity regularly at Day 0, 7 and 12 10. Have a system in place to manage the occupational health needs and obligations of staff in relation to infection

Key lines of enquiry Evidence Gaps in Assurance Mitigating Actions Completed by Date RAG Appropriate systems and processes are in place to ensure: A documented record of this discussion should be available for the staff member and held These are held in personal files. There is no Only the Line Manager is aware of centrally within the organisation, as part of employment record including Occupational Nil Matrons Apr-21 central repository and not sent to OH issues Health 7.7 CQC Well-Led Inspection Activity and Improvement Plan Progress Update as at 28th February 2021 1 Final_Trust Board_CQC well Led update report_March 2021.pdf

Trust Board Report

Meeting Date: 6th April 2021 Title: CQC Well-Led Inspection Activity and Improvement Plan Progress Update as at 28th February 2021.

Action Receive for information and assurance. Requested: For the attention of the Board • There are established governance arrangements for the Divisions to monitor CQC compliance and improvement actions via their quality performance meetings. In addition, assurance groups have been identified to oversee and support compliance with specific actions, for Assure example, medicines management, safeguarding and Mental Health. • Progress on the CQC Core Services and Well-Led inspection improvement plan will be reported regularly at Compliance Oversight Group, Trust Management Committee and Trust Board. • All actions will be subject to ongoing activity/monitoring and may require an assessment of assurance to determine their closure. Advise • The improvement plan for the 2019 CQC Core Services and Well-Led inspection contains progress on the Should Do actions. • CQC transitional monitoring approach call planned for end of March 2021. • Phoenix Urgent Treatment Centre re-opening on 1st March 2021, following temporary closure. Alert • CQC registration details were updated in relation to Acting Chief Nurse as nominated individual. • 8 actions remain open. These have been delayed mainly due to the last COVID wave. Author + Contact Tel 01902 695859 Email [email protected] Details: Tel 01902 307999 Ext 8120 Email [email protected] Links to Trust 1. Create a culture of compassion, safety and quality Strategic 2. Proactively seek opportunities to develop our services 3. To have an effective and well integrated local health and care system that operates Objectives efficiently 4. Attract, retain and develop our staff, and improve employee engagement 5. Maintain financial health – Appropriate investment in patient services 6. Be in the top 25% of all key performance indicators Resource No resource implications identified at the present time. Implications:

Report Data This is a standard report using the previous months’ data. It may be subject Caveats to cleansing and revision. CQC Domains Safe: patients, staff and the public are protected from abuse and avoidable harm. Effective: care, treatment and support achieves good outcomes, helping people maintain quality of life and is based on the best available evidence. Caring: Staff involve and treat everyone with compassion, kindness, dignity and respect. Responsive: services are organised so that they meet people’s needs. Well-led: the leadership, management and governance of the organisation make sure it’s providing high-quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. Equality and No adverse impact identified. Diversity Impact Risks: BAF/ TRR Risk 5448 Medicines Management, Risk 5388 Safeguarding and Risk 5527 Mental Health Risk: Appetite N/A Public or Private: Public Other formal Compliance Oversight Group bodies involved: Trust Management Committee References CQC Regulation Standards. NHS In determining this matter, the Board should have regard to the Core principles contained in Constitution: the Constitution of: • Equality of treatment and access to services • High standards of excellence and professionalism • Service user preferences • Cross community working • Best Value • Accountability through local influence and scrutiny

Brief/Executive Report Details Brief/Executive Summary CQC Well-Led Inspection Activity and Improvement Plan Title: Progress Update. Item/paragraph Key updates since the last report in January 2021 include: 1.0 • An improvement plan is in place and its progress is being reported to the Compliance Oversight Group, Trust Management Committee and Trust Board on a bi-monthly basis. All the outstanding Should Do actions are detailed in the improvement plan (Appendix 1). • Preparation has commenced in relation to the CQC TMA (transitional monitoring arrangement) call planned for end of March 2021. This involves a set of questions which will be asked by CQC. • Phoenix Urgent Treatment Centre was temporarily and is re-opening on 1st March 2021. • Acting Chief Nurse nominated individual for CQC registration as of January 2021, as a temporary arrangement. CQC informed accordingly. Appendices • Appendix 1 details Should Do actions from the Well-Led and core services inspection (2019).

1.0 Areas of improvement and actions

An improvement plan is in place, which incorporates the Should Do actions with key leads and timescales identified. This plan is tracked and monitored via the established governance oversight processes.

The overall number of identified actions and status is as follows:

CQC Well Led Inspection Trust Actions

Actions outstanding 8 Actions completed 62 Total Actions 70

0 10 20 30 40 50 60 70 80

Appendix 1 CQC Well Led Inspection Improvement Plan (2019)

Action Type CQC MUST/ SHOULD/ TRUST Domain CQC Action Reporting Owner Action Update Monitoring MUST Status Group Arrangements Community Adults (August 2019) Should Do 1. The service should consider Safe Partial Nicki Ballard Procurement timescales have been requested from commissioning as Monitored via the local providing staff with access to these were delayed due to COVID pandemic. risk register. machines which could measure blood glucose of patients Division 3 This is on the local risk register.

Timescales: 31st March 2021

Critical Care (August 2019) Should Do 01. The trust should ensure they Safe Partial Doreen Black Business case awaiting contract and commissioning approval, next meet the key standards for critical update due 31st March 2021. care workforce in relation to allied Ros Leslie health professionals, in line with Division 1 & 3

the guidelines for the provision of Governance intensive care services (GPICS) Edition 2, 2019. Medical Care (August 2019) Should Do 10. The trust should ensure a Well Led Partial Bev Morgan Performance meetings have recommenced with each Directorate in vision and strategy for all Division 2 / February 2021. All Directorates have now presented. The Renal directorates within division two is Operational Directorate has presented their vision and strategy independently of developed and actioned. group the performance meetings as this is a wide reaching and detailed plan. Services for Children and Young People (August 2019) Should Do 05. The provider should ensure all Safe Partial Nicki Ballard Staff on A21 to complete 'We can Talk' training by 30th April 2021. 4 staff have training in mental health staff to undertake Total Respect training - 2 in April 2021 and 2 in July Safeguarding and learning disabilities. 2021. Learning Disability Nurse working closely with the Directorate Operational and specifically during the transition period from Children's to Adult group Services. Current mental health training Level 1 at 77% across the Directorate and 100% on A21. Should Do 13. The provider should continue Responsive Partial Nicki Ballard Project pushed back to 1 April 2021. Funding agreed through Monitored by Directorate to work towards improvements for Charitable funding. Management Team and the sensory room, such as fixing or Divisional Management replacing broken equipment. Division Estates Project Manager identified and background work progressing. Team via performance 3/Capital This remains delayed due to the third COVID wave. Review date now meeting review Group July 2021.

Urgent and Emergency Care (August 2019) Should Do 03. The service should ensure all Safe Partial Bev Morgan MCA section to be incorporated into revised CAS Card, to review in relevant staff are aware of the April 2021. Safeguarding potential needs and management Operational of people with mental health Group conditions, learning disability and autism. Should Do 08. The service should ensure any Safe Partial Bev Morgan Audit delayed due to COVID pressures. Propose change to existing Division discharge advice provided to ED documentation audit to incorporate scrutiny of discharge 3/Health patients is documented within documentation to commence in April 2021. Records patient notes. Group

Should Do 09. The service should ensure that Caring Partial Bev Morgan Proposed timescale for completion of this affected by COVID. This personal and sensitive patient will be re-addressed by management team with the expectation that a information is not left on display. Division decision is made by April 2021. 2/Information Governance Steering A number of options have been and are being trialled for screen Group covers to meet the necessary requirements. If these options are not viable then a business case for ordering PAC screens will be submitted.

7.8 Midwifery Services Report 1 Part 1_TB midwifery report - April 2021.pdf

Trust Board Report Meeting Date: 6 April 2021 Title: Midwifery Services Report Action Accept, receive and note Requested: For the attention of the Board Assure • Midwifery and workforce position • Progress with Maternity CNST maternity Incentive Scheme (MIS) • Progress with 7 Essential Immediate Actions Ockenden – gap analysis Advise and action plan

Alert • Continuity of Care . Author + Contact Tracy Palmer Director of Midwifery: Women’s and Neonatal Services. Details: Tel 01902 698392 Email [email protected] Links to Trust Strategic 1. Create a culture of compassion, safety and quality 2. Proactively seek opportunities to develop our services Objectives 3. To have an effective and well integrated local health and care system that operates efficiently 4. Attract, retain and develop our staff, and improve employee engagement

Resource None Implications:

CQC Domains Safe: Effective: Caring: Responsive: Well-led: Equality and Diversity Impact None Public or Private: Public Other formal bodies involved: Trust Board April 2021 References Ockenden – The report into Shrewsbury and Telford Hospitals. December 2020

Maternity Incentive Scheme: Year 3 NHSR January 2021

(1) Maternity Incentive Scheme Year 3 – updated version March 2021 (2) RWT local Gap analysis and action plan Appendix (3) Board Assurance Document

. .

NHS In determining this matter, the Board should have regard to the Core principles contained in Constitution: the Constitution of: • Equality of treatment and access to services • High standards of excellence and professionalism • Service user preferences • Cross community working • Best Value • Accountability through local influence and scrutiny

Brief/Executive Report Details Brief/Executive Summary Title: Midwifery Services Report.

Item 1.0 Midwifery Workforce and birth ratio during COVID 19 Pandemic The report gives a brief overview of the birth / Midwife ratio’s including 1:1 care rates in labour during the COVID-19 Pandemic.

Item 2.0 CNST: Maternity Incentive Scheme Year 3 – Progress update The report gives an update on progress with the Maternity Incentive Scheme Year 3. The report included the change document received in March 2021.

Item 3.0 Ockenden Review of Maternity Services. Shrewsbury and Telford Hospitals. The report includes an update on progress with the local gap analysis and action plan following submission of the assurance and assessment tool to

NHSE in February 2021

Item 4.0 Continuity of Care The report gives a brief update on the trajectories and present position surrounding the maternity services continuity of care model.

1 Part 2_ TB midwifery report - combinedpdf.pdf

Detailed Report - Midwifery Services report for Trust Board – 6/04/21

Item 1.0 Midwifery Workforce and birth ratio during COVID 19 Pandemic

Presently Birth to Midwife ratios are funded for 1:27/28. This meets the 1.1 recommendations from the last Birth rate + review conducted in 2018 for the Trust .

Successful recruitment has taken place throughout the year and all existing vacancies 1.2 together with vacancies identified from the BR+ workforce review have been appointed into.

Recruitment during COVID 19 pandemic has continued remotely. Newly qualified Student midwives have been given appointments and commenced posts in September 1.3 2020. RWT have less 1% vacancy within the midwifery workforce.

During the COVID 19 pandemic March 2020 – March 2021 Midwifery workforce has 1.4 been significantly depleted by up to 30% Community Midwifery and up to 20% within the inpatient areas.

1.5 Midwife to birth Ratio March 2020 / 21 during the COVID-19 pandemic

1.6 Tolerance Mar Apr May June Jul Aug Sept Oct Nov Dec Jan Feb <30 30 >30 32 32 31 31 31 28 28 28 31 32 31 30

1.7 The table depicts the monthly midwife to birth ratios at RWT over the last year during the pandemic. The ratios are based on Midwives giving direct clinical care and do not include Midwives in the hub or working from home.

1.8 One to one care rates in labour for RWT during COVID – 19 pandemic.

Mar Apr May June July Aug sept Oct Nov Dec Jan Feb 99.% 98% 98% 98% 98.5% 99% 98% 99% 98% 98.% 98% 99%

The national ambition and recommendation in NHSR CNST Maternity Incentive 1.9 Scheme (MIS) safety action 5: Can you demonstrate an effective system of midwifery workforce planning to the required standard? Recommends that 100% of women receive 1:1 care in labour. The Director of Midwifery has devised an action plan in order

to achieve the recommendation for 1:1 care in labour. Reviews of any women not

receiving 1:1 care in labour is a quality improvement project (QIP) being led by

Intrapartum Midwifery Matron.

In February the maternity service has purchased the birth Rate + acuity tool. The tool 1.9.1 assesses real time work load for Midwives, the system is based upon an adaption of the same clinical indicators for intrapartum care used in the well-established workforce planning system. BR+. This system has been endorsed by NICE.

The Trust has commissioned Birth-rate + to perform a full workforce and acuity review 1.9.2 and this will take place in the next few weeks.

2.0 CNST: Maternity Incentive Scheme Year 3 – Progress update

2.1 The Maternity Incentive scheme was paused in March 2020 due to the COVID 19

pandemic. The Scheme was re-introduced in October 2020.

2.2 Changes to the original document were made in order to mitigate the challenge in attaining the 10 safety actions. A further revised document (Version 4) was published in March 2021 outlining the changes have been provided with this paper for information. (appendix 1)

2.3 The directorate management team are continuing to work towards achieving all 10 safety actions.

The submission of the Board declaration form detailing the Trusts position will be required to be signed off by The trust Board by 15th July 2021

3.0 Ockenden Review of Maternity Services. Shrewsbury and Telford Hospitals.

The Assurance and assessment tool that NHSE requested from all trusts outlining 3.1 compliance with the 7 Immediate Essential Actions (IEA’s) and 12 clinical priorities has

been submitted to NHSE in February 2021.

A local gap analysis and action plan has been devised by the directorate to monitor 3.2 progress with the recommendations. (appendix 2)

The Directors and Heads of Midwifery are meeting individually with the Regional Chief 3.3 Midwife for NHSE/I Midlands to review the assessment assurance tool submitted in

February. Each trust is then RAG rated in terms of their compliance. Following this a

Trust level report will be published at the end of March and sent to CEO’s.

3.4 Following NHSE letter to CEO’s in December highlighting the 7 IEA’s from the

Ockenden report one of the immediate actions was to implement a revised perinatal

quality surveillance model. Within the document there is reference to the minimum data

measures for Trust Board overview (appendix 3).

Following discussions with the Executive Board Level Safety Champion (Ex BLSC) the 3.5 Director of Midwifery (DoM) both propose that these data measures are presented to

Trust Board by the DoM / Ex BLSC each month.

Continuity OF Care 4.0

4.1 Continuity of care (COfC) trajectories timescales have been extended during the ongoing COVID pandemic.

Presently expectations from NHSE are that maternity services will have 35% of all 4.2 women and 35% of BAME women on a COfC pathway by March 2021.

Providing continuity of care from COfC has been a challenge during the ongoing 4.3 pandemic due to COVID related staff absence. Concerns regarding meeting the trajectory have been raised by HoM’s with the national team and Chief Midwifery Officer for England. RWT are now presently in the process of re-introducing continuity models back into the service.

4.4 Monitoring of the percentage of women on COfC continues via the LMNS to NHSE.

2

THE ROYAL WOLVERHAMPTON NHS TRUST Action Plan in response to the Ockenden Review – Immediate & Essential Actions for Trusts

Immediate & Essential Action 1: Enhanced Safety

Progress Outcome Required Action Lead (Job Title) Timescale Evidence / Comment RAG

Discussion with Local Maternity & 31st March – next Neonatal System to agree way forward. Implement Perinatal Quality LMNS Meeting Director of Midwifery Surveillance Model Detailed action plan to be developed 30th April 2021

Revise RWT Maternity Dashboard Digital Midwife 30 April 2021 Dashboards in place and reviewed Trust input to development of Local Continue with the development DOM / Digital Midwife Ongoing Maternity & Neonatal System dashboard of local dashboards. Local Maternity & Neonatal System Local Maternity & Local Maternity & Neonatal System dashboard reviewed formally at least Quarterly Neonatal System SRO Minutes every 3 months Governance & Perinatal Mortality Review Tool included as potential Clinical Director Complete speciality interest in vacant Consultant post to be advertised Ensure Perinatal Mortality Review Tool Agreed Perinatal Mortality Review Clinical Director / Group is factored into upcoming Consultant job 31st May 2021 Tool resources agreed and in place. Manager Increased support for PMRT plan reviews Interim capacity in place, requires a substantive solution. Quantify additional Midwifery support April & May 2021 to Perinatal Mortality Review Tool and Director of Midwifery 2021 identify capacity

Peer review to be established – Local Maternity & Neonatal System Local Maternity & Peer review process in place 30th April 2021 external clinical specialist for IP discussion on approach Neonatal System SRO LMNS minutes

Page 1 of 6 Version 7.0 Last Updated: 23rd March 2021

THE ROYAL WOLVERHAMPTON NHS TRUST Action Plan in response to the Ockenden Review – Immediate & Essential Actions for Trusts fetal death, maternal death, NN Ensure RWT Consultant engagement Clinical Director 30th April 2021 brain injury, NN death SI’S require reporting through the Local Maternity & Neonatal Local Maternity & Local Maternity & Neonatal System Agree frequency & process for reporting Complete System to ensure scrutiny, Neonatal System SRO Minutes Quality and Safety meeting oversight and transparency

Immediate & Essential Action 2: Listening to Women & Families

Progress Outcome Required Action Lead (Job Title) Timescale Evidence / Comment RAG

Further guidance on the senior independent advocate role profile NHSE TBC required Trusts must create an independent senior advocate Trusts awaiting further guidance role which reports to both the Process to recruit and ongoing form NHSE in terms of the NHSE TBC Trust and the LMS Boards management agreed independent advocate role.

Senior independent advocate in place NHSE TBC and accessible to the Trust

Process in place to capture and report on agreed actions as a result of upheld 31st March 21 complaints Action plans and trends available and Strengthening monitoring of Group Manager monitored regularly through complaints action plans Complaint & Concern trends reported to Directorate management team management team for appropriate 30th April 21 action to be agreed

Page 2 of 6 Version 7.0 Last Updated: 23rd March 2021

THE ROYAL WOLVERHAMPTON NHS TRUST Action Plan in response to the Ockenden Review – Immediate & Essential Actions for Trusts

Immediate & Essential Action 3 : Staff Training and Working Together

Progress Outcome Required Action Lead (Job Title) Timescale Evidence / Comment RAG

Professional Development Maintain PROMPT sessions Midwife / Director of Complete Training packages and records Maintain online packages Ensure MDT training process is Midwifery maintained Define the process with Local Maternity Local Maternity & Minutes of Local Maternity & & Neonatal System to external Neonatal System SRO / TBC Neonatal System Meetings validation 3 x year Director of Midwifery Increase consultant presence Clinical Director / Group Job Planning process, recruitment 31st May 2021 Completed job plans & rotas Saturday and Sunday Manager

Page 3 of 6 Version 7.0 Last Updated: 23rd March 2021

THE ROYAL WOLVERHAMPTON NHS TRUST Action Plan in response to the Ockenden Review – Immediate & Essential Actions for Trusts

Immediate & Essential Action 4: Managing Complex Pregnancy

Progress Outcome Required Action Lead (Job Title) Timescale Evidence / Comment RAG

Add to the annual audit plan Audit Team Complete Updated Audit Plan Provide assurance that Women with a complex pregnancy have Initial audit undertaken Audit team Complete Audit complete a named lead consultant. Updated process. Digital Midwife Review process for recording on EPR Digital Midwife 31st May 2021 addressing issues with EPR provider Understand what further steps Ongoing discussions are taking place are required by your with maternal clinical networks s and Clinical Director organisation to support the Local Maternity & Neonatal System re: Lead Consultant Maternal medicine service defined development of maternal the development of maternal medicine TBC Group Manager Service in place. medicine specialist centres. networks. National / Regional NHSE

Specific actions to follow

Immediate & Essential Action 5: Risk Assessment Throughout Pregnancy

Progress Outcome Required Action Lead (Job Title) Timescale Evidence / Comment RAG

The EPR system supplier has been requested to make the risk assessment Ensure each contact risk field mandatory at each contact. Digital Midwife Digital Midwife is addressing this assessment is effectively 31st May 2021 CleverMed Ltd issue with EPR provider recorded as completed This is a national issue for all users of BadgerNet and is addressed by the EPR provider.

Page 4 of 6 Version 7.0 Last Updated: 23rd March 2021

THE ROYAL WOLVERHAMPTON NHS TRUST Action Plan in response to the Ockenden Review – Immediate & Essential Actions for Trusts

Immediate & Essential Action 6: Monitoring Fetal Wellbeing

Progress Outcome Required Action Lead (Job Title) Timescale Evidence / Comment RAG

Further funding for the lead Consideration re: uplift for headroom Director of Midwifery Midwifery role. Local Maternity & for essential training related to FM for May 31st 2021 Chief Nurse Neonatal System SBL funding temp, multidisciplinary teams resubmit? substantive Director of Midwifery Funding for the lead Midwifery role for Local Maternity & FM secured via Local Maternity & Complete Funding received, temp role in place Strengthen the Fetal Neonatal System Project Neonatal System until March 2021 monitoring arrangements Manager Case for recurrent funding to ensure a Director of Midwifery 30th April 2021 Substantive post recruitment agreed. substantive lead midwife for FM Group Manager Timescales subject to recruitment Substantive FM lead midwife in post Deputy Head of Midwifery 30th June 2021 process Lead support in place. Not Appoint formal Lead Obstetrician for FM Clinical Director 31st May 2021 recognised in job plan

Immediate & Essential Action 7: Informed Consent

Progress Outcome Required Action Lead (Job Title) Timescale Evidence / Comment RAG

Continual development and update of App contains the most up to date Pathways of care clearly Digital Midwife Ongoing the EPR App guidance and information described, in written information in formats Breast Feeding Peer consistent with NHS policy and Review and update the Trust website Support & Community posted on the Trust website 31st May 2021 content, and plan for maintenance Engagement Co-ordinator Trust IT lead Page 5 of 6 Version 7.0 Last Updated: 23rd March 2021

THE ROYAL WOLVERHAMPTON NHS TRUST Action Plan in response to the Ockenden Review – Immediate & Essential Actions for Trusts

Maternity Workforce Planning

Progress Outcome Required Action Lead (Job Title) Timescale Evidence / Comment RAG

Intrapartum Matron and Outcome and actions from the Re-assessment of BR+ in 2021 Deputy HOM for 31st May 2021 review clear intrapartum services

Undertake next round of Consultant job Clinical Director Consultant job plans and timetables April & May 2021 Effective system of midwifery planning Group Manager agreed and activated and clinical workforce planning Director of Midwifery Deputy Heads of Directorate wide workforce plan Formalise a written workforce plan Midwifery 31st May 2021 written, actions agreed and Clinical Director information shared Group Manager

Page 6 of 6 Version 7.0 Last Updated: 23rd March 2021

8.1 Learning from Deaths update 1 Learning From Deaths - Trust Board April 2021.pdf

Trust Board Report Meeting Date: 6th April 2021

Title: Learning from Deaths

Executive The paper presents the Trust’s most recent mortality data and the work Summary: being undertaken to scrutinise and continually improve.

The national SHMI dataset shows the most recent score for RWT of 1.016 November 2019 to October 2020. The Trust is now ranked 64th out of 124 Trusts across the country and has remained in the expected range for the past year.

The crude mortality rate for February 2021 is 4% this is higher than February 2020 (2.87%) and has decreased from last month (6.7%). There are 197 in hospital deaths in February 2021, a decrease of 136 from January 2021. Of these deaths 94 are Covid-19 related based on a parts 1 and 2 of the death certificate. 104 of the deaths would be excluded from the SHMI data as there is a Covid diagnosis recorded in the hospital spell.

The percentage of deaths reviewed by the Medical Examiner (ME) in November 2020 was 94%, December 2020 was 83%, January 2021 was 88% and February 2021 was 92%. The reduction in the number of deaths scrutinised by an ME in December 2020 is due to the implementation of the new IT system. In January 2021, the percentage of deaths scrutinised has increased, however, the number of deaths in January was high due to the Covid-19 pandemic. The target set is 100% and work is being undertaken by the Lead Medical Examiner with the Divisions and Directorates to ensure we meet this target by April 2021.

Action Receive and note Requested:

For the attention To note the SHMI of 1.016, this remains within the expected range for the of the Board past year.

The Board has previously been reassured through data analysis that the previously increased SHMI is not an indicator of avoidable mortality or quality of care. However, work continues to review and, where possible, enhance Assure quality of care provision across admission pathways with elevated SMR’s. Work also continues to address coding & data capture with respect to accuracy and completeness prior to submission of data.

The SHMI is within the expected range. The SMR is studied as part of a suite Advise of indicators used to look at quality of care, experience and service provision as part of the Learning from Deaths Programme. The diagnostic groups with outlying elevated SHMIs for this reporting period (October 2019 - September 2020) are outlined below:

Alert  Pathological Fracture – The Directorate have undertaken a review for the alerting Pathological Fractures diagnostic group to establish the drivers. The final report has been presented to the Mortality Review Group in November 2020 with no significant concerns. Since September 2020 to January 2021 there has been one Pathological Fracture death so the Trust are within the expected range.  Short gestation; low birth weight; and fetal growth retardation – it has been agreed a review would be undertaken with a Consultant from the Directorate and the coding team. A further update with be provided to MRG once this review has been undertaken.  Peri-;endo-; and myocarditis; cardiomyopathy (except that caused by tuberculosis or sexually transmitted disease) – A coding review with clinical input has been undertaken to further analyse and understand the trend of the alerting diagnosis group. From 15 cases audited, only one primary diagnosis was amended by Coding. A case note review is now being undertaken and a report of the outcomes will be presented to MRG in April 2021.

Author + Contact Karenjit Chatha – [email protected] Details: on behalf of Dr Jonathan Odum – Medical Director 01902 695958 E-mail: [email protected]

Links to Trust 1. Create a culture of compassion, safety and quality Strategic 2. Proactively seek opportunities to develop our services 3. To have an effective and well integrated local health and care system that operates Objectives efficiently 6. Be in the top 25% of all key performance indicators Resource Revenue: Implications: Capital: Workforce:

Funding Source: N/A CQC Domains Safe: patients, staff and the public are protected from abuse and avoidable harm. Effective: care, treatment and support achieves good outcomes, helping people maintain quality of life and is based on the best available evidence. Caring: staff involve and treat everyone with compassion, kindness, dignity and respect. Responsive: services are organised so that they meet people’s needs. Well-led: the leadership, management and governance of the organisation make sure it's providing high-quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture.

Equality and N/A Diversity Impact Risks: BAF/ TRR BAF SR 12

Public or Private: Public Other formal Mortality Review Group/Compliance Oversight Group/Quality Standards bodies involved: Improvement Group/Quality Governance Assurance Committee/Trust Management Committee NHS In determining this matter, the Board should have regard to the Core Constitution: principles contained in the Constitution of:  Equality of treatment and access to services  High standards of excellence and professionalism  Service user preferences  Cross community working  Best Value  Accountability through local influence and scrutiny

Page 2 of 2 1 Learning from Deaths Update February 2021.pdf

The Royal Wolverhampton NHS Trust – March 2021 Learning from Deaths Update of monthly activity for February 2021

1. Update on Standardised Mortality Rates (SMRs) and inpatient data relevant to these calculations 1.1 Crude mortality*

 The crude mortality rate for February 2021 is 4%, this is higher than February 2020 (2.87%) and has decreased from last month (6.7%).  There are 197 in hospital deaths in February 2021, a decrease of 136 from January 2021. Of these deaths 94 are Covid-19 related based on parts 1 or 2 of the death certificate.  104 of the deaths would be excluded from the SHMI data as there is a Covid diagnosis recorded in the hospital spell.

The following table shows in-hospital deaths and crude mortality in February 2021 by Primary Diagnosis (SHMI episode). The group ‘Allergic reactions, aftercare & screening, R codes’ is the diagnosis group Covid sits within.

Pneumonia is an alerting diagnosis group in the latest available SHMI and HSMR data.

1

Alerting Group in Alerting Number most Group in of In recent most Hosptal Number of Crude SHMI Oct recent Primary SHMI Diagnosis Group - Hospital Admission (SHMI) Deaths Discharges Mortality 19- Sep 20) HSMR Allergic reactions, aftercare & screening, R codes 81 414 19.6% Pneumonia (excluding TB/STD) 16 70 22.9% Acute cerebrovascular disease 13 95 13.7% Acute myocardial infarction 13 116 11.2% Congestive heart failure; nonhypertensive 7 54 13.0% Septicaemia (except in labour), Shock 7 58 12.1% Fracture of neck of femur (hip) 6 36 16.7% Acute and unspecified renal failure 5 16 31.3% Cystic fibrosis, Other lower respiratory disease 3 18 16.7% Others (2 or less per group, 42 groups) 46 n/a n/a Grand Total 197 4966 4.0%

1.2 SHMI (Inpatient deaths plus 30 days post discharge)

The most recent published SHMI value, (11th March 2021) for the period November 2019 to October 2020 is 1.016 this has decreased slightly from last month and remains in the expected range. The Trust is now ranked 64th out of 124 Trusts across the country and has been within the expected range for the last year.

2

SHMI trend

Time period SHMI Value * SHMI Crude Mortality % Dec 2018 - Nov 2019 1.062 3.62 Jan 2019 - Dec-2019 1.058 3.64 Feb 2019 - Jan 2020 1.041 3.62

Mar 2019 - Feb 2020 1.037 3.61 Apr 2019 – Mar 2020 1.031 3.69 May 2019 – Apr 2020 1.025 3.72

Jun 2019 – May 2020 1.028 3.76 Jul 2019 – Jun 2020 1.033 3.79 Aug 2019 - Jul 2020 1.025 3.77 Sep 2019 - Aug 2020 1.023 3.80 Oct 2019 – Sep 2020 1.018 3.82 Nov-19 to Oct-20 1.016 3.86

This report has previously demonstrated that the change in SHMI is as a result of both an increase in expected deaths and a decrease in the observed.

1.3 SHMI in comparison with neighbouring Trusts

November 2019 Trust to October 2020 The Royal Wolverhampton NHS Trust 1.016 The Dudley Group NHS Foundation Trust 1.178 Walsall Healthcare NHS Trust 1.085 Shrewsbury And Telford Hospital NHS Trust 1.076 University Hospitals Of North Midlands NHS Trust 1.033 Sandwell And West Birmingham Hospitals NHS Trust 1.127

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1.4 RWT Diagnostic Groups with higher than expected SHMI*

In the table below, those in red are outliers; those in amber are not outliers but lie just below.

* Oct ‘19 to Sep ‘20, Source - HED Summary Hospital-level Mortality Indicator, NHS Digital based SHMI, diagnostic groups with <5 expected deaths are excluded

The Directorate have undertaken a review for the alerting Pathological Fractures diagnostic group to establish the drivers. The final report has been presented to the Mortality Review Group in November 2020 with no significant concerns. Since September 2020 to January 2021 there has been one Pathological Fracture death so the Trust are within the expected range.

Following a meeting with the Directorate Mortality lead, to discuss the 219 Short Gestation; low birth weight; and fetal growth retardation alerting group, it was agreed a review would be undertaken with a Consultant from the Directorate and the coding team. A further update will be provided to MRG once this review has been undertaken.

A coding review with clinical input has been undertaken to further analyse and understand the trend of the alerting diagnosis group for Peri-;endo-; and myocarditis; cardiomyopathy (except that caused by tuberculosis or sexually transmitted disease). From 15 cases audited, only one primary diagnosis was amended by Coding. A case note review is now being undertaken and a report of the outcomes will be presented to MRG in April 2021.

2. Directorate Learning / Feedback

At the Mortality Review Group (MRG) meeting on 11th March 2021, Directorate Learning / Feedback was presented by AMU for three cases. The first case that was rated as poor care has now been escalated to a SUI and affects ED, AMU and ITU and a further learning and information regarding this will be presented back to MRG at a later date. The second case presented was rated poor care; however, it was agreed by the Directorate and MRG that the rating should be changed from poor to adequate overall care. The third case presented is to be presented to the Directorate meeting in April for further discussion and learning to be identified, however, it was agreed an incident should be raised but it was deemed a serious incident was not required. The learning for these two cases will be fed back to the group.

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3. Deaths reviewed by the Medical Examiner Service

The percentage of deaths reviewed by the Medical Examiner (ME) over the last four months was as follows:  November 2020 – 94%  December 2020 – 83%  January 2021 – 90%  February 2021 – 92%

The target is 100% by April 2021 and work is being undertaken by the Lead Medical Examiner with the Divisions and Directorates to ensure we meet this target.

There are 104 SJRs outstanding for the period December to February 2021.

4. Learning from Deaths IT Platform

The Learning from Deaths IT Platform was rolled out successfully on 1st December 2020. The team are now working on pulling reports from this system and making future developments to incorporate reviews for Out of Hospital Deaths.

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8.2 Safeguarding Adults and Children 6 Monthly update- Clare Hope 1 TB - Safeguarding 6 monthly update report March 2021 v1.2 - UPDATED comb.._.pdf

The Royal Wolverhampton NHS Trust

Trust Board Report Meeting Date: 6th April 2021

Title: RWT Safeguarding Update Report

Executive Summary: This paper provides an update on key areas regarding children and adult safeguarding issues. Key points to note: • RWT have submitted requested compliance reports to WCCG (every quarter) and had excellent feedback on the commitment and focus of safeguarding during COVID; • RWT have attended all WST partnership meetings throughout 2020 – 2021 • The Safeguarding Team have raised the profile of safeguarding vulnerable clients within the Trust throughout COVID; • Safeguarding Training compliance has been ‘good’ (up to end of January 2021) despite COVID and staff attendance restrictions; • Safeguarding referrals (across children and adult service) has been 15 – 20% higher. MASH data. • DoLS activity across the Trust has slightly increased from October to December. Additional ward support has been implemented; • There is an anticipated Section 11 (Children Act 1989) safeguarding inspection due late 2021. No date yet. • CQC – Well Led inspection action plan monitored at Trust Safeguarding Group. • Safeguarding Policies all progressed during 2020/2021. LD policy outstanding, but will be written during 2021.. Action Requested: The Committee will receive the report for information and assurance of progress. .

Report of: Ann-Marie Cannaby – Chief Nurse RWT Board Lead for Safeguarding

Author: Fiona Pickford – Head of Safeguarding Contact Details: Tel: 01902 695163/07880087065 Email: [email protected] Links to Trust Strategic All Objectives

Resource Implications: N/A

References: Items reviewed at: (e.g. from/to other Trust Safeguarding Operation Group 2020 - 2021 committees) Wolverhampton Safeguarding Together (WST) local safeguarding board Appendices/ Appendix 1 – RWT MCA/DoLS Group – March plan References/ Appendix 2 – CQC action plan for safeguarding Background Reading

NHS Constitution: In determining this matter, the Board should have regard to the Core principles (How it impacts on any contained in the Constitution of: decision-making) Equality of treatment and access to services High standards of excellence and professionalism Service user preferences Cross community working Best Value Accountability through local influence and scrutiny

Background Details This report provides a brief overview of key safeguarding issues that have been addressed during the previous 6 months.

1 Safeguarding Reporting Framework 2020/21

The WCCG have received a safeguarding update report on a quarterly basis. This has provided assurance

that all aspects of the safeguarding agenda have been addressed and progressed. During 2020, The

Wolverhampton Safeguarding Partnership has liaised frequently with RWT to (as part of the WST Covid

Recovery Group) to ensure that during the pandemic, vulnerable people have been identified and services

are responding to meet their needs albeit that ‘care’ has often been delivered via a blend of face to face

and remote option. A particular focus has been on the 0-19, Maternity, Emergency Department and Sexual

Health Service.

2 Safeguarding Team update March 2021:

The safeguarding adult and children team have continuously worked across the organisation during the pandemic period and have provided face to face/virtual support via the on call system Monday to Friday 9-5. The Learning Disability team have also remained working throughout, providing bespoke support to patients, staff and families including strong links to Maternity, ED and all ward areas. Activity across the LD team has increased particularly from August onwards. The number of advice calls and ward support activity for the safeguarding adult and children team has remained steady (during Q2 and Q3) although up by 50% from Q1. Many of the cases have been ‘complex’ in nature and domestic violence and mental health issues have been a key feature in terms of types of enquiry.

A full time ‘Early Help Navigator’ post has been recruited to during September 2020. This post (an 18 month secondment) is commissioned by Wolverhampton Local Authority and Public Health England. This post holder is now working across the organisation raising awareness of the Wolverhampton early help services, and it is hoped will increase referrals into the local services over the 18 month secondment period.

The RWT Named Midwife for Safeguarding is leaving at the end of May 2021, and will be replaced.

The RWT Named Doctor for Safeguarding Children has left, and will be replaced imminently.

3 Safeguarding and ‘Serious Case Reviews’

Current cases that are being discussed across the partnership (which include those patients who have been managed through RWT) are discussed at the RWT CSPR/SAR/DHR panel – All plans are currently in review/partnership process. Overall activity has been buoyant with themes identified around safe discharge (raised at RWT safe discharge group and ED operational meeting). A domestic homicide review (DHR11) is awaiting publication. The focus of this is regarding the identification of abuse in older people.

4 Safeguarding Training Compliance:

The compliance for safeguarding is described in the below table (end of January 21 data)

SG Children Training (end Jan 2021) SG Adult Training (end Jan 2021)

• Level 1: 96.5% • Level 1: 95.5%

• Level 2: 95.7% • Level 2: 93.6%

• Level 3: 91.1% (Assessment) • Level 3: 90.6%

• Level 3 specialist = 81.7% (Key • MCA/DoLs 90.1%

Children/Maternity Service • Prevent 93.0%

staff)

Compliance for Training has been monitored during COVID and has been ‘good’ overall. All training programmes have been delivered via the electronic platform to ensure staff were able to access the training, whilst face to face options were removed. From end April 2021, in line with the safeguarding training legislation, the Adult Level 3 staff group will be extended to include Band 6 and above clinical staff (including allied health professionals and community staff), all medical staff in Div 1,2 and 3 and staff working in specific support roles: mental health, patient flow, including discharge co-ordinators, sexual health and ED.

‘Prevent’ training remains a key focus, and despite minimal national activity around the subject area, will be reviewed again during 2021.

Domestic Violence training is currently being mapped out to ensure that vulnerable areas within the Trust

have up to date information on local procedures (particularly in relation to escalation of ‘victims who

disclose DV’). The Wolverhampton Domestic Violence partnership will be delivering this training during

2021/22.

An updated Level 3 training package in Maternity (due for roll out in April 2021) will include specific information around DV disclosure/processes for referral and emergency planning.

In additional to safeguarding training, there will also be a focus on Autism, Learning Disability, Chaperone and Ligature Cutters training. In line with the current plan to refocus mandatory training, these are expected to be reported on after May 2021.

5 Multi Agency Safeguarding Hub (MASH) Update:

RWT are contributing to the multi-agency work regarding children and adult referral activity. The number of referrals into MASH from RWT (that required agency information sharing, checking and strategy discussions) during October to December 2020 has been slightly higher than previous quarter. For children referral activity: Oct = 91, Nov = 65 and Dec = 63 (up by approx. 15% in Q2). Safeguarding Adult activity reported in to MASH (from all sectors) has been slightly higher than previous quarter. For adult referral activity (overall): Oct = 146, Nov = 138 and Dec = 119 (up by approx 20% in Q2). It is expected that activity will continue to show an upward trend during 2021 following the lifting of COVID restrictions.

MCA and DoLs Support to Wards: 6 The Safeguarding Team continue to raise awareness of the MCA and DoLs agenda with ward staff via daily face to face contact in key sites at New Cross Hospital, Cannock and West Park and through the task and finish MCA/DoLs Group (which commenced in Oct 2020) (Appendix 1). The Safeguarding Team collate information on DoLs data and the Chief Nurse receives a monthly report with ward activity and compliance. The legislation around MCA/DoLs is under national review and it is expected that in 2022 the new arrangements known as ‘Liberty Protection Safeguards’ (LPS) will be rolled out. Further guidance is expected (on arrangements) to be communicated out in early 2021. The anticipated ‘code of practice’ for LPS will be circulated at this time. The number of DoLS applications submitted during Oct, Nov and Dec was 33, 26 and 30 respectively. RWT have set a quality standard target of 30 each month. An audit of MCA/DoLS and DNA/CPR processes are being progressed in March.

RWT and potential Safeguarding inspection procedures during 2021: 7 A Joint Targetted Area Inspection (known as JTAI) is due in Wolverhampton (for Local Authority and

partners) during 2021. No further details available. RWT have representation at the task group. Further

information will be escalated via Trust Safeguarding Ops Group to key areas for their intended support in

this process. National delay due to COVID. RWT are also due to participate in a Section 11 (Children Act

1989) Safeguarding inspection during late 2021.

Safeguarding Policy work:

8 Significant work has taken place in regard to updating key policies during 2020. The following policies are in the process of being updated: • Safeguarding Adult Policy by July 2021 • Safeguarding Children Policy June 2021 • Domestic Abuse Policy for staff – new. Completed March 2021 • Prevent Policy (January 2021). Completed • Consent Policy – due for update in Q3/Q4 • Learning Disability Policy – New policy to be written during 2021.

Safeguarding and Compliance 9 Following the RWT Well Led ‘CQC’ inspection, work has progressed across the organisation in regard to the key findings that were cited within the report. (Appendix 2)

. Key Themes following Section 42 referrals against RWT (2019 – 2020) 10 Over the past 12 months a total of ten safeguarding concerns were raised against RWT that met the Section 42 criteria as defined in the Care Act 2014. This demonstrates a 48% reduction in comparison to the previous year’s data.

Following a thorough review of each case, no safeguarding risks were identified in eight out of 10 cases, these enquires have subsequently been closed.

Two cases remain open to the Local Authority, one of which resulted in RWT developing a communication

log with relatives and the other is currently subject to an RCA, which is due for completion March 2021.

A position of trust (POT) issue was identified in one enquiry, this required specialist input from the Local Authority Designated Officer and RWT Human Resources Team.

Appendix 1 Appendix 2 TMC MCA.DoLS Action Pla report for Ann-Marie

MCA/DoLS Group Plan

When will this be How will this be Staff Rag Action How will this be achieved achieved and progress evidenced Responsible Status of action plan

To pilot a virtual A Trust brief to be A database of attendees to March 2021 – this Safeguarding safeguarding drop in developed to inform RWT be kept. project will commence in Adult Nurse clinic staff that weekly drop in May 2021. Initial interest support sessions are to be Post clinic evaluation to be is good. Aim to roll held by the Safeguarding undertaken project out to specific Adult team. ward areas who require Any patient specific advice given will be documented additional support with A weekly 45 minute virtual MCA/DoLS. drop in clinic to be held via as per Safeguarding Policy. teams.

To review current The current training Video recording to be March 2021 – Named Nurse MCA/DoLS E- package will be reviewed by discussed at the with Safeguarding learning package to the Safeguarding Adults Safeguarding Governance E-Learning package Adults ensure that it is fit for training lead. Meeting reviewed. Video (Training purpose. recording of MCA/DoLS Lead) A video recording of an The video recording will be training completed. MCA/DoLS training to be agreed by IMTG. completed, ensuring that all learning outcomes are met.

Training lead to discuss the replacement of the E- Learning with video recording at IMTG.

To improve the To video record the process A database of the number March 2021 – video Named Nurse quality of Mental of completing a Mental of DoLS applications that do recordings completed Safeguarding Capacity Capacity Assessment, and not meet the required and shared across the Adult (MCA Assessments and Deprivation of Liberty standard to be maintained. Trust. BIA training and DoLS Deprivation of Safeguards This evidence will be used postponed. Lead). Liberty Safeguard to update the risk register applications To video record the process and shared monthly with the March 2021 – additional Safeguarding of the Best Interest Meeting Senior Nurses meeting, packs sent to out- Adult and Mental Health Group, patients/community and Learning To upload video recordings specialist services Disability on the safeguarding page of Quality team, MCA / DoLS task and finish group and Lead. the intranet and the KITE January 2021 - DoLS the Trust Safeguarding site for staff to access cards disseminated as Group. part of a ‘Safeguarding To update the indication of a Pack’ sent to all clinical potential DoLS flow chart areas. and DoLS information card Dec 2020 - Recording on To quality assure completed hold until March 2021. DoLS applications received in the safeguarding inbox, DoLS flow chart and prior to sending to the information card appropriate Supervisory updated. Policy update Body sent to Claire Richardson.

3000 new DoLS prompt cards ordered to be disseminated January 2021.

Three members of the Safeguarding team to attend BIA training 2021.

2 Local Safeguarding Clinical areas to be asked To compile a database of March 2021 – Meeting Named Nurse champions in each for expressions of interest DoLS champions. held 18.3.2021. JD to be Safeguarding clinical area to be from staff or for staff to be developed. Further Adult (MCA identified to promote nominated by the Senior Action log of meetings to be meeting to be held with and DoLS the work of MCA Nurse for the clinical area. maintained. the SG team 16.4.21. All Lead). and DoLS. champions to be Two monthly meetings to be Evaluation of training to be Safeguarding undertaken. provided with Level 3 held with between training. Administration safeguarding team and champions March 2021 Champions project to be relaunched Bespoke safeguarding April 2021 training to be delivered to champions, so this January 2021 – no information can be change disseminated across the Trust. December 2020- Identification of champions on hold due to winter pressures and Covid. To be

recommenced March 2021.

3 To review Consent Consent policy to be To have a policy that is March 2021 – Policy Safeguarding Policy CP06 reviewed by leads, to compliant with legislation reviewed by the LA no Adult and ensure that it meets the and practice. significant comments Learning requirements of the Mental made. disability Lead. Capacity Act and reflects Standing agenda item on Trust practice. MCA and DoLS Task and March 2021 – Consent Named Doctor Finish Group Policy reviewed, updated Safeguarding policy on the Trust Adults intranet site. Policy sent to the Local Authority RWT Consent MCA/DoLS lead for Lead review. January 2021 – no change

December 2020

Due to Covid 19 this has been put on hold by Consent Lead.

To be tabled as an agenda item at the next MCA/DoLS task and finish group January 2021.

4 100% of staff Emails will be sent to all Compliance demonstrated March 2021 – non- Safeguarding mapped to level 2 non-compliant staff, advising via the Trusts training data compliant staff to be Adult Team safeguarding adults them to complete this base. Target of 95% or emailed April 2021. will have completed training as a matter of greater compliance. the MCA/DoLS E - urgency. SG team to deliver learning training Record of face to face training to trainee package. Level 2 MCA/DoLS training training to be maintained by physician associates. package made available the safeguarding from October 2019. Training department and submitted Bite sized video shared sessions to be offered twice to the Education across the Trust. monthly. Department. March 2021 – To offer clinicians face to To repeat MCA audit in mandatory training to be face bespoke MCA/DoLS January 2021 to reassess relaunched. Date to be training competency and confirmed. compliance. To promote training via January 2021 –no Communication brief and via change email December 2020

Mandatory training compliance on hold until February 2021 (unless as part of induction or new requirement of post).

All mandatory MCA / DoLS training to be delivered as eLearning due to Covid.

Additional bespoke training sessions will be offered to specific areas within the Trust and are available on request. These may be face to face, but will comply with IP guidance.

MCA audit recommenced March 2021

5 The Safeguarding The safeguarding team will: Notification letters to be March 2021 – increase Named Nurse team will review forwarded to CQC in DoLS applications, Safeguarding DoLS applications Contact and or visit wards template to continue to Adult (MCA on a weekly basis. with patients currently A DATIX incident form will be used to maintain and DoLS waiting for a BIA be completed by the improvement. Lead). assessment weekly, to safeguarding team, If determine progress of the advice is given to complete January 2021 – due to Safeguarding application. an MCA / DoLS and on limited capacity of ward Adult and review this is not completed staff, a template has Learning Follow up outstanding (patients circumstances been developed to Disability applications with the Local have not changed). enable professionals to Lead. Authority DoLS Lead and email patient details to Best Interest Assessors on the SG team, to enable Safeguarding a 2 weekly basis them to complete the Administration Will continue to complete DoLS application. This ‘on call’ advice practice has led to an increase in applications.

documentation which is December 2020- Due to shared with practitioners limited capacity within the safeguarding team, face to face contact with wards is reduced. Telephone contact is made on a regular basis. Support remains available via the ‘on call’ process, which is available 9-5 Monday- Friday. Regular, planned face to face support will be reestablished in February 2021.

6 Safeguarding Adults The Safeguarding Adult Feedback to be provided to March 2021 – meeting Named Nurse team to work closely team will have regular the Head of Safeguarding arranged for 26.3.21 Safeguarding with the MCA / DoLS contact with the MCA/DoLS and Safeguarding Adult and Adult (MCA Officer at Lead (Corrina Jefferies) at Learning disability Lead. March 2021 – meeting and DoLS Wolverhampton Wolverhampton Supervisory arranged with the Local Lead). Supervisory Body body. Meetings with Corina Authority MCA officer as Jefferies to be held on a two she was unable to attend Regular meetings to be monthly basis with Named the February MCA Task convened with senior Nurse Safeguarding Adults. and Finish group nursing staff and or safeguarding team as and To establish quarterly January 2021 – no feedback with other Trusts change regarding MCA/DoLS.

when required if concerns In addition establish December 2020 around DoLS are identified. network support on lead up to implementation of LPS. Meeting with MCA To establish link point of Officer from contact with main Wolverhampton Supervisory Bodies, Supervisory Body held including: Dudley, Walsall, on the 9th October 2020. Staffordshire and To meet every two Shropshire. months thereafter.

Read receipts for DoLS Corina Jeffries to attend applications to the the MCA/DoLS task and Supervisory Bodies to be finish group January saved as evidence that 2021. application has been sent and received LPS update training attended December 2020 by Named Nurse (MCA Lead).

7 Safeguarding Team To repeat dip MCA audit. Initial data to be collated March 2021 – data Named Nurse to repeat formal This will be a random and report complied. collected, analysis Safeguarding audit of Mental section of 100 in patient underway. Initial findings Adult (MCA Capacity records. To implement new action show no real and DoLS Assessments plan with interventions improvement. Lead). Ward Matrons, Consent lead and Named Doctor to Audit results to be Plan: MCA audit to be Safeguarding presented to Senior Nurses undertaken monthly via Adult and meeting, Mental Health be notified via email of Group, Quality team, MCA / My Assurance, this will Learning formal audit. DoLS task and finish group include Cannock and Disability and the Trust Safeguarding West Park Hospital. Team Data selection to be Group. recorded on spreadsheet. Additional monthly MCA / Third year nurses to support ED audit underway the audit process as part of clinical placements. March 2021 – Re audit commenced February 2021. Final report due by April 2021

January 2021 –limited progress due the operational pressures of Covid

December 2020 -Repeat audit recommenced by safeguarding team. Third year nursing students to support this work commencing January 2021.

Meeting held on 16/12/2020 Safeguarding Adult lead and Quality Matron, MCA questions to be included in the My Assurance monthly audit. Matron to attend the

MCA / DoLS task and finish group. Joint working to review current RWT documentation to ensure that safeguarding is embedded across practice.

8 To increase the Safeguarding Team to be a To see an increase in March 2021 – Ward visit Safeguarding number of DoLS visible presence on the numbers on DoLS database pathway developed, to Team applications wards each month be adopted in April 2021. received. A DATIX incident form to be Monthly DoLS data to be March 2021 – number of completed by the collated and presented at DoLS applications safeguarding team, If advice Senior Nurses meeting, completed to be mapped is given to complete an Mental Health Group, to the number of MCA / DoLS and this is not Quality team, MCA / DoLS days/inpatients to ensure actioned (patients task and finish group and that the data is circumstances not the Trust Safeguarding representative of activity. changed). Group January 2021 – Regular communication Risk 5388 Mental Capacity increased number of bulletins to be sent out on Assessment has been DoLS applications since the Trust Brief to raise escalated to Red the introduction of a awareness of the (consequence of 3 x template. SG team to importance and completion likelihood of 5 - 15). continue to complete of DoLS / MCA. applications.

December 2020 - Number of DoLS applications continues to decrease (36 September 2020 – 24 November 2020, 18 December 2020).

Trust standard set at 35 or more DoLS applications per month and 80% compliance with MCA.

Meeting held with the Dementia Outreach team, November 2020 with the aim to improve joint working around the MCA / DoLS agenda.

Action from the Senior Nurses meeting, if a significant issue is identified within a specific clinical setting by the safeguarding team, this is to be escalated by the Safeguarding Adult lead directly to the Chief Nurse.

Stickers developed by the safeguarding team

for the use in patients notes, which remind practitioners to complete MCA and or DoLS applications. Initial feedback very positive.

MCA documentation reviewed. Shortened document developed, sent to medical illustrations. This document will be piloted for three months and an audit of compliance completed April 2021.

9 MCA/DoLS task and A Trust wide email sent to Database of potential March 2021 – meeting Safeguarding finish group to be professionals requesting attendees collated, held February 2021. Adult and convened to expressions of interest to invitations via MS teams. Group agreed that the Learning coordinate RWT’s attend an MCA/DoLS meeting should be held Disability Lead approach to the meeting. Minutes and action log of bi-monthly. MCA/DoLS agenda meeting updated by the Initial meeting held to safeguarding administrative January 2021 –meeting discuss MCA/DoLS practice team following each postponed due to Covid within the Trust. meeting. December 2020- Bi-monthly meetings to be Action log and minutes Attendance at November held, initially via MS teams. used to inform main MCA/ meeting reduced, further DoLS action plan. meeting arranged for 12/01/2020.

MCA/DoLS risk to be Membership to be updated monthly. reviewed and further email to be sent Trust Feedback to be presented wide to encourage at Senior Nurses meeting, participation. Mental Health Group, Quality team, MCA/DoLS Representative from task and finish group and Wolverhampton the Trust Safeguarding Supervisory Body to Group. attend January meeting.

10. To ensure that RWT A joint action plan to be Updated review of March 2021 – flow chart Safeguarding is compliant with developed between adult compliance with NICE completed, this has been Children Lead NICE Guidance and children safeguarding Guidance QS194 Decision reviewed by the Trust QS194 Decision services to review making and mental capacity consent lead and legal Safeguarding making and mental compliance with QS194. services. To be included Adult and capacity, in relation Promotional work to in current Consent Learning to 16-17 year olds. A Think Family approach to disseminate the pathway Policy. Disability Lead MCA to be developed. across the trust, including Named Nurse to lead on discussion at Senior Nurses January 2021 – draft MCA within the children’s meeting, Trust bulletin, MCA flowchart team, working in conjunction intranet, drop in’s and on developed for 16-17 year with adult MCA lead. call service. olds. This will be sent to the Trust consent lead Flow chart/pathway to be Policy CP06 compliant with and legal for comments. developed to guide staff in QS194 completing the correct December 2020- documentation, decision Meeting held between adult and children’s safeguarding leads to

making and taking the right discuss development of actions. processes with RWT.

A training package to be Email sent to other jointly developed by the Trusts, requesting safeguarding children and information, which will be adult team. used to support the development of a MCA pathway for 16-17 year olds.

11. To ensure Best To establish from the To see an increase in the March 2021 – no Named Nurse Interest Assessors database which of the number of patients to have change, meeting Safeguarding are coming out to Supervisory Bodies aren’t been assessed by a Best arranged with LA lead. Adult (MCA assess patients assessing patients within Interest Assessor on the Risk on Trust Risk and DoLS within the time frame the timescales DoLS database Register. Lead).

A letter to be sent out to the To have a copy of the Best January 2021 –no Supervisory Bodies around Interest Assessors report change the concern that patients aren’t being assessed by a December 2020 Best Interest Assessor No DoLS applications within the time frame have been granted since To add to current MCA and May 2020. DoLS risk register Meeting held with To review with the MCA / Wolverhampton DoLS Officer Supervisory body, to discuss the situation.

Risk register updated monthly.

10 For the safeguarding A random selection of 40 Audit plan 5535 Compliance March 2021 – DNACPR Lead Learning team to undertake DNACPR forms, were Against CP 11 and the data collection Disability an audit of patient reviewed from inpatient Mental Capacity Act 2005 completed, final report to Specialist records, to ensure services at New Cross and when completing DNACPR be shared April 2021. Nurse that DNACPR’s are West Park Hospital sites. (2020/21) developed. completed as per SG team working closely Safeguarding CP 11, Report completed and an Audit report to be presented with End of Life team Adult and Resuscitation Policy action plan developed. to the Senior Nurses and Resus Training Learning the Mental Capacity meeting, Quality team, Team. Disability Lead Act 2005. MCA/DoLS task and finish group and the Trust Final audit report to be Safeguarding Group present to the Mortality Review Group.

March 2021 – DNACPR re audit recommenced February 2021, results to be shared by April 2021.

January 2021 – DNACPR audit postponed due to Covid. Team continues to support good practice across the Trust.

December 2020- Audit plan 5535 updated.

Audit to be repeated January 2021.

11 To place MCA on To meet with Governance Risk register to be updated March 2021 – risk Safeguarding the risk register team to place MCA on risk monthly register reviewed, Adult and register following discussion with Learning To provide monthly updates Chief Nurse and Head of Disability Lead To develop an action plan to the Senior Nurses Safeguarding, risk and interventions meeting, Mental Health lowered to Amber (3x4 – Group, Quality team, 12) To monitor outcomes of MCA/DoLS task and finish interventions and evaluate group and the Trust January 2021 – risk Safeguarding Group. register reviewed, no change

December 2020- Risk 5388 Mental Capacity Assessment has been escalated to Red (consequence of 3 x likelihood of 5 - 15) and is now on the Trusts risk register.

Closed Actions

12 To review clinical a) To ensure other To share and make New ward timetable to MCA and areas requiring RWT sites such as suggestions on policy with distribute via email to DoLs Lead / support with DoLS Cannock and West view to amend policy. Matrons. 15/11/2019 Safeguarding applications. Other Park have regular team. RWT sites will contact and access Flyers to be sent out to continue to receive to support. other RWT sites on a Ongoing 15/11/2019 onsite support. b) To monitor DoLS monthly basis applications on the To evidence advice given to inpatient wards over all RWT sites on the the next few months. safeguarding database. Identify additional areas to target. Informal audit of DoLS c) To complete a small applications to monitor scale audit of MCA numbers or wards requiring at West Park more support. To be Hospital and completed with MCA / DoLS Cannock hospital.

d) To offer additional Lead of Wolverhampton MCA / DoLS training Supervisory Body. dates at WPH MCA / DoLS training compliance

To write a report and share findings of audit in TSG.

A MCA/DoLs Policy a) The Team will The Policy will be agreed by July 2019 (MCA and Policy to be finalised, lead on RWT internal processes DoLs) Lead / in development of and be available on the Head of place the MCA/DoLS Trust Website. safeguarding. for Policy 22/07/2 b) To share draft An increased number of 019 with board and appropriate and timely make changes DoLS applications will be made by RWT. following recommendation s with implementation of LPS when more details are available. c) The DoLS Policy (CP02), will be launched and embedded within practice

To create a MCA / a) To review current To share draft prototype 23/09/2019 MCA / DoLS Ongoin DoLS prompt sheet document in with safeguarding team lead. g for inpatient records place to support colleagues. when potential MCA staff with / DoLS are identifying MCA / To produce a prototype identified. DoLS. document to submit to TSG b) Obtain proformas from medical illustrations. c) To formulate a draft proforma sheet d) To pilot draft proforma as intervention following MCA Audit.

The team will a) Team to provide The poster will be available Draft poster to be shared MCA and Poster promote the copies of the poster for staff in all clinical areas at TSG alongside DoLS DoLS Lead. emaile MCA/DoLS poster produced July 2019 and displayed. drop in data report d to produced by the to ward and clinical wards MCA / DoLS lead. areas. To share poster resource at 22/08/2 b) The will initiate TSG (August 2019) 019 conversations with

staff in the clinical area regarding the poster. Seek feedback.

Safeguarding Team a) Dip sample of 100 Initial data to be collated Commencing Safeguarding Comm to undertaken a sets of patient and report complied. September 2019 Adult Team encing formal audit of records from 10 Septe Mental Capacity inpatient wards. Audit results to be Report compiled by mber Assessments Wards selected: presented to Trust November 2019 2019 Safeguarding operations A23, A8, A9, A12, Report findings to TSG C21, C16, AMU, Group. on 04/12/2019 C24, C18 and B8. Action plan to be b) Ward Matrons, implemented surrounding Consent lead and findings. Named Doctor to be notified via email of Re-audit 6 months post formal audit. implantation of c) Data selection to be interventions. recorded on spreadsheet. d) Interventions to be implemented October 2019.

Safeguarding Operational Group - CQC Well Led Inspection Improvement Plan (2019)

Action Type CQC MUST/ SHOULD/ TRUST Domain CQC Reporting Owner Action Update Monitoring Data for evidence MUST Action Group Arrangements Status Community Health Inpatient services (August 2019) Must Do 01. The trust must ensure that all Effective Yes Bev Morgan The Adult Safeguarding Policy has been reviewed in Training compliance is staff aligned to community inpatient December 2019 and the training programme has monitored on a monthly Regulation 13 - services have received the required been updated which is aligned to the Adult basis as per the policy. Safeguarding level of safeguarding training for Safeguarding: Roles and Competencies for Health their role in line with National Care Staff (First edition: August 2018) – guidance. Intercollegiate Document. All levels of safeguarding training compliance is monitored and reported Safeguarding through the Trust’s Safeguarding Group every Operational month. All levels of safeguarding training compliance Group for Community Inpatient services is 96% as at 6th March 2020. All levels of safeguarding training compliance is monitored and reported through the Trust’s Safeguarding Group every month. All levels of safeguarding training compliance for Community Inpatient services is 96% as at 6th March 2020. Must Do 02. The trust must ensure that Well Led Yes Fiona Pickford All safeguarding incidents are recorded on DATIX. Electronic procedure Monthly submission of statutory notifications for notifiable The Safeguarding cases that require escalation to safeguarding cases to Regulation 17 events are submitted to the CQC in CQC are highlighted for the Trust's Governance CQC via NRLS Good line with the Care Quality Team to send to CQC via NRLS. Safeguarding Governance Commission (Registration) The safeguarding cases that require escalation to Safeguarding Dashboard: Operational Regulations 2009. CQC are highlighted the Trust's Governance Team Submission of Group prior to uploading to NRLS for CQC to access. safeguarding cases via NRLS as per CQC requirements by Ward is in place Must Do 03. The trust should ensure that Safe Yes Fiona Pickford The Adult Safeguarding Policy has been reviewed in The Policy has been Update 23.2.2021: Adult the safeguarding policy is up to December 2019 and it has been updated to reflect updated and has a 3 year Safeguarding Policy is Regulation 17 date with national guidance. the training programme which is aligned to the Adult review timescale or sooner currently being reviewed Good Safeguarding: Roles and Competencies for Health if guidance updates. and updated. To be Governance Care Staff (First edition: August 2018) – circulated for comments Intercollegiate Document. and received by Policy Safeguarding Group in July 2021.this Operational will include reference to Group Training. Referenced at Safeguarding Team Governance Meeting and Trust Safeguarding Group. Must Do 07. The trust must ensure that the Effective Yes Bev Morgan SOP for NRU ratified by SG team and neuro Safeguarding nurse 23.2.2021: Audit of Safeguarding Mental Capacity Act 2005 and governance laminated and displayed A visual prompt attends NRU weekly to compliance re MCA/DoLs Operational Regulation 11 – Deprivation of Liberty Safeguards for Neuro Rehabilitation Unit (NRU) has been ratified discuss patients and in progress.during March Group Need for consent by the safeguarding team and neuro rehabilitation 2021. There is a MCA / 2010 are correctly and consistently governance, this is laminated and displayed next to ensure that referrals are DoLS task Group in place applied. terminal used for referrals on NRU to out of area complete and accurate. with work plans. DoLs authorities. This visual prompt has been discussed in referrals data for NRU West Park senior nurse team meeting to ensure staff and understand and follow the prompts. trustwide.disseminated.

Future Safeguarding Dashboard: To include MCA and DoLs referrals by ward Medical Care (August 2019) Should Do 04. The trust should ensure all Safe Yes Bev Morgan The 5 Practice Education facilitators are working well Safeguarding oversight is Safeguarding Training relevant staff receive training on Safeguarding in medicine. During the summer months the through audit, quality compliance is recorded caring and treating patients with Operational Discharge Lounge was utilised as a training Hub. visits, incident reporting and reported on a complex needs. Group and PET feedback monthly basis via Trust Safeguarding Group Services for Children and Young People (August 2019) Should Do 04. The provider should ensure Safe Yes Nicki Ballard Ligature risk assessment completed 9/8/19. To be All risk assessments will Position with regards to they continue to complete, review reviewed annually as per Trust policy. Initial patient be reviewed on an annual ligature risk assessments and monitor risks concerning risk assessment undertaken in Emergency basis as per Trust policy. children and young people with an Safeguarding Department and monitored on an ongoing basis in Future Safeguarding identified mental health need, Operational the paediatric environment. Re-audit November Re-audit in November Dashboard: including individual and Group 2020. 2020 Position on Ligature risk environmental risk assessments assessments – including ligature risk highlighting non assessments. compliance? Should Do 05. The provider should ensure all Safe Partial Safeguarding Nicki Ballard On track to complete mental health level 1 training by LD Training monitored via staff have training in mental health Operational December 2020. The service is also looking at “We Safeguarding Dashboard and learning disabilities. group & Trust can talk” online crisis training and Respect Training via Trust Safeguarding Mental Health in addition. LD training to commence from April 2021. Group. Mental Health Group Training package developed. training via MH Group Should Do 06. The provider should ensure Safe Yes Nicki Ballard There is already a Trust- wide Abduction policy is in Division 3 Governance Safeguarding that there is a clear policy in place place. Group Operational for the abduction of a child that group relates to all areas of the division. Urgent and Emergency Care (August 2019) Must Do 01. The service must ensure all Effective Yes Bev Morgan A shortened version of the mental capacity An audit process has been MCA audit results patients who may lack capacity to assessment RWT tool was developed in August agreed to monitor shared by ED still Regulation 11 – consent to care and/ or treatment 2019 and has now been implemented. compliance and the first showing improvement Need for consent are appropriately assessed, and audit is planned for 30th required. that this assessment is recorded April 2020. Safeguarding within patient records. Safeguarding trust wide Operational audit for MCA – group communicated via Trust Safeguarding Group and via Divisional Governance meetings .

Should Do 03. The service should ensure all Safe Partial Bev Morgan There is an LD Champion in Paediatrics ED. .Re audit process Safeguarding risk register relevant staff are aware of the To re audit MCA potential needs and management Adults in ED who present with mental Health (MH) Compliance – March of people with mental health issues are assessed by the Mental Health Liaison 2021 conditions, learning disability and Team who make recommendations regarding autism. ongoing care or further input admission to a Mental To provide updates to Health Unit. The training for suicide prevention TSG with regard to makes recommendations as to how patients should compliance with Mental be kept safe in the department. There is a Trust Capacity Assessments Learning Disability Nurse who is part of the following audits – March safeguarding Team they are available for support 2021 and advice. Number of cases within MH training has commenced, Matron monitors RWT managed under compliance ED Band 7s each have an allocated MHA is now reported. team to manage training and compliance locally. Mental Health Group in Suicide Prevention training has formed part of the place. Minutes Safeguarding Junior Doctor changeover induction for the past two Operational years, this training has also been given to some Group nurses on the in-service nurse education days in ED. The training package is currently being converted to online training which will be available to all staff and will enable reliable and consistent monitoring of compliance.

MCA audit has commenced in Trust. Will be ongoing monitoring. There are plans for the MCA quarterly audit to continue to monitor compliance against an agreed criterion identifying potential conditions that could cause lack of capacity and to identify any underlying issues or themes that can be addressed via the governance process. The current ED MCA documentation is being incorporated into the main body of the CAS card to increase compliance with completion.

Also there is a trust-wide MCA audit being undertaken by Safeguarding team. Should Do 04. The service should ensure that Safe Yes Bev Morgan ED safeguarding administrator now in post support The directorate plan is ED safeguarding documentation pertaining to safeguarding agenda in ED and safeguarding for the continuation of documentation audit safeguarding risks are completed in process this audit with additional most up to date results? all instances. actions based on its The directorate audit is ongoing on a rolling monthly findings. What about trust-wide? Safeguarding basis and the results for the period October-19 and Operational March-20 along with April-20 to June-20 have been Future safeguarding group received. Compliance continues to require dashboard: improvement based on preliminary findings but is showing significant improvement between Qtr 4 When Clinical Audit has 19/20 and Qtr 1 20/21. The directorate plan is for been transferred to the continuation of this audit with additional actions InPhase this will be

based on its findings. easily to view.

Should Do 05. The service should ensure that Safe Yes Bev Morgan Qtr 1 safeguarding report completed and action plan Action plan to be Safeguarding Training the trust training target for required will follow monitored compliance is recorded safeguarding training is met for all Safeguarding on a monthly basis, as identified staff. Operational part of the safeguarding Group dashboard presented to Trust SG Group and WCCG.

9.1 Finance and Performance - Chair's Report 1 2.Report to Board - Chairs Report F+P 24.03.21.docx

Trust Board Committee Chairs Assurance Report

Name of Committee: Finance & Performance

Date(s) of Committee 24th March 2021 (Virtual meeting) Meetings since last Board meeting: The meeting was limited to one hour due to operational pressures.

Chair of Committee: Mary Martin

Date of Report: 31 March 2021

ALERT  Financial plan and performance requirements for 2021/22 The absence of clarification of financial allocations from the centre and of the Matters of concerns, gaps in assurance or key risks to escalate to planning guidance means that the committee has not been able to recommend the Board a full year budget to the Board, has not been able to endorse a delivery plan or properly consider the related strategic risks.

 Annual capital plan 2021/22 There is an outline Capital Programme of £24.4m in place. The STP have received capital confirmation for the next financial year, however, this is less than the previous year. A prioritisation round will need to take place at provider level and therefore the £24.4m that RWT require for 21/22 is at risk subject to those discussions.

 Annual cashflow 2021/22 The Committee had asked to see the cash flow going forward as the payment of one month in advance stops in March. The report had been completed and showed a year to end balance at 31 March 2022 of only £5m. This report was prepared using the business plan submitted to the STP which showed a deficit of £49m. The plan will be revised and mitigating actions planned once the financial allocations are known. A revised report will be submitted to the Committee in May 2021. APPROVALS Under delegated authority ADVISE Continued impact of Covid on performance The waiting list now stands at 42,800 (Last month: 40,363) with 2,453 (last month: 1,447) waiting more than 52 weeks. The committee asked for assurance around the process of prioritising 52-week patients against urgent cases. The Governance arrangements continue to be under review by the Medical Director both Trust wide and within Directorates.

The Surgical Team are in the midst of an eight-week restoration plan, which would ultimately return the Trust to 100% of pre-covid wave levels (or 90% of ‘normal’ activity). Patients will be prioritised according to priority classifications from the Royal College of Surgeons. The support of the Nuffield continues but reduces from 16 half day sessions to 4 (owing to the end of the National Contract) and will be prioritised for breast cancer patients with some orthopaedic long waiters also being sent.

University Hospitals of Leicester NHS Trust (UHL) Lessons Learnt A high-level review has been completed, using the lessons learnt/findings, to benchmark against and to provide assurance that the same issues are not occurring at RWT. The report was provided for information and it will be re- submitted to Finance & Performance Committee in April for further discussion. Internal Audit will be asked to undertake a survey of the finance function around open culture. . Recommendation(s) to the  The Committee recommended the Annual Revenue Budget 2021/22 paper be Board submitted to Trust Board to adopt as an interim measure for the first 6 months of the financial year subject to the additional guidance being released and formal notification of allocations and income.

 The ICE Portal for The Black Country Pathology Services Business case was reviewed and recommended to the Board for approval.

 The Payroll partnership Agreement was reviewed and noted. After legal review it will be ready for approval by all the partners involved. The partners are RWT, University Hospitals of North Midlands, Black Country Healthcare, Dudley Integrated Health and Care, Black Country West Birmingham CCG. Walsall has currently opted to stay on an SLA arrangement and Dudley Group and Sandwell & West Birmingham have their own in-house payroll functions.

Changes to BAF Risk(s) &  The following risks remain as watching briefs for the committee: TRR Risk(s) agreed Achievement of CIP Achieving Financial Balance Maintain Financial Health for appropriate investment for patients Risks of Acute Collaboration Risks from proposed ICP Performance risk re Covid restoration and recovery of performance

ACTIONS  The committee have requested that Internal Audit carry out a review of sub- Significant follow up action contracted work. They are seeking assurance regarding the management of the commissioned (including discussions contracts, the patient experience with the companies, complaints handling and with other Board Committees, compliance with all RWT protocols. changes to Work Plan) ACTIVITY SUMMARY The committee received and noted the Trust Financial Report for the eleven Presentations/Reports of note months ending 28th February 2021. received including those Approved  The Trust has a small surplus of £420k as at the end of month 11. The Trust had £87.3m cash in the bank as at 28 February against a plan of £61.8m.  Pay pressures were highlighted as a concern however the overspend on pay was offset by non-pay underspends.  The current best estimate is that the Trust will deliver a breakeven position for the year.

The committee received and noted the proposed emergency metrics

 There are 6 metrics which potentially will apply to RWT. They would start to be reported against once the measures have been confirmed and there will also be benchmarking against similar trusts.

Temporary Staffing dashboard

 Noted

Matters presented for  National Contractual Standards information or noting  Cancer action plan  Supplementary Finance Report  Financial Recovery Board report  Procurement report  NHSI monthly return  Annual Work Plan  Capital Report  Quarterly PLCS/Service Line Reporting

Self-evaluation/ Terms of Reference/ Future Work Plan

Items for Reference None Pack 9.2 Report of the Chief Financial Officer - Month 11 1 Report of Chief Financial Officer M11.pdf

Trust Board Report

Meeting Date: 0 Title: Report of the Chief Financial Officer - Month 11 □ Make a decision □ Approve X Receive for assurance Action Requested: □ Received and noted If the item has already been approved by a body with delegated powers of approval from the Board such as a Committee of the Board, then the item would be received and noted. For the attention of the Board Assure N/A Advise N/A Alert N/A Author + Contact Details: Kevin Stringer, Chief Financial Officer - 01902 695954 [email protected]

Links to Trust Strategic Objectives Maintain financial health – Appropriate investment in patient services

Resource Implications: None Report Data Caveats This is a standard report using the previous month's data. It may be subject to cleansing and revision. Well-led: the leadership, management and governance of the organisation make sure it's providing high-quality care CQC Domains that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. Equality and Diversity Impact N/A Risks: BAF/ TRR N/A Risk: Appetite N/A Public or Private: Public Other formal bodies involved: Finance and Performance Committee References N/A In determining this matter, the Board should have regard to the Core principles contained in the Constitution of:  Equality of treatment and access to services  High standards of excellence and professionalism NHS Constitution:  Service user preferences  Cross community working  Best Value  Accountability through local influence and scrutiny

Brief/Executive Report Details Brief/Executive Summary Title: Report of the Chief Financial Officer - Month 11 Item/paragraph This paper reports the in-month, year-to-date and the draft year end position for the Trust as at Month 11. The paper also 1 reports on delivery against financial targets. Reference Pack Report of the Chief Financial Officer

Finance Report February 2021 - Month 11

Safe & Effective | Kind & Caring | Exceeding Expectation Contents 3

Page

Dashboard 4 Summary 5 Income and Expenditure Run Rate 6 Capital and Cash 7 Pay Expenditure 8 Cost Improvement Programme and Reserves 9

Appendices Appendix A Income & Expenditure Account 10 Appendix B Statement of Financial Position 11 Appendix C Cash Flow 12

Notes: All tables/figures exclude PSF unless stated otherwise Adverse variances are shown in brackets Dashboard 4 Income & Expenditure Position Workforce Patient Income (see page 5) (see page 8)

In Mth YTD Actual Actual

Income £'m £'m Greyed out sections will not be used for 20/21 7.4% Employed 1. Block payment 48.88 505.25 1.0% reporting.

2. Other income 11.53 104.70 Bank 3. Top-up payment 1.18 28.17

Total 61.59 638.12 Agency 91.6%

Expenditure 61.18 637.70 Underlying Position Surplus/ (deficit) 0.41 0.42

Planned surplus/(deficit) 0.50 0.38 Variance to plan (0.09) 0.04 Other includes recharges to from other organisations Cost Improvement Programme (CIP) Cash in the Bank Covid-19 Expenditure (see page 9) (see page 7) The Trust incurred additional Covid-19 revenue Plan £61.8m costs of £2.5m in February. £1.58m identified against YTD target of £4.37m Actual £87.3m

Cash against Plan 20/21 100000 80000 Reserves 60000 Forecast Outturn (see page 9) 40000 (see page 5) 20000 0 To deliver a breakeven position £5.02m slippage on reserves to off set CIP shortfall Actual Financial Plan Summary 5

Overview of Financial Performance

The financial performance in February is very much similar to that seen in January remaining reflective of the operational priorities in the month. Pay was again very high which was driven in part by the impact of January (New Year) bank holidays (£0.2m) and bank and locum pay for sickness/ self-islation cover and enhanced rates.

The overspend on pay was offset by non-pay underspends which were as a result of the pausing on some elective activity.

Forecast Outturn

The Trust had a £3.8m deficit plan for 2020/21 which was due to £3m shortfall on MSFT income and £0.8m shortfall on forecast non-NHS income. It has previously been reported that the MSFT shortfall had been corrected. It is now confirmed that the loss of non-NHS income (i.e. catering, car parking, R&D funding) will also be funded and the plan adjusted. The Trust is therefore forecasting to breakeven at the end of the financial year.

It is apparent that there will be a number of technical items that the Trust will be expected to reflect at year end. These include a potential annual leave provision and a provision for a holiday pay dispute that is currently subject to legal argument and where the judgement will apply to the whole public sector. Based on national guidance it is currently assumed that these items will be funded and be cost neutral to the Trust.

System Updates

Capital

,The Trust was not successful in all the captial bids for Covid monies with funding withheld for equipment purchased which could have been borrowed from a national loan stock, a CCTV upgrade and some minor building works which were not considered to be sufficiently related to the response to the pandemic. The overall shortfall of funding confirmed is £1.3m. The Trust was successful on the emergency capital bid which was outlined in the report last month (£6.7m) and the capital related to Covid testing which was committed at risk. All relevant PDC monies have been drawn down in accordance with the timetable and the main issue remains of delivery of CRL which the Trust remain confident of delivering.

The Trust was asked to help facilitate the spending of late available diagnostic capital for Pathology for the West Midlands. However due to lack of support some of this capital money (£0.85m) could be required to be returned due to other Pathology networks pulling out of the deal. Income and Expenditure Run Rates 6

The run-rate analysis has been shown alongside the final five months of the previous financial year to show how the run rate has been affected by expenditure and loss of income related to Covid-19.

Commentary on variances and trends:

2019/2020 2020/2021 £m Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Patient Income - Is on plan in month, the increase from January is due to additional Patient Income 1 Plan 42.94 39.99 43.70 39.78 56.02 43.83 43.86 43.86 43.86 43.86 42.01 48.63 48.63 48.75 48.68 48.79 funding received from NHSE. 2 Actual 43.29 41.43 44.57 41.25 61.12 43.83 43.81 43.08 43.26 43.68 43.64 48.69 48.76 49.38 48.25 48.88 3 Variance 0.35 1.44 0.87 1.48 5.10 0.00 (0.06) (0.79) (0.60) (0.19) 1.63 0.06 0.13 0.62 (0.43) 0.09

Non Patient Income 4 Plan 14.01 10.57 12.73 11.03 10.45 12.69 13.09 12.88 12.68 14.70 10.10 10.79 10.53 12.03 11.38 13.32 Non patient income -has increased by £1m in month. This is predominantly income which 5 Actual 15.38 10.37 11.46 11.74 11.60 11.45 11.25 13.17 12.64 12.69 14.70 10.22 10.73 11.63 11.69 12.71 is funding additional specific expenditure in month. £400k due to research income for 6 Variance 1.37 (0.20) (1.27) 0.71 1.15 (1.24) (1.85) 0.30 (0.04) (2.01) 4.60 (0.57) 0.20 (0.40) 0.30 (0.60) 'restart' and vaccine schemes in (£300k in CRN). Education Income has increased by Pay Expenditure £500k in month due to additional scheme funding being recognised from Health Education. 7 Plan 33.03 32.37 32.93 32.83 31.92 34.34 34.62 34.71 34.75 34.89 41.58 35.86 36.27 36.24 36.52 36.57 8 Actual 33.46 33.55 33.60 33.86 35.14 35.47 36.10 35.96 35.32 35.94 36.11 35.67 36.41 36.50 37.74 38.13 Pay - expenditure in month has increased by £0.4m. BCPS has increased by £100k largely 9 Variance (0.43) (1.18) (0.67) (1.03) (3.23) (1.13) (1.48) (1.25) (0.56) (1.05) 5.47 0.19 (0.14) (0.26) (1.21) (1.56) due to increased staffing for LAMP Testing (funded by DHSC). The remaining increase is in clinical areas where additional hours, overtime and bank are all being used to cover Non Pay Expenditure 10 Plan 13.56 12.99 15.40 13.97 14.15 13.86 14.03 13.93 13.50 16.27 7.54 15.22 15.65 15.45 15.91 16.59 Covid pressures. 11 Actual 13.76 13.30 13.88 13.82 18.88 12.90 12.32 12.94 13.02 13.23 14.49 15.57 15.52 15.68 14.68 15.51 12 Variance (0.21) (0.31) 1.52 0.15 (4.74) 0.96 1.72 0.99 0.48 3.04 (6.95) (0.35) 0.14 (0.24) 1.24 1.09 Non pay - expenditure in February increased by £1m. But remains underspent due to reduced elective activity. £300k relates to CRN which is funded in the additional income Drugs Expenditure mentioned above. Cardiology elective activity increased in month accounting for a further 13 Plan 4.74 4.45 4.73 4.40 4.42 4.35 4.11 4.65 4.84 4.59 4.36 4.69 4.62 4.62 4.65 4.62 £300k of the movement. £200k increase in Corporate areas due to scheme funded through 14 Actual 4.85 4.55 4.96 4.46 4.76 4.14 3.93 4.61 4.83 4.44 4.97 4.96 4.79 5.08 4.74 4.56 15 Variance (0.11) (0.10) (0.22) (0.06) (0.34) 0.22 0.19 0.04 0.02 0.14 (0.60) (0.27) (0.18) (0.47) (0.09) 0.06 training income and the balance relates to BCPS.

CIP over/ (under) achievement 16 Actual (2.16) (0.99) (1.35) (2.30) (0.69) (0.01) (0.01) (0.01) (0.01) (0.01) 0.04 (0.52) (0.49) (0.27) (0.87) (0.63)

Reserves supporting position 17 Actual 0.10 0.63 0.90 0.54 11.43 1.20 1.43 0.68 0.70 0.06 (4.06) 0.97 0.72 0.93 1.04 1.36

Other Non Operating Expenditure Drugs - Remains in line with budget and last months trend with reductions due to elective 18 Plan (2.80) (2.80) (2.83) (2.83) (2.80) (2.77) (2.77) (2.77) (2.77) (2.77) (2.75) (3.10) (3.10) (3.10) (3.10) (3.10) activity being offset by increases in drugs used to treat Covid patients. 19 Actual (2.83) (2.84) (2.35) (2.94) (1.03) (2.78) (2.76) (2.76) (2.76) (2.77) (2.78) (2.77) (3.19) (2.97) (2.97) (3.00) 20 Variance (0.03) (0.05) 0.48 (0.11) 1.76 (0.00) 0.01 0.01 0.01 0.00 (0.03) 0.33 (0.09) 0.14 0.13 0.10 Other Operating Expenditure - remains consistent with the last three months. Total Plan 4.89 (1.68) 0.99 (1.47) 2.46 (0.00) (0.00) 0.00 (0.01) 0.00 (0.11) 0.10 (0.71) 0.72 (0.30) 0.48 Actual 3.77 (2.45) 1.24 (2.09) 12.91 0.00 (0.04) (0.02) (0.02) (0.02) (0.02) (0.06) (0.41) 0.77 (0.19) 0.39 Variance (1.12) (0.76) 0.26 (0.62) 10.45 0.00 (0.04) (0.03) (0.01) (0.02) 0.09 (0.16) 0.30 0.06 0.11 (0.09) Cash and Capital 7 Cash Position Capital

Cash Against Plan and Prior Year Gross Capital Expenditure including PFI and Finance Leases - in month spend against Plan 100000 14000 80000 12000 60000 Actual 10000 Financial Plan 40000 8000 Actual 20000 19/20 Actual 6000 Financial Plan 0 4000 19/20 Actual Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2000 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar The cash balance as at 28th February 2021 is £87.3m. Under the new financial regime the Trust holds c. one month's cash in advance (£43m) plus cash that is The year to date capital spend is £43.4m which is significantly higher than the same already committed against invoices. This will be clawed back in March as per national point last year and is driven in the main by Covid-19 related investment. guidance. The Trust continues to review and forecast the cash balance to ensure that the unusual balance is not masking any potential cash issues. The capital limit for 20/21 has been agreed with the Trust and the STP. As previously reported this is a risk as a number of the schemes have progressed. Across the STP some Trusts had more Covid capital approved than was expected therefore shortfalls could be covered across the STP. This is despite the Trust receiving £1.3m less Public Sector Payment Policy (PSPP) Covid Capital than it had bid for. The Trust are confident in meeting CRL.

The Public Sector Payment Policy sets out a target for payment of 95%, in value and volume, to be paid within 30 days of receipt. The Trust's performance against this Since the last report £6.7m Emergency Capital has been approved along with £1.3m target is: for Covid testing capacity. All relevant PDC capital has been drawn down from the centre in accordance with national timetable and guidance. M11 20/21 Cumulative M10 20/21 Cumulative Value 80% 85% 88% 85% There have been several late allocations of capital which are generally IT and digital Volume 79% 78% 78% 77% schemes. The most material scheme that the Trust is considering in this financial year is a scheme funded by late release of diagnostic capital to put in place an IT network to provide resilience between regional pathology networks. If successful the Debtor Days Trust would host finance elements. However due to lack of support some of this Calculated Debtor Days for the year are:- capital money (£0.85m) could be required to be returned due to other Pathology M11 Actual M10 Actual networks pulling out of the deal. This is urgently being discussed at Regional level. Total 3.51 5.62 Being:- NHS 3.33 5.14 Non NHS 4.45 8.17 Pay Expenditure 8 Year to Date Variance to plan Total Pay Expenditure Trend

9,000 £'000 7,000 44,000 5,000 42,000 3,000 40,000 38,000 1,000 36,000 (1,000) 34,000 (3,000) 32,000 30,000 (5,000) 28,000 26,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Monthly Actual Monthly budget Last Yr Actual

Bank Expenditure Trend Agency Expenditure Trend

£'000 £'000

1,800 1,300 1,600 1,100 1,400 1,200 900 1,000 700 800 600 500 400 300 200 - 100 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Monthly Actual Monthly Budget Agency Cap Last Yr Actual Monthly Actual Last Yr Actual Cost improvement Programme and Reserves 9 Cost Improvement The annual CIP plan for the Trust is £5.24m. £'000 5,300 4,300 To date £1.58m has been achieved non recurrently against a year to date target of £4.37m. 3,300 2,300 1,300 CJ 300 -700

Cumulative Actual Cumulative Plan

Reserves Start point - November 2020 11,499,602 Reserves at the beginning of the financial year (Note not April due to funding regime changes) stood at £11.49m.

Full Year Effect of reserves 'drawn down' upto current month (4,782,093) Year to date there has been reserves drawn Reserves phased into position (5,023,069) down of £4.78m and £5.02m released into the current financial position. Reserves available for future months 1,694,440 With no slippage of reserves expected, we Earmarked Reserves Division 1 (303,551) currently have a remaining available balance Division 2 (444,257) of £321k. Division 3 (43,738) Estates and Facilities (140,735) The available balance is being held in Corporate & Other (441,566) contingency. Less: Expected Slippage 0

(1,373,847)

Available Balance 320,593

Balance made up of Inflation 1,508 Contingency 319,085 0 320,593 Appendix A - Income and Expenditure Account 10

Last Year Current Month Annual Year to Date to Date Plan Actual Variance Budget Plan Actual Variance £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Income 419,738 48,789 48,878 88 Patient Activity Income 553,481 504,768 505,246 478 1,228 121 16 (104) Other Patient Care Income 1,747 1,626 1,519 (108) 0 1,583 1,181 (402) Top Up Income 30,268 29,384 28,172 (1,212) 37,635 4,817 4,760 (57) Education, Training & Research Income 46,910 42,919 42,132 (787) 32 0 0 0 Non Patient Care Other Income 0 0 179 179 842 40 6 (34) Private Patient Income 305 266 213 (53) 64,156 6,757 6,751 (5) Income on Directorate Budgets 66,011 59,996 60,662 666 523,631 62,107 61,591 (515) Total Income 698,723 638,960 638,123 (837)

Expenditure 331,935 36,574 38,130 (1,556) Directorate Expenditure Budgets - Pay 432,578 396,361 399,344 (2,983) 130,503 16,593 15,507 1,086 Directorate Expenditure Budgets - Non Pay 173,355 157,959 155,847 2,112 47,713 4,620 4,560 60 Directorate Expenditure Budgets - Drugs 54,716 50,097 51,044 (947) 0 843 0 843 Activity Changes/Service Dev./Cost Pressures/Inflation Reserves 4,264 2,888 0 2,888 0 520 0 520 Contingency Reserves 2,454 2,135 0 2,135 0 (631) 0 (631) Cost Improvement Savings (3,631) (2,769) 0 (2,769) 510,151 58,520 58,197 322 Total Expenditure 663,735 606,671 606,236 435

13,480 3,587 3,394 (193) EBITDA Surplus/(Deficit) 34,988 32,289 31,887 (401)

(17,040) (1,991) (1,901) 91 Depreciation (21,877) (19,886) (19,282) 604 (1,620) (183) (169) 13 Interest Receivable / Payable (2,198) (2,015) (2,004) 11 (8,945) (930) (929) 1 Other Charges (11,152) (10,222) (10,219) 3 (27,605) (3,104) (2,999) 104 Other non operating items (35,227) (32,123) (31,505) 618

(14,125) 483 395 (89) Net Surplus/(Deficit) before PSF income (239) 166 382 217

185 20 18 (2) Adjustments as per NHSI reported position 239 219 39 (180) (13,940) 503 413 (91) Adjusted Financial Performance as NHSI (0) 385 421 37

Note : Adverse in Brackets Appendix B - Statement of Financial Position 11 2020/21 Balance Sheet as at 28th February 2021

Feb 2021 Feb 2021 Jan 2021 Movement March 2020 Plan Actual Actual in Month Actual

£000 £000 £000 £000 £000

NON CURRENT ASSETS Property,Plant and Equipment - Tangible Assets 374,405 372,467 372,985 (518) 348,386 Intangible Assets 2,057 2,778 2,755 23 2,608 Trade and Other Receivables Non Current 1,319 1,319 1,319 0 1,319 PFI Deferred Non Current Asset 5,213 5,213 5,213 0 5,213 TOTAL NON CURRENT ASSETS 382,994 381,777 382,272 (495) 357,526

CURRENT ASSETS Inventories 7,038 8,230 8,398 (168) 6,901 Trade and Other Receivables 58,922 26,463 34,497 (8,034) 60,760 Other Current Assets 0 0 0 0 0 Cash and cash equivalents 61,824 87,336 67,403 19,933 12,045

TOTAL CURRENT ASSETS 127,784 122,029 110,298 11,731 79,706 Non Current Assets Held for Sale 0 0 0 0 0 TOTAL ASSETS 510,778 503,806 492,570 11,236 437,232 CURRENT LIABLILITES Trade & Other Payables (67,784) (72,659) (75,956) 3,297 (68,851) Liabilities arising from PFIs / Finance Leases (2,032) (2,031) (2,031) 0 (2,031) Provisions for Liabilities and Charges (5,028) (4,656) (5,254) 598 (5,084) Other Financial Liabilities (48,571) (49,657) (47,790) (1,866) (3,300) TOTAL CURRENT LIABILITIES (123,415) (129,003) (131,031) 2,029 (79,266)

NET CURRENT ASSETS / (LIABILITIES) 4,369 (6,974) (20,733) 13,760 439

TOTAL ASSETS LESS CURRENT LIABILITIES 387,363 374,804 361,539 13,265 357,966

NON CURRENT LIABILITIES

Trade & Other Payables (63) (683) (684) 1 (67) Other Liabilities (8,886) (5,343) (5,533) 191 (7,224) Provision for Liabilities and Charges (1,859) (1,859) (1,859) 0 (1,859) TOTAL NON CURRENT LIABILITIES (10,808) (7,884) (8,076) 191 (9,150) TOTAL ASSETS EMPLOYED 376,555 366,919 353,463 13,456 348,815 FINANCED BY TAXPAYERS EQUITY Public Dividend Capital 281,496 268,370 255,306 13,064 250,646 Retained Earnings 30,485 33,974 33,583 392 33,595 Revaluation Reserve 64,384 64,384 64,384 0 64,384 Donated Asset Reserve 0 0 0 0 0 Government Grant Reserve 0 0 0 0 0 Other Reserves 190 190 190 0 190 TOTAL TAXPAYERS EQUITY 376,555 366,919 353,463 13,456 348,815 Appendix C Cash Flow Statement 12 2020/21 Cash Flow as at 28th February 2021

Feb-21 Feb-21 Feb-21 Feb-21

In Month Plan £'000 Actual £'000 Variance £'000 Movement £'000 OPERATING ACTIVITIES Total Operating Surplus/(Deficit) 9,134 12,603 3,469 1,490 Depreciation 19,885 19,282 (603) 1,901 Fixed Asset Impairments 0 0 0 0 Donated Assets received credited to revenue but non-cash 0 (179) (179) 0 Interest Paid (2,074) (2,031) 43 (170) Dividends Paid (5,365) (5,895) (530) 0 Release of PFI /Deferred Credit 0 0 0 0 (Increase)/Decrease in Inventories (137) (705) (568) 792 (Increase)/Decrease in Trade/Receivables 24,825 34,679 9,854 7,411 Increase/(Decrease) in Trade/Payables (9,501) (2,445) 7,056 (3,695) Increase/(Decrease) in Other liabilities 46,357 46,357 1,866 Increase/(Decrease) in Provisions (56) (428) (372) (598)

NET CASH INFLOW/(OUTFLOW) FROM OPERATING 81,981 101,237 19,256 8,998

CASH FLOWS FROM INVESTING ACTIVITIES Interest Received 48 26 (22) 0 Payment for Property, Plant and Equipment (37,753) (41,364) (3,611) (1,939) Payment for Intangible Assets 0 (450) (450) (0) Proceeds of disposal of assets held for sale (PPE) 0 0 0 0 Proceeds from Disposals 0 0 0 0

NET CASH INFLOW/(OUTFLOW) FROM INVESTING (37,705) (41,788) (4,083) (1,939)

NET CASH INFLOW/(OUTFLOW) BEFORE FINANCING 44,276 59,449 15,173 7,058

FINANCING New Public Dividend Capital Received 7,714 17,725 10,011 13,065 Capital Element of Finance Lease and PFI (2,212) (1,881) 331 (190)

NET CASH INFLOW/(OUTFLOW) FROM FINANCING 5,502 15,843 10,341 12,874

INCREASE/(DECREASE) IN CASH 49,778 75,292 25,514 19,932

CASH BALANCES Opening Balance at 1st April 2020 12,046 12,045 (1) Opening Balance at 1st February 2021 67,403 Closing Balance at 28th February 2021 61,824 87,336 25,512 87,336 9.3 Integrated Quality and Performance Report 1 Trust Board IQPR February 2021.pdf

Trust Board Report Meeting Date: 6th April 2021 Title: Integrated Quality & Performance Report – February 2021 Action Receive and Note: Current Progress Requested: For the attention of the Board  All data reported with thorough validation checks and relevant Assure departments are aware of any underperformance. Advise  None in this report Alert  None in this report Author + Contact Performance Manager ext 6746 Email: [email protected] Details: Deputy Chief Nurse ext 5968 Email: [email protected] Deputy Chief Nurse ext 4298 Email: [email protected] Deputy Director Strategic Planning and Performance ext 5914 Email: [email protected] Links to Trust 1. Create a culture of compassion, safety and quality Strategic 3. To have an effective and well integrated local health and care system that Objectives operates efficiently 6. Be in the top 25% of all key performance indicators Report Data All data reported with thorough validation checks and relevant departments Caveats are aware of underperformance. CQC Domains Safe: Effective: Caring: Responsive: Well-led: Equality and None Diversity Impact Risks: BAF/ TRR None Public or Private: Public Session Other formal Trust Management Committee, Finance & Performance Committee and bodies involved: QGAC NHS In determining this matter, the Board should have regard to the Core Constitution: principles contained in the Constitution of:  Equality of treatment and access to services  High standards of excellence and professionalism  Service user preferences  Cross community working  Best Value  Accountability through local influence and scrutiny

Brief/Executive Report Details Brief/Executive Summary Title: Integrated Quality and Performance Report – February 2021 Quality VTE VTE assessment is 92.83%, a revised pathway for ED lower limb immobilisation is place and ED education will be completed by April 21. CQI team are supporting local projects.

C-difficile 5 cases have been reported in month. C-Diff remains above trajectory within year. A bed space equipment decontamination unit has been re-installed for medical wards.

Never Event There has been 1 Never Event reported in month relating to unintentional connection of a patient requiring oxygen to an air flowmeter. Immediate actions have been taken this includes a reminder and short video sent to all matrons relating to the three barriers that reduce the risk of oxygen tubing being connected to air flow meters and an immediate review of all areas within the organisation to ensure air flow meters are not insitu unless explicitly required.

Sepsis ED monitoring has remained at 90% for screening and 85% for antibiotics within an hour. A focused quality improvement project continues.

C sections Emergency C-sections has decreased in month to 23.9% from 28% in January. The combined rate has reduced to 34.8%. A piece of work is currently underway looking at the breakdown of C section rates in terms of number of women who had C section for physical health reasons, early presentations, and stage of presentation related to C section aligned with the outcome of the babies.

Performance Referral to Treatment (Incomplete) The percentage of patients waiting within 18 weeks deteriorated during February, this is due to the effect of cancellations of both routine elective inpatients and outpatient clinics as a result of the current Covid-19 outbreak. We continue to monitor this very closely to ensure patients are dated and treated in the correct order of priority, whilst we commence the re-introduction of services. A large demand and capacity project is continuing along with a recovery action plan which focused on prioritising by clinical priority.

We have reported 2,054 patients who have now breached the 52+ weeks at month end - this figure is likely to grow with the priority being given to shorter waiters with higher clinical priority. Of the patients who are currently over 52 weeks, 80% of these are waiting for an inpatient/day case procedure, 13% are awaiting diagnostic tests and 7% are awaiting a first outpatient appointment.

The overall incomplete number was reported as 42,235 at month end (below 40,000 is the targeted position), this has risen in month due to continued reduction in activity. Referral numbers are not yet back to pre-covid numbers, they are currently around 65% of normal numbers.

Diagnostics We saw slight improvement in performance during February 21. Mobile scanners remain in situ, in order to maximise the number of tests being carried out whilst maintaining social distancing rules, in addition to this we continue to use external support in ultrasound, endoscopy and echocardiography.

Emergency Department There was 1 patient who breached the 12 hour decision to admit target during the month, this was a mental health patient awaiting a specialist bed. Performance against the 4 hour standard improved during February 21 when compared with the previous month and attendance numbers were around 80% of pre-Covid numbers.

Ambulance handover breaches saw a significant improvement for both the 30- 60 and >60 minute targets. Ambulance numbers continue to be lower when compared with the same period last year (-13.69%).

Cancer We are currently predicting failure of 8 out of 9 indicators for February 21 due to reduction of clinics during the current Covid-19 outbreak - these clinics have

now been restored. Final cancer data is uploaded nationally 6 weeks after month end. We are working to ensure as many treatments as possible can continue to be undertaken during the Covid-19 period and waiting times are reducing. Specific themes/actions are:-  Fast track clinics have increased during February 21 and now in line with normal levels.  Breast referral numbers remain the biggest concern, however, plans are in place with additional clinics set up throughout February & March 21, and we continue to work through the backlog of patients.

Integrated Practice Appointments Care Appointments reporting has been revised to use APEX data due to recent mapping process. This will ensure appointment data is accurately picked up consistently across all sites. All data is based on booked appointments. Reporting only shows booked appointments for all of our PCN Practices, the booked appointments equate to 56.92% of all appointments offered for February 2021 which is an increase from December 20 when it was 55.14%.

The nursing workforce is currently being revised to ensure consistent nursing presence at each practice, to ensure nurse appointments are available to all practices. This will come into effect from April 1st 2021.

The decrease in appointments for both GP and nurses will have been reflective of staff absences due to COVID-19 isolations, annual leave and working across the PCN vaccination hub.

Appointment numbers are still not back to normal numbers, due to COVID-19 related working arrangements and staff absences and now the implementation of a national lockdown.

Emergency Admissions The average number of Emergency admissions per 1,000 RWT PCN patients per month is currently at 7.43 which is lower than the average pre VI model of 8.38.

February 21 data shows an improvement from January 21 for emergency admissions rate with 6.01 Emergency admissions per 1,000 RWT PCN patients, down from 6.81.

RWT PCN practices continue to have lower emergency admissions per 1,000 patients when compared to other practices within Wolverhampton with a difference of 6.01 VI practices compared to 7.43 for non- VI practices

Actions:  Data is reported monthly and cascaded to Senior Managers.  Discussions around low appointment uptake and high DNA rates to be picked up with Service Delivery Managers and Management Team – As a result of queries around this, the appointment report will be ran weekly – this had been on hold due to an APEX issue at one practice. This has now been resolved and can therefore be implemented.  Any potential discrepancies to be investigated and escalated to Service Delivery Managers and Management Team.  Emergency Admission dataset access available to PCN central team. We are waiting for training on process to be able to revise data – this has been requested but due to leave has not been possible. This has been chased again this month and will remain a priority to resolve. Once handed over, data will need to be cross checked, to ensure most up to date information is utilised.

Community Nursing February 2021 shows a lower number of referrals compared to last month but it is comparable with this time last year. Digital solutions to keep patients at home and provide access to services remain in place which has been successful.

As part of community transformation new portfolios are in place with the urgent care portfolio including RIT's, GP home visiting team and community matrons enabling greater flexibility of working and access for patients. The team are piloting the Tekihealth app with 1 care home to enable remote diagnostics of patients which has evaluated well and we are looking at a broader pilot moving forward.

Other digital solutions are being developed to build on this work to enable remote monitoring of patients.

Our COVID-19 Oximetry@home service commenced during December 20. This service enables patients to be case managed and monitored at home. The COVID virtual ward service has also commenced in January 21 to enable patients to step down from acute beds and be monitored at home. Both services will aim to support various patient pathways in line with admission avoidance and early supportive discharge initiatives. A successful funding bid for a digital first remote monitoring solution from NHSX for 15 months has been awarded, which will enable greater scope of the service and potential roll out to respiratory patients post COVID. Both services went live using the Luscii app during February 21. The CCG have requested these services to continue during the next quarter.

Care Home DES for primary care is in place from January 21 although still in early stages of implementation, so no visible impact on community services to note. An increase in step down for COVID patients available at 1 home supported by RWTPCN.

Referrals from WMAS continue to rise, enabling more patients to stay at home successfully. A further test of change with WMAS is being planned for April 21.

0-19 Health Visiting - actions:-  A new quality dashboard is being developed to give better information on the team’s performance.  We are working with commissioners on the investment into the service following the business case; this includes a post to develop the Eclipse system.  A working group has been established to look at how staff use the Eclipse system led by the Head of Information.  Listening events with the staff are taking place – including F2SU guardian and staff side.  We have spoken to the Institute of Health Visiting about undertaking a service review and are awaiting a proposal.  These elements will be collated into a single service plan during April 2021.

1 IQPR Reference Pack February 2021.pdf

IQPR Reference Pack

February 2021 Exceeding Expectation

Page 1 of 22 Contents

Indicator Page Indicator Page

Quality Dashboard 3-5 Diagnostic Test - 6 week wait 14

Mortality 6 Urgent care 15

Maternity - emergency C-section rates 7 Ambulance handover breaches 15

HCAI 7 Ambulance arrivals 16

Complaints 8 Emergency Admissions via ED 17

VTE risk assessment 9 Cancer waiting times 18-19

FFT response and recommendation rates 10 Integrated Care Dashboard 20

Safer staffing & Care Hours per Patient Day 11 Community Nursing - Rapid Intervention Team 21

Performance Dashboard 12-13 Primary Care 22

Referral to Treatment - Incomplete 14

Page 2 of 22 Quality Dashboard Patient Experience Target Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Number of cancelled operations on the day of Surveillance 41 47 0 1 3 10 13 20 35 17 24 3 1 surgery for non-medical reasons Cancelled operations as a % of elective 0.73% 1.11% 0.00% 0.06% 0.12% 0.27% 0.34% 0.46% 0.73% 0.36% 0.57% 0.11% 0.04% admissions <0.8% Green, Cancelled operations as a % of elective else Red 0.61% 0.65% 0.00% 0.03% 0.07% 0.15% 0.20% 0.27% 0.37% 0.36% 0.39% 0.37% 0.34% admissions (cumulative) Number of cancelled operations not re- 0 0 0 0 0 0 0 0 0 0 0 0 0 admitted within 28 days 0 = Green, Number of urgent cancelled operations else Red 0 0 0 0 0 0 0 0 0 0 0 0 0 cancelled for a 2nd time Number of complaints as a % of admissions Surveillance 0.46% 0.38% 0.62% 0.32% 0.45% 0.62% 0.43% 0.60% 0.57% 0.59% 0.49% 0.71% 0.67% >/= 90% Complaints response rate against Policy Green, else 97% 100% 100% 100% 95% 100% 96% 100% 96% 91% 96% 97% 98% Red FFT response rates (Trust Wide - excluding ED) 12.0% 13.0% 11.0% 13.0% 9.0% 16.0% 14.0% 14.0% 15.0% 13.0% 12.0% 10.0% 11.0% FFT recommendation rates (Trust Wide - 94.0% 94.0% 93.0% 92.0% 92.0% 93.0% 93.0% 93.0% 94.0% 94.0% 93.0% 92.0% 94.0% excluding ED) Surveillance FFT response rates (Emergency Department) 14.0% 16.0% 19.0% 18.0% 13.0% 11.0% 11.0% 17.0% 19.0% 18.0% 17.0% 18.0% 19.0% FFT recommendation rates (Emergency 85.0% 88.0% 91.0% 88.0% 87.0% 87.0% 87.0% 81.0% 84.0% 82.0% 84.0% 86.0% 85.0% Department) Late observations (Trust Wide) <5% Green, (Monthly prevalence data reporting from >6% Red, else N/A 4.76% 5.00% 4.01% 2.00% 3.90% 5.90% 4.20% 2.90% 4.40% 8.50% 4.80% 4.60% January 2020 onwards) Amber Duty of Candour - Element 1: notifying patients and families of the incident and investigation 0 0 0 0 0 0 0 0 0 0 0 0 0 taking place. Due 10 working days after incident is reported to STEIS 0 = Green, Duty of Candour - Element 2: sharing outcome else Red of investigation with patients/relatives. Due 10 0 0 0 0 0 0 0 0 1 0 0 0 0 working days after final RCA report is submitted to CCG

Page 3 of 22 Quality Dashboard Patient Outcomes Target Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Pressure Ulcers - all cases 26 37 36 19 25 31 24 19 31 28 32 28 28 Pressure Ulcers - STEIS reportable cases Surveillance 0 0 0 2 2 1 0 0 0 0 1 0 0 Pressure Ulcers per 1,000 occupied bed days 1.05 1.50 1.87 1.20 1.28 1.51 1.15 0.85 1.35 1.26 1.36 1.17 1.38 Patient falls - all cases Surveillance 56 71 85 92 97 91 97 90 98 97 106 125 63 Patient falls - with harm (reported as serious 0 = Green, 0 0 0 0 2 1 0 1 0 1 0 0 0 incidents) else Red <5.6 Green, Patient falls - rate per 1,000 occupied bed days 2.25 2.87 4.42 5.80 4.98 4.43 4.65 4.01 4.26 4.36 4.49 5.23 3.10 else Red Crude mortality rate 2.88% 4.98% 8.30% 3.35% 2.63% 2.09% 2.77% 2.62% 3.08% 4.38% 3.81% 6.79% 4.05% RWT SHMI Surveillance 1.058 1.0367 1.031 1.0281 1.0326 1.0245 1.0225 1.0183 1.016 Number of deaths 166 241 283 143 121 111 141 136 172 220 193 336 198 Stranded patients (over 21 days) Surveillance 137 146 N/A N/A N/A 90 102 105 91 98 108 151 114 Patient Safety Target Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 >/= 95% VTE % risk assessment data Green, else 93.23% 93.10% 92.31% 93.22% 93.86% 94.21% 93.90% 93.90% 93.23% 94.43% 92.89% 92.38% 92.83% Red Yearly target Clostridium Difficile = 40 4 2 3 2 5 2 6 2 2 7 2 5 5 (profiled) 0 = Green, MRSA Bacteraemia 0 0 0 0 0 0 1 0 0 1 0 0 0 else Red E.Coli 20 18 19 19 20 26 21 17 19 25 30 22 19 Surveillance % Rate of medication error 1.62% 1.11% 2.08% 1.64% 1.63% 1.57% 1.67% 1.40% 1.55% 1.27% 1.41% 1.07% 1.27% Serious incident reporting - report incidences 0 0 0 0 0 0 0 0 0 0 0 0 0 within 48 hours Serious incident reporting - update on 0 = Green, 0 0 0 0 0 0 0 0 0 0 0 0 0 immediate actions within 72 hours else Red Serious incident reporting - share investigations 0 2 2 0 1 0 0 0 0 0 0 0 0 report/action plan (60 days) Never Events 0 0 0 0 0 0 0 0 0 0 0 0 1 Radiation incident rate - radiotherapy 0.0 0.4 0.6 0.5 0.0 0.0 0.0 0.5 0.0 0.0 0.0 0.0 0.0 Surveillance Radiation incident rate - radiology 0.40 0.43 0.34 0.40 0.5 0.23 0.34 0.18 0.23 0.4 0.2 0.22 0.17

Page 4 of 22 Quality Dashboard Patient Safety Target Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 >/= 7.6 Care hours per patient - total nursing & Green, <6.6 7.6 9.2 13.3 12.1 10.8 10.6 10.0 9.5 9.5 9.5 9.6 8.8 9.6 midwifery staff actual Red, else Amber >/= 4.5 Care hours per patient - registered nursing & Green, <3.5 4.8 6.1 9.1 9.0 7.0 7.1 6.6 6.4 6.1 6.1 6.2 5.8 6.4 midwifery staff actual Red, else Amber >/= 3 Green, Care hours per patient - healthcare workers <2 Red, else 2.8 3.4 5.2 5.5 4.4 3.6 3.5 3.2 3.3 3.3 3.4 3.3 3.7 actual Amber The % of patients who met the criteria of the local protocol for sepsis screening and were screened for sepsis and for whom sepsis screening is appropriate - Emergency 90.0% 100.0% 75.0% 70.0% 100.0% 100.0% 100.0% 90.0% 85.0% 100.0% 85.0% 90.0% 90.0% Department Monthly sample size: 20 patients (adults, paediatrics and neutropenic patients - random selection) Pre July 2019 The % of patients who met the criteria of the >/=90% local protocol for sepsis screening and were Green. <50% screened for sepsis and for whom sepsis Red, else 82.5% 88.3% 76.7% screening is appropriate - Acute Inpatient Amber Departments and other emergency portals. Quarterly sample size: 20 eligible patients July 2019 The % of patients who present with suspected onwards sepsis to the Emergency Department and who >/= 90% were administered intravenous antibiotics Green within 1 hour - Emergency Department 70-89% 80.0% 95.0% 70.0% 65.0% 90.0% 90.0% 100.0% 85.0% 80.0% 90.0% 80.0% 85.0% 85.0% Monthly sample size: 20 patients (adults, Amber paediatrics and neutropenic patients - random <70% Red selection) The % of patients who present with suspected sepsis and who were administered intravenous antibiotics within 1 hour - Acute Inpatient 85.7% 100.0% 100.0% Departments and other emergency portals Quarterly sample size: 20 eligible patients

Maternity Target Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 <13% Green, C-Section rates - elective >15% Red, 10.3% 12.1% 12.8% 9.6% 12.1% 14.6% 9.9% 11.7% 12.2% 11.1% 13.3% 11.3% 10.9% else Amber <17% Green, C-Section rates - emergency >20% Red, 16.8% 21.3% 22.6% 21.2% 19.2% 19.7% 18.5% 18.7% 20.4% 23.2% 22.2% 28.0% 23.9% else Amber Midwife to birth ratio: 33 Red, else 27.0 33.0 32.0 32.0 30.0 30.0 28.0 28.0 28.0 32.0 32.0 30.0 28.0 Birthrate plus recommended standard for Amber the Trust = 1:27 FFT response rates (Maternity only) 11.5% 10.9% 12.5% 12.3% 13.2% 12.0% 12.2% 11.7% 21.5% 12.3% 14.5% 12.1% 12.8% Surveillance FFT recommendation rates (Maternity only) 92.1% 89.5% 95.0% 91.3% 89.6% 90.0% 82.1% 84.8% 90.4% 88.4% 91.1% 89.7% 94.5%

Page 5 of 22

Mortality

th

Mortality • Following publication of the SHMI on 11 March 2021 (period November 2019 - October 2020), the SHMI has reduced marginally to 1.016 and remains within the expected range. NB: As of the July 2020 publication, COVID-19 activity has been excluded from the SHMI. • At the last reported position to MRG as at 4th March 2021 there were 11 outstanding SJR1s for the period March 2020 to November 2020 (i.e. pre LfD Platform) and; 85 outstanding SJRs for the period December 2020 to February 2021). Please note: data on LfD Platform changes daily as it is a live system. • SJR completion has been impacted by covid with Mortality Reviewers being focused fully on clinical duties. The backlog is actively monitored via MRG and a plan for recovery of the position pre-covid will be developed. • The Learning from Deaths platform went live as at 1st December 2020 and have received positive feedback from users. The reporting section of the platform is currently being refined. • Of the SJRs completed during Q4 reported to MRG on 11th March 2021 were 4 cases in total were assessed where an element of poor care has been identified at any phase of care. NB: We are currently working through the reports on the LfD Platform therefore numbers of SJRs are subject to change for December 2020 until this has been completed.

Page 6 of 22 Safety & Quality

Themes:

• Elective C-section are 10.9%. Section Section - • Emergency C-section are 23.9%. • Combined rate is 34.8%, although there has been a reduction in emergency rates from last month the emergency rate remains in higher tolerance levels.

Actions:

Emergency C Emergency

- • A piece of work is currently underway looking at the breakdown of CS rates in terms of number of women who had CS for physical health reasons, early presentations, and stage of presentation

related to CS etc. aligned with the outcome of the babies. Maternity Maternity

C difficile 12

Themes: 10 Clostridium difficile remains above trajectory. 8 Actions:

• The Infection Prevention team continue to closely 6

monitor COVID-19 outbreaks and cases and provide 4 HCAI advice. • Common themes and actions from outbreak meetings 2 are cascaded to all staff. • Bed space equipment decontamination unit has been 0 re-installed in an empty ward space – a previous trial appeared to reduce C difficile numbers in the trial wards. Target Upper process limit Lower process limit Measure Mean

Page 7 of 22

Safety & Quality cont …………

Complaints

There were 43 formal complaints received in comparison to 46 in the previous month. This represents a 7% decrease from the previous month, however, it is noted that when compared to the same reporting period in 2020, this volume represents a decrease of 1%.

Actions: • The Emergency Services directorate were noted as receiving the highest increase in complaints. A review of the complaint themes will be undertaken by the directorate with measurable actions for improvement defined.

Page 8 of 22

Safety & Quality cont …………

Themes: VTE risk assessments for February 2021 is 92.83% of inpatients had an assessment completed within 24 hours of admission.

Ongoing impact of COVID: Reduction in elective activity, increase in direct admissions to base wards, changes in activity/use of wards % VTE Assessment VTE % and movement of medical staff.

Actions: • Quality improvement plan in place for Cardiology. • ED agreed to work towards implementing VTE risk assessment 1st April 2021 for patients immobilised in lower limb casts. • Information services reviewing ED plaster room information to look at data extraction that can be used for reporting compliance of ED lower limb risk assessments. • Information specialists looking at options for possibly linking VTE risk assessments to missed doses report. • Deputy Chief nurse and VTE nurse to meet with Nuffield team re VTE risk assessment compliance. • Paediatrics following up non compliance and additional teaching/training is being arranged.

Page 9 of 22 Safety & Quality cont ………… FFT Response Rates (Trust Wide) FFT Recommendation Rates (Trust Wide) 25% 95% 94% 20% 93%

92% 15% 91% 90% 10% 89% 88% 5% 87% 86% 0% 85%

England Upper process limit England Upper process limit Lower process limit RWT Lower process limit RWT

RWT Mean RWT Mean

Recommendation and Response Rates Response and Recommendation

-

The overall Trust wide response rate for February 21 was 19%, with 3,068 (90%) recommending the Trust and 183 (5%) not recommending the Trust. The response, recommendation and not recommendation rates have all remained consistent with the previous month. In terms of the FFT response rate (Trust wide – excluding Emergency Department), the overall response rate for February was 11%. This shows a 1% increase when compared to January; the recommendation rate for February is 94%, which is an increase of 2%. In terms of the FFT response rate (Emergency Department), the overall response rate for February is 19%. This shows an increase of 1% when compared with the previous month’s data. There has been a marginal decrease in the recommendation rate with February’s Friends and Family Test Family and Friends score noted as 85% in comparison to January’s score of 86%. Actions: • FFT – arrangements to be made with Quality Matron and Governance to provide timely updates in relation to ward moves. This will help improve response and recommendation rates for these areas.

Page 10 of 22

Safety & Quality cont …………

Safer Staffing: Safer Staffing Safer 78.1% of wards on days and 81.25% of wards on nights achieved 80% or higher fill rate for registered nurses.

90.6% of wards on days and 96.8% of wards on nights achieved 80% or higher fill rate for Healthcare Assistants/unregistered staff.

Care hours per patient day (CHPPD) Care hours per patient day is monitored via the nursing quality dashboard, alongside other nurse sensitive indicators on a monthly basis. The Trust average is 10.4 for February 2021; the model hospital dashboard shows a national median to be 8.0 (September 2019). - Adult inpatient range between 5.6 - 16.0, Mean 8.7 - Critical care/neonatal range between 21.8 - 38.0, Mean 29.9 - Emergency portal range between 10.4 - 11.8, Mean 11.1

Page 11 of 22 Performance Dashboard

Waiting Times Target Variation Assurance Feb-21

RTT - % of patients on an incomplete pathway >/= 92% Green, else Red 68.73%

RTT - number of patients waiting over 52 weeks 0 = Green, else Red 2,054

Total Incomplete Number Surveillance Surveillance 42,235

Diagnostic Test - % of patients waiting 6 weeks or more <1% = Green, else Red 45.33%

Urgent Care Target Variation Assurance Feb-21 Total time spent in ED (4 hours) - New Cross Hospital 80.35% Total time spent in ED (4 hours) - Phoenix Walk in Centre N/A Total time spent in ED (4 hours) - Cannock Minor Injuries Unit >/= 95% Green, else Red N/A Total time spent in ED (4 hours) - Vocare 99.17% Total time spent in ED (4 hours) - Combined 83.87%

Trolley waits in ED longer than 12 hours 1

Ambulance handover breaches - 30-60 minutes 0 = Green, else Red 89

Ambulance handover breaches - >60 minutes 31

% of emergency admissions via Emergency Department Surveillance Surveillance 30.57% Stroke Target Variation Assurance Feb-21 Patients admitted with primary diagnosis of stroke should spend greater than 90% of >/= 80% Green, <58% 81.03% their hospital stay on a dedicated stroke unit Red, else Amber >/= 60% Green, <50% Stroke patients will be assessed and treated within 24 hours 41.86% Red, else Amber Organisational Efficiency Target Variation Assurance Feb-21 >/= 95% Green, <90% Electronic discharge summary within 24 hours of patient discharge - Base wards 95.96% Red, else Amber >/= 90% Green, <85% Electronic discharge summary within 24 hours of patient discharge - Assessment wards 89.48% Red, else Amber

Page 12 of 22 Performance Dashboard

Cancer Waiting Times Target Variation Assurance Feb-21 2 Week Wait - Cancer Referrals >/= 93% Green, else Red 68.70%

2 Week Wait - Breast Symptomatic Referrals >/= 93% Green, else Red 1.61%

31 Day to First Treatment >/= 96% Green, else Red 87.92%

31 Day Sub Treatment - Anti Cancer Drug >/= 98% Green, else Red 98.51%

31 Day Sub Treatment - Surgery 76.47% >/= 94% Green, else Red 31 Day Sub Treatment - Radiotherapy 87.30%

62 Day Wait for First Treatment >/= 85% Green, else Red 37.93%

62 Day Wait - Screening >/= 90% Green, else Red 68.75%

62 Day Wait - Consultant Upgrade (local target) >/= 88% Green, else Red 66.02%

28 Day Faster Diagnosis Standard - 2 Week Wait >/= 75% Green, else Red 46.51%

28 Day Faster Diagnosis Standard - Breast Symptomatic >/= 75% Green, else Red 5.08%

28 Day Faster Diagnosis Standard - Screening >/= 75% Green, else Red 53.23%

Page 13 of 22 Performance Measures

Themes: 2,054 patients are reported as waiting 52+ weeks at month end. Of the patients who are currently over 52 weeks, 80% of these

are waiting for an inpatient/day case procedure, 13% are having

Incomplete

- diagnostic tests undertaken and 7% are awaiting an outpatient appointment. Actions:

• Continue through immediate restoration plan taking us to pre- Treatment Treatment third wave levels by wc 19th April. • Telephone consultation clinics continue to be used as much as possible. • Treat patients in line with priority codes from the Royal Referral to Referral College of Surgeons.

Themes: • February 21 saw a slight improvement in performance when compared to the previous month (3.01%) and was reported as 45.33% (compared to 48.34% in January 21).

Actions:

6 week wait 6 week

- • Ultrasound scans, endoscopy and echocardiography

remain an issue due to large backlog and a significant Tests

increase in GP referrals, additional capacity has been introduced and we are currently working through the backlog. • We continue to a have mobile scanners in situ in order

Diagnostic to maximise the number of tests being carried whilst maintaining social distancing rules.

Page 14 of 22

Performance Measures cont …………

Themes: • Nationally RWT ranked 55th out of 114 Trusts for the month (compared with rank 67th from the previous month). • Locally RWT we ranked 6th out of 14 Trusts (compared with the same rank in the previous month).

Emergency Department Emergency

89 ambulances breached the 30-60 minute ambulance handover target during February 2021 compared with 164 for the same period Ambulance Handover Ambulance last year. There were 31 ambulances that breached the >60 minutes handover target during the month compared with 26 for the same period last year. The longest waiting ambulance during the month was recorded at 2 hours and 48 minutes, this was on 1st of the month when we had 142 ambulance arrivals and a total of 332 attendances on the day.

Page 15 of 22

Performance Measures cont …………

Quarter 1 Quarter 2 Quarter 3 January February 2019/20 12,987 12,508 13,654 4,448 4,068 2020/21 10,443 12,224 12,386 4,192 3,578 In the graph above it is noted that February 21 saw RWT Diff -2,544 -284 -1,268 -256 -490 a reduction in ambulance numbers when compared % Var -24.36% -2.32% -10.24% -6.11% -13.69% with the same period last year of -490 (-13.69%) 2019/20 10,430 3,309 11,260 3,811 3,327 ambulance arrivals. Ambulance Arrivals Ambulance 2020/21 8,860 3,293 10,169 3,395 3,173 Dudley Diff -1,570 -16 -1,091 -416 -154 % Var -17.72% -0.49% -10.73% -12.25% -4.85% The number of Stroke ambulances also saw a 2019/20 14,657 14,440 15,009 5,097 4,562 decrease when compared with the previous month City & 2020/21 11,014 13,452 13,787 4,872 4,035 and these accounted for 5.03% of all ambulances Sandwell Diff -3,643 -988 -1,222 -225 -527 into the Trust during the month. % Var -33.08% -7.34% -8.86% -4.62% -13.06% 2019/20 8,762 8,736 9,426 3,174 2,837 2020/21 7,398 8,600 8,637 3,150 2,537 Walsall Diff -1,364 -136 -789 -24 -300 The table to the left shows the number of ambulance % Var -18.44% -1.58% -9.14% -0.76% -11.82% 2019/20 11,598 11,803 12,581 3,909 3,557 conveyances into RWT and surrounding Trusts and Shrewsbury & 2020/21 9,163 10,731 10,910 3,512 3,290 the variance compared with the same period last Telford Diff -2,435 -1,072 -1,671 -397 -267 year. % Var -26.57% -9.99% -15.32% -11.30% -8.12%

Page 16 of 22

Performance Measures cont …………

These graphs show the admission rates and numbers of patients who are admitted via the Emergency Department compared with the same period last year.

Emergency Admissions via ED via Admissions Emergency At the end of month 11 we have seen a total reduction of -28,983 attendances to ED and also a reduction in emergency admissions (-5,243) when compared with the same period last year.

The emergency admission rate for February 21 improved when compared with the previous month and was reported as 30.57%, this represents a -1.44% reduction.

Page 17 of 22 Performance Measures cont ………… 62 Day Breaches by Cancer Site Themes: The breaches in month were as follows:- Tumour Site Total Pts Breaches % • 81.3% due to internal issues (capacity) Breast 7 6 14.29% • 11.1% delays due to Covid-19 delays Colorectal 10.5 10.5 0.00% • 2.7% due to patient choice Gynae 10.5 9 14.29% • 3.9% due to complexity of case Haem 7 4 42.86% • 1.0% were tertiary referrals received between days 36 and 82 of the patient pathway. Of the tertiary referrals received 2 (22%) were before day H&N 6 2 66.67% 40 of the pathway, and 2 (22%) were received on or after day 62 of the Lung 5 3 40.00% patient pathway. Skin 18 3 83.33% Patients over 104 days - Following January 2021 month end final upload, 14

Upper GI 3.5 3.5 0.00% patients were treated at 104+ days on a cancer pathway during the month, all of these patients had a harm review and no harm was identified. Urology 5 4 20.00% Total 72.5 45.0 37.93%

Average Cancer Waiting Times by tumour site The following table shows the average wait time of all patients who were treated on a 62 day pathway within the month they are treated

- this is shown by cancer tumour site and shows; of the patients who were treated in month the average waiting time in days. Cancer Waiting Times Waiting Cancer

Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Breast 57 51 50 49 33 42 52 49 53 50 73 79 Colorectal 71 59 104 112 109 108 58 88 87 89 109 95 Gynae 97 79 62 136 91 76 95 86 94 95 82 91 Haem 73 64 64 88 56 53 76 81 105 105 36 64 H&N 111 93 103 106 91 86 106 53 65 65 83 70 Lung 97 N/A 41 N/A N/A 35 37 49 71 71 70 80 Skin 22 29 29 55 40 28 32 31 40 44 40 37 Upper GI 66 55 77 64 71 68 44 67 64 64 62 79 Urology 92 86 75 90 117 151 111 134 91 92 72 68

Page 18 of 22

Performance Measures cont …………

Cancer Waiting Times Waiting Cancer

Page 19 of 22 Integrated Care Dashboard Sexual Health (Quarterly) (reported 1 month in arrears) Target Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 >/= 4,500 per Qtr Total number of appointments against block contract 4,176** 2,013** 4,209** 4,223** Green, else Red

>/= 95% Green, % appropriate patients offered HIV test <70% Red, else 83.2%** 33.7%** 37.1%** 70.0% Amber Community Nursing (Rapid Intervention Team) Target Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Referrals received 787 840 779 585 608 614 733 919 861 872 837 948 739 Patients accepted and seen (actuals) 602 639 652 474 511 586 588 746 664 655 620 671 536 Number of patients sent to ED or admitted to hospital by RITs (Including accepted patients and patients who have 55 32 8 8 11 32 53 47 34 62 61 50 48 been telephone triaged and an emergency ambulance Surveillance advised) % of referred patients who are sent to ED/admitted 6.9% 3.8% 1.0% 1.3% 1.8% 5.2% 7.2% 5.1% 3.9% 7.1% 7.2% 5.2% 6.4%

Number of referrals from West Midlands Ambulance Service 41 68 61 55 35 25 43 42 38 46 60 65 59

0-19 Health Visiting (reported 1 month in arrears) Target Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 >/= 93% Green, % of infants who receive a face to face New Birth Visit (NBV) <85% Red, else 88.72% 92.03% 82.14% 79.64% 79.50% 79.92% 87.19% 83.53% 85.17% 86.52% 88.38% 84.62% within 14 days from birth, by a Health Visitor Amber >/= 82.5% Green, % of children who receive a 6-8 week review <70% Red, else 89.90% 77.08% 83.33% 84.55% 85.43% 85.60% 88.11% 89.31% 87.27% 86.74% 88.12% 86.97% Amber >/= 78% Green, % of children who receive a 2-2.5 year review by the age of <70% Red, else 83.33% 84.78% 71.43% 70.24% 77.30% 75.88% 73.53% 77.05% 71.33% 70.96% 74.29% 82.17% 2.5 years Amber Primary Care Target Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Emergency admissions per 1,000 patients (VI) 6.76 5.61 3.92 5.67 5.48 5.74 4.96 5.89 5.74 6.3 6.6 6.81 6.01 Surveillance Emergency admissions per 1,000 patients (Non VI) 8.08 6.88 4.29 5.86 6.15 7.17 6.73 7.24 7.48 6.66 7.21 7.91 7.43 ** Activity and performance continues to be down due to Covid-19 pandemic

Page 20 of 22

Integrated Health and Care

Rapid Intervention Team Intervention Rapid

- The Rapid Intervention Service is a Nurse Led Service supported by a Medical Consultant which provides a highly responsive service in the community that sees, assesses, diagnoses and treats patients who are acutely unwell within two hours of referral to the service with the intention of avoiding unnecessary hospital admission. The services supports patients in their own home, nursing homes and care homes to provide crisis response and clinical support and advice. The team works in partnership with community services, including housing and the voluntary sector, to provide a responsive and robust service, with an emphasis on self-management of conditions.

Community Nursing Community Themes : • The overall referral rate has decreased slightly following Covid-19 surge in January. • The percentage of patients sent to ED reflects the acuity of the patients being assessed.

Actions: • Continue to monitor referral numbers.

Page 21 of 22 Integrated Health and Care cont …………

Emergency Admissions per 1,000 patients - VI vs Non VI Practices 10 9 8 7 6 5 4 3 2 1

0

Non-VI Practices VI Practices Average UCL LCL Primary Care Primary

The average number of Emergency admissions per 1,000 RWT PCN patients per month is currently at 6.01. This remains lower than the average pre VI figures of 7.43.

RWT PCN practices continue to have lower emergency admissions per 1,000 patients when compared to other practices within Wolverhampton.

Page 22 of 22 10.1 Innovation, Integration and Research Director's Report 1 Trust Board Chief Innovation Integration and Research Officers Report A....docx

Trust Board Report Meeting Date: 6th April 2021 Title: Chief Innovation, Integration and Research Officer’s Report

Action Requested: The Trust Board is requested note the contents of this report.

For the attention of the Board

Provides assurance that significant work has taken place across the digital first integrated care programme.

To provide assurance that all digital innovation opportunities are being actively explored and pursued to ensure that post COVID Digital Innovation moves even further to become the standard way of doing things

Assure the Board that key relationships and partnerships are being forged to Assure address digital exclusion across the Wolverhampton and regional landscape

Assure the Board that digital solutions to support the trust to embrace the new business as usual such as Digital Outpatients is actively being explored

Assure the Board that the commercial partnerships are actively moving forward and tangible and demonstrable progress is being made

To update the board on the progress to date in relation to the Digital First Integrated Care Programme.

Update the board on key partnership developments and progress in relation to the linked digital care pathways Advise To advise the board on the key milestones achieved in relation to establishing the Wolverhampton Place.

Advise the board on the activities that are being undertaken to communicate and embed the RWT Digital Offer

Partnership Organisation’s rely upon the income from commercial clinical trials to maintain their research workforce which includes investing in the workforce to support NIHR non-commercial studies.

Due to the pandemic the projected income from commercial clinical trials will Alert be reduced for PO’s and hence will be an additional financial pressure for them.

Current R&D Accommodation, including lack of adequate clinical facilities is impacting on the ability to open and deliver clinical research.

Author + Contact Details: Alvina Nisbett Head of Digital Innovation and Integration

Tel 01902 307999 [email protected] Trust Board Report Links to Trust Strategic 1. Create a culture of compassion, safety and quality Objectives 2. Proactively seek opportunities to develop our services 3. To have an effective and well integrated local health and care system that operates efficiently 4. Attract, retain and develop our staff, and improve employee engagement 5. Maintain financial health – Appropriate investment to patient services 6. Be in the top 25% of all key performance indicators Resource Implications: Revenue: None Capital: None Workforce: None Funding Source: None Report Data Caveats None at present

CQC Domains: Safe: Effective: Caring: Responsive: Well-led:

Equality and Diversity N/a Impact Risks: 1. R&D Accommodation – current R&D accommodation, including lack of adequate clinical facilities, impacting on the ability to open and deliver clinical research. Risk Level: Amber. 2. External Monitor visits – lack of space to safely accommodate required visits by commercial contract research organisations, thereby limiting ability to reopen studies. Remote monitoring being trialled, but this is very time intensive on clinical research teams. Risk Level: Yellow 3. Reduction in commercial research income - reduction in commercial income as a result of pausing studies in March 20, consequent severe cost pressure within R&D, with the potential to destabilise Trust research activity. Risk Level: Amber

Risk register reference: N/a Other formal bodies Non-Executive Directors involved: Primary Care Network Clinical Directors NHS England Wolverhampton City Council Wolverhampton Voluntary Sector Compton Care University of Wolverhampton West Midlands Combined Authority Good Things Foundation

References Next steps on the NHS Five Year Forward View 2018/19 Planning Guidance NHS Long Term Plan (published 7th January 2019) Good things foundation Blueprint for a 100% Digitally Included UK The NHS Digital Inclusion Report Digital Response to COVID-19 NHSX

NHS Constitution: In determining this matter, the Board should have regard to the Core principles contained in the Constitution of: • Equality of treatment and access to services • High standards of excellence and professionalism • Service user preferences • Cross community working • Best Value • Accountability through local influence and scrutiny Page 2 of 4 Trust Board Report

Brief/Executive Report Details

Brief/Exe Chief Innovation, Integration and Research Officer’s Report cutive Summary The Wolverhampton Place: Title:  The Wolverhampton Place Board Meetings will commence from April 2021 and will be Co-Chaired between David Loughton, CEO, RWT and a PCN Clinical Director (on a rotational basis)

 This marks a successful developmental programme with the Trust acting as anchor organisation working in close alignment with BCHFT, LA, PCN, Voluntary Sector, Health watch and Compton

 Work programme developed focussing on 6 key areas with 3 underlying principles

Digital Innovation and Strategic Partnerships:

. The digital collaborative which is which is a collaboration between RWT, Sensyne and Microsoft has identified exemplar projects which will enable joint collabration to utilise the RWT rich dataset combined with research and Artifical Intelligence to provide anticipatory care for patients and better patient outcomes.

. The operational deployment of the Digital Primary Care Babylon Solution has commenced with key activities underway (see section 2.3)

. Recent dialogue has identified where there is potential for aspects of the RWT digital offer to support outpatients with the smart triage of patients to support to reduce the waiting list backlog as we start to return to business as usual and also an end to end cancer dashboard. These opportunities are being explored further and will be progressed as appropriate.

. The Huddle Data Capture Tool (HDCT) as approved by the Trust Management Committee with bthe support of RWST Chief Executive Officer is being provided in the format of a daily executive report which displays a snapshot of the pressures the Trust is facing has been established and is being automatically emailed out to executives & operational managers to highlight issues which need addressing on a daily basis. Adoption has been particularly strong in Divison 2 where it has been utilised in bed mangement meetings

. The on boarding process for the Sensyne Partnership has commenced and a number of key activities and tasks have been undertaken. The Draft on boarding roadmap being refined which will outline the 3-6 months plan for mobilisation (see section 2.5)

Clinical Research Network West Midlands:

 This year for the first time we carried out the Participant in Research Experience Survey PRES almost exclusively online. Our previous best total was approximately 900 and we set ourselves a target of 1,200 responses this year. As of 5 March, we have well exceeded that, with 1,375 responses.

Page 3 of 4 Trust Board Report  We were successful with the recent pump priming funding bid and have been awarded a further £182,000. This was the final round of Vaccine Taskforce (VTF) funding.

Research and Development:

 Non-COVID research activity has restarted in the following specialties: Oncology, Haematology, Rheumatology, Cardiology/Cardiothoracic, Obstetrics, Surgery, Paediatrics, Gastroenterology and Respiratory.

 RWT is currently in the top 10 nationally for the number of NIHR COVID-19 studies open and in the top 30 for the number of participants recruited (3rd in the CRN WM region) (Source: NIHR ODP)

 Current R&D Accommodation, including lack of adequate clinical facilities is impacting on the ability to open and deliver clinical research. Therefore the R&D accommodation is under active review in order to scope opportunities to improve the facilities.

Page 4 of 4 1 April Reference Pack FINAL.DOCX

Chief Innovation, Integration & Research Officer Report

The Wolverhampton Place Digital Innovation & Strategic Integrated Care Partnership Partnerships

1 Brief/Executive Report Details Brief/Executive Summary Title: Chief Innovation, Integration and Research Officer’s Report

Item/ 1.0 – The Wolverhampton Place: paragr aph Key Headlines:

. Integrated Care Partnership (ICP) Board Meetings will commence from April 2021. The RWT CEO will co-chair with the Primary Care Network (PCN) Directors. This marks a successful developmental programme with the Trust acting as anchor organisation working in close alignment with BCHFT, LA, PCN, Voluntary Sector, Health watch and Compton.

. Work programme developed focussing on 6 key areas with 3 underlying principles.

. A draft Outcomes and Operating Framework has been developed.

. Governance of the ICP as RWT as host organisation is being developed with the CCG.

. Contracting framework is in development which will be based on the scope of services, current contracts and proposed STP level discussions and is being led by the BCCG.

1.1 Work Programme

A draft work programme has been developed which focussing on a number of key areas:-

. Community/Complex . Discharge/D2A . Healthy Ageing . Mental Health . Children and young People . Urgent Care . All these areas will utilise the SCDU, linked data, to drive care processes

Within each of the work areas will be 3 underlying principles:-

1. Reducing health inequalities 2. Adopting a personalised care approach 3. Improving patient experience

It should be noted that these are not just project teams working on specific projects but are collaborative’s with key stakeholders from all relevant organisations and communities that will be responsible for transformational change within their area but also responsible for the day to day delivery of local and national requirements relating to their area.

For example the Discharge/D2A collaborative is responsible for ensuring that the Hospital Discharge Policy is implemented, and that the Home First pathways are introduced and encouraged.

Discussions are now underway with partners to determine the key objectives of each of the areas, and the appropriate colleagues to be involved in the collaborative’s

2 1.2 Operating and Outcomes Framework:

The first draft of the operating and outcomes framework (Appendix 1) has been produced and presented to partners. This will be amended following any comments and to reflect the work programme. This links in with the Sustainability and Transformation Partnership (STP) / Integrated Care System (STP) Framework.

Following the initial review it has been agreed to socialise the framework within each organisation and with key stakeholders and partners to gain a place based view on the content and ensure that the direction and vision of the framework is cohesive.

1.3 Contracting Framework:

Work has commenced on the development of a contracting framework. This includes a scoping exercise in relation to identifying a breakdown of certain contract lines i.e. RWT community. This will also involve the contract lines and values of partners to provide a wider picture.

1.4 Management Support:

Resources have been identified by BCCG and RWT/CCG are working to draw the down funding in order to provide management support for the development of the ICP, undertaking a system diagnostic and engaging with partners.

1.5 Key Milestones:

. First ICP Board meeting April 2021 . Final approval of ToR, Operating and Outcomes Framework and Work Programme . Confirming funding and specification/brief for external support . Further development of the Contracting Framework

3 Digital Innovation & Strategic Partnerships

Alvina Nisbett Head of Digital Innovation & Integration

4 Item/ 2.0 - Digital Innovation and Strategic Partnerships paragr aph Key Headlines:

. The digital collaborative which is which is a collaboration between RWT, Sensyne and Microsoft has identified exemplar projects which will enable joint collabration to utilise the RWT rich dataset combined with research and Artifical Intelligence to provide anticipatory care for patients and better patient outcomes.

. The operational deployment of the Digital Primary Care Babylon Solution has commenced with key activities underway (see section 2.3).

. Recent dialogue has identified where there is potential for aspects of the RWT digital offer to support outpatients with the smart triage of patients to support to reduce the waiting list backlog as we start to return to business as usual and also an end to end cancer dashboard. These opportunities are being explored further and will be progressed as appropriate.

. The Huddle Data Capture Tool (HDCT) as approved by the Trust Management Committee with the support of RWST Chief Executive Officer, is being provided in the format of a daily executive report, which displays a snapshot of the pressures the Trust is facing, this has been established and is being automatically emailed out to executives & operational managers to highlight issues which need addressing on a daily basis. Adoption has been particularly strong in Divison 2 where it has been utilised in bed mangement meetings.

. The on boarding process for the Sensyne Partnership has commenced and a number of key activities and tasks have been undertaken. The Draft on boarding roadmap being refined which will outline the 3-6 months plan for mobilisation (see section 2.5).

2.1 – The “Digital Wolverhampton” Partnership and the Digital Inclusion Coalition

Discussions have commenced with the CIO at BCHFT in relation to digital matters and the data provisioning of our live data set combining (primary, secondary and community live data) for the purposes of direct patient care - similar to what we have done with all GPs in Wolverhampton, the work underway with Compton and Wolves City Council.

It is agreed that the work to have bi-directional feeds of patient data between our organisations is a very worthwhile thing to do as the impact on care is instant.

Relevant steps are being taken to ensure that the relevant governance processes i.e. a DSA is completed. This supports the regional/sub-regional work being undertaken at STP level.

In relation to the digital divide a range of stakeholder (council, third sector, university, GPs) are working collaboratively and are engaged in this work. Two stake holder meetings have been arranged and there is

5 consensus that there is a digital divide problem and there is a lot of a priori information.

A collective of GP and GP service have been identified for a pilot study and for a future substantive study and a scoping literature review is ongoing to identify a questionnaire. Some work has already been undertaken and the literature has provided the tools that will underpin the survey.

The partnership continues to meet monthly, the next meeting will focus on:

. Data: The Wolverhampton Digital Enablement Programme (WODEN project) . Digital Inclusion: feedback from WM Coalition for DI; Connectivity options: fixed vs mobile; Community Renewal Fund . Digital Innovation: initial discussion around potential areas of focus to inform future imagination lab session to develop . Strategic Project pipeline opportunities: overview of Levelling Up fund opportunity . Centre of excellence for Digital Innovation

2.2. - Digital Collaborative

The collaborative has agreed to identify exemplar projects refining the focus of co working and moving from preliminary engagement to a deeper dive, ensuring that there is calibration around a focus on scope and outcomes.

Sub groups of the collaborative will be meeting to define the purpose and focus of the collaboration as described in feasibility and practicalities as well as in mutualised benefits and outcomes.

The following projects are considered to have vast potential but only as exemplars and it is acknowledged that selecting the focus for co working would require more significant thought.

. The Wolverhampton Digital Enablement Programme (WODEN) o Patient / Client Facing Digital Exclusion Project

. HUDDLE – which encompasses complex care o Live active and predictive flow analysis

. Pathology Blood Sciences o Link our Global clinical data asset to the pathology set and identify an area to focus on

Population Health Management / predictive risk links closely to all of the above and will be the golden thread through all projects which will ensure that the patent centric population heath approach is maintained.

The Collaborative will regroup at the end of April to review the high level plan on moving forward with the exemplar projects.

2.3 - Digital Primary Care – Babylon

The partnership with Babylon has moved into the operational deployment phase which focuses on Digital Primary Care

The vison of digital primary care is to empower people to manage their health care through a digitally enabled model. Creating better access, more choice and flexibility plus a range of expert knowledge from the right

6 local clinician when needed.

The objectives are :

Patients: . Access & choice – widening access options for our registered population to ensure a modern and resilient primary care service . Experience - giving people the best experience of healthcare through a multi-channel delivery offer

Staff: . Releasing time to care – enabling clinicians to prioritise patients with greatest need while ensuring equity of offer for the wider population . Workforce flexibility – supporting a new model of delivery that offers the opportunity to change the place of work and person doing the work

Organisational: . Digital flagship leader – establishing RWT primary care as a leader of innovation, creating future investment opportunities for research and innovation . Delivering a sustainable and long term model of primary care – affordable, flexible and adaptive to changing needs

A Project Steering Group has been established and meets monthly. In addition key work streams have been identified as follows and are representative of both RWT and Babylon clinical, strategic and operational colleagues working collaboratively:

. Finance and Governance . Communications, Engagement and Marketing . Mobilisation . Systems . Quality Assurance

Key Milestones:

. Primary Care Network Website build commenced – March . Scope and agree preferred deployment method – April . Agree Statement of Work – April . Agree Primary Care Data Sharing Protocol– April . Commence mobilisation activities – April / May

The intended go live date is June 2021 on the proviso all governance requirements have been met, user (both staff and patients) testing has been completed, stakeholder engagement has been undertaken, appropriate communications plan is in place and clinical safety sign off has been approved.

2.4 - RWT Digital Offer

It is vital that post COVID, digital innovation moves even further to become the standard way of doing things at the Trust.

During COVID, digital innovation has been accelerated due to the need to be able to respond and continue to provide services for patients and service users albeit in difficult circumstances.

The Trust has responded remarkably well to this challenge and staff and colleagues have adapted to new ways of working and we must build on this momentum to build the RWT digital offer for service users and

7 staff alike which becomes business as usual.

Some of the digital innovations that have been deployed to date are:

. Development of the live Covid-19 dashboard . Development of the Covid-19 Care assistant app . Outpatient video consults . Wide scale move to digital meetings . Use of the Structured Clinical Dataset Unit (SCDU) . Increased use of technology re communications . Rheumatology initiatives re patient information . Shielded patient dashboard to improve communication with patients and prioritisation of deferred treatments

This is a snapshot of the work undertaken but identifies the progress that has been made in terms of the deployment in a short period of time.

To build on this momentum the RWT Digital Offer is being developed and refined and incudes but is not limited to:

. SCDU - Digitally Linked Pathways - Primary, Secondary, Community – data driven care . ZESTY - patient portal . Babylon - Ask A&E app and future work . Sensyne Health . Population Health work . Clinical Assessment System . The Digital Innovation Forum (DiF) and Innovation Committee . The Digital Collaborative . The Wolverhampton Digital Partnership

By building the brand awareness and applying the necessary communications internally and externally will support a platform for attracting both local and national awareness which could attract inward investment.

This is also an opportunity to engage clinicians who could act as Digital Champions’ in piloting these areas and bringing in new innovations to support the Trusts Digital Innovation aspirations.

Recent dialogue has identified where there is potential for aspects of the digital offer to support outpatients with the smart triage of patients to support and reduce the waiting list backlog as we start to return to business as usual and also an end to end cancer dashboard. These opportunities are being explored further and will be progressed as appropriate.

2.5 - Sensyne Strategic Partnership

The initial on boarding familiarisation meeting has taken place with key stakeholders from RWT and Sensyne, this process aims to identify the key activities that need to be undertaken to ensure that the appropriate processes, systems and resource are in place to support the projects that will be agreed under the agreement.

The contracting and discovery phases have been completed (February) and the Establishing the availability of the core dataset phase has commenced. It is anticipated that this phase will be completed during April.

8 The on boarding activities undertaken to date:

. Data checklist (baseline data) initial scoping exercise undertaken and gaps identified (February 21) . Common Data Model reviewed (March 21) . Draft On boarding Roadmap developed and is being refined which will outline the longer term (3-6 months) plan for mobilisation including the identification of projects and allocation of resources . Met with pharmacy and Pathology teams to specify what approach / resource is required to set up data flow to Data warehouse (March 21)

The core team are liaising with Chelsea and Westminster Hospital NHS Trust who have been working with Sensyne for approx. 5 years to gain an insight into lessons learnt and best practice in regard to the process of anonymisation of data and also the safe transfer of data.

This has provided invaluable intel which will be considered by the Trust to identify the most appropriate model for the Trust in line with best practice and governance principles in regard to the anonymisation and safe transfer of data.

The process for allotting the new shares and applying for the new shares to be admitted has begun which will lead to delivering a share certificate to the Trust and entering the Trust’s name in the register of members, which is being overseen by the Trust’s Chief Financial Officer. It is anticipated that this will be completed by April 2021.

3.0 – Huddle Data Capture Digitally Linked Pathways Tool

The Huddle tool in recent months and weeks has become an increasingly important aid in managing patient flow in the hospital. The tool has received support from the Trust Management Committee, Chief Executive Officer and Executives.

The tool allows patient flow assistants to capture actions against patients and record the constraints faced by hospital wards.

This in turn allows the Trust to understand what the delays are and more importantly, put measures in place to reduce these delays. There have been further developments in enhancing the tool in the last month. This includes:

. The inclusion of the early warning score in HDCT which was successfully tested on C15 and a roll out plan has been devised for other wards. . The Huddle tool ‘mirrored’ on the big tele-tracking screens during the huddle meetings has been successfully tested on C15, and a roll out plan has been devised for other wards. . A daily executive report which displays a snapshot of the pressures the Trust is facing has been established and is being automatically emailed out to Executives & operational managers to highlight issues which need addressing on a daily basis. This includes identification of medically fit patients and also long length of stay patients. . Adoption in Division 2 has been positive and the tool is being utilised at bed meetings.

The enhanced version also includes the following additions:

. More focus on highlighting delays today . Inclusion of an executive checklist

9 . SPC charts (when clicking on delay reasons) . Adding more visual indicators

The intellectual property belongs to RWT and as such external legal counsel is preparing the documentation around securing the Intellectual Property (IP). This includes securing copyright and trademarks for the software.

The digital innovation team are designing a pack/manual which will enable the Trust to market this to other organisations as we anticipate significant commercial interest and have already been approached to provide demonstrations of the tool.

4.0 - Population Health Management

The team has continued to support the COVID response, by providing epidemiological analysis for the multiagency Strategic Coordination Group and Local Outbreak Engagement Board, allowing policy responses to be targeted effectively.

Current priorities include:

. Starting to move forward with workstreams under ICP now that outcomes framework has been agreed – including end of life, healthy ageing, ethnicity coding, digital exclusion, 0-19 dataset, community services . Recruiting under the national Black data science internship programme, for a 6 week placement in the summer . Starting discussions with DPH about the third year of the contract with Public Health and what working arrangements look like going forward

10 . Recruitment of a Public Health Specialist to support the various projects / work streams . Continuing the routine epidemiology for COVID, as well as regular audits of vaccination equity to support the GPs and community champions to target outreach / catch up

5.0 - Structured Clinical Dataset Unit (SCDU) & Digital Care Pathways Projects

Several key “interface” projects which cover “end to end” care spectrum are being deploying across the care spectrum. This work has been undertaken in conjunction with the clinical leads, clinical teams and operational teams.

The report provides an update on the progress to date and the next steps and associated timelines for the digital pathway projects.

Digital resource has been secured which is ring fenced to support the stabilisation of Huddle and Diabetes projects.

The Huddle tool in recent months and weeks has become an increasingly important aid in managing patient flow in the hospital. There have been enhancements to the tool which continue to add to the functionality of the tool.

The progress of the individual projects is set out overleaf in table 1.

11 Table 1:

Project Status

Project Project Outline Summary Progress to date Next Steps Timeline Level ID Name

A GP A system that risk escalates Pilot practices have been New version of the system to be 26th March 2021 whole GP practice populations confirmed. released and enabling capture of triage 4 assessments and actions Introduction and The pilot practices are working through Pilot first point triage required. Risk escalation is orientation meetings the first point triage completion: 30th March dynamic and live with have concluded. 2021 integration of data across primary, acute and community The pilot start date has Following this, the pilot practices will be Initial assessment: 12th care. been confirmed. expected to complete the needs April 2021 assessment Two pilot sites are now reviewing the patient lists The MDT pilot between GP and MDT Pilot: April 2021 ready for piloting the Community to take place MDT with the Community team.

B Community A Community system that Project group confirmed. To confirm the proof of concept with 25th March 2021 highlights patients within their Clinician support to refine the 2 caseload who a) can be Proof of concept being dashboard reviewed to see they are deployed to the receiving appropriate Community teams. Agree how the dashboard will be 31st March 2021 community care deployed b) Reviewing patients with GP Proof of concept practices in a virtual MDT where feedback been provided Pilot the PCN / Team level dashboard April 2021 either GP’s (from System A) or ready for potential

12 community teams have changes. identified patients for MDT review.

Again this system involves risk escalating patients with dynamic and live integration of data across primary, acute and community care. MDT assessments and actions are also captured. Project Project Outline Summary Progress to date Next Steps Timeline Level ID Name

C Parachute An overarching system, as part D2A have been engaged Key stakeholders to meet to discuss May 2021 of D2A and linking systems A, B, for the IPZ work stream next steps and the links with the Huddle 1 C & E to ensure patients tool. discharged from hospital have Resource is being sort to appropriate ongoing support support the IPZ work with GP and Community teams. stream. D Palliative An end of life tool to complete Currently undertaking the Due to COVID-19 pressures, the service 31st March 2021 while patients are in the pilot stages. is testing the system again through 3 ward. Again this system March. involves risk escalating patients The end of life, key with dynamic and live question and care plan Staff are reviewing the national April 2021 integration of data across has been added to standards and are undertaking a gap primary, acute and community Clinical Web Portal. analysis to identify the gaps which will care. For patients who meet Compton DSA and DPIA then require clinical sign off. risk criteria, the ‘Surprise EOL’ being developed with question is asked regarding Compton. Final feedback on deployment to be April 2021 prognosis. GSF care plan agreed

13 assessments and actions are also captured. Agreement reached with Compton for a April 2021 joint digital resource initially for a 12 month period to support the data sharing arrangements and governance requirements

Project Project Outline Summary Progress to date Next Steps Timeline Level ID Name

E Huddle When patients are discussed in A trust wide roll out has Initiate plan to stabilise the system April / May 2021 4. clinical ‘Huddle’ meetings, this occurred in recording within the current EPR system allows capture of key ‘Criteria to reside’ In the information such as EOL, Frailty tool. This is a national Secure IP for the tool and develop a May 2021 assessments, Actions, Action requirement for hospitals ‘manual / package’ which can be leads and ‘red and green’ days. to report on but it also commercialised and marketed to other highlights patients who organisations. This system has a built in are medically fit on wards analytical reports which and therefore the Trust measure and analyse hospital can be more pro-active in Explore opportunities to enhance the Ongoing delays that have been captured enabling discharge. This use of the tool through the extended so that the Trust can act and is also being used for a analytical capacity from key commercial reduce these delays. national return partners.

Digital resource has been Linked to Huddle data, explore the secured to support the opportunities to integrate the other stabilisation of the tool. developing systems of Palliative, D2A and best practice ward round. Confirm the transition of the system to a new Develop a Trust wide rollout plan platform and server. To project the system on a

14 Tele Tracking type screen while Clinicians discuss the huddle

Vital Pac information such as the early warning score and also oxygen data has incorporated in the system for visibility.

Requests from the CQI team to incorporate the following in the system: extensive reporting has been developed to help senior Trust management understand patient flow within the organisation, from the system.

F Diabetes This is a specialist collaborative Database is set up to Ring fenced resource to build each Build: May 2021 1 which utilises SCDU data to help identify patients / module of this database now that the Diabetes teams. This demographics. patients have been identified. This will Deploy: June / July 2021 system is a register of all include: Diabetes patients that the Trust A developer has been - Pathology results . interacts with. This database recruited who will lead on - Retinal screening gets update from any system this work going forwards - Other pertinent clinical data. which identifies possible or confirmed Diabetes patients from either primary or secondary care.

15 This integrated database will help manage the Diabetes population in general. Discussions are also taking place with Babylon with regards to introducing a patient facing app which interacts with this database.

Project Key:

Level 1 Data set accrued from multiple sources and managed under effective data governance.

Level 2 System outline defined working with relevant service and clinical leads.

Level 3 Proof of Concept system developed and tested.

Level 4 Tactical deployment of that system tested in preliminary pilot project

Level 5 All of the above complete, now requires “mainstreaming” from test position into full and stable deployment into clinical systems ensuring stability and scalability.

16 Clinical Research Network West Midlands

Pauline Boyle Chief Operating Officer

17 5.0 – Key Headlines

. Due to the pandemic HLO’s for 2020/21 have been suspended by the NIHR CRN CC. A prioritisation of studies has been agreed between the NIHR CRN CC and DHSC

. West Midlands is still the top recruiting region for the highest priority (level 1a studies).

. Nationally, our region is the largest recruiter for two Level 1a studies and four Level 1b studies.

. This year for the first time we carried out the PRES almost exclusively online. Our previous best total was approximately 900 and we set ourselves a target of 1,200 responses this year. As of 5 March, we have well exceeded that, with 1,375 responses.

. 189 studies led from West Midlands were paused to recruitment. As of 5 March, this is now down to 36 studies and we have performed significantly better than the national average for both groups.

. We were successful with the recent pump priming funding bid and have been awarded a further £182,000. This was the final round of VTF funding.

. CRN West Midlands will submit the Qtr. 4 return at the start of May 2021 and there will be a zero balance on this return.

. An additional £30 million has been awarded nationally for distribution to LCRN’s although the CC have not yet decided how this should be distributed.

5.1 - Performance

Due to the pandemic HLO’s for 2020/21 have been suspended by the NIHR CRN CC. A prioritisation of studies has been agreed between the NIHR CRN CC and DHSC:

Prioritisation list:

Level 1a (Top Priority) - COVID-19 UPH vaccine and prophylactic studies (as prioritised by the Vaccines Task Force and agreed by Jonathan Van-Tam, deputy CMO) and platform therapeutics trials (currently RECOVERY/RECOVERY +; PRINCIPLE; REMAP CAP).

Level 1b - Other COVID-19 UPH studies.

Level 2 - Studies where the research protocol includes an urgent treatment or intervention without which patients could come to harm. These might be studies that provide access to potentially life preserving or life- extending treatment not otherwise available to the patient.

Level 3 - All other studies (including COVID-19 studies not in Level 1a or 1b). Priority 1a recruitment.

18

West Midlands is still the top recruiting region for the highest priority (level 1a studies).

The Queen Elizabeth Hospital in Birmingham has recruited more to these studies than any other single site in the country and the Royal Stoke is the sixth largest.

Nationally, our region is the largest recruiter for two Level 1a studies and four Level 1b studies.

Efficient Study Delivery

Current Forecast

England average 69% 52%

West Midlands 80% 56%

Only commercial studies that had opened since the start of the pandemic and that will have closed by 31 March 2021 are included. This means that far fewer studies and sites are counted than in previous years.

A number of studies which have yet to close by the end of the month are behind target so the outcomes is forecast to be lower than the current performance. But West Midlands has performed better than the England average on both counts.

Provider Participation

There are three targets to ensure that research is as widely available as possible.

Target Performance Note

A 99% of Trusts to recruit 100% Achieved

B 70% of Trusts to recruit to a commercial study 52% England averaged 61%. Smaller Trusts have not had capacity due to redeployment

C 45% of GP Practices to recruit 30% England averaged 45%. Primary Care team redeployed due to pandemic Participant in Research Experience Survey (PRES)

This year for the first time we carried out the PRES almost exclusively online. Our previous best total was approximately 900 and we set ourselves a target of 1,200 responses this year. As of 5 March, we have well

19 exceeded that, with 1,375 responses.

Initial high-level analysis of the responses indicates very high levels of satisfaction, but after this year’s survey closes, we will compile a thorough report.

Restart Objective: Restart 80% of the studies that had been paused due to the pandemic. Separate targets for commercial and non-commercial studies.

189 studies led from West Midlands were paused to recruitment. As of 5 March, this is now down to 36 studies and we have performed significantly better than the national average for both groups.

We have achieved the commercial target and need to restart just one more non-commercial study in order to reach 80% for that group.

5.2 Vaccine studies

We were successful with the recent pump priming funding bid and have been awarded a further £182,000. This was the final round of VTF funding. The West Midlands has been awarded £1,024,288 in total funds to assist partner organisations with the regional set up of Vaccine Research Hubs and Vaccine study delivery.

Vaccine studies currently in setup include Valneva Phase III. The West Midlands has submitted 4 expressions of interest for the region. UHB as the Lead Site and also RWT, MPFT and UHCW. Site evaluation visits have taken place and site selection confirmation is expected this week.

Recruitment is expected to begin at the end of April for this study.

The ComCov study has completed the recruitment phase successfully at UHB.

The Novavax Study has submitted for approval for a crossover study to vaccinate the placebo participants. There has been a large number of participants that have requested to be unblinded from the study. There are a number of steps to complete first including discussions with MHRA and amendments to the protocol.

20 The Janssen, ENSEMBLE2 study has completed recruitment in the West Midlands, only the age 65+ cohort remains open to recruitment at one site nationally. This study is also expecting MHRA approval shortly for a one dose versus two dose vaccine amendment to the protocol.

5.3 – Workforce

LCRN funded staff deployment

LCRN funded staff deployment details are submitted to the CRN CC on a weekly basis based on self-reporting figures from each Partner Organisation (PO).

All POs are continuing to support 1a studies - some had reduced capacity for all other research activity to achieve this. Clinical and non-clinical LCRN hosted staff are currently deployed to support 1a study delivery across our POs.

5.4 - Finance

Q4 20/21 Reporting:

CRN West Midlands will submit the Qtr. 4 return at the start of May 2021 and there will be a zero balance on this return.

Additional Restart Funding of £318k will be received from NIHR between Qtr. 3 and Qtr. 4 making the total funding £789k to tackle the “multiple and competing pressures on CRN resources” in this financial year. 70% of the latest funding has already been allocated to our Partner Organisations (POs).

All POs have reported that they will spend this additional funding within this financial year; the remaining 30% will be allocated in the near future.

We are mitigating the risk of over/under spending in the network by maintaining close ties between operational and finance teams within the host organisation. We also work closely with the different POs within the network to ensure that the funding is utilised most appropriately.

21 Vaccine Funding:

Originally £500k was sent to CRN West Midlands from NIHR regarding Vaccine Funding in late September 2020 with an additional £343k awarded to CRN WM between Qtr. 2 and Qtr. 3. NIHR then confirmed that a further £181k would be sent for West Midlands making the total funding for vaccine studies £1,024k.

The Vaccine Funding is expected to be totally utilised in this financial year.

Local funding model 2021/22:

Due to disruption caused by COVID-19, the CRN has acknowledged the need for stability in funding for our POs. It was agreed that all POs will receive stable core funding for 2021/22.

POs were also asked to submit bids for Improvement and Innovation Strategic Funding in late 2020 for research projects in 2021/22. PO’s are currently receiving feedback on their bids from the Senior Leadership Team regarding the outcome of their bids.

Confirmation of LCRN funding 2021/22:

The CRNCC recommended to the Department of Health & Social Care that the 2021/22 funding allocations per LCRN be fixed at the same level as 2020/21. Since then an additional £30 million has been awarded nationally for distribution to LCRN’s although the CC have not yet decided how this should be distributed.

Any decisions regarding how additional funding will be distributed locally will be discussed by the networks Partnership Group.

Financial pressures:

PO’s rely upon the income from commercial clinical trials to maintain their research workforce which includes investing in the workforce to support NIHR non-commercial studies. Due to the pandemic the projected income from commercial clinical trials will be reduced for PO’s and hence will be an additional financial pressure for them.

Excess Treatment Costs (ETCs):

The CRN continues to process the payment of ETCs on behalf of NHS England & NHS Improvement. A reduction to the annual threshold for POs before ETCs can be paid has been agreed by NHSE/I.

Just over £5k was sent from NIHR and will be passed onto one of our PO’s before year end

5.5 - Organisation of the CRN: Entry Plan

Entry Plan Programme Board (update since 26 Jan 2021):

• Second session of Entry Plan Programme Board took place 9 Feb • Priority areas of work discussed • Did not achieve final list by end of session so members asked to send in their thoughts before the third session, 9 March

22 At session three, the Board will prioritise/refine these ideas further and discuss how we will deliver these, and identify the role they will play in supporting their delivery.

23 Research and Development

Sarah Glover, Directorate Manager Professor James Cotton, Clinical Director for R&D

24 6.0 – COVID-19 Research Activity

6.1 Key Headlines

. The Trust is participating in a number of research projects informing the national response to the coronavirus outbreak and investigating the management and treatment of patients with COVID-19.

. In line with NIHR requirements, the R&D Directorate continues to focus on the set-up and delivery of priority COVID-19 studies.

. In addition, a process to review and re-start non-COVID research is also underway, although has slowed during the latest wave of COVID admissions. This process reflects both national NIHR ‘restart’ guidance, the opening of local clinical services and our capacity to deliver study requirements. . Non-COVID research activity has restarted in the following specialties: Oncology, Haematology, Rheumatology, Cardiology/Cardiothoracic, Obstetrics, Surgery, Paediatrics, Gastroenterology and Respiratory.

. 397 participants have been recruited into non-COVID studies so far in 2020/21. 23% of studies remain paused to recruitment.

. RWT is currently in the top 10 nationally for the number of NIHR COVID-19 studies open and in the top 30 for the number of participants recruited (3rd in the CRN WM region) (Source: NIHR ODP)

. A target of 10% of COVID +ve admissions recruited into RECOVERY has been set by the NIHR (RWT at 6.9% for 2 week time period ending 09/03/2021)

25 6.2 - Studies open to recruitment

6.2.1 Summary:

Performance Activity COVID-19 Research Studies  24 Studies open  15 NIHR Urgent Public Health Research (UPHR) studies opened

Recruitment into COVID-19 Studies  5715 – Total recruitment to date  4170 - Recruitment into UPHR studies  329 – Recruitment into interventional studies

NIHR UPHR Priority 1 studies  RECOVERY – 6.9% of COVID + VE admissions recruited during 2 weeks ending 09/03/21. (NIHR target of 10%)  PRNCIPLE – VI practices 2nd in CRNWM region for recruitment (n=63) Alfred Squire practice is 6th nationally.

NIHR Portfolio adopted study, developed by Trust researchers and sponsored by  1144 staff have consented into the study to date RWT : CHiP (COVID-19 Health Professional Impact Study)

RWT is currently in the Top 15 acute Trusts nationally for the number of NIHR UPHR studies open and in the Top 20 for the number of participants recruited

(3rd in the CRN WM region) (Source: NIHR ODP)

COVID Vaccine Trial – Phase 3  RWT not selected as a study site

Non COVID-19 Research Studies  397 participants recruited to date in 2020/21.  35 studies recruiting participants.  23% of studies remain paused to recruitment. 

26 6.3 COVID-19 Research Activity

6.3.1 Studies open to recruitment

NIHR UPHR – Priority 1a studies

Study Title Summary Details PI Study Type NIHR Urgent Recruitment Public Health Research 1 ISARIC Clinical investigation of severe or potentially severe acute Dr J Pooni Observational Yes 2650 infections by pathogens of public health interest. – (https://www.nihr.ac.uk/urgent-public-health-research-studies- for-covid-19/covid-19-isaric-coronavirus-clinical-characterisation- consortium-isaric-4c-ccp-uk/24518) 2 RECOVERY Randomised trial of therapeutic treatments on the outcomes of Dr S Gopal Interventional Yes 219 patients with COVID-19 - (https://www.recoverytrial.net/)

Paediatric arm opened 07/05/2020 (Lead - Dr K Davies) 3 REMAP-CAP To identify the effect of a range of interventions to improve Dr Gopal Interventional Yes 15 outcome for patients with severe CAP who are admitted to ICU. https://www.remapcap.org/coronavirus

4 PRINCIPLE Open, prospective, individually randomised, platform controlled Dr Anna Stone Interventional Yes 67 clinical trial of Interventions Against COVID-19 in Older People in community care comparing standard care to standard care plus hydroxychloroquine OR Azithromycin. (Hydroxychloroquine arm suspended by sponsor) https://www.phctrials.ox.ac.uk/principle-trial/ 5 TACTIC-R Clinical trial testing whether existing drugs, which are already used Dr T Sheeran Interventional Yes 26 to treat other immune-related conditions, can prevent the

27 development of severe symptoms in patients hospitalised with confirmed COVID-19. The treatments currently being tested in TACTIC-R are: Baricitinib – used to treat severe rheumatoid arthritis Ravulizumab – used to treat blood diseases where the immune system destroys red blood cells https://cctu.org.uk/portfolio/COVID-19/TACTIC

6.3.2 NIHR UPHR Priority 1b & non-UPHR studies

Study Title Summary Details PI Study Type NIHR Urgent Recruitment Public Health Research 6 GENOMICC The GenOMICC (Genetics of Susceptibility and Mortality in Critical Dr S Gopal Observational Yes 38 Care) study will identify the specific genes that cause some people to be susceptible to specific infections and consequences of severe injury. Identifying these genes will help the better use of existing treatments, and to design new treatments to help people survive critical illness– https://www.nihr.ac.uk/urgent-public-health- research-studies-for-covid-19/genetics-of-susceptibility-and- mortality-in-critical-care-genomicc/24596 7 UKOSS Study to investigate the effects of the novel coronavirus epidemic Prof D Observational Yes 88 and its treatment on pregnant women and their babies using the Churchill UK Obstetric Surveillance System (UKOSS). https://www.nihr.ac.uk/urgent-public-health-research-studies-for- covid-19/ukoss-pandemic-influenza-in-pregnancy/24545 8 CERA This study aims to capture the psychological impact on staff of the Not required Observational Yes Not available coronavirus pandemic, at 3 timepoints (preparation, peak, resolution) via an on-line questionnaire for front-line workers in

28 ED/ICU/AMU

9 COVID-SURG Capturing real-world data and sharing international experience to Dr A Habib Observational No Service inform the management of this complex group of patients who Evaluation undergo surgery throughout the COVID-19 pandemic, improving their clinical care. 10 PAN COVID A global registry of women affected by COVID-19 in pregnancy and Prof D Observational Yes 69 their neonates, understanding natural history to guide treatment Churchill and prevention https://pan-covid.org/ 11 PROTECT PROTECT- ASUC: Covid-19 Pandemic Response Of assessment, Prof M Observational No 0 EndosCopy and Treatment in Acute Severe Ulcerative Colitis. A Brookes multi-centre observational case- control study. 12 PREPARE PREPARE-IBD: Physician Responses to disease Flares and Patient Dr Helen Steed Observational No 203 Adaptation in Relation to Events in Inflammatory Bowel Disease during COVID-19 pandemic: A multicentre cohort analysis. 13 COVID-19 The aim is to confirm the COV-HI clinical phenotype and using Dr S Observational No 50 hyperinflam routine data to try to infer the inflexion point where COV-HI VenkataChala mation emerges. This would enable refinement of the proposed treatment m syndrome algorithm and translates to routine clinical practice to improve the (COV-HI) outlook for COV-HI. https://www.hra.nhs.uk/covid-19-research/approved-covid-19- research/282626/ 14 Coronavirus Study to describe the clinical spectrum of COVID-19 infection in Dr Karen Observational Yes 29 infection in children who have a condition that makes them more vulnerable Davies (RWT as PIC immune to infections to inform clinical policy and to enhance the quality of site) supressed information given to patients and parents children www.uhs.nhs.uk/immunoCOVID19study 15 STAT-STRESS A regional online survey evaluating the incidence of self-reported Ms Anna Observational No Not available Survey symptoms of post traumatic stress disorder (PTSD) and post- Grant (RWT as PIC) traumatic growth amongst hospital workers in the West Midlands

29 during the Covid-19 pandemic. 16 CHiP **NIHR Portfolio adopted Trust sponsored study** Prof S Basu Observational No 1144 (COVID-19 Health A pilot assessment of the COVID 19 antibody status and associated Professional factors, in individuals employed by a large acute NHS trust during Impact the Coronavirus pandemic. Study)

6.3.3 - Studies closed to recruitment

Study Title Summary Details PI Study Type NIHR Urgent Recruitment Public Health Research 1 PRIEST Review of the triage of people using the emergency care system Dr J Pooni Observational Yes 612 with suspected respiratory infections during a pandemic to identify the most accurate triage method for predicting severe illness Study closed among patients attending the emergency department with to suspected respiratory infection - (https://www.nihr.ac.uk/urgent- recruitment public-health-research-studies-for-covid-19/the-priest- 28/05/2020. study/24544) – 2 GILEAD Expanded Access Treatment Protocol for the use of Remdesivir Dr A MacDuff Interventional No 2 (EAP (RDV; GS-5734) (EAP) closed) 3 The COVID- Understand the psychological and physical impact of the COVID-19 Alison Observational No Not available 19 and Stress pandemic in the community by measuring self-reported outcomes. Hardwick- Study closed Study Hazelgren to recruitment 30/04/2020 4 The COVID- Longitudinal study on the impact of COVID-19 on the NHS Sarah Milgate Observational No 146 19 Resilience workforce to guide trauma-informed and psychologically-informed Study closed Project support provision. to

30 recruitment 14/08/2020 5 Neonatal National study collecting information about newborn babies who Julie Icke Observational Yes 0 Complication have coronavirus and need medical care or who are born to Study closed s of mothers who have coronavirus. All paediatricians and to Coronavirus neonatologists in the UK are requested to report any babies that recruitment Disease meet the surveillance case definition to the BPSU every week. on (COVID-19) https://www.rcpch.ac.uk/work-we-do/bpsu/study-neonatal- 14/07/2020 Study complications-coronavirus-disease-covid-19#case-definition

6 SIREN Prospective cohort study to determine incidence of new SARS- Dr Clare Ford Observational Yes 251 COV2 infection in seronegative and seropositive healthcare Study closed workers to recruitment 23/09/2020 7 RECOVERY- Study comparing the three different treatments to assist Dr. Atul Gulati Interventional Yes 0 RS breathing; CPAP, High-Flow and Standard Care. - Study closing https://warwick.ac.uk/fac/sci/med/research/ctu/trials/recovery- at RWT. rs/ 8 CLARITY Impact of Biologic and Immunomodularity Therapy on SARS-COV2 Prof M Observational Yes 106 infection and immunity in patients with inflammatory bowel Brookes Study closed disease. to recruitment 23/12/2020

31 6.3.4- Studies currently pending

Study Title Details PI Study Type NIHR Urgent Public Health Research 1 VALNEVA Phase 3 Non-inferiority study comparing immunogenicity against COVID-19 of VLA2001 Prof Matt Intervention Yes with [ACTIVE COMPARATOR]. Brookes / al Vaccine COVID Vaccine Trial Dr T Taskforce RWT not selected as study site. No. of sites selected in UK reduced. Sheeran

6.4 - Non COVID-19 research activity

In line with NIHR requirements, the R&D Directorate continues to focus on the set-up and delivery of priority COVID-19 studies.

In addition, a process to review and re-start non-COVID research is also underway, although has slowed during the latest wave of COVID admissions. This process reflects both national NIHR ‘restart’ guidance, the opening of local clinical services and our capacity to deliver study requirements.

Non-COVID research activity has restarted in the following specialties: Oncology, Haematology, Rheumatology, Cardiology/Cardiothoracic, Obstetrics, Surgery, Paediatrics, Gastroenterology and Respiratory.

397 participants have been recruited into non-COVID studies so far in 2020/21. 23% of studies remain paused to recruitment.

6.5 - R&D Finance

R&D activity is funded via a combination of NIHR CRN monies, commercial and grant income.

The CRN WM core allocation to the Trust in 2020/21 was equivalent to that received in 2019/20, providing welcome stability during unprecedented times of research.

The suspension of many active commercial research studies during the first wave of the pandemic has resulted in a significant reduction in commercial income. A

32 result of which has led to the directorate developing a recovery plan to address this shortfall.

A forecast is being undertaken to quantify this financial position and complete a risk analysis of the impact of this reduction on the capacity for research activity at the Trust.

6.6 Risks

The following risks have been identified and are being managed within the R&D Directorate:

1. R&D Accommodation – current R&D accommodation, including lack of adequate clinical facilities, impacting on the ability to open and deliver clinical research. Risk Level: Amber. 2. External Monitor visits – lack of space to safely accommodate required visits by commercial contract research organisations, thereby limiting ability to reopen studies. Remote monitoring being trialled, but this is very time intensive on clinical research teams. Risk Level: Yellow 3. Reduction in commercial research income - reduction in commercial income as a result of pausing studies in March 20, consequent severe cost pressure within R&D, with the potential to destabilise Trust research activity. Risk Level: Amber

33 Sensitivity:1 Appendix 1 - Outcomes Operating Framework Wolverhampton ICP v2.pdf NOT PROTECTIVELY MARKED DRAFT Sensitivity: NOT PROTECTIVELY MARKED Principles

Our outcomes and operating framework; • Reflects areas that require partnership collaboration and that the ICP has a direct influence over • Reflects the person-centric segmentation approach, and particularly the segments that we have prioritised for collective action • Acknowledges that some outcomes can’t currently be measured and highlights workstreams needed to change data capture accordingly • Embeds health inequalities firmly into the ambitions of the partnership • Gets the balance between too much detail and too high level • Reflects the “triple aim” of integrated care in its 3 domains Sensitivity: NOT PROTECTIVELY MARKED

Outcomes Framework – 10 Ambitions in 3 Domains

Population Health & Wellbeing Service User Experience Right care, right place, right time System infrastructure Put people at the heart of what we do •Well – enable healthy choices and Work better together communities, ensure equitable coverage of universal services, identify risk and - Ensure service users, families and need earlier - Have partnership oversight of carers feel heard and well informed resources and outcomes, to make the •Chronic needs – enhance self about their health and wellbeing, most of the Wolverhampton pound and management and support in primary services and their condition/s ensure distribution is equitable care, delay complications, reduce - Provide person-centred, holistic care, exacerbations, identify issues early - Develop, attract, train and retain a and capture outcome measures that workforce fit for the future •Complex needs – provide personalised matter to people - Support integrated team working at a care planning and case management, - Ensure access to care is equitable, integrated team working, focus on local level, using integrated data to drive particularly for groups who are often coordinated care according to need quality of life, dignity at the end of life excluded •Acute illness/injury – ensure people receive care in the appropriate place Sensitivity: NOT PROTECTIVELY MARKED Outcome measures – Long Term up to 5 years

Improved quality of life for social care Reduction in the life expectancy gap Increased proportion of people clients over 65, increased early between people with mental health reporting high satisfaction with detection of dementia and conditions and the rest of the services, and clear evidence of co- osteoporosis, reduced admissions for population, and an increase in production methods in use for quality falls in people over 65 and delayed employment for people with mental improvement, particularly with health progression from mild to moderate to health conditions or learning disability inclusion groups severe frailty at population level

Improvement in self care and Increase in equity of access or uptake Increased proportion of people with a reduction in emergency admissions of services for prevention and early documented End of Life plan, and for asthma, diabetes and epilepsy in detection, by deprivation, ethnicity, more people dying in their preferred children and ambulatory care sensitive age and sex, including vaccination, place, with fewer emergency hospital conditions in adults, especially from screening and in-disease prevention admissions in the last months of life the most deprived parts of the City Sensitivity: NOT PROTECTIVELY MARKED Operational Framework

• Seeks to use the outcomes framework as a guiding principle • Identifies the annual priorities for development as part of a multi-year strategy for delivery

• Creates the structure for further operational planning which should be

delivered through individual work streams, to include Key Performance

Indicators (including Better Care Fund targets) Sensitivity: NOT PROTECTIVELY MARKED Operating Framework Milestones for 2021/2022: Population Health

Children with Long •Integration of data from primary care, hospital and community •Pilot of collaborative care between paediatrics and general practice to reduce Term Conditions inappropriate outpatient referrals and support and upskill GPs

•Evaluation of the Healthy Ageing Coordinator service Healthy ageing •Deliver an equitable COVID vaccination programme

•Proactive identification of people at the end of life and completion of Advanced Care Plans during inpatient stays Complex care •Establish virtual MDT meetings for people who need multiagency input and coordination •Continuation of key workstreams and indicators from the BCF programme Sensitivity: NOT PROTECTIVELY MARKED Operating Framework Milestones for 2021/2022: Patient Experience

Capture what • Co-produce person defined outcome measures so we can matters measure what’s important to our key groups

• Work with academic partners to research digital exclusion Equity of access • Improve the completeness of ethnicity coding in primary care to enable better equity audit – target 95%

Sensitivity: NOT PROTECTIVELY MARKED Operating Framework Milestones for 2021/2022: System infrastructure

Partnership • Establish the Wolverhampton Health Board and governance processes Oversight

Workforce • Integrate the work of people in new roles in primary care and community settings; for example pharmacists, social prescribers, health coaches and mental health development practitioners

•Community Services transformation programme to better meet population need Integrated data and •Develop a person-centric, integrated data resource for population level planning and team working research •Establish a work programme to deliver new models of outpatient specialist care 10.2 Chairs’ Report – Charity 1 Board meeting report Charity March 21.docx

Trust Board Committee Chairs Assurance Report

Name of Committee: Charitable Funds Committee

Date(s) of Committee 25th March 2021 (Virtual Meeting) Meetings since last Board meeting: Chair of Committee: Sue Rawlings

Date of Report: 26th March 2021

ALERT  None Matters of concerns, gaps in assurance or key risks to escalate to the Board ADVISE  Independent review of charity –Wootton George has completed the Area’s that continue to be reported review and presented to the committee. A range of actions and on and/or where some assurance recommendations highlighted to enable the Charity to grow and develop has been noted/further assurance sought effectively were noted. Intention is to hold a separate session to fully consider the Review and develop an Action Plan  Annual Fundraising charge comparisons noted

ASSURE  Report of the Charity Fundraising Co-Ordinator (see below) Positive assurances & highlights  Report of the Charity Finance Team (see below) of note for the Bo  ard An update was given on the Covid 19 balances to date. At time of meeting, £405,238 received in respect of donations with £118,966 overspent. Shortfall (as a result of staff benefit and thank you) to be made up from General Purpose funds. With regard to ITU balances £179,970 received and spent (with exception of £20)  Feedback received from previous funding requests. Agreed need an agreed format to ensure outputs and outcomes are captured effectively in addition to the qualitative information

Recommendation(s) to the  Consider recommendations for expansion and development of Charity Board

Changes to BAF Risk(s) &  None TRR Risk(s) agreed ACTIONS  Action plan to agree and implement findings from the Independent Review Significant follow up action  Chair and Fundraising Co-Ordinator meeting with counterparts in Walsall commissioned (including discussions to discuss potential joint working (N.B additional note: this was a positive with other Board Committees, changes to Work Plan) meeting with agreed action to consider a joint event and potential project development in due course.)

V1 April 2020 Page 1 of 2 ACTIVITY SUMMARY Business Cases for approval: Presentations/Reports of note  Recruitment of Volunteers and Volunteer Isolation Project– Research received including those Approved undertaken and recommendation made to appoint a short term post to develop partnership approach on a Wolverhampton Place based focus for development of a steering group and project. This was rejected in favour of looking at building on Wolverhampton Place Management Board links and existing joint working opportunities with Community Staff and Social Prescribers.

 Holistic therapies – Approved through SMT, noted at meeting.

 Bid Writer Post – Innovation, Integration and Research – rejected – Innovation Committee unaware of bid and departmental changes will impact on need for post.

ACTIVITY SUMMARY Charity Fundraising Co-Ordinator’s report Major agenda items  Independent review of charity discussed including those  Covid 19 Recovery and Post Pandemic Grants Stage 3 Approved  Staff Vouchers – deadline of 30th April agreed for return of unallocated vouchers from departments– to be used for future Charitable spending.

Charitable Funds Finance Report  2020/21 Summary Finance to 31st December 2020– income ££885k, expenditure ££677kk, reserves £2,510k.  Value of investments £2,646k

Matters presented for  information or noting Self-evaluation/  Terms of Reference to be amended to include Review recommendations Terms of Reference/ and approved at next meeting Future Work Plan Items for Reference  Independent Review of the Charity Pack

V1 April 2020 Page 2 of 2 1 Royal Wolverhampton NHS Trust Charity Opportunities Review.pdf

Fundraising Review for The Royal Wolverhampton NHS Trust Charity

15 March 2021

CONTENTS 1 INTRODUCTION 2 DISCLAIMER 3 METHODOLOGY 4 BACKGROUND 5 EXECUTIVE SUMMARY 6 FUNDRAISING SWOT ANALYSIS 7 RECENT RESULTS 8 THE CASE FOR SUPPORT 9 THE CURRENT FUNDRAISING STRATEGY AND KPIS 10 TRUSTS & FOUNDATIONS 11 CORPORATE PARTNERSHIPS 12 INDIVIDUAL GIVING 13 MAJOR DONORS 14 EVENTS AND COMMUNITY FUNDRAISING 15 DIGITAL FUNDRAISING 16 LEGACIES 17 IN MEMORIAM GIVING 18 PUBLIC LOTTERIES 19 WHAT ARE OTHER HOSPITAL CHARITIES ACHIEVING? 20 SUMMARY OF MAIN FUNDRAISING OPPORTUNITIES 21 CAPITAL APPEALS – A FUTURE OPTION 22 FUNDRAISING CULTURE 23 FUNDRAISING CAPACITY 24 ESTABLISHMENT OF A DEVELOPMENT BOARD 25 KEY CONSTRAINTS AND HOW TO OVERCOME THEM 26 FUNDRAISING RISKS 27 OPPORTUNITIES IN THE COMMUNITY 28 IMPLICATIONS OF THE NEW WALSALL COLLABORATION 29 THE HARLEQUIN DATABASE 30 CHARITY PARTNERSHIPS 31 CONCLUSION 32 FUNDRAISING RECOMMENDATIONS 33 REVIEW OF THE DECLARATION OF TRUST AND THE TERMS OF REFERENCE 34 BUSINESS OPPORTUNITIES (TRADING) 35 CHARITY PATRONS 36 INTERVIEWEES

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1 INTRODUCTION The Royal Wolverhampton NHS Trust Charity is a local good cause with a corporate trustee that receives and raises funds in support of the Trust, its patients and staff. Funds are received from a range of sources and the Trustees are now interested to explore how these could be grown in future and to what level. In addition, they are seeking advice on the continued suitability of the memorandum and articles, on the use of patrons, as well as on any wider business opportunities open to the charity. Finally, the Trustees have also requested a comparison with the work of other hospital charities, in case anything can be learned from them.

2 DISCLAIMER We have conducted this study on the basis of our fundraising experience and sector knowledge. However, the issues covered in this report are only those which came to our attention during the course of the study and are not necessarily an exhaustive list of all those that may exist or of all the opportunities or challenges facing the charity. For the avoidance of doubt, we are not qualified to give legal or investment advice and, where such issues arise, the Trust Charity should seek professional advice before making important decisions.

3 METHODOLOGY This study has been conducted in three stages. Firstly, we have held interviews with a relevant cross-section of people at the charity, as well as collecting documents and records of recent activity. Secondly, we have analysed the information collected in the light of our market knowledge and looked at how similar charities are performing. Thirdly, we have prepared this report for the Trust Charitys Trustees to consider.

4 BACKGROUND The Trust Charity is a typical general hospital charity that historically was the conduit for receiving donations and allocating funding to wards and departments. In recent years, it has become more proactive in seeking to stimulate donations and to grow its income. In so doing, it is moving from the traditional “thank and bank” model to that of an active fundraising charity, targeting a range of funds. Some good progress has already been made and this study has sought to establish if and how further growth can be achieved and, if so, in which areas of activity.

5 EXECUTIVE SUMMARY This review has found that the Trust Charity has a number of opportunities to grow its income, provided certain barriers can be removed. There are clear opportunities to increase the funds raised from trusts & foundations, assuming the Trust Charity can be made aware in good time of upcoming funding needs from the Trusts

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departments and that additional capacity can be created for what is a time consuming activity. Given the strong ratio of return here, it will be worth investing in this area for the future. Similarly with companies, we believe more could be achieved, but again this would require some additional capacity, as it is time consuming to make and grow relationships with corporate partners, some of which also expect a high degree of servicing. Major gifts from wealthy individuals are a further opportunity, which has not yet been developed. Assuming the Trust Charity can identify a suitable project (perhaps a future capital appeal), then we see no reason why this area could not also be developed too. A very significant opportunity will be the growth of legacy income, if the Trust Charity can overcome its reticence about asking for legacies and devise a simple legacy strategy. Although a long term opportunity, this is by far the biggest potential source of growth. There are additionally further opportunities to expand individual giving and in memoriam donations, which are discussed below, as well as some potential in events and community. An exploration of what comparable charities are currently achieving endorses the view that there is still considerable growth potential for the Trust Charity to exploit. In order to achieve this, however, it will be necessary to expand its capacity and expertise by establishing three new posts, which are discussed below. It will also make sense for the Trust Charity to take over the function of thanking all donors, which is currently spread across the Trust and is inefficient. There is also a pressing need for further training in the Harlequin fundraising software, which we understand will happen soon. Having reviewed the options for trading, we do not see any significant opportunities at present and certainly nothing which can compete with some of the fundraising options. In reviewing the Declaration of Trust, we find that this is still fit for purpose and does not need to be changed (especially as there is no obvious trading option). The Terms of Reference for the Charitable Funds Committee, however, will benefit from some additions, which we have set out below. In the area of charity patrons, we have provided a list below of some well-known people associated with Wolverhampton, some of whom may be willing to take on such a role. This support would be of particular benefit if the Trust Charity were to launch a capital appeal in the future, which is also discussed below. In summary, there are numerous opportunities for the Trust Charity to exploit and we have made a long list of recommendations below about the measures that will be needed to develop these. If they can be implemented in full, we believe the ultimate potential to raise funds to be in the region of £2 million per annum.

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6 FUNDRAISING SWOT ANALYSIS Strengths Weaknesses Long record of receiving and raising The support base is still small and shrank donations due to a GDPR cull A very successful year in 2020/21 Staff capacity for fundraising is limited A wide range of potential projects (if the Awareness of the charity among Trust staff is necessary information can be provided by still patchy departments) The charity already has a mixed income from Lack of notice of departments funding a range of sources needs hampers fundraising efforts Low physical visibility of the charity internally There is no agreed case for support yet There is a lack of clarity about fundraising objectives and priorities Staff still need training in use of Harlequin database

Opportunities Threats Grow trust & foundation income Competition for funds is increasingly co mpetitive Increase legacy income for the longer term The UK may be heading into a recession Grow corporate support Wolverhampton is not a wealthy city and may continue to struggle economically Become more proactive in seeking individual gifts (e.g. by testing specific appeals) Test themed appeals to groups of individuals Begin major gift activity and screen database for wealth indicators Consider a capital appeal when new capacity and structures are in place

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7 RECENT RESULTS Year Total Raised Gen. donations inc. corporates 2015/16 £604,000 £286,000 2016/17 £461,000 £261,000 2017/18 £1,040,000 £596,000 2018/19 £575,000 £297,000 2019/20 £367,000 £163,725 In the table, the total raised figure shows all income to the charity, including fundraising, trading and investments. The right hand column shows the directly fundraised income once we strip out lines such as investment income, trading and legacies. This gives us a picture of the underlying income that is being raised every year. Here we see that general donations from individuals and companies typically averaged £261,000 p.a. to £297,000 p.a. apart from in 2018, when the figures were skewed by high corporate giving and in 2019/20 when there was a significant drop-off in income due to staff sickness and a decline in support from the Goodyear Workers enevolent und. or 2020/21, income to the third quarter from individual donations and corporates was £542,885, which promises to be a stronger year and reflects the rise in giving caused by Covid-19. Some of this will of course be in one-off donations, so the challenge will be how to maintain momentum and build on recent achievements. These results show that the charity already has a diversified base of support, if still modest in some areas. It does, however, provide a good foundation on which to build for the future. Analysis of the different income streams is given below.

8 THE CASE FOR SUPPORT There is currently no agreed case for support document that sums up why the Trust Charity deserves to be funded. However, elements of the case are to be found on its website and in the charitys literature. The website summarises the case for support as follows, under the heading Support our Charity:

“Our Charity makes a real difference to our patients, their families and the staff that treat them above and beyond that provided by the NHS.

We support the Trust’s Vision to be an organisation striving continuously to improve patient experience and outcomes - to be safe and effective, kind and caring and exceeding expectation.”

This is then expanded in a mission statement:

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“To make a real difference to the patients of The Royal Wolverhampton NHS Trust, their families and the staff who treat them above and beyond that provided by the NHS through:

- additional facilities and an improved environment

- additional equipment that can make a real difference to patient care

- opportunities for staff training

- opportunities to further medical knowledge through research”

A factual explanation of how funds are used then follows:

“We would not be able to continue supporting the Trust without the kind generosity of our supporters. They have helped us to provide:

• Additional patient comforts – better quality comfortable furniture, additional furniture such as parental beds on the Children’s Ward and special support cushions used during radiation therapy • More advanced, specialist pieces of equipment, not generally provided by the NHS for example a linear accelerator for the advanced treatment of cancer patients • Items that improve the environment/ambience and patient experience • Opportunities to further medical knowledge through research • Children’s books and toys • TVs, DVDs and other patient entertainment media”

The charityʼs general supporter leaflet says the following:

“By supporting The Royal Wolverhampton NHS Trust Charity, you can help us to assist the Trust to continually improve patients eperiences an outcomes our vital support provies aitional resources to patients, their families an the staff that treat them, above an beyon that provie by the NHS

Everything that the Charity funs supports the Trusts vision- to be an NHS organisation that continually strives to improve patients eperiences an outcomes Funs can be use to provie a variety of items from chilrens books an toys through to more specialist, lifesaving pieces of equipment” While these statements and information make the valid point that the Trust Charity exists to provide more than the NHS can on its own, they are not very inspiring or compelling. The style is rather bland and lacks urgency and emotion. Here is an example of how another hospital charity (Leeds Hospitals Charity ) summarises its case for support on its website:

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Headline: mzg NHS ff , m” Main Text: “We support NHS staff to deliver the best care for over a million patients and their families each year. Working with local communities, schools and businesses across the city and beyond, each year we provide £5 million in additional funding for Leeds Teaching Hospitals Trust.

Your generous donations have funded lifesaving equipment, research fellowships and improvements to the patient environment. Every penny donated helps to support the hard- working staff at our hospitals and enhance the experience of patients and their families.”

The Difference we Make Leeds Hospitals Charity is proud to support all of the hospitals that make up Leeds Teaching Hospitals NHS Trust: Leeds General Infirmary, St James’ University Hospital, Leeds Cancer Centre, Leeds Children’s Hospital, Chapel Allerton Hospital, Seacroft Hospital, Wharfedale Hospital, Leeds Dental Institute.

These services are supported by 18,000 dedicated NHS staff, and we support them to deliver the best care for over a million patients and their families each year.

Through generous donations in 2019/20 - funding from Leeds Hospitals Charity has been awarded to over 1,000 applications, totalling over £6m.”

This charity uses more inspiring language and also sets out more clearly the difference it is making, with headline figures provided (though we note they use two different figures for how much is given in grants!).

The key points are that the language is more “charity” and less “NHS speak” and that it makes a stronger case by focussing on its outputs. We are not suggesting that this example is perfect (we struggled to find any really good ones). However, it does highlight that the Trust Charity could make a stronger case.

We therefore recommend that the Trust Charity considers the development of a new, inspiring case for support, that will help it to convey the needs, impact and urgency of its work more effectively. This would be used to underpin all of its fundraising, whether online, in literature or in posters and displays etc.

9 THE CURRENT FUNDRAISING STRATEGY AND KPIS The Trust Charity has a document entitled The RWT Fundraising Strategy 2019 – 2022. However, this is primarily a set of statements and policies which set out the parameters of how the Charity

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will operate, including governance and compliance, risk etc. It is not a typical fundraising strategy in the normal sense, in that it does not describe how the Charity will go about raising funds, what the objectives will be, what case for support will underpin the work and so on. It reflects the rather bureaucratic NHS culture in which it operates. We understand that the Trust Charity is constrained in how it sets out its documentation. As a result, we recommend that two versions of the strategy be created in future – a public one with basic information and an internal one with additional detail, which can include the content typically found in a charitys fundraising strategy. We would normally expect to see the following: Introduction Funding Needs Assumptions Funding Sources and Objectives • Trusts • Companies • Community fundraising • Own events • Individual giving • Lottery funding • Major gifts • Legacies Resources for Fundraising • People • Budget • Funding information • IT • Literature/web Timetable Monitoring Appendices • Fundraising SWOT analysis • Action plan • The case for support

The strategy should set out how the Charity will deliver fundraising and achieve the objectives set, with a narrative for each income stream, describing how each of these will be developed.

In addition to the fundraising strategy, the Charity has developed some KPIs that cover certain aspects of its work, including the growth it aims to achieve in specific income streams. However, these KPIs include the aim to increase legacy income, as well as trusts and corporate income, by 1% per annum, which is largely meaningless. Instead, some realistic objectives need to be set for each income stream, based on planned activity for the year.

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Also, there is little point putting in any income figures for legacies at this stage, as the volume is currently too low to predict future results and any legacy activity delivered now will not have an impact for some years to come.

We recommend that, following this opportunities review, the Charity creates a new fundraising strategy, which will provide a more useful roadmap for its future development.

10 TRUSTS & FOUNDATIONS For many charities, trusts & foundations provide an important income stream. They are of interest because each year over £3 billion is distributed in the UK by around 10,000 trusts, offering a good ratio of return on the time and cost of securing grants (typically 6:1 or even 10:1 for an established programme). Currently, bids to trusts & foundations are made either by the Fundraising Coordinator, who typically completes just 6 bids per year, or by hospital departments, which also make applications. Although this provides additional capacity, it also creates the potential for duplication and crossed wires, as the fundraising team is not always informed about these bids. This could cause confusion with funders and therefore departments should be encouraged to inform the fundraising team of their plans to apply to grant makers in advance, to avoid any problems. Bids prepared by Fundraising Coordinator have a very high success rate (100% in some years), partly due to the low volume but also because applications tend to be made to funders that know the Trust Charity and are therefore warm contacts. There is clearly scope to increase funding from this source. However, there are currently some constraints that will need to be addressed to make this possible. Firstly, there is a capacity issue. The Fundraising Coordinator does not have the time to prepare a higher volume of applications, given her many competing tasks. Trust applications are time consuming and there is no way around this, as bids need to be tailored to each funder. Many fundraising charities have a dedicated grant fundraiser, covering trusts and the National Lottery, either on a part time or full time basis. Given the good return on investment, this is usually a sound investment. Secondly, the fundraising team is not always aware of the funding needs of departments in advance. Currently, only around 6 departments submit their plans each year, meaning that many potentially fundable projects are not known about and therefore cannot be presented to trusts as funding needs. Most funders want to support a specific project, such as a piece of equipment or a defined piece of work, so it is essential for the fundraising team to be well informed about what is planned across the Trust. It also needs to have good notice about funding needs, as applications take time to prepare and funders work to often quite long lead-in times. Indeed, some only have one funding round per year, so if this is missed, applicants have to wait another twelve months before applying. Thirdly, funder research is mainly conducted using Google. This is a rather haphazard approach and so it would be worth the charity investing in an online subscription to Fundsonline published

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by DSC, as well as using other methods as time allows (such as viewing the funders of other hospital charities and of local causes in Wolverhampton). Fourthly, people give to people, even in the sphere of grant making, so it will be worth the charity carrying out contact mapping to see if it can identify any personal contacts (e.g. of board members or senior clinicians) with the decision makers at its target funders. This can make a big difference both to the success rate and to the average grant size. If these barriers can be addressed, we think it possible that the charity could aim to raise perhaps £200,000 p.a. from this source.

11 CORPORATE PARTNERSHIPS In recent years, the Trust charity has succeeded in securing support in various forms from companies to the following values: Year Value 2016/17 £116,000 2017/18 £426,000 2018/19 £156,000 2019/20 £41,316 Average £184,829

These figures are somewhat clouded by the inclusion of significant grants from the Goodyear orers enevolent und, which are now finishing. The rest is a mixture of corporate donations and employee fundraising/donations. or a local charity these are good results. Apart from the Goodyear support, the rest has mostly come from local businesses. The charity also receives a lot of gifts in ind, in addition to cash. The question then is whether the charity is able to increase the support of businesses and how it would go about this. e believe there is further growth potential and here are some suggestions for increasing corporate support: irstly, the charity has not been provided with the list of suppliers to the Trust. This will include companies receiving significant levels of business, which they will wish to eep. This list will mae a good starting point for research (for example, to identify which ones have a corporate foundation or operate a charity of the year scheme etc). e would expect this exercise to identify a good list of prospects to approach. Secondly, the charity needs to develop a clear proposition, setting out why a business should support it and what it would receive in return. Today, much corporate support is seen as a transaction, not as pure philanthropy and businesses generally see benefits in return for their help. The current corporate leaflet aimed at attracting businesses needs to spell out these benefits more clearly, e.g. to say exactly how their support will be recognised and what publicity they should expect.

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Thirdly, the idea of a Supporters orum or business club should be developed further, perhaps with different tiers to allow for a range of support levels, each with a price tag and benefits pacage (e.g. bronze, silver and gold). ourthly, the charity should see to identify and map out the personal contacts of ey people at the Trust, such as board members and senior staff, in order to open up doors and start conversations with businesses. ifthly, additional capacity in this area will enable the charity to mae greater inroads into developing corporate partnerships. This wor is very time consuming and is ain to sales and account management and so there is a direct correlation to investment in and results out.. inally, where a company has given once, whether in cash or in ind, its details need to be carefully recorded, so that the relationship can be developed and further support can be requested (for example, cross-selling, as well as promoting business club membership, inviting them to events, asing them to hold dress down days etc). If business support can be developed in these ways, then it should be possible to maintain income (without Goodyear support) at perhaps £150,000 per year.

12 INDIVIDUAL GIVING Individual giving forms an important income strand for any hospital charity, with donations typically coming from grateful patients and relatives following their treatment and care. Mostly, these are one-off gifts with little further contact or activity. In 2019/20 this giving amounted to just under £50,000 (excluding third party fundraising). Records are kept in the Harlequin fundraising database, which also links to the Harlequin finance package. Staff feel these work well, though there is a need for some additional training in how to get the best out of the system, which is now planned. The database contains 1,182 records, which includes both individuals and companies. Many of these have been added in the past 18 months, with 50 or 60 new names per month typically. This is, however, a very small base of support, which will need to be grown in future. For the most part, the individual giving aspect of fundraising still reflects the charitys thank and bank” origins. The process of thanking and recording donations is also currently cumbersome, with some of this being done by wards, some by the general office and some by Fundraising. As a result, Fundraising does not always know if a ward has sent a thank you letter for a gift or not and it is also possible that donors sometimes get more than one, which gives a poor impression of the charity. We understand that receipts are also sent out, which not now a common practice among charities. When a donor makes a donation, they are asked to complete a form to capture their address, the purpose of their gift and their communication preferences. However, these are not always completed and so Fundraising is sometimes unable to follow up or even send a thank you letter. This also means that it is not possible to appeal to the donor for any further support in future. In other words, there is no real donor journey, just a bureaucratic process to thank people.

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Individual fundraising is currently therefore mainly a reactive process, with little relationship building in place for a lot of donors. While it is likely that some donors only ever want to make a single gift, the charity is missing out here on the possibility of seeking repeat gifts (perhaps on the anniversary of their last gift or in aid of a relevant appeal) or of converting one-off donors to regular gifts (we understand there are very few people who give regularly via the bank at the moment). While it would take a considerable shift in practice, as well as an investment in admin capacity, we suggest the charity explores the option of centralising all donor thanking and contact in Fundraising, so that it is able to be in better control of data and ensure that, wherever possible, donors receive timely thank you letters and further communications. This would be a significant change in practice but would ultimately lead to a better donor experience and feed through into fundraising results. We estimate that a part-time admin role would be needed to cover this work, although this post could also help cover the administration of the lottery and of JustGiving donations, freeing staff up for more productive activity. At present, we understand that no targeted appeals are aimed at individual donors. It would, however, be possible to test such appeals, for example aimed at those who had supported a specific department, such as the neonatal unit, cancer department or heart & lung. We recommend that this be tested and, if successful, rolled out to other departments where possible. A further development that is already being considered is to provide all clinicians with charity cards they can give to patients or relatives who wish to donate. This is a good suggestion, which we support. Ideally, the information provided should lead the donor to a web page, where their data can be captured, so that there is a clear record of who has given and they have the opportunity to state their contact preferences. This would help reduce the number of anonymous gifts, which cannot be followed up. Another suggestion to improve donor acquisition is to include the charitys general leaflet within inpatient packs. Many patients (and especially older people) like to read to pass the time, so this is a good opportunity to talk to the about the charity. Some departments already now developing such leaflets to be used in this way. Finally, the charity should ensure that copies of its newsletter are always available in outpatients, where people have a chance to read them and take them away. If the systems to capture individual data can be tightened up and it is possible to develop relationships with more donors after the first gift, then we believe this area of fundraising could be developed to raise £150,000 per annum.

13 MAJOR DONORS Major gifts are significant donations by private individuals and, although different charities have widely varying definitions of what constitutes a major gift, common thresholds are £5,000+ or £10,000+. Such gifts are often made towards a specific project or capital need, such as a piece of equipment and are usually solicited (i.e. they are not usually given spontaneously).

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Currently the charity does not seek or receive many major gifts, although some significant donations were recently made by Wolves players (£180,000 in 2020/21), which shows the potential. It is likely that each year the Trust will have spending needs that could attract major gifts, if the charity has enough advance notice and information about these. They could then be developed into a menu of projects needing support, that could be used with wealthy individuals. Although Wolverhampton is not a wealthy area, there are still people with money, including some who may have been treated or whose families have been helped by the Trust. There are several ways to identify who might be in a position to make a major gift, including: • Screening the database for wealth indicators (this is still possible, even since GDPR) • Asking clinicians to advise on patients they think could make a significant gift • Conducting cold research into wealthy people in the area • Asking senior Trust staff and Board members to view lists of wealthy people, to identify personal contacts Assuming a list of suitable projects and a group of wealthy individuals can be identified, the charity will then have the ingredients of a major gift campaign. The case for support will then need to be written/adapted for major donors and a plan made for engaging with them. This is not a quick fix and can take up to two years if the prospects are all relatively cold (but less if they are warm). The aim is first to make friends with donors before seeking their support. Very often, a capital appeal is the way that a charity can make a start in this area. It has the advantage of being a clear and concrete project with a defined beginning and end. The donor can see what their money will support and a “shopping list” can usually be developed of cost items to suit different donors budgets. The Trust has the advantage of having a physical site that donors can visit to see what is planned, which is an opportunity to sell them the vision of the project to be funded (see more on capital appeals below). The field of major gifts is often one supported by a Development Board. See below for more on this topic. It is difficult to estimate the potential here without knowledge of future spending plans, but if the charity can take the approach outlined above, we see no reason why, if sufficient projects and prospects can be identified, support of £250,000 p.a. or more should not eventually be forthcoming.

14 EVENTS AND COMMUNITY FUNDRAISING This area of fundraising is run by the Community and Events Fundraiser, who joined the charity in mid-2019 and who had planned an events programme for 2020, most of which had to be cancelled due to the pandemic. It is hoped that these events can recommence during 2021/22 and a programme of planned activities has been developed, in case the restrictions are lifted. These include such things as The

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Bid Tea, a Winter Fair, a sweepstake and a spelling bee competition. Further ideas are also being explored. While this type of fundraising has a relatively low ROI and is labour intensive, it does however provide other benefits for the charity, including raising awareness and helping to attract new donors, whose support can then be developed further. One issue of note is that the programme calendar does not contain any financial targets for the activities, which would be a helpful addition. The Community and Events Fundraiser feels that online events, in lieu of physical activities, could raise between £2,000 and £5,000 p.a. but clearly more would be achievable once normal events can be run again. As well as planning and running a series of events, the charity also benefits from supporters running their own activities, which increased during the early Covid-19 pandemic, but has since reduced again. This is mostly reactive, i.e. the charity is approached by people who want to fundraise for it. Supporters are encouraged to set up JustGiving pages to gather donations from friends, family and colleagues and support is provided by the charity (e.g. their events can be shared on social media, the charity logo is provided for publicity material and fundraising advice is given). At present, capacity to produce posters or fundraising materials to support third party fundraisers is limited by the availability at Medical Illustrations. Events and community fundraising will always be hard work and time consuming. As far as possible therefore, volunteers should be used to support this area, to free up staff time. The charity should ensure that it is maximising all the potential of the events and activities by: • Making sure that full publicity is obtained in each case (social media, newsletter, external press) • Using them to open new relationships and build existing ones • Making sure that, as far as possible, events use volunteer support (even the charitys own events) rather than taking up paid staff time • Ensuring permission to contact supporters is captured and recorded (this is currently an issue which can prevent supporters being followed up) • Ensuring that all supporters are properly thanked, wherever possible At present, the Community and Events Fundraiser spends a lot of time on data entry and basic admin tasks associated with fundraising. If she can be freed up by increased volunteer use or by the addition of some admin support, she would have more time to work with current and past supporters, building relationships for the future. This would have a knock-on impact on results. Again, it is difficult to predict with any accuracy the ultimate potential of events and third party fundraising. However, if the support base can be developed further via the methods suggested, we suggest an annual target of perhaps £100,000 could be achievable.

15 DIGITAL FUNDRAISING During the past 18 months or so, the Community and Events Fundraiser has made good progress in building up the social media following of the Trust Charity. Currently, it can reach these people: Facebook – 2,229 followers

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Twitter – 988 followers Instagram – 264 followers LinkedIn – about 40 followers (used for corporate promotions only) The aim of building a following is to be able to alert people to forthcoming events, encourage them to take on fundraising activities, thank people for their support and generally promote the charity. In other words, currently, social media is mainly used to support fundraising in general, rather than to raise funds directly and, as such, supports a number of income streams (individual giving, events and community). Numbers of followers are tracked on a weekly basis and posts are also shared by the Trusts own communications team, who can help reach the 10,500 staff employed by the Trust. As well as using social media, the Trust Charity can have messages posted on the Trusts intranet and of course on the Trusts website. Email bulletins are also sent to staff The Community and Events Fundraiser has not had any training yet in digital fundraising, which is a specialist area. We recommend that an investment be made in this area, in order to maximise its potential. For example, a day course would be a good use of resource and could be tailored to the needs of the Charity. In addition to social media, the Charity has a own section on the Trusts website with the URL https://www.royalwolverhampton.nhs.uk/about-us/our-charity/ As such, the Charity is somewhat buried, as the pages still carry the Trusts logo at the top and the main Trust menu to the left, which is confusing for visitors. Ideally, the Charity should have its own website, with a link to and from that of the Trust. This would enable it to present itself as a separate entity, with its own identity and web presence. We understand this idea has been raised before and rejected. However, we still believe it is something the Trust Charity should aim for in the future. In addition, the Charitys pages need to be far more engaging, with better use of photographs (mainly of people) and, as mentioned above under case for support, a more compelling case for why people should donate. While there is a short reference to making a gift in a will, it is buried in the How to Donate page and does not make a strong enough case for legacies. Really, there should be a separate page about gifts in wills, with a much clearer ask and examples of what legacies have achieved and could achieve in future. Similarly, there is no dedicated page for corporate supporters, which would set out the benefits of partnering the Charity, why help is needed and what forms support can take, with examples of recent corporate giving. Such a page could also promote the idea of a corporate donor club. All of these issues can be addressed, ideally with the creation of a dedicated Charity website. While there would be a cost to creating this, we believe it would more than pay for itself in future, if well planned and executed.

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16 LEGACIES Currently the charity receives charitable legacies each year with very little promotion. Recent results have been as follows: Year Legacy Income 2016/17 £18,000 2017/18 £261,000 2018/19 £124,000 2019/20 £39,582 2020/21 (to 3 rd quarter) £95,999 This is very valuable income and, in the last two financial years (including the part year 2021), the average gift size was £10,429, which is respectable. The average total for the past five years was £107,716, which shows the potential, as this giving is largely unsolicited, suggesting that if a more proactive stance we re taken towards legacies, more could be achieved. The benchmarking exercise (below) is also encouraging and confirms this view. In 2021/22 there is a good chance that legacy income will beat the recent average for the charity, as there was a delay to the granting of probate for a lot of estates during 2020, meaning that there is likely to be a backlog of legacies in the pipeline for 2021. We understand there has been some reticence at the charity about asking people for legacies, given the perceived association with death. However, given that hospices and many other hospitals do successfully ask for legacies, we think this is misguided. In reality, legacies are not about death but are about continuing to do good beyond ones lifetime, as well as saying thank you for good care received. By not offering this as an option to patients and families, the charity is arguably depriving them of a choice which more would take up if prompted. Currently, there is a paragraph about legacies in the charitys leaflet and they are also mentioned on the website, but this is all very low key and much more would be possible, which would certainly have an impact over time. Legacy marketing is not a quick fix, but given the high average values and the strong return on investment (the highest of any form of fundraising), it is an obvious area to develop. We also understand that the charity team is not always informed of legacies or of legacy pledges and enquiries, as these often go to the Finance and Legal departments. It is imperative that the Trust Charity be informed of any such contacts, so it can respond properly to individuals and families, as needed, as well as recording the information on Harlequin, in order to be able to track developments and identify the impact of fundraising activities. For example, anyone who has enquired about legacies or who has pledged one needs to be treated very differently from other supporters and only by knowing about them can the Trust Charity do this. To build a bigger legacy income, the charity would need to: • Develop a strategy for legacies • Prepare its legacy case for support (which will be different from its general case)

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• Create some dedicated legacy materials and ensure they are easily available to patients and families • Mention legacies regularly, if gently, in its publicity materials • Create some examples of how past legacies have made a difference to patients and use these in a newsletter, on the website and in social media • Ideally identify some legacy champions, who are prepared to make a public pledge to encourage others to follow suit • Ensure that details of all enquiries, pledges and legacies received are logged on Harlequin If a more proactive legacy campaign were to be developed (and we see no reason why it cannot), then ultimately the average annual legacy income could be grown to perhaps £1 million. This would of course take some years but is realistic if we look at the amounts received by comparable charities below.

17 IN MEMORIAM GIVING In memoriam giving is where a donor makes a gift in memory of a loved one who has died, either shortly after their death or at an anniversary. This is common area for hospital charities to benefit from, given that inevitably some patients will die each year. In 2019/20, the Trust Charity received £66,702 from in memoriam giving, which is currently promoted by a range of methods, including in the charity leaflet and on the website, as well as in social media, in press releases, in Trust Talk, in the Trust Charitys newsletter and in the Book of Celebration. The approach is very much a soft sell (which is correct), taking a behavioural approach by sharing examples of families that have given in memory of someone. As with legacies, in memoriam fundraising has to be done gently. To some extent, in memoriam donations are driven by the numbers of people who die. However, further promotion would be likely to encourage more families to consider such a gift, albeit taking care to do this is a sensitive way. In particular, if data can be better captured and stored in Harlequin and then interrogated more effectively, it should be possible to increase in memory giving. One area that may prove fruitful is to seek to convert gift in kind donors to in memoriam, on the basis that they are already grateful for treatment received. A separate spreadsheet is currently used to record such donors. However, really this should all be done in Harlequin. Another area through which in memoriam giving can be developed is by building closer relationships with funeral directors, who routinely have conversations with families about funeral collections. However, this will require additional fundraising capacity and could be part of the role of the individual giving fundraiser. A further way in which in memoriam giving can be grown is by developing the support base and reach of the charity in general. I.e. building up the numbers of supporters over time. This will inevitably lead to a growth in income, even if nothing else were done in this area. The Book of Celebration is an excellent way to recognise and thank donors for their support, including those who have given in memory of a loved one. However, it would be benefit from a

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more visible presence on the Trust Charitys web page (e.g. with a strong graphic or image, rather than just a text link). The Book of Celebration could also be developed further into a Tribute page. In this regard, it is also worth mentioning the idea of Tribute Funds. This is where a named fund is established in memory of someone who has died (primarily a child or young person). The family and friends then donate and raise money in their name over a period of time. Often, a web page is set up about the person and people continue to donate on anniversaries. Such funds often reach four or even five figures and continue to operate for several years. The money is often donated as general funds, or by agreement with the family concerned. This is a specialist area of fundraising and the Trust Charity could either develop it itself, or it could work with a platform provider, which is the preferred route, given that it has its own ins and outs. The market leader is Much Loved , which is a charity itself, but others are available. It is also possible to obtain specialist advice, should the Trust Charity decide to develop this area itself. Good examples of existing tribute funds can be seen here: https://tribute-funds.nspcc.org.uk/ https://www.samaritans.org/support-us/gifts-memory/set-memory-fund/ https://mnd.muchloved.org/ While it is difficult to predict the ultimate income achievable in this area, we believe a target of £150,000 would ultimately be reasonable.

18 PUBLIC LOTTERIES The Trust Charity currently operates a small lottery via a commercial partnership with Unity Lottery, run by Sterling Lotteries. There are typically between 30 and 50 players each month, buying tickets for £1 a week, of which 50p goes to the charity, the rest being used for prize money (the top prize is £25,000) and to cover Unitys costs and profit margin. While Unity runs the lottery, the Trust Charitys role is to promote it to potential players among staff and supporters, which it does via the website, the newsletter, in Trust Talk and on social media. More could be done by the Trust Charity, such as putting up posters in hospital sites and sending these to GP surgeries. In particular, when further training has been received on Harlequin, it should also be possible to target past donors who have given permission to be approached again. At the moment, the lottery is clearly of low significance, given the level of income achieved, the main issue being the low volume of players for what is essentially a low value product. Lotteries only really become profitable when there are high volumes of players and, currently, the Trust Charity is limited in how many people it can reach. It has been suggested that the Trust Charity could make more money from a lottery by taking it inhouse. However, this would not overcome the basic issue of volume. It would also mean shouldering the administrative burden and taking the prize related risk (i.e. that someone could win a prize which is more than the income).

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The alternative would be to negotiate with an alternative lottery provider for a better deal (some will pay up to 75% of monies received). There are other commercial players in the market besides Sterling, including Woods Valldata and the Giving Lottery. However, unless these partners are going to help with recruitment, the Trust Charity will still come up against the same issue of low volumes. We therefore do not see charity lotteries as a major opportunity, at least not in the short or medium term. If the Trust Charity can build up its support base significantly over the next few years, then it may be worth revisiting again in the future. In the meantime, however, there are better alternatives on which to focus time and resources.

19 WHAT ARE OTHER HOSPITAL CHARITIES ACHIEVING? In comparing performance with other hospital charities, it is important that we compare like with like. There is little point, for example, in comparing per formance to that of a chilrens hospital or to a specialist cancer hospital (both of which raise significant sums each year), but only with similar trusts aroun the country. The following gives an overview of what some other hospital charities in the Milans are achieving: Income stream Derby & Burton* Leicester Hospitals** UHNM (Stoke)** General onations £745 ,000 £2 .353 million £389,000 Legacies & In Mem £1.357 million £307,000 £1.003 million Traing £173,000 £277,000 £245,000 Investments £364,000 £152,000 £217,000 Other £2 3,000 £0 £0 TOTAL VOL INCOME £2.662 million £3.088 million £1.854 million * 2019/20 figures ** 2018/19 figures From this we see that each of these hospital charities is raising consierably more that at Wolverhampton. The stan-out figures are the general onations an the legacy/in memoriam income. The achievements of these charities show what Wolverhampton coul be achieving in years to come, if it is prepare to invest now in eveloping its capacity an removing some of the barriers. This is a very positive an encouraging picture. If we look at what each of the above charities is investing in funraising, we see the following: Charity Cost of Funraising ROI Achieve Leicester Hospitals £543,000 5.6 8 : 1 Derby an Burton £570,000 4.67 : 1 UHNM £108,000 17.16 : 1

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Among these figures, the UHNM ROI is clearly an outlier an there may be a ifference in how this charity accounts for the cost of funraising compare to the other two. Nevertheless, each of these charities is getting a goo return on investment, with Leicester an Derby being fairly typical of funraising charities. What is clear is that they i not get here by accient but by investing in funraising over many years. Each has a funraising team, with a mix of specialisms. They are each perhaps 5 years ahea of Wolverhampton in terms of their evelopment.

20 SUMMARY OF MAIN FUNDRAISING OPPORTUNITIES The table below sets out what we estimate should be possible for the Trust Charity to achieve in future years, if it is prepared to invest consistently in staff capacity and fundraising activities over time and if the barriers to successful fundraising can be removed (in particular the need to have a clearer indication of departmental funding needs). This level of income will not happen overnight, but will take some years to achieve. Nevertheless, the results will be worth the time, effort and investment (NB the figures do not include investment or any miscellaneous income). Funding stream Potential income per annum Trusts & foundations £200,000 Corporate support £1 50,000 Major gifts £250,000 Individual giving £150,000 In memoriam £150,000 Events and community, inc £100,000 Just Giving Legacies (in the long term) £1,000,000 TOTAL POTENTIAL £2,000,000

21 CAPITAL APPEALS – A FUTURE OPTION A capital appeal is defined as a one-off campaign for a big ticket item , often a new building or (in the case of hospitals) a large piece of equipment, such as a diagnostic scanner or treatment machine. Such appeals often take several years to raise the funds needed and are not to be undertaken lightly, as they require a concerted team effort over time. They cannot just be delegated to the fundraising team as part of the day to day work. However, they do represent an opportunity to scale things up and to attract additional support, especially from wealthy individuals. In order to countenance a capital appeal, a charity should already be in a strong fundraising position and be “fit to fundraise”. This means having a solid support base and strong leadership, with a clear case for support for the project to be funded. Ideally, there will already be some close

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relationships with the lead donors (i.e. those that will commit early on to making large donations) and some clear candidates for the voluntary leadership that will be required (such as local business leaders). The standard approach to a capital appeal is firstly to carry out a funding feasibility study to ascertain if a successful appeal is likely to be possible. If this proves positive, the next stage is to develop the appeal strategy, followed by implementation. This final stage normally occurs in two phases – the quiet phase (when the larger donations and pledges are solicited), followed by the public phase, when the charity seeks maximum publicity and to complete the appeal with smaller donations and public fundraising. Short-circuiting this process increase the chance of appeal failure. A successful capital appeal can have several benefits for a charity. Firstly, it helps to grow the support base, with contributors being retained for further support. Secondly, it helps to expand the group of people willing to advocate for it and, thirdly, it raises the profile of the charity among all its stakeholders (in this case, staff, patients, patients relatives and the wider community). In our view, the Trust Charity is not yet in a position to launch a major appeal as it first needs to grow its capacity and widen the support base. However, once this is achieved, we believe a capital appeal could be considered in perhaps two years time, giving the Trust time to consider what project would form the basis of a suitable appeal. In the first instance, we also suggest that such an appeal should not be over-ambitious and aim for a target of, say, £1 million. Once this has been achieved and the support base had been expanded, then a larger capital appeal for another project could be considered.

22 FUNDRAISING CULTURE In some organisations, fundraising is delegated to one or more paid staff, who are expected to raise funds unaided, simply as their job function. In others, fundraising is owned and carried across the charity as a whole, where everyone from Trustees , to senior management, to frontline staff and volunteers all take pride in representing the organisation externally, in being ambassadors and in helping to bring in the money by using their contacts and external opportunities to promote the charity. This type of organisation tends to raise more. Between these two ends of the spectrum, there are various shades. So how do we identify whether a fundraising culture exists within an organisation and whether fundraising is fully valued, supported and resourced? There are a number of questions we can ask: • Is fundraising properly resourced or is it expected to raise increasing targets with a small or diminishing resource? • Is fundraising represented at the top of the organisation, e.g. at senior management level? • Are the needs of fundraisers understood by the people who manage them? (which can affect target setting and the interpretation of results, as well as knowledge of expected returns and timescales) • Do Trustees and the CEO see themselves as having a role to play in fundraising? • Do staff and Trustees donate to the charity or carry out fundraising on its behalf?

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• Is fundraising recognised and celebrated in the organisation, for example when a success is achieved? • How do other staff regard the fundraising team (for example as important allies who help bring in valuable resources or as just a necessary evil or an irrelevance)? Most NHS charities currently sit closer to the “fundraising as a function” end of the spectrum, not least because fundraised income is usually a small percentage of overall income of the Trust and is therefore not seen as critical to the work or survival of the organisation. The impression gained in Wolverhampton is that fundraising is beginning to be seen as an important area of work but that there is still some way to go before it becomes part of the culture or DNA of the Trust. For example, there is still mixed awareness among Trust staff of the Charity and its potential value to the Trust, including among some department heads. The lack of visible premises as a base for the charity also suggests it (and therefore fundraising) has not been seen as a priority in the past. Although displays and posters can be positioned around the Trusts sites, it would help cement the value and profile of the Trust Charity to have its own very visible premises. It is encouraging, however, that the Trust board is taking an interest in fundraising and that there is a willingness to invest in the Trust Charity for the future. This augers well. We would encourage the Trust board and senior management to champion the work of the Charity across the Trust, in order to raise its profile among staff and to underline its growing importance to staff and patients. Certainly, whenever a major success is achieved, this should be celebrated across the organisation on the basis that success breeds success. While changing organisational culture does not happen overnight, with the right leadership and resources, it should be possible to position fundraising internally in a way that will boost future results. Other organisations have been able to achieve this, so we see no reason why the Trust Charity should not in time do likewise.

23 FUNDRAISING CAPACITY In fundraising, there is a direct correlation between the investment of effort and the results achieved. In other words, the larger the capacity, the more money will be raised (assuming of course that the right expertise is available and that the quality of fundraising is high). In other words, you have to speculate to accumulate. Current capacity for fundraising at the Trust Charity (as opposed to accounting for or administering gifts received), is quite limited, consisting of the Fundraising Coordinator and a Community & Events Fundraiser. This means that time for each aspect of fundraising is currently rationed. If more were available (for example to make more grant applications), then more activity could be undertaken and stronger results would ensue. If we look at the other hospital charities described above, it is not a coincidence that they are raising more money than in Wolverhampton, given that each has a fundraising team to deliver

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the work. For example, HNs charity has 3 fundraisers and 3 admin staff. Derby and Burton have a total team of 7, while H Birminghams charity has a team of 15 fundraisers. If the Trust Charity is keen to grow its income, it will therefore need to invest in additional capacity and so we recommend the following structure: • Head of Fundraising (FT). NB This role would also support the Trusts and Corporate work • Community and Events Fundraiser (FT) • Digital and Individual Giving Fundraiser (FT) • Trusts and Corporates Fundraiser (FT). This could also be 2 x PT roles • Fundraising Administrator (FT) • Treasury and Charitable Funds officer (PT) • Charity Accountant (PT) With regard to major gift fundraising, we suggest this function could be part of the role of a Capital Appeal anager, should the Trust Charity embark on such an appeal. This could be planned in say 2 years time, once the new posts were established and the team had bedded in successfully. A capital appeal is a good way to kick start this specialist area and would provide the opportunity to develop a “shopping list” of larger ticket items for wealthy individuals. We recommend that the new roles of Fundraising Administrator, Digital and Individual Giving Fundraiser and Trusts and Corporates Fundraiser be created in the next financial year (as opposed to introducing them gradually over several years). This will ensure a speedier growth towards the future target. In the medium term to longer term and as the team grows, the role of Head of Charity should also be considered. This is already found in some of the comparator charities. As well as overseeing the running of the Trust Charity and managing the fundraising team, the role would also cover grant making and evaluating the impact of the funding given. In addition to paying for dedicated staff time, the charity could also increase the use of volunteers in specific roles, for example in the area of community fundraising or in supporting low level grant applications. sing volunteers (who will of course need training and managing) not only takes some of the load off the paid staff, it also increases the ROI of the charity and expands the breadth of work that can be delivered. any fundraising charities use volunteers to good effect, although they should be seen as an addition to, and not a replacement for, paid staff. We understand that the Charity currently benefits from support from the Trusts Communications team. However, this is not ring-fenced for the Trust Charity and it seems that the Charity sometimes feels it is a low priority (which is disputed by Communications). This could be addressed by guaranteeing a set amount of support, which is ring-fenced. Not only would this enable the Charity to receive the help it needs when it needs it, but would also potentially free up the Trust Charitys team from some of the communications tasks they currently deliver. Finally, in some specialist areas, it may be necessary for the Trust Charity to seek external advice and support to develop specific aspects of fundraising (such as legacies or tribute funds) or to help draft a compelling case for support. Further advice can be provided about this, if required.

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24 ESTABLISHMENT OF A DEVELOPMENT BOARD In order to widen their contact networks and bring in additional donations, some charities set up a Development Board. This is a sub-committee of the trustee body, which has the power to co- opt in outside members from the wider community. These can include people from business, wealthy individuals and those representing grant makers. The idea is that they each bring with them their own networks to add to those of the charity and members are encouraged to help make peer-to-peer approaches and to solicit donations. Often, such a board is set up when preparing for a capital appeal, although there have been examples of charities establishing successful such boards to help raise revenue for specific projects. We recommend that the Trust Charity revisits this idea when it is starting to plan a major appeal, in other words not immediately. However, it will do no harm for the Trustees to be thinking about good candidates for the Development Board in the future. As mentioned below, to enable the charity to co-opt outside members, it may first be necessary to amend the Terms of Reference for the Charitable Funds Committee. Training can also be commissioned for Development Board members in asking for donations, for those who are reticent about such things.

25 KEY CONSTRAINTS AND HOW TO OVERCOME THEM In any fundraising operation, there will be a number of key constraints, relating to such things as: • The fundraising budget • Staff numbers, skills and experience • What relationships are in place with donors and prospective donors, including the scale of the support base • The quality and quantity of data available to inform fundraising • The strengths or otherwise of the case for support • What projects are available to present to donors • The strength of leadership and internal support for fundraising • Whether there is a fundraising culture within the organisation or not Clearly, each of these can impact on fundraising results. The current fundraising budget is sufficient to achieve todays results, but will require further investment if a larger total is to be achieved. Put simply, it costs money to raise money. In particular, the Trust Charity will need to consider an expansion of the fundraising team if it is serious about growing its results. The database of donors, while containing some valued supporters, is very small and will need to be grown considerably to support increased results. Some records also lack communication preferences (i.e. data is patchy), which will need to be addressed. The charity can make a strong case for support and healthcare is currently an area of public concern, which will support future growth. However, the proposition or case for support will need to be developed further and expressed in more inspiring ways. The issue of project availability is a major constraint that will need to be addressed by senior Trust staff, if this current blockage is to be removed.

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There is good support for the charity among the Trustee body and Trust board. However, we understand that not all department heads are fully aware of what the Trust Charity can offer them. This could perhaps be addressed by publicising money raised and grants made to specific departments more loudly. The issue of fundraising culture is a challenge to all NHS charities, which struggle to create their own separate identify and charity culture. Instead, they are often seen as an extension of their Trust and are impacted by its prevailing culture, which is typically risk averse, often slow to make decisions and bureaucratic. It is beyond the scope of this study, but one solution to this can be to change from the corporate trustee model to that of an independent trustee board.

26 FUNDRAISING RISKS The main risks in relation to growing fundraising are as follows: Under resourcing. If not enough is invested in the people, systems and materials needed to raise funds, the main risk is underperformance, in other words that targets are not met and opportunities are missed. Setting unrealistic targets. In this scenario, the fundraising team is set up to fail, which is demoralising. As a result, targets are missed and staff leave, taking their skills and experience with them. Over delegation. If fundraising is viewed purely as a departmental function and not as part of the DNA of a charity, the risk is that it will not raise the level of funding that might be possible. Reputational damage. If fundraising is not executed well or if compliance issues are overlooked (such as data handling) or if funds are not spent well, there is a risk of negative publicity and the loss of support. Poor stewardship. If donor relationships are taken for granted, supporters will leave (and potentially switch their support to other organisations). Reticence about “making the ask”. If staff or Trustees are uncomfortable about asking for money, opportunities will be lost. The charity needs to bear these risks in mind as it develops plans to grow its fundraising.

27 OPPORTUNITIES IN THE COMMUNITY As well as running local hospitals, the Trust also covers primary care and community services locally. This potentially widens the reach of the Charity and offers additional opportunities to reach the local population. Currently, copies of the Trust Talk magazine (which carries 2 – 4 pages about the Charity) are sent to GP practices for patients to read, along with the Trust Charitys own newsletter and posters to display. It is unclear, however, whether these are actually used or not. We understand that, to date, no GP practice has approached the Charity for support. We therefore suggest that a representative from the Charity visit each GP practice to make them aware of the potential for grants (e.g. for equipment) and to check on the uptake of literature. We suspect that the Practice

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Managers will be the key gatekeepers to influence. Some of the Trust Charitys leaflets could also be provided for patients to take. Finally, it may be possible for the Trust Charity to be covered on the GPs websites (though it is unclear who maintains these). In summary, there is a modest opportunity for the Trust Charity to build stronger links with GP practices, using the offer of grants as a motivation to help. Community services are delivered mainly by nurses in patients homes and, as such, appear to offer little opportunity raise funds (unless information packs are left with patients, in which case there is the chance to include a leaflet about the Charity in these). Other than this, we do not see community services as a major fundraising opportunity. The main scope for the Trust Charity by far is that offered by the hospital sites, with their specialist departments and inpatient wards. The GP and community elements are unlikely ever to compete with these as a major focus.

28 IMPLICATIONS OF THE NEW WALSALL COLLABORATION We understand that the Trust will likely soon be working more closely with Walsall Healthcare NHS Trust, which will have implications for the Trust Charity, not least in whether a separate charity is to continue operating at Walsall or be joined with Wolve rhamptons own charity The Walsall Healthcare NHS Trust General Charitable Fund has a corporate trustee and raises funds under the branding of “Well Wishers” In the year to March 2020, it raised £236,490, which has steadily declined from £553,250 in 2017 The current year to date figure is not known Certainly, it appears that the charitys income is in decline and that it would benefit from reinvigoration This suggests that joining with the Trusts Charity could be a sensible move, although we have not been asked to look specifically at the Walsall charitys operation It is currently run by two staff (a Fundraising manager and a Senior Comms and Engagement Manager), supported by volunteers Only the cost of one staff member is recharged to the charity by Walsall Healthcare The Well Wishers accounts do not give any insight into the breakdown of income funds, apart from splitting out investment income and trading, so it is not possible from published sources to see how the rest is made up (eg from trusts, companies, individual giving, legacies, community etc) The main precedent in the region for joining the two charities is that of Derby and Burton, which used to run separate charities and now has a combined operation If the charities are to join together, it may still be worth keeping the Well Wishers branding in Walsall, as it is already established there and is likely to be a snappier name than any joined up body will provide

29 THE HARLEQUIN DATABASE The Trust Charity uses the Harlequin fundraising database as its system for storing supporter data. This is a well-known and long established package, on the market since 1986 and used by 350 UK charities. Harlequin claims to have a 99% retention record among its users, which include Addenbrooks Charitable Trust, Kidney Care UK and Nightingale House Hospice.

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Alongside Harlequins fundraising module, the charity also uses the Harlequin finance package, with the two linking together to share income details. It has been suggested that the Harlequin database is not fit for purpose and should be replaced. However, we did not find any real evidence for this. Although the Trust Charitys staff were recently locked out of Harlequin for some weeks, this turned out not to be a problem with Harlequin itself and this issue is now resolved. At present, the Trust Charity is using the database for very standard recording and processing of fundraising data, including donor records and donations. As such, it does not require anything bespoke or particularly complex. Where the database is seen as not meeting the Trust Charitys requirements, this is highly likely to be because staff do not know how to carry out a task or have not been fully trained in its use. We understand that some additional training will now be arranged with Harlequin for the fundraising team and that staff are assembling lists of questions to ask of the trainer. This will be the third training session by Harlequin. On previous occasions it has been of mixed quality but the fundraising team were happier with the last session and are clear what they want to learn this time around. We see no evidence that the Charity should consider migrating its data to another database package (which would also be costly and also take up valuable staff time). No database is perfect but, in our experience, problems of functionality are usually due to a lack of knowledge on the part of the user and not to the quality of the product. We recommend that the Charity should persevere with Harlequin and ensure it is maximising its full potential, rather than switching to a different software package. A modest investment in additional training is likely to address the vast majority of questions and issues raised. Following the training and before significant further work is done on Harlequin, the Trust Charity may also wish to consider commissioning a data compliance review, to ensure it is adhering to current best practice on data protection. We have not examined data protection compliance within this study, as it is outside the brief. Nor have we identified any obvious problems. However, data protection by charities has been a hot topic in recent years, since the charity data scandals of 2016 and the introduction of GDPR into UK law in 2018. It is therefore something the Trustees should at least be mindful of and potentially should investigate further.

30 CHARITY PARTNERSHIPS It has been suggested that the Trust Charity could increase its inco me by working in partnership with other charities, on the basis that it would then receive additional support as a result. The example of a joint project with Compton Care has also been cited in this context. There is potentially some value in exploring joint-working, as partnerships are generally viewed positively by grant makers. Here the Trust Charity would need to be very clear about its objectives of course, given that it is in competition with other fundraising charities (including Compton Care).

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It may well be possible for a jointly developed project to be presented to a grant maker as a potential funding opportunity. In this context, a partnership with another charity that already has relationships with funders could work well. For example, Compton Care has a well-developed portfolio of funder relationships on which the Trust Charity could “piggy back”. Joint partnerships are most likely to apply in the field of charitable trusts & foundations, as well as companies and potentially also the National Lottery.

31 CONCLUSION This study has found that the charity has considerable growth potential and, provided the Trustees are willing to invest in it over time, could aim to increase annual income to £2 million. This growth will not happen overnight and will also require the removal of the barriers which are currently holding the charity back, such as the lack of communication from departments about their funding needs. If the recommendations below can be implemented, then we see no reason why the charity should not improve its results significantly and emulate the success of other hospital charities.

32 FUNDRAISING RECOMMENDATIONS Expand Capacity and Skills for Fundraising • Invest now in additional fundraising capacity (i.e. in trusts and grants, corporate, individual giving and admin support) • Ensure the Charity has some dedicated support from the rusts Communications team • At a later point (e.g. in 2 yearstime) add a Capital Appeal Manager with responsibility for major gifts and, as the rust Charity grows, a Head of Charity role • Invest in some digital fundraising training for the Charitys staff Improve Communications • Encourage all departments to share their spending plans well in advance, in order to inform fundraising needs • Encourage all departments to check with the Trust Charity before submitting external funding bids, to prevent any duplication or crossed wires • Ensure that the charitys literature is available in outpatients for people to read and that it is regularly topped up so that people can take it home with them • Ensure that all inpatient packs include a leaflet about the charity, what it does and how people can support it • Identify a more visible location from which the charity can operate • Consider giving the Charity its own website Develop the Charitys Fu ndraising Infrastructure • Create a new fundraising strategy , taking into account the opportunities identified in this review and the suggested additional capacity required • Consider commissioning the drafting of a really compelling case for support

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• Centralise all donor thanking and contact in fundraising to improve the donor eperience and increase efficiency • eview the categorisation of donations and adopt a more uniform approach if possile • est targeted appeals to individuals for specific departments • Consider commissioning a review of the rust Charitys data protection compliance efore the use of arlequin is developed further Expand the Contact Network • Enlist the support of one or more patrons • Consider setting up a Development Board to support the approach to businesses, wealthy individuals and grant makers • Carry out contact mapping of trusts and corporate prospects before approaching them • Subscribe to Fundsonline, or similar, as a research tool for identifying grant makers • Obtain and use the Trustʼs supplier list to identify potential corporate supporters • Develop and promote the Supportersʼ Forum/business club idea further • Consider having the database screened to identify wealthy individuals In order to implement many of these recommendations, additional capacity will be needed, either in the form of the suggested new roles, or potentially from external suppliers, who can be brought in to help with specific tasks and thus speed up implementation.

33 REVIEW OF THE DECLARATION OF TRUST AND THE TERMS OF REFERENCE

The two governing documents of the Trust Charity are the Declaration of Trust (a deed dated 3.10.96) and the Terms of Reference for the Charitable Funds Committee. The Declaration of Trust is a legal document (a deed) that sets out the objects of the charity, along with the powers and duties of the Trustees, providing for them to receive donations, hold them in trust and apply them for “any charitable purposes relating to the National Health Service wholly or mainly for the services provided by the Royal Wolverhampton Hospital NHS Trust” (later amended in 2012 to the Royal Wolverhampton NHS Trust). The Declaration of Trust also sets out the accounting and reporting requirements on the Trustees and establishes how the deed can be amended and the Charity dissolved. The Terms of Reference for the Charitable Funds Committee is an internal document setting out the delegated powers that the Trust Board has given to the Charitable Funds Committee. As such, it can be amended by decision of the Trust Board, without reference to any external regulator. Given that the role of the Royal Wolverhampton NHS Trust is now broader than in 1996, when the Declaration of Trust was signed, the question has arisen as to whether the deed is still fit for purpose and whether any aspects of it needs to be amended in order to avoid any limits on future activity. In reviewing the current activity of the Trust Charity and in the interviews conducted, we have not identified any significant impediments that need to be addressed, with the possible exception of the bar on trading in section D(10)c, which states that the Trustees “shall not have the power under this clause to engage in trading ventures”. Given that we do not see trading as a major

15/03/2021 undraising eview for he oyal olverhampton rust Charity

opportunity for the charity, we do not believe this to be significant. While the charity already engages in trading on a very limited scale via the sale of merchandise, this is not at a level as to be considered trading, but rather as a promotional activity. The area in which the Declaration of Trust may need to be amended in future relates to the consequences of the collaboration with Walsall. This will depend on the form of k U : OE PEP8 U M : M kk - k -

34 BUSINESS OPPORTUNITIES (TRADING) In our conversations with staff and Trustees, only three ideas have emerged for trading, which are to sell charity merchandise, to open one or more charity shops or to sell training and consultancy. Merchandising by charities typically consists of selling branded items, such as mugs, tea-shirts, caps , key rings, fridge magnets etc for a profit. The main challenge is getting these out to market, i.e. finding ways to sell them to enough people to make the operation worthwhile. Where a charity has a large support base or a chain of shops, or a website visited by many thousands, this can be

5// Fundraising Review for The Royal Wolverhampton NHS Trust Charity 30

viable. A good example is the RSPB, which sells to its members via its magazine, as well as via its website and at its reserves. This is of course a major national charity. While it would be possible for the Trust Charity to develop a range of branded merchandise, it will struggle to make sufficient sales at present to make significant money. We therefore do not see merchandise sales as a significant trading opportunity. The main value of it will be to support people who wish to undertake fundraising and to raise awareness of the Trust Charity. The Trust Charity does not yet operate any shops, through which it could sell donated goods (Indeed, it is currently struggling to find a high profile base at New Cross from which to operate the charity itself). Operating charity shops is a specialist area and, like any business venture, carries some risk. Important decisions include where to locate the shop(s), whether to pay a manger (or just to use volunteers) and how to source a sustainable supply of good quality stock. If the Trust Charity wishes to develop this area, it first needs to develop a business plan and to answer the questions above about the fundamentals. Much can be learned from the experience of other charities. For example, local hospices such as Compton Care often have very establ ished networks of shops (currently closed due to Covid-19), as well as running online shops, eBay shops and online accounts on platforms such as Depop. Online trading can be more profitable as it does not require a physical shop to trade from, although storage and despatch space is still needed to process goods. If these operations can be run by volunteers, then they represent a lower risk entry point to shop trading . In the case of the Trust Charity, our advice is to focus firstly on making fundraising mor e effective before embarking on shop sales, especially as charity shops are currently closed due to Covid-19. Another trading option for some charities is to sell expertise via training or consultancy. For example, the Trust has a large number of highly trained people, some of whom have knowledge and skills which could be marketed to businesses, with the fees donated to the Trust Charity. However, we understand that the Trust already sells training, with proceeds going to the Trust itself. Any Charity activity in this area would therefore be in direct competition with the Trust. We do not see this therefore as a money spinner for the Trust Charity (unless there was some benefit to the buyer in the money going to the Charity instead of to the Trust). Should the charity decide to embark on any significant trading activity (as opposed to the small scale selling of merchandise), it would also need to consider the provisions of its Declaration of Trust (Section D1), which state that “in raising funds the Trustees shall not undertake any substantial permanent trading activity”. If, for example, a chain of shops were to be opened, the turnover of which became substantial, then the Declaration of Trust would need to be amended. There is no definition in the Declaration of what is meant by “substantial”, so the Trustees would need to take a view at the time about that. Small scale selling of merchandise is unlikely to be a problem. Any changes to the Declaration of Trust would need to be made by a deed and a copy sent to the Charity Commission. A further option for generating income is to offer speakers for engagements, where the fee or donation is paid to the charity. The Trust has some highly accomplished staff, including clinicians, able to speak on a wide range of health topics. They could be offered to organisations that look for e.g. after dinner speakers. Where a speaker is well received, they tend to gain a reputation which then leads to further invitations. Ideally, the speaker(s) should be ones who enjoy the role

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and who will make good representatives of the Trust and the Charity. They can also take with them copies of charity literature to distribute to audience members. One caveat here is that groups booking speakers will need to be made aware that there is a minimum donation, to avoid wasting speakers time. Again, this area is unlikely to be a major opportunity, not least because the Charity already sends its own staff to speak to groups. In summary then, we do not see trading as the way forward for the Trust Charity at this time.

35 CHARITY PATRONS As a large city, Wolverhampton has given birth to a number of famous and successful people, as well as hosting some interesting incomers (such as people associated with Wolverhampton Wanderers). Famous or accomplished people associated with the city include: • Jay Blades (TV presenter and furniture restorer). A Londoner who lives locally • Steve Bull (former Wolves player). A local person who lives locally • Conor Coady (Wolves captain). From Liverpool but very popular locally • Mel Eves (former Wolves player and journalist). A local person who lives locally • Baron ess Hayman (politician) . From Wolverhampton but lives in London • Dave Hill (Slade guitarist). A local person who lives locally • Noddy Holder (Slade singer). From Wolverhampton but lives in Cheshire • Denise Lewis (Olympic gold medallist). From Wolverhampton • Lord Mervyn King of Lothbury (former Governor of the Bank of England). From Wolverhampton but lives in London • Beverley Knight MBE (singer), who is already a contact • Rajinder Kaur Mann OBE DL (Deputy Lieutenant of the West Midlands) . Lives locally • Caitlin Moran (Times journalist) . From Wolverhampton but lives in London • Jacqui Oatley MBE (TV sports commentator). From Wolverhampton • Liam Payne (singer/songwriter). From Wolverhampton • Robert Plant (rock singer). Lives at Kidderminster. Vice-presiden t of the Wolves • Aaron Rai (champion golfer). From Wolverhampton • Tessa Sanderson (Olympic gold medallist) . From Wolverhampton • Sathnam Sanghera (journalist and author). From Wolverhampton but lives in London • Nuno Espirito Santo (Wolves manager and major donor to local foodbanks) • Nigel Slater (celebrity chef). From Wolverhampton • Meera Syal (actress and comedienne) . From Wolverhampton • Kristian Thomas (Olympic gymnast). From Wolverhampton There will no doubt be other names to add to this list. As such, there is certainly a pool of potential patrons to consider. Unfortunately, it is also the case that a lot of people born in Wolverhampton leave the city for education or career reasons and do not come back. Despite this, it is likely that, should the Trust Charity decide to seek patrons, it would find some. When considering the issue of patrons, it is important to decide what their purpose would be. Is it simply to have the names on a letter head for reasons of credibility (we suggest this would have

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little point in this context), or is it to have working patrons who are prepared to help the charity by attending events, opening doors or helping to secure donations? If the latter, then patrons can be a valuable add-on to a fundraising operation (although they are never a substitute for getting the basics right, such as developing a strong case for support). Patrons can be helpful in a range of fundraising, including with trusts & foundations (by being willing to use their contacts and to endorse appeals), in major gift fundraising (by helping to make or to facilitate approaches) and in corporate fundraising (by attending events and adding some sparkle). Where a capital appeal is planned, patrons can also be of great value, if they are prepared to be proactive on the charitys behalf. We therefore make the following suggestions: • Further research will need to be done into which potential patrons are of interest and whether there is any current link to the Charity, the Trust or its people • Careful thought will need to be given to the specific role the patrons are to be asked to take on (i.e. what will be expected of them) • Potential patrons will then need to be approached (ideally by someone with a connection to them or by someone senior at the Trust) Given the goodwill of the public at present towards the NHS and its staff due to the pandemic, now is a good time to be developing this area and it may be that potential patrons will be more willing to support than before. Finally, as the Trust Charity bears the title Royal in its name, it may be possible for it to secure the patronage of a member of the royal family (We note that the Duke and Duchess of Cambridge are patrons of NHS Charities Together). Advice on this should be taken from the Office of the Lord Lieutenant of the West Midlands (Tel 0121 222 5040 or email [email protected] ).

36 INTERVIEWEES We are grateful for their insights to the following people interviewed for this review: Leanne Bood, Fundraising Coordinator Roger Dunshea, RWT Charity Trustee Sally Evans, Director of Communications and Stakeholder Engagement, RWT Prof Steve Field, RWT Chair and Charity Trustee Emma Greybanks, Treasury Manager and RWT Charity Accountant Zoe Lees, Treasury and Charitable Funds Officer Sue Rawlings, RWT Charity Chair of Trustees Rachel Robinson, Community and Events Fundraiser Kevin Stringer, CFO & Deputy CEO of RWT

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10.3 Trust Strategy Update/revision/progress 1 Strategy Board Front Sheet.docx

Trust Board Report Meeting Date: 6 April 2021 Title: Refresh of Trust Strategy (2021/22) Action Approve the 2021/22 strategy Requested: For the attention of the Board  The strategy takes account of the local and national environment The approach to developing the strategy and the strategic objectives has Assure  been agreed with board members through the Board Development sessions, non-executive briefings and board sub-committees.  Progress against the strategy and the objectives will require monitoring Advise which will initially be through the sub-committees of the Board Alert  N/A Author + Contact Tim Shayes, Deputy Director of Strategic Planning and Performance Details: Tel 01902 695914 Email [email protected] Links to Trust The strategy proposes new strategic objectives for 2021/22 Strategic Objectives

Resource None identified that are directly attributable to the development of this Implications: strategy

Report Data Some public health data has not been updated recently Caveats CQC Domains Safe: Effective: Caring: Responsive: Well-led: Equality and This strategy seeks to improve equality and diversity Diversity Impact Risks: BAF/ TRR BAF risks are developed from the strategic objectives Public or Private: Public Other formal The strategic objectives have been presented to the sub-committees of the bodies involved: Board as well as the wider strategy being discussed through non-executive director briefings. References The strategy takes account of the key national policy documents, including:  The NHS Long Term Plan  NHS Operational Priorities 2021/22  ‘Integrating Care: Next steps to building strong and effective integrated care systems across England’ (NHSEI November 2020)  ‘Integration and Innovation: working together to improve health and social care for all’ (Department of Health and Social Care, February 2021)  ‘Legislating for Integrated Care Systems – five recommendations to Government and Parliament’ (NHSEI February 2021)  ‘NHS Provider Selection Regime – consultation on proposals’ (NHSEI February 2021)

NHS In determining this matter, the Board should have regard to the Core principles contained in Constitution: the Constitution of:  Equality of treatment and access to services  High standards of excellence and professionalism  Service user preferences  Cross community working  Best Value  Accountability through local influence and scrutiny Brief/Executive Report Details Brief/Executive Summary Title: Following the multiple non-executive briefings on the subject, attached is the final draft of the Trust’s strategy for 2021/22. It incorporates the agreements reached through the sub-committees of the Board and the non-executive briefings, namely:  The approach for 2021/22 which differs intentionally from the normal approach  The revised strategic aims and objectives  The updated analysis of the internal and external environment 1 Final Draft Trust Strategy 2021.22.pdf

Trust Strategy 2021/2022

Safe & Effective | Kind & Caring | Exceeding Expectation 1 Trust Strategy 2021-2022

Contents Page Our Vision 1

Strategic Objectives 1

Trust Overview 3

How our patient profile is changing 3

Building on a solid foundation and driving innovation 4

How are we improving patient experience and outcomes? 4

External Landscape 7

Internal Analysis 10

Achieving Our Vision - Strategic Objectives 12

Strategic Plan on a Page 23 Trust Strategy 2021-2022

Our Vision

Our vision is to be an NHS organisation that We therefore recognise that we have to continually strives to improve the outcomes make brave decisions and develop innovative and experiences for the communities we solutions to ensure that our patients and serve. wider communities continue to receive the highest levels of care. Whilst our vision remains unchanged, there is no escaping the impact that Covid-19 has had Strategic Aims on the environment in which we operate. The Accordingly, we have based our strategy disease has acted both as an illuminator and around the following six key aims: catalyst for some of the changes required as well as identifying new challenges in the form 1. To have an effective and well- of restoration and recovery. integrated local health and care system that operates efficiently Owing to the exceptional circumstances and the uncertainty of the current environment, 2. Seek opportunities to develop our this strategy intentionally focuses on the services through digital technology strategic direction for a shorter timeframe and innovation than usual - the 2021/22 financial year. This allows us to develop our usual longer term 3. Attract, retain and develop our staff strategy once there is more certainty over the and improve employee engagement environment in which we operate. 4. Deliver a safe and high-quality service In order to achieve our vision, we have 5. Operationally manage the recovery established a clear set of strategic objectives from Coronavirus to achieve national that are supported and underpinned by standards our core values. We know that the journey ahead of us can only be achieved through 6. Maintain financial health – the collaboration and support of our staff, appropriate investment to patient stakeholders and the communities with which services we work. We want every patient who interacts with our services to know that we are working Our strategic aims are underpinned by tirelessly to deliver safe and clinically effective strategic objectives (detailed later in the services. We want them to experience the document) – these are the specific, time- highest standards of care, and for them to based measures which we use to judge our feel as though we have been kind, thoughtful, achievement against our strategic aims. respectful, caring, compassionate and above The strategic aims are long term in their focus all listened to throughout their patient and we are already well in to our journey to journey. If we can achieve this, then we are achieving them. We are working closely with confident that we can enhance our reputation our health and social care partners to develop and be seen by others as a beacon of good an Integrated Care System (ICS). Within this practice and leader for innovation. system, we will continue to take a leading role Notwithstanding the above, the longer-term in the delivery of the PLACE based agenda – challenges facing the NHS have remained working with other stakeholders to maximise unchanged. In its simplest form, the current the use of the Wolverhampton pound. configuration of services cannot cope In doing so, we will ensure that we consider with the level of demand, has inequality the health and wellbeing of the community, in outcomes, has too much overlap and and not simply intervene during periods unnecessary bureaucracy, has an ageing of ill health. Our approach will see greater workforce with shortfalls in current and future community-based care. Services will be recruitment and, fundamentally, is financially integrated and based on the principle of unsustainable.

1 Trust Strategy 2021-2022

multi-disciplinary working among health and We recognise that our patients and the care professionals. communities we serve want to interact with us in many ways, and that technology has an Our patients will be supported to manage important role to play in this. We have and their own care, and will no longer be passed will continue to use digitally enabled solutions from one organisation to another as they seek so that people can book appointments, see to identify the care they support and require. clinical staff and safely monitor their own We believe that this approach will enable us to health. We will embrace this change, and work remove unnecessary duplication, and ensure with partners across the whole heath care resources are used effectively. system to automate processes and information Separate organisations will cease to have sharing. We will help create a system where competing agendas as we will work together patients feel supported to live healthier and to put the patient at the centre of all we do. more independent lives. Together, we will be mutually accountable We will continue to work with our for the delivery of services as we share all communities, patients, partners and staff available resources. We believe that this is as we evolve. Understanding the need and the most appropriate, safe and financially requirements of the diverse communities responsible solution for the future of health of Wolverhampton, Staffordshire and the and care provision in Wolverhampton and Black Country is fundamental in our vision beyond. as well as identifying and addressing the Collaboration will also extend beyond the inequalities within these communities. Our city as we look to work more closely with approach will always be inclusive, and we will other providers of care. We know that safe share, discuss and consult on all major service services are those that are well resourced reconfiguration. and have adequate clinical support. Making This vision, our values and the strategic best use of collective resources to achieve objectives provides the narrative for this this goal is a positive step for patients. journey. Together with Walsall Healthcare NHS Trust, The impact of the pandemic has meant that we have expressed our intention to work the key operational priority for 2021/22 will be closer with each other to ultimately improve on restoration and recovery. patient outcomes and reduce duplication and inefficiency. Our history suggests that we have adapted What Success looks like by 2022 well to the challenges we have faced and embraced innovation to achieve our strategic Amongst other things, we will have: aims. • Established the Wolverhampton We must continue on this path if we are to Integrated Health and Care remain financially and clinically resilient. Partnership and South Staffordshire Integrated Care Partnership Similar to all healthcare providers, perhaps the biggest challenge we face over the coming • Developed a person centric years concerns our is our staffing capacity integrated data resource for to accommodate the demand in the system population level planning and and the ability to successfully attract and research retain appropriate staff. We know that as • Reduced the gap in engagement different generations enter the workforce we scores for BAME staff need to adapt and provide career paths that satisfy their needs. We will respond to this • Recovered services following Covid in challenge through innovative and creative line with the national ambitions career development pathways, working collaboratively with academic institutes. We • Delivered the RWT component of the will look to develop a sustainable workforce in STP medium term financial plan. a caring, supportive and exciting environment.

2 Trust Strategy 2021-2022

Trust Overview

The Royal Wolverhampton NHS Trust is one What population do we serve of the largest healthcare providers in the Black Country and West Midlands, providing Whilst the majority of our patients still come primary, secondary, community and tertiary from Wolverhampton, we have seen an care services to a combined population of increasing number of patients from outside 450,000 people. of the city. We see a significant number of patients from Southern Staffordshire and, We provide 850 beds at our New Cross site 3% in recognition4% of our status as a specialist (including intensive care beds and neonatal provider, receive income from Specialised cots), 56 rehab beds at West Park Hospital, and Commissioners. 54 beds at Cannock Chase Hospital. Over the past few years, we have treated an We are one of the largest employers in increasing number of patients from other Wolverhampton, with more than 10,000 15% Black Country Clinical Commissioning Groups staff, providing services from the following which demonstrates the importance of locations: working as a system and the lack of distinct boundaries. • New Cross Hospital - Secondary and 40% tertiary services, Maternity, Accident 2020/21 Patient Income £557.1M & Emergency, Critical Care and 3% Outpatients 4% • West Park Hospital - Rehabilitation,

Inpatient and Day Care services, 15% Therapy services, and Outpatients

• Community Services - More than 20 40% community sites providing services for children and adults, Walk-in Centres,19% and Therapy and Rehabilitation services

• Cannock Chase Hospital - General 19% Surgery, Orthopaedics, Breast Surgery, Urology, Dermatology, and 1%

Medical Day Case investigations and 1%

treatment (including Neurology and 18% Endoscopy) Inpatient rehabilitation 18% Wolverhampton CCG Wolverhampton Council Wolverhampton CCG Wolverhampton Council beds Specialised Services Staffordshire CCGs Specialised ServicesOther Black Country CCGs NHS StaffordshireEngland CCGs Other Black Country CCGs • Primary Care - Nine GP practices have Other Black Country CCGs NHS England now joined us. Other Black Country CCGs We also successfully host the West Midlands Local Clinical Research Network (WMCRN), and have done since its establishment in April 2014.

3 Trust Strategy 2021-2022

Building on a solid Innovation The Trust has established a reputation foundation and driving for innovative practice, and developing alternative models to improve patient care. innovation We pioneered new approaches around dementia care and infection prevention, and As a Trust, we foster a culture that embraces held the record for the longest consecutive innovation in the work place. We recognise period without a case of MRSA across all that if the NHS is to meet rising demand, hospitals in England. We won the national we must continue to innovate and develop Carter Innovation Award for our pioneering new technologies that enhance and improve healthcare project SafeHands. This provides patient care. real time information on bed status, patient Black Country Pathology Services pathway tracking and asset management and has provided numerous benefits. Staff from neighbouring Trusts joined The Royal Wolverhampton NHS Trust as part of the Huddle Tool Black Country Pathology Service (BCPS). Trusts across the country are facing the The BCPS is a ‘hub and spoke’ service model challenge of having to maximise the through with the “hub” located in showcase facilities put of patients within the hospital. In order at New Cross Hospital in Wolverhampton to do this visibility is needed on what patients and essential service laboratories (ESLs) are waiting for on a day by day basis. The Trust supporting acute services in the other partner has invested in a Continuous Improvement sites at Dudley, Walsall and Sandwell & West Team who have developed the ‘huddle’ tool. Birmingham Trusts. A live and interactive tool showing what patients are awaiting next in their stay. Global Digital Exemplar Developed internally, the tool is the only one The Trust has been recognized as a Global of its kind in England and allows for greater Digital Exemplar - an internationally transparency on the reasons for delay. recognised NHS provider delivering improvements in the quality of care, through the world-class use of digital technologies How are we improving and information. Exemplars will share their learning and experiences through the creation patient experience and of blueprints to enable other trusts to follow in their footsteps as quickly and effectively as outcomes? possible. Over the last three years we have seen a number of developments that have supported Babylon our ambitions to improve the outcomes and The Royal Wolverhampton NHS Trust experiences of patients. (RWT) and Babylon have launched a Vertical Integration 10-year partnership to develop a new healthcare delivery model of ‘Digital-First 2016 saw the launch of the Royal Integrated Care’, for 300,000 people across Wolverhampton Trust Primary Care Wolverhampton and its surrounding areas. Programme. This is a Vertically Integrated (VI) model where GPs and Primary Care teams Patients will get greater control over their work closely with Community and Secondary own health, faster treatment, fewer trips to Care teams to reduce fragmentation in care hospital, treatment from their own home and delivery. greater access to their own data. Staff will have time freed-up for patients with the most The programme has evolved throughout the urgent and complex issues, avoid duplication, years and the Trust now has its own ‘Primary and improve information-sharing. Care Network’ – the group of vertically integrated practices working more closely together to improve patient outcomes and reduce duplication.

4 Trust Strategy 2021-2022

As of April 2021, nice GP Practices are now Other significant developments part of the Trust. This means that we are across the Trust include: directly responsible for the delivery of primary care. This vertical integration offers • Development of Stroke network with a unique opportunity to redesign services Walsall Healthcare NHS Trust from initial patient contact, through ongoing • Development of unplanned flow management to end of life care. programme focused on improving As a single organisation, the issues of scope the flow of patients throughout of responsibility, funding, differing objectives hospital and drivers will be removed, and clinicians will be in a position to design effective, high • Outpatients transformation quality clinical pathways which will improve programme designed to implement appropriate access and positively impact on some of the best practice seen patient outcomes. throughout the pandemic, including virtual attendances and effective ‘Physician A’ Model and Emergency triage. Care We opened the new Emergency Department Quality Overview in November 2015 which saw a much The Trust has highlighted three key quality improved physical facility for patients, staff priorities that will help ensure that the and ambulance crews. We have continued experience a person has of their care, to look at ways that the ED can evolve treatment and support will be of high quality, and improve the experience for patients clinically effective and safe. These priorities by developing new clinical practice that is are: revolutionary in its approach. • Preventing the spread of infection The Physician A model was introduced in early 2016, and sees a consultant physician • Minimising the impact of Covid-19 permanently based in ED, working alongside ED consultants to assess, investigate and • Improve waiting times, patient treat patients before discharge or referral experience and outcomes for cancer for ongoing care. Their overall role is to diagnostics and treatments. assess medical patients in the Emergency The work we are doing to achieve these Department, with the aim to reduce priorities is described in more detail in the admissions, refer to community services, Strategic Objectives and Enabling Strategies and start treatment earlier. This has been sections of this document. extremely successful with a 15% reduction in admissions avoided since its development. We have continued to pursue improvements to the service with the introduction of ambulatory care where patients can receive timely intervention without the need for admission. From April 2021, the Trust will take over the running of the Urgent Care Centre (on the New Cross Site). This allows us to ensure patients follow the most appropriate pathway to their needs.

5 Trust Strategy 2021-2022

Workforce Overview Finance Overview We employ over 10,000 people, which The financial challenge facing the NHS has makes us the largest single employer in possibly never been greater than it is now. Wolverhampton. The last few years have seen national financial settlements that are historically low, and this More than 60% of our staff live in is now coupled with rising pressures from the Wolverhampton, and speak highly of us both Covid-19 pandemic. as an employer and as a service provider. This is reflected within the national Friends and Underlying demand on the service continues Family Test scores. to increase, whether this is the cost of new technology, or the cost of an ageing Employees work across three hospital sites, population living longer with chronic diseases. 20+ health centres and primary care sites and At the same time, waiting lists have grown walk-in-centres. We invest heavily in education as Covid-19 has disrupted patients planned and training for staff, and foster learning treatment. As a result, the NHS needs to strive through links with the Academic Institute of to be as efficient as possible. Medicine (AiM), University of Wolverhampton, and other education partners. We have our The table below shows the income and own library, and Education and Training expenditure position for 2020/21 and previous centre, as well as a Clinical Research Network. years: During 2016, we were voted as the best place 2017/18 2018/19 2019/20 2020/21 to train by Junior Doctors, and the 12 month nursing preceptorship programme is a model £m £m £m £m of best practice. Income 534.4* 539.2* 537.4* 557.1 Retrospective Our values underpin the culture of the Trust. Top Up 25.0 We have embraced the national ‘Freedom to Income Speak Up’ framework and we are signed up Operating 506.0 510.0 504.5 548.2 to the ‘National Call to Action’ on bullying Expenditure and harassment. We are in the process of Non- implementing the NHS ‘Equality Delivery Operating 26.80 27.6 27.5 33.9 System’ which helps to strategically embed Expenditure equality, diversity and inclusion across our Surplus 1.6* 1.6* 5.4 0.0 workforce and services. Memo line - the above Our Vision plan includes: An NHS organisation that continually strives to CIP Total 26.9 30.0 29.5 2.1 improve the outcomes and experiences for the CIP as % of operating 5.3% 5.9% 5.8% 0.4% communities we serve expenditure Our Values *The figures are presented excluding Sustainability and Transformation Funding. If Safe and Kind and Exceeding this were included, then both the income and Effective Caring Expectation the surplus would be £10m higher in 2017/18 We will work We will act We will and 2018/19. collaboratively in the best grow a Ordinarily a forecast for the future year to prioritise interest of reputation would be included. However, owing to the the safety others at all for exceptional circumstances we find ourselves of all within times excellence as in, funding for 2021/22 has not yet been our care our norm confirmed. environment

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External Landscape

National Picture External Analysis and As head into 2021/22, the national picture is heavily influenced by the Covid-19 pandemic Assumptions and the impact it has, and will continue to We have examined our external environment have, on the NHS and society in general. using an analysis of the Political, Economic, This impact has been seen across the country Societal, Technological, Legal, and and will be as relevant for others as it is for Environmental (PESTLE) framework. Wolverhampton. From this assessment, the key issues are Prior to Covid, NHS England released the described as: ‘Long Term Plan’ detailing the priorities and • Political/Legal – The political agenda challenges facing the NHS. These still hold has been dominated by Covid-19 in with Covid having magnified some of these the last year and this is expected to challenges and giving greater emphasis to the continue into 2021/22. The focus is priorities. expected to turn to recovery and the The key drivers contained within this implications for the NHS of living document are wider than individual with the disease. organisational concerns. However, they Recent new legislation has given do reflect the issues and concerns facing Integrated Care Systems (ICS) Wolverhampton as a city. They are: greater powers with them becoming statutory bodies in their own • What does recovery from Covid right. This reflects the focus seen look like and how do we achieve it in recent years on more integrated (recognising our capacity constraints working and RWT will continue to from before the pandemic and the act as a key player both within this patients who have subsequently had system, and more locally, within the their treatment delayed). Wolverhampton PLACE. • How we can we work collaboratively The Covid pandemic has shone a as an Integrated Care System to light on the health inequalities prevent illness and then support within the population we serve. We patients and users before they enter are committed to understanding the acute care system these inequalities and developing a plan, alongside our partners, for • How do we realise the benefits of eliminating these. working more closely with our acute partners, and specifically in Walsall, • Economic – the economic outlook to deliver improved outcomes to clearly looks challenging following patients and eliminate inefficiency the pandemic and the funding for the NHS remains unclear. That • How care is delivered across the city, said, it is widely expected that we and whether the formal distinctions will face a challenge to make some between primary, secondary and level of efficiency savings and move community-based care need to be away from the previous ‘Payment By made more integrated Results’ (PBR) approach. • The level of resource that is available This represents a significant change for the across the city to meet the existing NHS and Trust, fundamentally changing the and future demand needs to be put business model previously at play. The new to best use to support the whole of payment system emphasises the need to the health economy maximise the use of our resources and manage our patients in different ways.

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• Social - The NHS has an ageing • Deliver financial stability and workforce, and there is an inability efficiencies throughout the local to recruit sufficient new entrants. health care system Covid has changed the way that we work and new opportunities present The Trust will be a member of the ICS as well themselves as a result of the increase as being part of a provider collaborative in remote working. allowing us to work with neighbouring Trusts Wolverhampton is a very diverse city to integrate services locally. The boards of the with stark health inequalities. One of Royal Wolverhampton and Walsall Healthcare our key priorities over the next year NHS Trust have already both committed is to understand these inequalities to embarking on a strategic collaboration and establish a plan, alongside our focused on improving outcomes for the stakeholders to work to eliminate populations of Wolverhampton and Walsall them. whilst making services more sustainable. We also expect to see the evolution of the • Technological – We serve a Wolverhampton PLACE based agenda in population, the majority of whom 2021/22. This agenda brings together health are comfortable with the use of and social care stakeholders from across technology and use it in their daily Wolverhampton in the development of a lives. As we embark on our recovery programme of work aimed at making best from Covid-19, we need to embrace use of the Wolverhampton pound for the new ways of working and build population of Wolverhampton, on some of the initiatives already introduced, e.g. the increase in virtual attendances. Our Patients • Environmental – Awareness of We serve a number of communities and the impact we all have on the our main Trust site resides in the heart of a environment has arguably never diverse city with a CCG registered population been so high. Like with the rest of of 263,000 people. Recognising the close society, the NHS needs to be aware proximity to neighbouring areas, the wider of the impact of its operation and population that we serve is closer to 450,000. identify the measures it can take to This covers patients from across South reduce this. Staffordshire, Walsall, and, to a lesser extent, patients from other areas of the Black Country and Shropshire. Local Picture and ICSs The Office of National Statistics (ONS) 2021/22 will see greater focus on estimates that the population of collaborative working. For the past few Wolverhampton will grow to 273,000 by 2025, years, Wolverhampton has been part of the an overall increase of 4%. The population of Black Country STP. This comprises 18 local South Staffordshire will grow slightly from health and social care organisations across 112,000 in 2018 to 114,000 in 2025, an increase the Black Country. From 1st April 2021, the of 2%. STP will evolve to become an Integrated Care System (ICS) which, under recent government proposals will ultimately become an independent statutory body. The aims of the ICS are to: • Improve the health and wellbeing of local people • Improve the quality of local health and care services

8 Trust Strategy 2021-2022

The current age profile of Wolverhampton We know that high levels of deprivation is broadly in line with that of the country are a determining factor in the health of a whereas a greater proportion of people over population. Life expectancy in Wolverhampton the age of 65 reside in South Staffordshire is lower than for England as a whole and compared with the country generally. the mortality rate across all causes is higher than for England as a whole. In terms of behavioural risk factors, Wolverhampton has Wolverhampton and a lower percentage of physically active adults than the country and a higher percentage Staffordshire’s Health classified as overweight or obese. Smoking prevalence is however slightly below the Needs English average. A key challenge for the Trust is the diversity Finally, males experience a health inequality of the communities we serve. Wolverhampton at birth of 7.8 years and females, 6.3. Both are is characterized by high levels of deprivation higher than the national average. whereas South Staffordshire is typically more prosperous and less ethnically diverse. As a Trust, we work closely with colleagues in Commissioning and the Local Authority to develop the Health and Wellbeing Strategy. We also contribute to the Joint Strategic Needs Assessment (JSNA) that defines the health considerations across our communities.

Wolverhampton South Staffordshire Population 1 c263k 3 c112k Ethnic 2 White: 64.5% 3White: 96.5% Background BME: 35.5% BME: 3.5% Life Expectancy 1 Males: 77.3 3 Males: 80.3 Females: 81.9 Females: 84.3 Below national average Above national average Quality of Life 2 Males: 58 years 5 Males: 71 years (lower than national average) (higher than national average) (Disability free life expectancy) Females: 61 years Females: 73 years (lower than national average) (higher than national average) Deprivation 1 17th most deprived LA 5 250th most deprived district 51.3% of population amongst the 9% of population amongst the 20% 20% most deprived nationally most deprived nationally Morbidity 167.3% of adults (18+) classified as 362.7% of adults (18+) classified as overweight or obese overweight or obese 2 27.7% suffer from one or more LTCs 4 18.7% suffer from one or more LTCs Single greatest cause of years of life Single greatest cause of years of life lost: circulatory diseases lost: Cardiovascular Disease Taken from: 1 Health Profile 2017-19, Public Health England 2 Wolverhampton JSNA 2019 3 Health Profile 2017-19, Public Health England 4 Health & Wellbeing Profile 2015 for South Staffordshire 5 South Staffordshire E-JSNA

9 Trust Strategy 2021-2022

Internal Analysis

We have used a SWOT tool to complete the internal analysis. The key themes that have Weaknesses emerged from this are: Like with other Trusts across the country, the impact of Covid-19 has been seen in our waiting times and we have patients waiting Strengths longer than we would like. • Experienced and well-established Board with over 200 years of • Whilst we have low levels of clinical experience at board level. This gives and nursing vacancies generally, the Trust stability and confidence we face specific challenges in some to deal with the current and future areas (e.g. emergency) and have a challenges facing the health sector as workforce profile that mirrors the well as influence outside of the Trust national position. This means we have a high proportion of staff that • There is a good level of clinical are experienced and skilled, but are engagement with clinicians leading due to retire over the next 5-10 years the development of their services in a culture of innovation • The Trust has an old estate requiring significant investment, alongside a • The Trust is currently rated as ‘Good’ capital programme that is insufficient by the CQC – the highest rating of for the investment required any provider in the Black Country • We have inconsistency with regard • We are a combined acute, community to the achievement of national and primary care service provider performance standards with specific which enables us to consider the total areas of challenge - the most notable pathway of care for all our patients of which is the achievement of the when planning our services. This gives 62-day cancer standard us the opportunity to develop new services and work to prevent patients • Like other Trusts, there is a from attending hospital unnecessarily fundamental lack of capacity (both and makes us an attractive company staffing and physically) to treat the for external stakeholders to work backlog of patients caused by the with Covid-19 pandemic • There are low levels of clinical and • The Trust recognizes that there are nursing vacancies which support us in health inequalities being faced by delivering our strategic priorities people within the population we serve. • The Trust has a history of strong financial performance and sits in the top quartile of most efficient Trusts (as measured by our cost per weighted activity unit). Our hospital at Cannock allows us to run ‘cold site operating’ – increasingly important during Covid

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Opportunities Threats • The Trust recognises the • The impact of Covid continues to opportunities that come from represent one of the biggest threats working more closely with our ever faced by the Trust and the NHS neighbouring Trusts. Together with in general. Despite the roll out of Walsall NHS Foundation Trust, we vaccinations, we remain conscious of are pursuing the benefits of this the further disruption it could bring approach • Following the recent legislative • Following the recent legislative proposals that offer greater influence proposals that offer greater influence and decision-making power to and decision-making power to Integrated Care Systems, there is Integrated Care Systems, there is the a threat that this could negatively opportunity for the Trust to have an impact on the Trust influence on a larger scale • The demand on services is not • Vertical integration offers further sustainable – this was true before opportunities for the Trust to affect Covid and has been emphasised in the whole patient pathway the backlog of patients waiting as a result of Covid • Our recently announced 10-year partnership with Babylon combines • Delivering the financial plan remains the experience of running a hospital a challenge. The expectation on us with cutting edge technology to to continually deliver a significant CIP bring innovative solutions for our whilst demand for services increases patients puts considerable pressure into the system • We can further improve our CQC rating to ‘Outstanding’ and take • Financial pressures faced by other advantage of the benefits that come partners in the health and social care with this. sector, could have a de-stabilising effect. This puts pressure elsewhere in the system, and creates inefficiencies and poorer health outcomes.

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Achieving Our Vision - Strategic Aims and Objectives

We have refreshed our strategic objectives to ensure they remain relevant and fit for purpose. In doing so, we have moved to a tiered approach comprising high level, long term aims that are underpinned by SMART (Specific, Measurable, Achievable, Realistic and Time Based) objectives. Our strategic aims and objectives underpin all of the work we do across the Trust and help us to remain focused. All of the key decisions identified within this strategy will support our strategic objectives as we build the foundations that will enable us to deliver our vision.

Our Values

Safe and Effective Kind and Caring Exceeding Expectation We will work collaboratively to We will act in the best interest of We will grow a reputation for prioritise the safety of all within our others at all times excellence as our norm care environment Strategic Aims Seek To have an Operationally opportunities Attract, retain Maintain effective and well manage the to develop and develop our Deliver a safe financial health integrated health recovery from our services staff and improve and high quality – appropriate and care system Coronavirus to through digital employee service investment to that operates achieve national technology and engagement patient services efficiently standards innovation Strategic Objectives (2021-22)

Establish the Identify and implement Maintain the lowest Recover and restore planned activity to at least Delivery of the RWT Wolverhampton Health a digitally enabled vacancy levels in the 85% of normal levels by July 2021. component of the STP Board and implement operating model in Black Country medium term financial the associated partnership with plan operating framework Babylon

Work with partners Develop a person Increase the percentage Achieve best practice By March 22, reduce Use our influence to develop a model centric integrated data of staff who deem the for the management of the number of patients for Black Country of care collaboration resource for population organisation has taken Covid patients awaiting initial cancer investment into RWT across the Black level planning and positive action on their treatment to the levels and maximise external Country research health and well being seen in February 2020 capital opportunities to support the Establish a South- Establish a Digital Improve overall Reduce indirect harm Prioritise the treatment development of the West Staffordshire Collaborative to focus employee engagement caused by Covid by of P1 and P2 patient, estate and related Integrated Care on the construction, establishing systems to reducing the number assets Partnership engineering and identify and monitor waiting to the levels analysability of a high learning from related seen in February 2020 quality clinical and incidents care data set Improve outcomes for Reduce the gap in Reduce harm by patients and efficiency engagement scores assessing, recognising of process through for BAME staff and and responding closer collaboration improve performance to prevent patient with Walsall against the Workforce deterioration Race Equality standard Promote equity of access and equality of outcomes by understanding and reporting the outcomes of service users

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Deliver a safe and high-quality service

We already know from demographic data We will use tools that have been tried and that the population we serve has poorer tested nationally or internationally to measure outcomes than the national average and and monitor patient quality and safety. there are inequalities within this. We also Where these are not available we will work to know that there is improved understanding of develop ways of measuring good quality and public health, and our population are aware safety ourselves. of the high levels of care they should receive. These measures will provide our patients, Our vision is to ensure that we improve the Board, commissioners and regulators with the outcomes and experiences of the community assurance that patients and their loved ones we serve. We can only do this by having a feel happy and safe to be cared for by the relentless focus on providing safe, high quality Royal Wolverhampton NHS Trust. care in every patient interaction. We want our patients to be treated in accordance Each year we will publish our quality and to our values, and to be able to feel cared safety performance in the Annual Quality for, experience effective services, and know Account in accordance with the current that the organisation prioritises their safety. guidance. This will be shared publicly and also We will achieve this by continually driving provide focus for the coming year. standards and looking for innovative and Whilst at the time of writing, the vaccination improved ways of care delivery. programme is reducing the level of Covid Our three quality priorities for 2021/22 infection within our population, we remain support this vision: vigilant in our efforts to maintain excellent infection, prevention and control standards. • Preventing the spread of Infection In support of reducing the spread of infection • Minimising the impact of Covid-19 we will develop and promote best practice to prevent the transmission of Covid-19 within • Improve waiting times, patient hospital. We will continue to develop testing experience and outcomes for cancer and risk assess the placement of patients. This diagnostics and treatments. is in line with our zero tolerance of avoidable In order to ensure we deliver the agreed hospital acquired infections and sustains the outcomes defined in the ‘Our Patient Quality excellent reputation our Trust already has. and Safety Strategy’ we will innovate, share With regard to the improvement in waiting and spread best practice, learn methods of times, we recognise that the best way to continuous quality improvement, adopt new achieve this, and in turn improve patient guidance, and benchmark our performance to outcomes, is by restoring and recovering our enable us to compare with the best. services following Covid. This is a key priority We will formally involve patients and the for the Trust in 2021/22 with the focus on public in our quality and safety improvements restoring pathways for patients with elective in line with the Patient Experience, care safely and in line with new Infection Engagement and Public Involvement Strategy Prevention and Control standards. 2019-2022 and staff in line with the People We recognise that our cancer performance and Organisation Development Strategy does not match our own aspirations. This is 2016-2020, which sets our plans to engage and reflected in the emphasis that is being placed further develop organisational culture in line on cancer in 2021/22. The Trust is establishing with our this strategy. an improvement group, supported by the Continuous Quality Improvement Team to take forward this work.

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Continuous Quality Strategic Objectives Improvement • Recover and restore planned activity to 100% (initially) of normal levels Continuous Quality Improvement is the application of a systematic approach to tackle • Achieve best practice for the complex challenges that are common in management of Covid patients healthcare. It is focused on improving patient • Reduce indirect harm caused by Covid and staff outcomes and experience and is by establishing systems to identify and a way of giving everyone a voice, bringing monitor learning from related incidents staff and service users together to improve and redesign the way that care is provided. • Reduce harm by assessing, recognising Continuous quality improvement can be a and responding to prevent patient powerful vehicle for improving organisational deterioration effectiveness and behaviours. • Promote equality of access and outcomes A new CQI Team was established in April 2019 by understanding and reporting the with two initial aims: outcomes of service users 1. Build the organisation’s CQI capability and capacity – a standardised approach to quality improvement across an organisation is a key determinant of success with no particular model showing an overall advantage. We will train our colleagues through a staged education offer using the Quality Service Improvement and Re-design (QSIR) framework which has been successfully implemented in other Trusts and is supported by NHS Improvement. 2. Practical support for CQI projects - for directorate and divisional teams to deliver improvements where an opportunity for significant and meaningful improvement has been identified through quality the Trust’s quality assurance process including governance systems (e.g. serious incidents, complaints) and benchmarking (e.g. Mortality, GIRFT, other audit resources).

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Attract, retain and develop our staff, and improve employee engagement

We are acutely aware that it is our people that Coupled with our work to maintain our underpin all of our strategic objectives and low vacancy rate, are our efforts to further is our most important asset. With a national improve the health and wellbeing and shortage of suitably qualified individuals, one engagement of our existing staff. of our key priorities is to both attract and There is increasing recognition of the inequity retain these people. faced by black, Asian and minority ethnic We are thankful that our efforts to do this groups in society. We will focus our attention mean we have the best vacancy rate in the on understanding our employee engagement Black Country and score better than most for this group of staff, how it may differ from on our Staff Survey. We will not become the rest of our staff and the reasons for this. complacent, with our efforts focused on how Finally, we are proud that the recent NHS staff we can improve further and maintain this Survey results demonstrate that we perform position. better than the national average for 9 out of Nurse recruitment has historically been a the 11 indicators (our performance for the challenge, partly owing to changes to the remaining two being in line with the average). number of applicants into new training places The focus for 2020/21 is in improving this for nurses from both the UK and overseas. score further – particularly with regard to The Trust has tackled these issues head on – the percentage of colleagues who deem the working in partnership with higher education organisation has taken positive action with establishments to attract suitable candidates regard to their health and well being and and widening our recruitment oversees. As a also employee engagement. Whilst this was a result, our nursing vacancies continue to fall focus pre-Covid, we recognise the immensely consistently and are as low as they ever have difficult environment they have worked in been. over the past year and the need to support our staff. We have also developed a highly successfully Clinical Fellowship Programme in partnership with The University of Wolverhampton, Strategic Objectives Academic Institute of Medicine (AIM). This is • Maintain the lowest vacancy levels in the a high-quality training programme for junior Black Country doctors seeking experiential service-based learning outside of the standard UK training • Improve overall employee engagement programmes. This award winning initiative has enabled us to attract Fellowship posts to • Reduce the gap in engagement scores for work across the Trust in a variety of medical BAME staff and surgical specialties. This is an exciting • Increase the percentage of staff who programme that is targeting doctors at several deem the organisation has taken positive stages of their career and will help to support action on their health and well being. patient safety and care, and reduce reliance upon costly short-term locum staff to support service delivery. The success of this initiative has led us to extend it to nursing roles offering individuals the chance to develop their career and work within cutting edge clinical practice.

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Seek opportunities to develop our services through digital Seek opportunitiestechnology to develop and innovation our services through digital technology and innovation

Digital technology plays a role in the vast • Show information online which is majority of our lives and we recognise that available to them wherever they are it can also play a role in the delivery of healthcare. Not only is there an appetite • Provide them with options as to how for it amongst the population we serve but they receive information from the also a need for it if we are to find new and hospital. innovative ways of meeting our challenges. Babylon We also recognise that the BI software will The Royal Wolverhampton NHS Trust support us with our numerous strategic (RWT) and Babylon have launched a projects including: 10-year partnership to develop a new • Clinical metrics/indicators through healthcare delivery model of ‘Digital-First analysis of SafeHands and other Integrated Care’, for 300,000 people across clinical systems Wolverhampton and its surrounding areas. • Additional support to Carter and Patients will get greater control over their Costing Transformation Programme own health, faster treatment, fewer trips to hospital, treatment from their own home and • Additional analytical support to greater access to their own data. Staff will Divisions have time freed-up for patients with the most • Digitisation urgent and complex issues, avoid duplication, and improve information-sharing. • Pathway projects such as Ambulatory Emergency Care (AEC) and stroke Digital Support for Colloborative Working • Integration projects such as VI and the ACS With increasing emphasis on working collaboratively, there is increasing importance In order to achieve this, we have invested on the ability of organisations to share and developed a data warehouse solution meaningful data and utilize digital solutions. with enhanced Business Intelligence (BI) The Trust is developed a Structured Clinical tools. This will give us the opportunity to Data Set (SCDU) to support this work with provide automated standard information workstreams across inpatient flow, palliative requirements readily available at analysts and care, overarching projects, community and manager’s fingertips and, more importantly, it primary care. will free up analytic time to support managers in making quicker decisions to help patient Strategic Objectives care. • Identify and implement a digitally myRWT Portal enabled operating model in partnership with Babylon To support our patients, we launched the myRWT patient portal in March 2021 which is • Develop a person centric integrated data accessible via a smartphone, laptop or other resource for population level planning smart device. and research The aim of the portal is to:- • Establish a Digital Collaborative to focus • Give patients easier access on the construction, engineering and to information about their analysis of a high quality clinical data set. appointments • Reduce the chance of lost letters and confusion about appointment dates and times 16 Trust Strategy 2021-2022

To have an effective and well-integrated local health and care system that operates efficiently

The Trust has been a committed partner across We welcome the increased national emphasis the local health economy and the STPs for a being placed on collaboration and the number of years. We recognise the challenges increased powers being given to Integrated that all providers face in the current climate Care Partnerships (ICPs) in the recent in and that if we are to realise our strategic legislative changes. ambitions we need to work together focusing During 2021/22 we expect to see the Black on collaboration rather than competition. Country and West Birmingham STP develop We have already seen the benefits of this into an Integrated Care System (ICS) from 1st approach. April 2021. This ICS is expected to evolve in maturity during the course of year ultimately • In June 2016 we embarked on an resulting in the establishment of the ICS as ambitious Primary Care Programme an independent statutory body by April 2022. (Vertical Integration) whose aim As part of this, the Trust will be represented was to address these issues. We on the ICS board whilst also being part of already have nearly 60,000 patients a provider collaborative -allowing us to registered with our GPs, and the Trust integrate services locally. is directly responsible for the delivery of primary care Wolverhampton Place • Pathology services across the Black Whilst the ICS develops across the Black Country are now working together Country and West Birmingham, the Trust in a service hosted by Black Country will continue to play the leading role it Pathology Services (BCPS). This allows has established in the development of the us to exploit economies of scale and Wolverhampton PLACE based agenda. This improve the sustainability of the agenda brings together health and social care service stakeholders from across Wolverhampton in the development of a programme of • Both the Royal Wolverhampton work aimed at making best use of the NHS Trust and Walsall Healthcare Wolverhampton pound for the population of NHS Trust have agreed to strategic Wolverhampton. collaborate. In doing so, we aim to improve outcomes for patients, Strategic Objectives improve the sustainability of services and reduce inefficiency. • Establish the Wolverhampton Integrated Health and Care Partnership and We believe that collective responsibility implement the associated operating for resources and wider population health framework through coordinated, joined up care will help people to live healthier for longer and • Work with partners to develop a model improve the health and wellbeing of the of care collaboration across the Black communities we serve, in the context of rising Country demand and financial pressures. • Establish a South-West Staffordshire Our vision is for a system of integrated Integrated Care Partnership services founded on multi-disciplinary working • Improve outcomes for patients and among health and care professionals. This will efficiency of process through closer encompass: collaboration with Walsall.

17 Trust Strategy 2021-2022

Operationally manage the recovery from COVID-19 to achieve national standards

The operational performance of the Trust in Referral to Treatment – The Trust delivers a 2019/20 was severely compromised by the comprehensive range of services, and takes Covid-19 pandemic, as it was for the NHS referrals from a catchment population that generally. This has regrettably led to patients extends far beyond Wolverhampton and the waiting much longer than usual and that we Black Country, into Staffordshire, Shropshire would aspire for them to. and Wales. The pandemics impact on our waiting list has been similar to that seen across The key operational priority for 2020/21 will England with patients waiting longer than be on restoration and recovery combined with normal. Our focus for 2021/22 will be on: an improvement to cancer waiting times. At the time of writing, the immediate national • The restoration of services and focus is on restoring services and treating as treating as many patients as possible many patients as possible. • Treating patients according to their Cancer – Alongside the restoration of services, clinical priority (using the framework delivery of the cancer waiting times standards from the Royal College of Surgeons) remains one of biggest priorities moving forward. There is a suite of performance • Clinically reviewing those patients measures – the main measure currently being who have waited the longest the 62-day target. Our performance on this • Embedding the innovation and best standard is not at the levels we would wish practice seen during the pandemic, it to be. We recognise the emphasis that e.g. the increase in virtual outpatient needs to be given to further understanding attendances being offered. the complexities of these pathways and the improvements that can be made to reduce Diagnostics – the number of patients awaiting waiting times for patients. We recognise that a diagnostic test has increased as a result of in addition to the patients referred directly the impact of Covid. We are focusing our to us, as a tertiary provider of cancer care, attention on reducing this waiting list to the we will receive referrals from a number of levels seen pre-Covid. other providers. This provides additional complexities and delays across the pathway of care between providers. We therefore need to be more creative and innovative in our approach so that we can achieve this target. We will also focus our efforts on the achievement of the 28-day faster diagnosis standard being introduced in 2021/22.

18 Trust Strategy 2021-2022

Urgent Care – We have made significant We will commit to the following actions: investment over the past three years in urgent • Work collaboratively with care. This has seen the opening of a new ED neighbouring Trusts to develop facility, and the development of a co-located, improved patient pathways that Urgent Care Centre which the Trust will run provide equitable access from April 2021. Our current performance puts us in the top half of all trusts in the • Establish working groups with country, but we want to improve upon this. other Providers to take forward Our ambition is be in the top 25% of all Trusts key initiatives such as Community nationally. Diagnostic Hubs We have already made a number of positive • Implement the new 28 day cancer and innovative changes to the way we deliver diagnosis standard. care in ED. This has seen considerable patient benefits as fewer patients now require admission, and we are able to triage patients Strategic Objectives to the most appropriate point of care upon • Recover and restore planned activity to at arrival. In addition to this we have developed least 85% of normal levels by July 2021. an Ambulatory Emergency Care facility which will specifically support identified patients. • The number of patients awaiting initial This affords greater opportunity to provide cancer treatment to the levels seen in appropriate and enhanced care for patients February 2020 and should, again, result in the requirement for fewer patients to have a hospital • Prioritise the treatment of P1 and P2 admission. patient, reducing the number waiting to the levels seen in February 2020. We note the recent consultation into new standards for patients in need of Urgent and Emergency Care and support the principles underpinning the new standards. We will continue to monitor our performance against these standards in anticipation them being introduced.

19 Trust Strategy 2021-2022

Maintain financial health - Appropriate investment to patient services

Even prior to the pandemic, the Trust faced The development of the Integrated Care financial challenge stemming from the System (ICS) is a positive step forward in this increasing demand being placed upon its regard, as we look to build new ways for resources. The pandemic has further increased patients to receive care without the need the pressure both in the direct cost coming to create organisational boundaries and from treating patients with the disease as well infrastructure costs. We recognise the need to as the backlog of patients waiting for their deliver care closer to home and have effective planned treatment. community services. It is our intention, through the ICS, to create a seamless care Underlying this, we have seen that the service. We will work with primary care, public population of the city and surrounding areas health, and mental health colleagues so that is predicted to grow, alongside the number the new model of care focuses on prevention of health-related conditions that will require and wellbeing, helps to manage demand, and intervention. ensures any intervention with a care provider This will put pressure on the Trust and the adds value, is effective, and is financially system in a number of ways: affordable. • Increased demand leads to increased We will also work with our neighbouring costs – in the short-mid term this Trusts (Walsall in particular) as we look to demand comes from the backlog of establish more effective services for patients patients already in the system through collaborative working. We know that duplication and inefficiency currently • Services will need to change exist as services are replicated, often less than significantly to reflect the change 3-5miles away. Trying to deliver comparable in demand, and capital resource is services without having the necessary already stretched resources available can lead to poor clinical • It assumes that the workforce is experiences and create financial pressures. We available and affordable, at a time are committed to having a mature dialogue when we already have vacancies with all partners to create a health system that and are struggling to appoint to key offers the best experience for all patients that clinical posts is affordable. We know that this model works from the success we have had in delivering • We are operating in an environment Black Country Pathology Services, stroke where Covid continues to transmitted networks and back office services such as and gives rise to reduced productivity payroll. • There is still considerable uncertainty over future funding making it more difficult to plan. The scale of the financial challenge described means we will need to consider innovative and radically different ways of delivering care. The current configuration of services and organisations is no longer fit for purpose. As a result, we will need to work collaboratively with other stakeholders across the system to develop new models of care are effective and safe for patients whilst maintaining a level of affordability.

20 Trust Strategy 2021-2022

When using the ‘Cost per Weighted Activity Unit’ we know that we benchmark favourably Strategic Objectives when compared to other trusts. This gives us some understanding of how efficient we are • Delivery of the RWT component of the in the day to day running of the organisation. STP medium term financial plan The contrast to this is that we find it difficult • Use our influence for Black Country to continually find the cost improvement investment into RWT and maximise levels required of us to be financially stable. external capital opportunities to support However, we are committed to financial the development of the estate and stability and this requires us to explore every related assets. opportunity to become more efficient. Getting It Right First Time (GIRFT) The Trust is an active participant in the GIRFT programme. This is a programme run by NHS England that supports the NHS in delivering productivity and efficiency opportunities. A rolling programme of GIRFT visits take place, underpinned by action plans that are held by directorates. Model Health System The Model Health System portal supports Trusts in the following: reducing unwarranted variation, continuously evaluating and improving productivity in order for better care for patients. The Model Health System dashboards and metrics provide information to identify the Trust’s drivers for efficiency opportunities, and benchmark against peers and national median. Service Efficiency Team The Trust has invested in a service efficiency team. Programme partners within the team are responsible for working with our clinical divisions to ensure we make our operation as effective as it can be, taking learning from best practice, national guidance etc.

21 Trust Strategy 2021-2022

Maintain financial health - Appropriate investment to patient services

We recognise that the Trust Strategy is a document that should not sit in isolation. A clear structure is in place, outlined in the table below. The Trust has one strategy and one set of strategic aims and objectives which are supported by nine enabling strategies which align to the sub-committees of the Board. Delivery plans sit underneath the enabling strategies setting out the detailed philosophy of delivery.

Type of Document Number of Purpose Trust Strategy 1 To set out the Trust’s Strategy, Strategic Objectives and other key enduring themes and values. Enabling 9 To set out the strategic approach and Strategies actions within each of these areas • Clinical including the high level aims to be • People engagement & OD, achieved over the life of the Enabling • Quality & Safety, strategy and philosophy of delivery. • Patient engagement, • Finance & performance • Innovation & Research • Estates • Digital & IT • Trust Charity Delivery Plans As agreed* To set out the detailed objectives/ deliverables and detailed philosophy e.g. Under People: of delivery together with a credible • Attraction and Retention action plan to be monitored through • Engagement the *relevant board committee. • Leadership and OD • Wellbeing • Employee Relations • Education *tbc by relevant Committee of the Board Planning and Monitoring Delivery We understand that our objectives will only be delivered if we continue to plan and monitor the work we are doing throughout each year. We will use our sub-committees as well as the divisional performance review process on a quarterly basis, to ensure we are making progress towards delivery of our objectives. We will look to ensure that additional assurance is obtained by presenting updates through various forums across the Trust, this will cover the following domains: • Quality of Service Delivery • Activity and Finance • Operational Performance

22 Trust Strategy 2021-2022

Strategic Plan on a Page

Our Vision An NHS organisation that continually strives to improve the outcomes and experiences for the communities we serve

Our Values

Safe and Effective Kind and Caring Exceeding Expectation We will work collaboratively to We will act in the best interest of We will grow a reputation for prioritise the safety of all within our others at all times excellence as our norm care environment Strategic Aims Seek To have an Operationally opportunities Attract, retain Maintain effective and well manage the to develop and develop our Deliver a safe financial health integrated health recovery from our services staff and improve and high quality – appropriate and care system Coronavirus to through digital employee service investment to that operates achieve national technology and engagement patient services efficiently standards innovation Strategic Objectives (2021-22)

Establish the Identify and implement Maintain the lowest Recover and restore planned activity to at least Delivery of the RWT Wolverhampton Health a digitally enabled vacancy levels in the 85% of normal levels by July 2021. component of the STP Board and implement operating model in Black Country medium term financial the associated partnership with plan operating framework Babylon

Work with partners Develop a person Increase the percentage Achieve best practice By March 22, reduce Use our influence to develop a model centric integrated data of staff who deem the for the management of the number of patients for Black Country of care collaboration resource for population organisation has taken Covid patients awaiting initial cancer investment into RWT across the Black level planning and positive action on their treatment to the levels and maximise external Country research health and well being seen in February 2020 capital opportunities to support the Establish a South- Establish a Digital Improve overall Reduce indirect harm Prioritise the treatment development of the West Staffordshire Collaborative to focus employee engagement caused by Covid by of P1 and P2 patient, estate and related Integrated Care on the construction, establishing systems to reducing the number assets Partnership engineering and identify and monitor waiting to the levels analysability of a high learning from related seen in February 2020 quality clinical and incidents care data set Improve outcomes for Reduce the gap in Reduce harm by patients and efficiency engagement scores assessing, recognising of process through for BAME staff and and responding closer collaboration improve performance to prevent patient with Walsall against the Workforce deterioration Race Equality standard Promote equity of access and equality of outcomes by understanding and reporting the outcomes of service users

23 Trust Strategy 2021-2022 Trust Strategy 2021-2022 Trust Strategy 2021-2022

Designed and produced by The Department of Clinical Illustration, New Cross Hospital, Wolverhampton - Tel: 01902 695377 MI_8152314_31.03.21_V0.2 10.4 The Wolverhampton Pound – Development of the Anchor Network 1 The Wolverhampton Pound - Anchor Network TB Rep.pdf

Trust Board Report Meeting Date: Tuesday 6th April 2021

Title: The Wolverhampton Pound – Anchor organisations working together to support our City

Action Requested: Approve – agree the Trust approach and support to the programme

For the attention of the Board  The Trust has nominated senior leads for all of the work streams and will report Assure internally via the Chief Strategy Officer  Three work groups have been established: workforce, estates, procurement. The Advise Trust is contributing data as part of the fact finding process at this stage  The potential benefits in the procurement work stream may be mitigated as we are Alert already part of a collaborative approach with UHNM Author + Contact Tel 01902 694290 Email [email protected] Details: Chief Strategy Officer

Links to Trust 1. Create a culture of compassion, safety and quality Strategic 2. Proactively seek opportunities to develop our services 3. To have an effective and well integrated local health and care system that operates efficiently Objectives 4. Attract, retain and develop our staff, and improve employee engagement 5. Maintain financial health – Appropriate investment in patient services 6. Be in the top 25% of all key performance indicators Resource (None Implications:

CQC Domains Safe: patients, staff and the public are protected from abuse and avoidable harm. Effective: care, treatment and support achieves good outcomes, helping people maintain quality of life and is based on the best available evidence. Caring: staff involve and treat everyone with compassion, kindness, dignity and respect. Responsive: services are organised so that they meet people’s needs. Well-led: the leadership, management and governance of the organisation make sure it's providing high-quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. Equality and None as a result of this paper Diversity Impact Public or Private: Public References The National Organisation for Local Economies https://cles.org.uk/

NHS In determining this matter, the Board should have regard to the Core principles contained in the Constitution: Constitution of:  Equality of treatment and access to services  High standards of excellence and professionalism  Service user preferences  Cross community working  Best Value  Accountability through local influence and scrutiny

The Report The Wolverhampton Pound – Anchor organisations working together to support our City 1. Background

Alongside the other major public sector organisations in the City, the Trust has agreed to join an ambitious programme that is aiming to revitalize Wolverhampton.

The approach, known as community wealth building, has been successfully adopted in Preston, Lancashire, where the council credits the initiative with creating 1,600 new jobs, £74 million of investment into the city and £200 million into the regional economy.

2. Objectives

The five ‘Anchor Organisations’ across the City: The City of Wolverhampton Council, City of Wolverhampton College, Royal Wolverhampton NHS Trust, University of Wolverhampton and Wolverhampton Homes have all signed an agreement committing them to identifying opportunities to support the city, working with businesses, communities and the voluntary sector to retain local wealth, create new jobs and opportunities for residents. This programme will be known as known as the ‘Wolverhampton Pound’.

The five core objectives of the Wolverhampton Pound scheme are:  retaining and growing local wealth by prioritising local spending through procurement and commissioning approaches to strengthen and support local supply chains, encouraging the growth of new sectors and creating new local jobs  embedding social value in the city – leveraging maximum value from investments through social value to strengthen local supply chains, supporting local small and medium sized enterprises (SMEs) and building skills for the future  leading the green transition – The city is at the forefront of the green transition with the development of the National Brownfield Institute and the National Centre for Sustainable Construction and the circular economy. There are growing green energy, retrofit and green construction clusters in Wolverhampton with more than 2,000 SMEs engaged in these industries  supporting and growing the health and wellbeing economy – the health and residential care sector provides thousands of local jobs. We will support development of a robust skills pipeline for the city’s health and wellbeing sectors, strengthen health and care business models and grow local SMEs  growing and promoting Wolverhampton as a cultural and creative city – Generating a vibrant city which is built on the city’s cultural strengths, the partners will explore the use of cultural and creative improvement districts to support the growth of the arts, cultural and creative industries

3. Next Steps

Three work streams have been developed and initial meetings are currently taking place. The starting point for each of the groups will be an assessment of key data and intelligence to identify potential opportunities. The work programmes are being supported by the leadership team from CLES (the National Organisation for Local Economies). The work streams are:  Land and assets  Workforce  Procurement and commissioning

4. Recommendations

The Board are asked to note the positive developments around the Wolverhampton Pound and endorse the continued support to this important programme.

Sensitivity: PROTECT Sensitivity: PROTECT Sensitivity: PROTECT Sensitivity: PROTECT Sensitivity: PROTECT Sensitivity: PROTECT Sensitivity: PROTECT Sensitivity: PROTECT Sensitivity: PROTECT Sensitivity: PROTECT Sensitivity: PROTECT Sensitivity: PROTECT Sensitivity: PROTECT 11.1 Workforce & Organisational Development (WOD) Committee - Chair's Report 1 Chairman's WOD Report - Mar 21.docx

WOD CHAIRMAN’S SUMMARY REPORT

Meeting Date: 6th April 2021

Title: Workforce & Organisational Development (WOD) Committee – Chairman’s Summary Report from 22nd January 2021 Executive This report provided a chairman’s summary of WOD and the key areas of discussion Summary: covered are as follows:  Recruitment Analysis  Covid Vaccinations  WOD Annual Work Plan  Workforce & OD Strategic Objectives  WOD Terms of Reference  Black Internship Programme  Equality, Diversity & Inclusion Update  Review of BAF Risk Action Receive and note Requested: For the attention of the Board Advise Advise

Author + Contact Alan Duffell – Chief People Officer Details: Junior Hemans – Committee Chair

Links to Trust 4. Attract, retain and develop our staff, and improve employee engagement Strategic 6. Be in the top 25% of all key performance indicators Objectives

Resource N/A Implications:

CQC Domains Well-led: the leadership, management and governance of the organisation make sure it's providing high-quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. Equality and Diversity Impact

Risks: BAF/ TRR SR1 Risk: Appetite No change Public or Private: Public Other formal Board Committee bodies involved: References N/A

Mar 2021 NHS In determining this matter, the Board should have regard to the Core Constitution: principles contained in the Constitution of:  Equality of treatment and access to services  High standards of excellence and professionalism  Service user preferences  Cross community working  Best Value  Accountability through local influence and scrutiny

Mar 2021 Workforce & OD Committee – 22 Janurary 2021 Summary Report

The key headlines/issues and levels of assurance are set out below, and are graded as follows:

Assurance level Color to use in ‘Assurance level*’ column below Not assured Red - there are significant gaps in assurance and we are not assured as to the adequacy of current action plans If red, commentary is needed in “Next Actions” to indicate what further is steps are required to address the gap Partially assured Amber - there are gaps in assurance but we are assured appropriate action plans are in place to address these Assured Green – there are no gaps in assurance

Key issue Assurance Committee update Next action(s) Timescale level* Recruitment Green The committee were It was agreed to bring Jul 2021 Analysis presented with a the paper back in 6 detailed analysis of months to provide a recruitment within RWT, 12 months review which outlined sustained progress and the The Princess Trust committee noted that a data would also be significant number of the included within the new starters were next iteration of the recorded as not having paper current/previous employment. Covid Vaccinations Green The committee were informed of the progress made with regards to the delivery of vaccinations. Circa 6000 vaccinations had been given, however the limiting factor continued to be vaccine supply WOD Annual Work Amber The annual plan was It was agreed to Feb 2021 Plan reviewed and agreed amend the plan to subject to one addition incorporate a quarterly update on the progress of the new 21/22 objectives, linked to the refresh of the Trust strategic objectives. Workforce & OD Amber As the Trust was More specific Mar 2021 Strategic Objectives undergoing a refresh of metrics/targets to be the strategic objectives added, including a Mar 2021 Key issue Assurance Committee update Next action(s) Timescale level* and recognising that the focus on WRES. development of the Trust People & OD It was agreed to Jul 2021 strategy was delayed include greater level due to Covid19, the of pay/ethnicity committee reviewed and related data within the agreed W&OD strategic annual EDI report objectives for 20/21. However, the committee asked for quantifiable and more ambitious targets to be set against these objectives. WOD Terms of Amber The ToRs were ToRs to be amended Apr 2021 Reference reviewed and in light of and then presented to the national people plan, board for approval it was agreed to rename WOD to People & OD Committee. In addition to this, it was also requested to incorporate a greater focus on culture within the ToRs. Black Internship Green The committee were Programme informed that the Trust had signed up to the internship, which is targeted at students in their final year. The committee were supportive and were keen to see how this progressed. Equality, Diversity & Green The committee It was agreed to have 21/22 Inclusion Update discussed the key high the wider EDI agenda lights of the report, on a future board which included the development session cultural ambassador programme, update on the employee voice groups and inclusive recruitment practices. Review of BAF Risk Green The BAF risk was Consider Mar 2021 reviewed and it was downgrading and agreed that no further removing workforce changes should be risk from the BAF made, however, the committee felt that should the current position of recruitment Mar 2021 Key issue Assurance Committee update Next action(s) Timescale level* and Trust vacancies remain in a positive position by the end of the FY, the committee should consider downgrading this risk and removing from BAF.

Mar 2021 11.2 People and Organisational Development Committee (PODC) terms of reference 1 PODC v2TORs 2021-2022.docx

PEOPLE & ORGANISATIONAL DEVELOPMENT COMMITTEE (PODC) TERMS OF REFERENCE

Trust Strategic To attract, retain and develop all employees and improve employee Objectives engagement year on year

BAF & Trust Risks SR 1 - Workforce - Recruitment and Retention of staff across the Trust and in particular the future pipeline of nursing and medical staff.

Meeting The purpose of the committee is to provide the Board with assurance Purpose/Remit that:

 The organisational development and workforce strategy, structures, systems and processes are in place and functioning to support employees in the provision and delivery of high quality, safe patient care  Processes are in place to support optimum employee, engagement, wellbeing and performance to enable the delivery of strategy and business plans in line with the trust’s values  The Trust is meeting its legal and regulatory duties in relation to its employees  Where there are human resource risks and issues that may jeopardise the Trusts ability to deliver its objectives, that these are being managed in a controlled way through the Trust Management Committee.  The organisational culture is diagnosed and understood and actions are in place to ensure continuous improvements in culture.

To provide assurance on the following key areas of workforce governance:

 Resourcing  Skills  Leadership & organisational effectiveness  Engagement & Culture  Wellbeing  Productivity Responsibilities The Committee will lead on the assurance of the workforce and organisational development including ensuring that:

1. Legal and regulatory requirements relating to the workforce are met. 2. There is an overarching organisational development and human resources strategy that enables the Trust to deliver its strategy, vision and values 3. Effective identification and mitigation of Human Resources risks

Approved at PODC 26/03/2021 Page 1 within the supporting infrastructure of the Board Assurance Framework and Risk Register 4. Robust workforce planning and recruitment processes are in place, supported with attraction & retention approaches, to ensure that the Trust has a workforce to deliver its strategy and annual plan 5. Mechanisms are in place and effective to communicate with and inform the workforce in relation to strategy as well as constitution, values and ethos. 6. The Trust is monitoring staff engagement and experience, reviewing staff surveys (national & local) and delivering its plans to achieve a highly motivated and engaged workforce to enhance the quality of patient care 7. There are mechanisms in place to effectively diagnose the organisational culture and ensure focus on driving through a positive organisational culture as monitored through the national staff survey 8. There are processes in place to identify and develop organisational structures, leadership and management capability to ensure the delivery of the Trust’s strategy 9. Arrangements are in place for the effective training and education of the workforce in all professions and disciplines 10. The Trust is delivering its ambition and legal obligations in relation to the Diversity/Equal opportunity of the workforce 11. Processes & resources are in place, to ensure the development of healthy teams and indicators of poor team health are acted upon, as well as support the wider Trust H&WB agenda. 12. Performance management reports are reviewed 13. National reports and best practice relating to Human Resource Management and OD is shared, reviewed for relevant findings and actions and the necessary actions implemented. 14. To oversee the requirements and governance assurance against the national agenda for Developing Workforce Safeguards

Supplementary areas for assurance:

15. Receive assurance on the HR aspects of any external/internal compliance reviews that have raised concerns at Board and/or Executive Team. 16. By exception, consider whistleblowing and receive assurance on how workforce concerns raised are being dealt with. 17. Review the Board Assurance Framework/Trust Risk Register high scoring risks for assurance on traction of actions, and adequacy of controls and assurances taken e.g. staffing. 18. To review and monitor effectiveness of workforce related strategies and key performance indicators such as:

o Staff survey results (local and national) o Attendance levels o Demographic makeup of the organisation o Turnover o Occupational health data o Recruitment o Annual Workforce plan

Approved at PODC 26/03/2021 Page 2 19. The Trust has in place the range of policies necessary to effectively manage the workforce and allow for fair and consistent treatment of staff as well as receives assurance and recommends support for policies relevant to HR/OD/Education/Training and Occupational Health, on behalf of the Trust.

Authority & The WOD Committee is established to evaluate and report on the Accountabilities workforce/OD agenda and the operation of risk management systems and controls to the Trust Board.

The Committee is authorised by the Trust Board to investigate any activity within its terms of reference obtaining independent advice if necessary. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee shall transact its business in accordance with national/local policy and in conformity with the principles and values of public service (GP01). Reporting The minutes will be submitted to the Trust Board, and the Chair shall Arrangements report on the main issues discussed and decisions made, highlighting any matters of concern or significant risks identified.

Membership  Chair of the Committee  Chief People Officer  Two Executive Directors, one of which is the Chief Innovation, Integration & Research Officer, the other Executive attendee to join on a rolling attendance basis  Two Non-Executive Directors  One Deputy Chief Operating Officer (on a rotational basis)  Divisional Manager Estates & Facilities

Attendees  Deputy Director of Workforce  Head of Education & Training  Head of Nursing - Workforce  Head of Occupational Health and Wellbeing (as required)  Other Operational Leads, as required, which may include; Heads of HR Advisory, Resourcing, Equalities and Workforce, as appropriate  Other attendees may be requested to attend the meeting by the Chair or may attend with the permission of the Chair. Chair The Chair of the committee shall be the Trust board nominated Non- Executive Director and if he/she is absent, another NED from those present at the meeting

Approved at PODC 26/03/2021 Page 3 Quorum Chair, (or nominated Deputy), and 4 other members, one of whom must be:

 An Executive director  A Non-Executive director  A Deputy COO Frequency of meetings The committee will meet bi-monthly.

Administrative The HR & OD department will provide administrative support. Agenda support and papers will be circulated 4 working days prior to the meeting.

Standards  NHS Improvement Single Oversight Framework (to include Quality Governance and Well led guidance)  Equality Act & NHS EDS  NHS Employers standard recruitment checks  Medical & Dental and AfC Terms & Conditions

Standard agenda  Future Workforce/Resourcing items  Education & Training  Organisational Development/Leadership  Engagement & Culture  Workforce Planning, Intelligence & Productivity  Underpinning Work & Assurance (including BAF)

Review of WODC  To be carried out on a bi-annual basis Performance & Effectiveness

Subgroups  Attraction & Retention Steering Group  Equality & Diversity group  Academy Steering Group  Medical Workforce Group  Role Development Steering Group Date Approved Trust Board – XX XXX 2021

Date Review March 2022

Approved at PODC 26/03/2021 Page 4 11.3 Executive Summary Workforce Report 1 TB Exec Workforce Rpt 06 04 2021.pdf

Trust Board Report Meeting Date: 6th April 2021

Title: Executive Summary Workforce Report

Action To receive and note Requested: For the attention of the Board

• Actions on Recruitment, Retention and Engagement to mitigate SR1 on Assure Board Assurance Framework.

• Progress on delivery of the actions within the People and Organisation Advise Development Strategy 2016 – 2020 to support with the approach to OD.

• The Trust performance in respect of rolling 12 month and in-month Alert sickness absence against target is red rated with sharp increases in the sickness rate due to COVID-19.

Author + Contact Adam Race, Deputy Director of Workforce Details: Tel 01902 695430 Email [email protected]

Links to Trust Strategic 4. Attract, retain and develop our staff, and improve employee engagement

Objectives 6. Be in the top 25% of all key performance indicators

Resource NONE Implications: Report Data Data for this report is taken in large part from the Trust’s Electronic Staff Caveats Record.

This is a standard report using the previous month’s data. It may be subject to cleansing and revision. CQC Domains Well-led: the leadership, management and governance of the organisation make sure it's providing high-quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture.

Equality and The Trust Approach to Equality, Diversity and Inclusion addresses actions for Diversity Impact WRES, EDS2 and WDES and the Trust approach to EDI and the provisions of the Equality Act 2010 as part of the People and Organisation Development Strategy 2016-2020.

Risks: BAF/ TRR BAF Strategic Risk SR1 – Workforce Risk: Appetite The report seeks to provide Board Assurance and to decrease the Workforce Risks within the Trust.

Public or Private: Public Other formal Workforce & Organisational Development Committee (WODC) bodies involved: References NONE – National Workforce Strategy currently in consultation phase.

NHS In determining this matter, the Board should have regard to the Core principles contained in Constitution: the Constitution of: • Equality of treatment and access to services • High standards of excellence and professionalism • Service user preferences • Cross community working • Best Value • Accountability through local influence and scrutiny

Brief/Executive Report Details Brief/Executive Summary Title: Executive Summary Workforce Report

Item/paragraph This report provides the Trust Board with information and assurance on key 1.0 workforce metrics and an update on key workforce matters. In relation to Key Performance Indicators, the reports sets out that:

• Attendance levels have worsened significantly in month (January) as reported at the time and remain above the target. High levels of absence as a result of COVID-19 continue to impact performance in relation to the 12 month rolling absence rate. • Normalised turnover is 8.01% following an improvement in month; it remains below the target of 9.75%. • The Trust target in respect of 90% of staff having an up to date appraisal is not being met. There has been a significant reduction in compliance as non-urgent activity had been stood down as part of the COVID-19 response. • Mandatory Training compliance has slightly declined but within the range of normal variation and continues to meet the external target of 85% with performance at 90.40%. • The vacancy rate has improved in month and is now 4.72%. The vacancy rate has been lower than average (April 2019 – date) for 11 consecutive months.

The report offers a brief overview of a number of key work streams:

• Leadership Apprenticeships in development • Staff Risk Assessments • National Future of HR and OD Programme • Health and Wellbeing developments including an update on the Holistic Therapy bid and a further bid for funding to support an online resilience offer • E-Job Planning • E-Leave, E-Rostering and Activity Manager for medical staff.

Executive Summary Workforce Report

Trust Board 6th April 2021

Alan Duffell Chief People Officer

Page 1 Executive Summary

This report provides the Board with information and assurance on key workforce metrics and an update on key workforce matters.

• Three of the six workforce indicators continue to meet the agreed targets; vacancy rate, turnover rate and mandatory training. 24 month retention is rated amber. Appraisal compliance and Sickness have worsened in month and are rated red.

• Normalised turnover is 8.01% following an improvement in month; it remains below the target of 9.75%.

• The vacancy rate has improved in month and is now 4.72%. The vacancy rate has been lower than than average (April 2019 – date) for 11 consecutive months.

• Attendance levels have worsened significantly in month (January) as reported at the time and remain above the target. High levels of absence as a result of COVID-19 continue to impact performance in relation to the 12 month rolling absence rate.

• Performance in relation to generic Mandatory Training compliance has worsened such that performance is outside that provided by the lower control limit of normal variation. Performance, however, continues to meet the external target of 85% with performance at 90.40%. Role specific Mandatory Training compliance has worsened slightly in month, however, at 90.70% remains above the target. In relation to appraisal, compliance rates have improved 77.70% to 78.60%. This indicator continues to be rated red and below the target of 90%. The target in relation to appraisal compliance was last met in December 2019.

• The fill rate through the bank in February was 89% for registered nursing staff (up from 84% in January) and 92% for healthcare assistants (up from 87%). The medical bank fill rate remains credible at 60%. The bank has grown considerably over 2020 as external recruitment has been undertaken to recruit such staff and, as students have returned to placements, they have retained their bank engagement with the Trust.

• The report offers a brief overview of a number of key work streams:

• Leadership Apprenticeships in development • Staff Risk Assessments • National Future of HR and OD Programme • Health and Wellbeing developments including an update on the Holistic Therapy bid and a further bid for funding to support an online resilience offer • E-Job Planning • E-Leave, E-Rostering and Activity Manager for medical staff.

Page 2 Key Workforce Metrics

Three of the six workforce indicators continue to meet the agreed targets; vacancy rate, turnover Vacancy Rate rate and mandatory training compliance. 4.72% Retention rate is rated amber. Appraisal compliance and sickness absence are rated red, the latter as a result of COVID-19 absence.

Turnover Turnover has reduced to 8.01%. Turnover Appraisals (Normalised) performance continues to meet the standard in 78.60% 8.01% all but healthcare science staff groups where it is over the target. In Healthcare Science roles this is largely driven by turnover in BCPS Key including a number of redundancies following the transfer of Cytology from a number of Workforce Midlands Trusts to RWT.

Indicators In month attendance levels have worsened significantly. The rolling 12 months attendance Mandatory Retention levels have also worsened and continue to Training (24 Months) (Generic) exceed the target following elevated levels of 84.28% absence as a result of COVID-19. 90.40%

Mandatory training (generic) compliance rates Sickness have worsened over the last month however, (Rolling 12 Month) 4.77% they continue to exceed the 85% target.

(In Month) 6.55% Appraisal compliance has improved although is not meeting the Trust target of 90%.

Page 3 Staff Engagement and Leadership

Summary Update with Public Health, Primary Care and Occupational Health Colleagues was Leadership Apprenticeship Programme launched.

Work has continued with the Head of Corporate Learning Services As at 29 March 2021 97.42% of all staff had been risk assessed in and Deputy Director of Workforce to put in place a range of relation to COVID-19. apprenticeship programmes for managers and leaders within the Trust. These programmes, the first of which is expected to The risk assessments are closely monitored and at the time of commence in May 2021 will initially provide an ‘early career this report: manager’ apprenticeship covering the skills and behaviours required of line managers. Following on from this, the programme will seek • 97% of all staff had a risk assessment in place; to develop further more advanced (e.g. level 7) apprenticeships for • 97% of those classed as ‘at risk’ by NHS England and more senior managers. Improvement had a risk assessment in place; and • 96% of BAME staff had a risk assessment in place. A Task and Finish Group is in place with a range of stakeholders, including the Head of EDI, as the content is put in place to ensure Where risk assessment have not been put in place, in many programmes focus on inclusive leadership. cases relates to those who have recently joined the Trust and those returning from absence. This continues to be managed Work continues with KnowledgeBrief to build the programme, through the Divisions. tailored to RWT, incorporating many elements of the local leadership development offer and ensuring that the programme It is noted that at the time of writing (on 29 March) Government meets the required standards for accreditation. guidance in relation to shielding has been issued which will come into effect from 1 April. In respect of this, managers will be Staff Risk Assessments and COVID-19 required to ensure formal shielding staff benefit from an updated risk assessment based on their high risk status. Board members will be aware of the disproportionate impact of COVID-19 on individuals in particular groups with those from a BAME background, older people and men experiencing more severe illness. Board members will also know of the Trust’s approach to risk assessments that was developed at a system level

Page 4 Staff Engagement and Leadership

Summary Update

Chief People Officer’s Future of HR and OD in the NHS Also, over February there have been a range of engagement Programme events with leaders, including NHS Provider Chief People Officers to further engage in the developing vision. The CIPD As part of the National People Plan, the NHS Chief People diagnostic has been completed by NHS colleagues from Officer, Prerana Issar, set out the intention to conduct a review of across England. the HR and OD profession in the NHS. Tom Simons, Chief HR and OD Officer, has been appointed to lead this work. Over March the findings from this initial phase have been reviewed and shared with a number of stakeholders and In commissioning this focussed piece of work, a number of further tested in a Midlands engagement session on 25th partners have been engaged to ensure a truly independent March to validate the findings and to check and challenge the perspective: collective insights provided from the work that has been undertaken thus far. - CIPD - Lancaster University It is anticipated that the 2030 vision together with key - EY deliverables will be published by May 2021. - Clever Together

The programme commenced at the beginning of February 2021, with the launch of the Clever Together crowdsourcing platform enabling a conversation across the NHS around the future of the HR and OD profession in the NHS. Members of the profession and those who engage with HR and OD in the NHS can join the conversation by registering at ournhspeopleprofession.org.

Page 5 Attract, Recruit & Retain

Key Issues & Challenges • The Retention Rate at 24 months continues to be below 85% target at 84.28%, albeit against a generally improving trend. Performance is still above the average for the 12th month running. • Whilst the rostering project continues, aimed at improving retention, there have been some delays to progress due to the Rostering Team prioritising the effective rostering of redeployed staff.

Key Actions & Progress • The vacancy rate is showing an improving trend with the last 10 months showing below average vacancy rates. It is below the Trust target of 7.5% at 4.72% as at the end of February. • Turnover remains below the 9.75% target at 8.01% with the upper limit of normal variation for this indicator below the target. • The ‘effective rostering’ project continues. It is tasked with fully deploying e-rostering across nursing areas and ensuring best rostering practice to support flexible working as well as effective deployment of staff. Progress has been further reviewed in March 2021, given the focus of this team on supporting staff redeployment. Page 6 Attract, Recruit & Retain

Key Issues & Challenges • The 24 month retention rate is below the 85% target for nursing and midwifery staff, but the trend is one of each of the last 12 months being above average. • Nursing turnover is below target at 8.30%, however, could, whilst remaining within normal variation, exceed the target with work life balance a key driver of turnover.

Key Actions & Progress • Nursing turnover has shown a marked improvement over the last 7 months. • Vacancy rates for Nursing and Midwifery staff are below the target at 2.34%. • The ‘effective rostering’ project will deliver improved flexibility – a key driver of retention. • International nursing recruitment continues. This work continues with support in place for those joining from overseas in view of the travel restrictions in place in response to COVID-19.

Page 7 Attract, Recruit & Retain

Key Issues & Challenges • There are some hotspots in key services where vacancy levels give cause for concern, such as in clinical oncology, emergency medicine and microbiology.

Key Actions & Progress • All recruitment and retention metrics for medical staff are being met. • The targeted work in oncology continues at pace and the Trust is in discussions with a number of prospective clinical candidates with one established consultant candidate having been appointed. • Proposals are in consideration in relation Emergency Medicine to consider a similar piece of work in relation to clinical appointments in that specialty.

Page 8 Attract, Recruit & Retain

Key Issues & Challenges • Metrics for AHPs cover Podiatry, Dietetics, Occupational Therapy, Physiotherapy, Orthoptics, Radiography (diagnostic and therapeutic), Orthotics, Speech and Language Therapy, and Operating Theatres (ODPs). • There are hotspots in particular staff groups, specifically, Podiatry (1.57 WTE 11%) and Occupational Therapy (11.66 WTE, 14%).

Key Actions & Progress • Previously reported hotspots of Radiology, Dietetics and Orthoptics have made a number of appointments and are no longer flagged as hotspot areas. • There are temporary staffing arrangements in place (through direct engagement model) for vacancies where necessary to ensure services are appropriately staffed. • Targeted recruitment continues in these areas as part of the work to identify and pro-actively recruit to hard to fill areas. An AHP Open Day event was held in February 2021.

Page 9 Attract, Recruit & Retain

Key Issues & Challenges There remains a cohort of inactive bank only staff, although the number of bank only staff actively working through the bank has increased in each of the last five months.

Key Actions & Progress • The number of staff registered with the bank only (i.e. without a substantive post) is now 1,667 an increase of 25 on the prior month. • The bank user group continues to progress the improvement actions with senior nursing colleagues and ensure that the changes that were made in response to COVID-19 are embedded as appropriate. • Electronic timesheets were implemented for this staff group for the month of December, ensuring swifter more accurate pay and freeing up capacity within the temporary staffing office which has been key over the December/ January period.

Page 10 Attract, Recruit & Retain

Page 11 Attract, Recruit & Retain

Key Issues & Challenges - Bank request levels for Registered Nursing Staff and Healthcare Support Workers spiked in January 2021 and remain high for registered nursing staff in February 2021. - The fill rate fell slightly in January, but has recovered in February, remaining at all times (since March 2020) within normal range.

Key Actions & Progress - HCA and medical bank request volumes remain within normal range. - Bank fill rates remains credible: - 60% fill rate for medical staff in month; - 89% fill rate for registered nursing staff in month; - 92% fill rate for HCSW staff in month. - Actions in place to sustain these improved fill rates are being delivered through the Bank Improvement Plan and include: - Increased use of electronic booking systems to increase the ease of accessing bank work and being paid; - Increased opening hours for the temporary staffing teams.

- Further updates will be provided as this work progresses.

Page 12 Staff Training & Development

Key Issues & Challenges • Whilst the 85% target for mandatory training compliance is being met, the internal 95% stretch target is not being met. • The Trust target in respect of 90% of staff having an up to date appraisal is not being met. There has been a significant reduction in compliance as non- urgent activity had been stood down as part of the COVID-19 response. Appraisals were also challenged by staff being redeployed and unavailable for appraisals. This continues at the present time and the need to have an up to date appraisal for pay progression is currently paused. The Head of Corporate Learning and Development are reviewing the appraisal documentation to consider whether this can be altered to support a greater level of uptake with a focus on wellbeing and development as the Trust restores services.

Key Actions & Progress • Both Generic and Role Specific Mandatory Training are meeting the 85% target (and indeed the lower control limit for both indicators is above 85%). • Divisions shall need to consider recovery plans for mandatory training and appraisals.

Page 13 Health & Wellbeing

Summary Update services through a number of pathways; The wellbeing agenda continues to develop in support of staff, - The Employee Assistance Programme throughout and indeed beyond the COVID-19 initial surge. As part has been promoted offering 24/7 advice and telephone of the planning for the second wave the wellbeing support offer counselling 7 days per week 8:00am – 8:00pm; that was put in place has been fully reviewed: - Remploy mental health support, commissioned via occupational health; Access to the National Support Offer - The establishment of Wobble Rooms locally and the Serenity Room in the WMI, creating a safe space for staff to reflect; The NHS national wellbeing support offer ranges from helplines, - Listening circles to allow for peer listening to be provided to apps and access to a wide range of counselling and culturally staff who may need to decompress; and sensitive resources that are free and available to all NHS staff until - Socially distanced Schwarz Rounds have been established. the end of the financial year. In addition there are resources for staff to share experiences and conversations through a series of Access to Holistic Therapies Common Rooms, together with Leadership resources including Leadership Circles, coaching and mentoring. The Trust is about to launch expanded holistic therapy services, having secured funding from NHS Charities Together. The This offer is available at https://people.nhs.uk/help/ and this has reflexology service, which has been established for many years been regularly publicised for staff. will be expanded to include Indian head massage and back and shoulder massage being provide across the week and on both RWT Support Offer for Staff the West Park and Cannock Chase sites. A second therapist has been recruited to support this expansion. In addition to the national response the Trust has also put in place a place a local support offer with considerable content to support Embrace Resilience staff wellbeing available at https://www.rwt.nhs.uk/wellbeing/Index.html. In December 2020 the Trust made a bid for funding to support the wellbeing of staff, specifically an online support package The support available on a referral basis, e.g. to psychological which provides staff and their families with access to online services or for instance to Remploy continue to be in place: resilience and other training. This has been rolled out in March.

- Referral to psychological support

Page 14 Health & Wellbeing

Key Issues & Challenges • The rolling 12 month absence rate remains above the Trust target at 4.77% as a result of elevated absence due to COVID-19. Given the unprecedented impact of the pandemic absence levels when measured over the rolling 12 months have been in excess of the upper control limit for ten consecutive months.

Key Actions & Progress • HR colleagues have been reviewing COVID related sickness absence returns to ensure that in cases where the absence (or household isolation) is seen as an outlier it is followed up and support offered to the manager/ staff member as necessary. • HR teams continue to sensitively support the management of long and short term sickness absence cases as appropriate in the current circumstances. • Considerable work has been done to develop the wellbeing support offer, including psychological and practical wellbeing support for staff. A business case has been submitted seeking support to ensure robust arrangements are in place across in the Occupational Health and Wellbeing Service, including resources to improve the Trust’s psychological support offer in the long term. • Guidance has been developed to support shielding staff in their return to work from 1 April 2021.

Page 15 Productivity – e-Rostering Metrics

Key Issues & Challenges:

• Inconsistent adherence to rostering metrics and general roster maintenance remains a key issue. This can be attributed to the lack of confidence and knowledge of end users combined with resource challenges within the E-Roster team • Further work is required to identify the barriers end users face when accessing the service or associated rostering systems

Key Actions & Progress:

• Compliance achieved for rosters approved six weeks in advance (96%) • Roll out of HealthRoster to remaining nursing areas (64% clinical staff currently using the system) • Further drive use of roster automation • Revision of E-Roster Intranet pages and available resources to better drive effective use of the system • Improve metric adherence

Page 16 Productivity – e-Job Plan (Medics) e-Job Plan Divisional Update

The graph below provides an update on e-job plan progress.

- 78% of job plans have been completely signed off at Job Planning Consistency Group (JPCG). - 20% of job plans are still in discussion stage. - 1% of job plans are awaiting Clinical Director approval

Of the 89 job plans that are under discussion, just under half of these relate to division one where there has been issues agreeing the job plan at the directorate level. This requires a directorate/ divisional level discussion to resolve issues across the team. Further review of the report shows that there is a significant lack of engagement by Specialty doctors/associate specialists.

Job plans that remained in discussion have now been updated and given the new job plan start date of 31/05/2021. All other signed off job plans have been republished with the updated start date of 31/05/2021 also.

Job planning process training sessions have been arranged to take place on 25th, 29th March and 9th April. The sessions will be lead by the Acting Chief Medical Officer and supported by the Medical E-Rostering Manager. Invites have been sent to Clinical Directors, Directorate and Group Managers, Divisional Medical Directors and Deputy Chief Operating Officers. Points of discussion will include the updated Job Plan Procedure, group job planning, new SPA guidance and a demo of e-Job Plan 11.

Trust Wide Job Plan Progress Trend

500 Job Plans Signed Off at JPCG 400 86 117 117 156 156 155 154 196 300 241 264 289 295 Job Plans Awaiting 2nd or 3rd Sign Off 314 352 176 165 165 126 200 129 129 134 84 47 35 70 58 58 77 4 4 100 68 68 82 77 68 57 66 61 347 Job Plans Awaiting 1st Sign Off

Number of of Number Users 5 102 86 86 110 110 89 88 96 94 98 95 94 84 89 0 Job Plans In Discussion

Page 17 Productivity – e-Leave/e-Rostering (Medics)

e-Leave Update

e-Leave for all medical staff has been implemented. This will now be monitored for use.

e-Rostering Update

The implementation of 44 junior doctor rotas within Health Roster commenced in October 2020. 40% of rotas (18) have been implemented and are live in Health Roster.

The remaining rotas for Ophthalmology, T&O, General Surgery, Urology, Neonates and General Medicine were scheduled to be implemented throughout January and February, however owing to Covid-19 pressures the dates for rollout are currently being reviewed.

Weekly reports have been created using the ICCU redeployment rota to identify junior doctors who have worked shifts in ICCU. Reports were sent on to Directorate and Group managers to confirm shifts were worked and if additional to normal working hours. Any hours over and above have been identified and this information has been passed on to payroll for payment.

Activity Manager Update

Activity Manager is the next module to be implemented within Health Roster. It is used to assign staff to clinical activities ensuring the appropriate staff are delivering care at all times.

Following on from meetings in January, owing to the spike in Covid-19 admissions, the Acting Chief Medical Officer made the decision to delay the implementation of Activity Manager which was planned and scheduled to commence mid-February. Once pressures ease, a meeting will be re-scheduled with Allocate colleagues to identify a timeline and plan the implementation once again. An early adopter (directorate) will need to be identified to commence the implementation.

Page 18 Workforce Metrics - Trust Board M11: Data Effective 28th February 2021 Full Trust Month 11 14 Sickness 10 0 0 0 E-Roster 11 31st Mar 2020 2020-21 YTD Change B01 Workforce Profile Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Out-turn B01.1 Substantive Staff WTE 8487.95 8619.21 8696.45 8757.94 8749.39 8760.49 8720.45 8737.09 8803.83 8827.53 8852.62 8909.07 0.00 421.12 Inc Permanent, Fixed Term, & Locums with WTE on Payroll B01.2 Substantive Staff WTE (Exc Rotational Doctors) 8172.70 8302.23 8378.94 8440.09 8435.54 8425.89 8382.18 8398.18 8466.02 8492.93 8519.90 8572.98 0.00 400.28 Inc Permanent, Fixed Term, & Locums; Exc Rotational Drs B01.3 Substantive Staff Headcount 9781 9917.00 10020.00 10092.00 10089.00 10088.00 10043.00 10055.00 10118.00 10143.00 10166.00 10232.00 0.00 451 Inc Permanent, Fixed Term, & Locums with WTE on Payroll B01.4 Bank Staff Only Headcount 1277 1383.00 1358.00 1360.00 1425.00 1450.00 1394.00 1458.00 1490.00 1615.00 1642.00 1667.00 0.00 390 B01.5 Agency LMS Headcount 152 152.00 152.00 153.00 155.00 157.00 101.00 102.00 107.00 113.00 115.00 115.00 0.00 -37 B01.6 % Staff from a BME background 30.75% 0.31 0.31 0.31 0.30 0.30 0.30 0.30 0.30 0.30 0.31 0.31 0.00 0.03% B01.7 TUPE In WTE 21.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.03% B01.8 TUPE Out WTE 41.04 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.03% Data Owner: Workforce Planning & Business Intelligence

31st Mar 2020 2020-21 YTD Change B02 Changes to Workforce Profile Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Out-turn B02.1 Change in Workforce Profile WTE (Exc Rotational Doctors) 70.35 -22.65 -6.76 11.28 34.26 52.68 27.59 79.10 39.99 26.27 36.03 36.03 Leavers current month target calculated as 1/12th of 10.5% of in-month B02.2 Starters WTE (Exc Rotational Doctors) 0 103.47 68.80 76.95 43.92 69.11 77.31 59.84 60.63 43.00 73.87 65.75 742.65 Staff in Post B02.3 Leavers WTE (Exc Rotational Doctors) 0.00 59.08 45.25 28.93 66.65 75.44 56.71 54.71 57.73 54.55 74.03 37.69 0.00 610.77 Data Owner: Workforce Planning & Business Intelligence

31st Mar 2020 2020-21 YTD Change B03 Workforce Profile by Staff Group Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Out-turn B03.1 Add Prof Scientific and Technic WTE 281.59 285.13 280.75 281.65 293.92 296.83 303.51 305.66 311.35 309.35 308.47 312.14 0.00 30.55 B03.2 Additional Clinical Services WTE 1567.51 1,576.53 1,573.14 1,583.22 1,586.28 1,583.60 1,573.89 1,566.36 1,605.60 1,631.66 1,649.48 1,668.51 0.00 101.00 B03.3 Add Clin Serv: Newly Qualified / Overseas Nurses Awaiting PIN 20.51 15.00 22.00 22.00 25.00 24.85 24.80 20.00 61.00 86.00 79.00 67.00 0.00 46.49 B03.4 Administrative and Clerical WTE 1791.71 1,804.37 1,804.41 1,813.53 1,819.60 1,835.98 1,848.41 1,854.83 1,863.34 1,860.77 1,867.38 1,877.00 0.00 85.29 B03.5 Allied Health Professionals WTE 415.43 415.22 413.32 416.58 417.24 419.48 423.49 426.02 427.08 427.29 425.93 423.77 0.00 8.34 B03.6 Estates and Ancillary WTE 585.00 585.07 586.03 584.55 587.04 585.69 586.75 585.82 582.74 580.13 572.88 571.60 0.00 -13.40 B03.7 Healthcare Scientists WTE 479.15 480.90 481.99 481.00 477.19 480.11 482.49 477.80 476.05 476.95 476.82 476.98 0.00 -2.17 B03.8 Medical and Dental WTE (Exc Rotational Doctors) 651.15 660.89 662.75 686.53 679.48 653.78 669.39 668.19 679.10 692.15 692.48 698.68 0.00 47.53 B03.9 Medical and Dental WTE (Rotational Doctors) 315.25 316.98 317.51 317.85 313.85 334.60 338.27 338.91 337.81 334.60 332.73 336.09 0.00 20.84 B03.10 Nursing and Midwifery Registered WTE 2370.45 2,386.97 2,393.06 2,389.31 2,368.17 2,380.63 2,417.78 2,453.09 2,475.62 2,474.22 2,487.06 2,512.57 0.00 142.12 B03.11 Students WTE 30.71 107.15 183.49 203.72 206.62 189.79 76.47 60.41 45.14 40.41 39.41 31.73 0.00 1.02 Data Owner: Workforce Planning & Business Intelligence

31st Mar 2020 2020-21 2020-21 B04 Vacancy Rate by NHSI Staff Group Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Average B04.1 Total 6.55% 7.50% 4.61% 4.47% 4.01% 4.30% 4.55% 5.11% 6.09% 5.60% 5.58% 5.38% 4.72% BLANK 4.95% Staff in Post WTE vs Budgeted WTE in ESR B04.2 Allied Health Professionals 8.54% 7.50% 8.85% 9.37% 8.67% 8.54% 8.21% 7.29% 6.93% 6.89% 6.85% 7.13% 7.56% BLANK 7.84% Refined calculation 2019/20: removal of recharges and reserves from B04.3 Healthcare Scientists 13.32% 7.50% 8.36% 11.07% 11.29% 11.94% 11.28% 11.15% 12.04% 13.56% 13.27% 12.69% 12.75% BLANK 11.76% Budgeted WTE therefore not directly comparable to previous figures B04.4 Medical & Dental 4.72% 7.50% 6.08% 5.25% 3.14% 4.30% 5.09% 4.38% 6.84% 5.59% 4.70% 4.43% 4.10% BLANK 4.90% Staff Group definitions determined by NHS Improvement B04.5 NHS Infrastructure Support 10.62% 7.50% 11.76% 11.91% 11.70% 12.08% 11.90% 11.07% 10.83% 11.04% 11.50% 11.95% 11.77% BLANK 11.59% Staff in Post ajusted for St Helen's employed Rotational Doctors and B04.6 Other ST&T 2.88% 7.50% -0.24% 2.36% 2.77% 2.37% 0.48% -7.23% -5.35% -8.22% -6.73% -2.38% -1.18% BLANK -2.12% removal of Chair / NEDs B04.7 Registered Nursing, Midwifery and Health Visiting Staff 4.97% 7.50% 4.38% 4.02% 4.13% 5.11% 5.20% 4.06% 4.56% 4.24% 4.77% 4.20% 2.34% BLANK 4.27% RAG ratings updated effective Jan 21 B04.8 Support to Clinical Staff 5.56% 7.50% 0.26% -0.33% -0.89% -1.47% -0.67% 3.28% 4.83% 3.91% 3.48% 2.84% 2.45% BLANK 1.61% Data Owners: Finance & Workforce Planning & Business Intelligence

31st Mar 2020 2020-21 2020-21 B05 Vacancies by NHSI Staff Group Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Average B05.1 Total 597.14 417.72 408.10 367.52 394.89 419.06 469.53 565.77 521.39 520.75 504.77 441.19 0.00 457.34 B05.2 Allied Health Professionals 39.43 40.96 43.51 40.25 39.66 38.18 33.90 32.27 32.19 31.97 33.28 35.27 0.00 36.49 Staff in Post WTE vs Budgeted WTE in ESR B05.3 Healthcare Scientists 73.64 43.97 60.10 61.31 64.83 61.16 60.66 65.52 75.01 73.29 69.30 69.68 0.00 64.08 Refined calculation 2019/20: removal of recharges and reserves from B05.4 Medical & Dental 49.71 65.83 56.47 33.84 46.41 55.11 46.20 73.95 60.19 50.58 49.28 44.22 0.00 52.92 Budgeted WTE B05.5 NHS Infrastructure Support 133.43 150.29 152.37 150.00 155.67 153.56 142.03 139.06 142.17 148.62 163.08 159.92 0.00 150.62 Staff Group definitions determined by NHS Improvement B05.6 Other ST&T 6.77 -0.55 5.47 6.43 5.76 1.16 -16.63 -12.61 -19.38 -15.99 -5.89 -3.01 0.00 -5.02 Staff in Post ajusted for St Helen's employed Rotational Doctors and removal of Chair / NEDs B05.7 Registered Nursing, Midwifery and Health Visiting Staff 123.87 109.31 100.21 103.07 127.57 130.68 102.35 117.36 109.73 123.98 108.98 60.12 0.00 108.49 B05.8 Support to Clinical Staff 170.30 7.91 -10.03 -27.38 -45.00 -20.59 101.01 150.20 121.47 108.30 86.73 74.99 0.00 49.78 Data Owners: Finance & Workforce Planning & Business Intelligence

31st Mar 2020 2020-21 2020-21 B06 Turnover Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Average B06.1 % Total Workforce Turnover (Rolling previous 12 months) 11.06% 11.10% 11.08% 10.10% 10.31% 10.73% 10.62% 10.55% 10.73% 10.41% 10.31% 10.02% 0.00% 10.54% Exc Rotational Drs (reflects NHS Digital Benchmarked data) B06.2 % Normalised Workforce Turnover (Rolling previous 12 months) 9.46% 9.75% 9.55% 9.71% 9.29% 9.47% 9.00% 8.74% 8.64% 8.73% 8.40% 8.27% 8.01% BLANK 8.89% B06.3 % Normalised: Additional Professional, Scientific, and Technical 11.77% 9.75% 11.68% 12.59% 10.53% 10.79% 10.47% 9.32% 9.33% 8.31% 7.43% 7.64% 6.81% BLANK 9.53% B06.4 % Normalised: Additional Clinical Services 11.07% 9.75% 11.03% 11.08% 10.87% 10.92% 11.01% 11.13% 10.52% 10.25% 9.77% 9.05% 8.66% BLANK 10.39% B06.5 % Normalised: Administrative and Clerical 8.21% 9.75% 8.39% 8.72% 7.80% 7.61% 7.28% 7.01% 6.92% 7.22% 6.85% 6.56% 6.38% BLANK 7.34% Exc Rotational Drs, Students, TUPE Transfers, End of Fixed Term B06.6 % Normalised: Allied Health Professionals 9.13% 9.75% 9.33% 9.90% 9.67% 10.63% 9.44% 8.59% 8.74% 9.08% 8.94% 9.42% 9.52% BLANK 9.39% B06.7 % Normalised: Estates and Ancillary 6.58% 9.75% 6.93% 6.79% 6.54% 6.74% 6.92% 7.39% 7.02% 7.46% 7.36% 7.94% 8.29% BLANK 7.22% RAG ratings updated effective Jan 21 B06.8 % Normalised: Healthcare Scientists 11.76% 9.75% 12.32% 12.10% 11.77% 12.58% 11.82% 12.06% 13.14% 13.77% 13.07% 13.12% 11.72% BLANK 12.50% B06.9 % Normalised: Medical and Dental (Exc Rotation Drs & Clinical Fellow 7.89% 9.75% 8.03% 7.91% 7.52% 7.09% 5.93% 5.63% 6.20% 5.81% 5.35% 5.81% 5.79% BLANK 6.46% B06.10 % Normalised: Nursing and Midwifery Registered 9.69% 9.75% 9.61% 9.75% 9.68% 10.08% 9.27% 8.70% 8.55% 8.70% 8.59% 8.52% 8.30% BLANK 9.07% Data Owner: Workforce Planning & Business Intelligence

31st Mar 2020 2020-21 2020-21 B07 Retention Rate Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Average B07.1 Retention Rate (12 months) 91.11% 90.77% 90.67% 91.38% 91.42% 91.80% 92.10% 91.95% 91.82% 92.18% 92.30% 92.42% 0.00% 91.71% No. Employees with 1 or more years service now / No. Employees B07.2 Retention Rate (18 months) 87.35% 87.18% 87.13% 87.47% 87.44% 87.37% 87.99% 87.90% 87.83% 88.34% 88.07% 88.50% 0.00% 87.75% employed one year ago x 100. Exc Rotational Drs, Students, TUPE B07.3 Retention Rate (24 months) 84.26% 85.00% 84.22% 84.27% 84.42% 84.57% 84.46% 84.52% 84.60% 84.54% 84.72% 84.36% 84.28% BLANK 84.45% Transfers, Clinical Fellows, & Fixed Term Data Owner: Workforce Planning & Business Intelligence Page 19 31st Mar 2020 2020-21 2020-21 B08 Sickness Absence (1 month in arrears) Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Average B08.1 % Sickness Absence (In Month) 5.86% 0.00% 6.86% 4.79% 4.08% 3.79% 4.06% 4.56% 4.38% 5.15% 4.91% 6.55% Avail Mar 0.00% 4.91% B08.2 % Sickness Absence (Rolling previous 12 months) 4.26% 3.85% 4.52% 4.62% 4.62% 4.59% 4.60% 4.61% 4.58% 4.63% 4.63% 4.77% Avail Mar BLANK 4.62% B08.3 WTE Days lost to Sickness 15,471.14 17,599.25 12,876.33 10,698.96 10,270.53 11,007.45 11,913.80 11,899.86 13,569.78 13,422.23 17951.39 Avail Mar 0.00% 13120.96 B08.4 % Short Term Sickness 1.55% 3.09% 1.45% 1.34% 1.39% 1.45% 1.93% 1.97% 2.28% 1.60% 1.69% Avail Mar 0.00% 1.82% B08.5 % Long Term Sickness 2.71% 3.77% 3.34% 2.74% 2.40% 2.61% 2.64% 2.41% 2.87% 3.03% 3.07% Avail Mar 0.00% 2.89% B08.6 Estimated Cost of Sickness (£) £1,360,728 £1,586,612 £1,127,545 £943,878 £933,916 £1,004,155 £1,100,679 £1,098,187 £1,238,452 £1,226,972 £1,589,339 Avail Mar 0.00% £1,184,973 Data Owner: Workforce Planning & Business Intelligence

2019-20 Season 2020-21 2020-21 B09 Flu Campaign Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cumulative B09.1 Front Line Staff Vaccinated (Cumulative) 3828 2898 4029 4185 4749 4914 4914 Seasonal reporting only. B09.2 Non Front Line Staff Vaccinated (Cumulative) 1619 1655 2041 2206 2786 3177 3177 Figures reported here those submitted to Public Health England for month- B09.3 Total (Cumulative) 5051 4553 6070 6391 7535 8091 8091 end periods. B09.4 % Front Line Staff Vaccinated (Cumulative) 61.73% TBC 45.09% 62.37% 65.28% 68.76% 70.23% 70.23% Data Owner: Workforce Planning & Business Intelligence

31st Mar 2020 2020-21 B10 Open Employee Relations Cases - Number of Cases Target 20.84 Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar B10.1 Open Formal Grievances Cases + Open Bullying & Harassment Cases 10 13 7 10 12 12 13 13 24 25 24 24 0 16 B10.2 Open Capability Cases 4 3 2 2 1 1 1 1 1 1 1 0 0 1 B1103 Open Disciplinary Cases 29 22 18 19 27 28 35 34 33 30 27 24 0 27 Data Owner: HR Employee Relations

31st Mar 2020 2020-21 2020-21 B11 Freedom to Speak Up Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cumulative B11.1 New Genuine Whistleblowing Cases Raised 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Cases reviewed and confirmed as Whistleblowing by FtSU Guardian B11.2 Number of Concerns Raised through FTSU Guardian In Month 74 6 4 9 11 7 18 12 7 8 11 5 0 98 Data Owner: Freedom to Speak Up Guardian

31st Mar 2020 2020-21 2020-21 B12 Apprenticeships Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cumulative B12.1 Number of New Apprentices Started in Month 2 0 1 0 1 3 5 2 6 1 1 1 0 21 B12.2 Number of Existing Staff Converted to Apprentices in Month 10 1 0 0 1 0 31 7 0 7 17 2 0 66 Data Owner: Education & Training

31st Mar 2020 2020-21 2020-21 B13 Education / Organisational Development Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Average B13.1 Trust Induction 97.20% 0.00% 96.70% 96.00% 92.90% 89.00% 84.70% 87.60% 87.00% 86.60% 83.70% 80.70% 77.80% 0.00% 87.52% B13.2 Local Induction 80.30% 0.00% 77.30% 76.00% 75.40% 74.80% 75.00% 77.30% 78.00% 75.40% 73.50% 70.80% 71.20% 0.00% 74.97% B13.3 Mandatory Training - Generic 91.20% 85.00% 91.60% 91.90% 92.70% 93.40% 94.00% 94.40% 94.70% 94.30% 93.70% 92.70% 90.40% BLANK 93.07% B13.4 Mandatory Training - Specific 93.60% 85.00% 92.60% 93.20% 93.50% 93.20% 93.10% 93.50% 93.40% 92.70% 92.50% 90.90% 90.70% BLANK 92.66% B13.5 Appraisal 84.90% 90.00% 75.10% 80.10% 79.40% 77.90% 77.90% 81.40% 81.50% 81.60% 79.90% 77.70% 78.60% BLANK 79.19% Data Owner: Education & Training Period 0 2020-21 2020-21 B14 Temporary Staffing Spend - Agency 2019-20 Total Target Comments Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cumulative B14.1 Agency Spend - Total £7,357,952 £496,198 £426,704 £318,555 £555,323 £427,812 £497,878 £496,815 £477,656 £463,270 £379,402 £371,654 £0 £4,911,267 B14.2 Agency Spend - Nursing & Midwifery £379 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 B14.3 Agency Spend - Medical Staff £5,851,374 £425,554 £316,813 £251,983 £462,269 £350,968 £395,370 £388,386 £398,303 £376,387 £315,119 £55,497 £0 £3,736,648 B14.4 Agency Spend - Other £1,506,199 £70,644 £109,891 £66,572 £93,054 £76,844 £102,507 £108,429 £79,353 £86,884 £64,284 £55,497 £0 £913,958 Data Owner: Finance

2020-21 2020-21 B15 Temporary Staffing Spend - Bank 2019-20 Total Target Comments Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Cumulative B15.1 Bank Spend - Total £20,272,342 £2,092,193 £1,814,594 £1,684,432 £1,544,938 £2,214,291 £1,800,254 £1,755,498 £2,329,917 £2,070,693 £2,861,607 £2,817,452 £0 £22,985,870 B15.2 Bank Spend - Nursing & Midwifery £4,089,812 £893,436 £854,916 £455,428 £485,427 £886,075 £700,540 £586,265 £903,241 £355,716 £502,570 £489,785 £0 £7,113,399 B15.3 Bank Spend - Medical Staff £7,621,209 £730,437 £641,773 £862,668 £713,926 £853,802 £755,471 £709,105 £893,888 £909,554 £1,087,848 £1,206,028 £0 £9,364,501 B15.4 Bank Spend - Other £8,561,321 £468,320 £317,905 £366,336 £345,584 £474,414 £344,244 £460,128 £532,788 £805,423 £1,271,189 £1,121,639 £0 £6,507,970 Data Owner: Finance

31st Mar 2020 2020-21 2020-21 B16 Bank Fill Rate Target Comments Out-turn Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Average B16.1 Registered Nursing Shifts Filled 0.00% 85.00% 80.00% 93.00% 93.00% 91.00% 85.00% 85.00% 88.00% 91.00% 87.00% 84.00% 89.00% BLANK 81.00% Previously reported as number of shifts, now reporting fill rate B16.2 Unregistered Nursing Shifts Filled 0.00% 90.00% 90.00% 96.00% 97.00% 97.00% 94.00% 90.00% 93.00% 91.00% 89.00% 87.00% 92.00% BLANK 92.73% B16.3 Medical Staff Shifts Filled 0.00% 50.00% 45.00% 76.00% 76.00% 69.00% 58.00% 58.00% 58.00% 61.00% 60.00% 62.00% 60.00% BLANK 62.18% RAG ratings updated effective Jan 21 Data Owner: Resourcing and LMS

2020-21 8th Mar 2020 2020-21 B17 e-Rostering Target 9 Mar 20 06 Apr 20 04 May 20 01 Jun 20 29 Jun 20 29 Jul 20 26 Aug 20 21 Sep 20 21 Oct 20 18 Nov 20 16 Dec 20 13 Jan 21 10 Feb 21 Comments Out-turn Average 05 Apr 20 03 May 20 31 May 20 28 Jun 20 26 Jul 20 25 Aug 20 22 Sep 20 18 Oct 20 17 Nov 20 15 Dec 20 12 Jan 21 09 Feb 21 09 Mar 21 B17.1 % Rotas Set 6 Weeks in Advance (42 Days) 61.13% 80.00% 73.00% 87.00% 74.00% 74.00% 82.00% 57.00% 70.00% 87.00% 87.00% 79.00% 67.00% 96.00% BLANK 84.82% Reporting periods 4 weeks (28 days) B17.2 Unused Hours 6881.90 e-Roster WTE * 6hrs 14,610.23 19,099.50 19,991.20 18,783.50 20,915.51 21,355.00 23,402.00 26,003.70 5,300.00 6,327.00 8,298.00 8,000.00 0.00 17,462.33 B17.3 % Staff on Annual Leave 16.00% 14.00% 13.10% 11.00% 11.60% 9.70% 9.60% 16.92% 17.18% 11.04% 11.95% 11.09% 17.46% 9.24% BLANK 13.63% RAG ratings updated effective Jan 21 Data Owner: e-Rostering

Page 20 11.4 Education and Training Academy Report- Louise Nickell 1 TB Education Report 6 April 21.docx

Trust Board Report Meeting Date: 6th April 2021 Title: Education and Training Academy Report Action requested: To receive and note For the attention of the Board  Positive assurances provided from external quality visits by: Assure  The Royal College of Physician’s Presidential visit  The University of Birmingham Medical School visit  Risk 5365 - Expiry of Apprenticeship Levy Funds: RAG rating=9 Amber  Creation of new Apprenticeship vacancies has dropped Surgical training recovery plan required Advise   Teaching accommodation for face to face curriculum delivery- including requirements around increased students numbers from Aston Medical School Alert  No items Author + Contact Louise Nickell, Director of Education and Training Details: Tel 01902 307999 ext. 86180 Email [email protected] Links to Trust 1 Create a culture of compassion, safety and quality Strategic 4 Attract, retain and develop our staff, and improve employee engagement 6 Be in the top 25% of all key performance indicators Objectives Resource None - Activity mostly managed through Learning and Development Implications: Agreement (LDA) income Report Data This is a standard report using the previous six month’s data. Caveats It may be subject to cleansing and revision. CQC Domains Safe: Effective: Caring: Responsive: Well-led: Equality and None Diversity Impact Risks: BAF/ TRR None Risk: Appetite The report seeks to provide Board assurance Public or Private: Public Other formal Trust Management Committee March 2021 bodies involved: References HEE Quality Framework and Quality Standards NHS In determining this matter, the Board should have regard to the Core principles contained in Constitution: the Constitution of:  Equality of treatment and access to services  High standards of excellence and professionalism  Service user preferences  Cross community working  Best Value  Accountability through local influence and scrutiny

Brief/Executive Report Details Brief/Executive Summary Title: Education and Training Academy Report 1.0 Postgraduate Medical Education 1.1 Recovery of Training – Health Education England (HEE) direction  HEE steer is to maximise training opportunities to aid the recovery of lost learning time. The Trust has been asked to highlight any areas able to offer extra training.  RWT has also been asked to identify any trainees that may be at risk of failing and to address learning gaps and aid progression wherever possible. 1.2 Recovery of Training – RWT direction  Unprotected Foundation teaching has restarted and is open to both grades if clinical commitments allow.  Internal Medicine Training (IMT) doctors are now able to take 1 hour of self- development time, whilst their protected teaching programme is finalised. 1.3 Royal College of Physicians’ Presidential visit  The Trust underwent a very successful virtual visit in October 2020 from the President of the Royal College of Physicians Professor Andrew Goddard, and the Registrar - Professor Donal O’Donoghue.  Over 20 Doctors in Training attended their session, and all were very positive about their experience at RWT, giving particular praise around training, supervision, PACES prep and simulation opportunities. Feedback on the first phase of Covid was overall positive.  The Consultant session was also positive, with particular praise for the CEO, who the consultant body described as ‘an inspirational leader’. 1.4 Surgical Curriculum Update  The new surgical curriculum will be implemented in August 2021. Covid has had a significant impact on the theatre time for doctors in training in surgery across the country, and consequently the Postgraduate Education team are working with the Surgical College Tutor and Clinical Tutor to scope a Postgraduate Surgical Simulation area to support recovery of training. 2.0 Undergraduate Medical Education 2.1 Quality Visit from University of Birmingham (UoB)  In November 2020, RWT underwent a virtual quality visit from UoB Medical School. The visit was an extremely successful review of the training on offer for Medical Students at RWT. 2.2 Teaching Curriculum  Challenges remain around provision of training with restrictions around safe face to face education for large numbers of students. However, plans include recording of face to face speciality lectures, accessed by at convenient times. This, alongside additional virtual teaching, will support learners achieving curriculum requirements. 2.3 Extension to Simulation area  In readiness for additional students expected from Aston Medical School in September, coupled with the increased requirements for more simulated education, the WMI is being refurbished to accommodate an additional simulation ward provision. This will be completed by end of May 2021. 2.4 Recruitment  The Undergraduate team have successfully recruited to three Clinical Teaching 2 Physician Associates – the first in the region – to assist with the development and delivery of teaching to medical students (including those from Aston). 3.0 Library Service 3.1 Usage and Service Delivery  Usage of the library service has remained constant during Covid following full re- opening in September. Now offering more electronic resources, a chat function for queries and a booking system for personal study spaces. A self-scanning system for loaned books will go live this month. 3.2 Trust Repository - https://rwt.dspace-express.com/  A new online research repository system launched November 2020 provides a database of research authored by staff, it includes formal articles, presentations and conference proceedings. The searchable system includes 250 new and archived records. 3.3 Improvements to Services  Additional study spaces are available on the first floor for quiet study. 3.4 Covid-19 Research Support  Two of the library team have produced in excess of 25 Covid Research bulletins to update staff on new developments linked to Covid. 4.0 Induction and Mandatory Training 4.1 Learning Management System (LMS)  The rollout of e-Learning using ESR Oracle Learning Management (OLM) has ceased due to browser incompatibility and poor end user experience.  Staff will continue to use KITE and the external training site RWTe to complete e- Learning.  A new learning management system ‘My Academy’ will replace the ‘front face’ of ESR with respect to Education and Training, and will launch later in 2021. It will provide state of the art e-Learning, an enhanced user experience and live recording of Mandatory Training compliance for managers. 4.3 Mandatory Training compliance escalation process  The escalation process around Mandatory training compliance was paused in December 2020, for all mandatory training renewals; but continued for all new starters to support staff and patient safety.  Escalation for non-compliance will be reinstated from the 1 April 2021. 4.4 Training Needs Analysis (TNA) 2021-22  Following the CQC inspection in 2019, several new topics were required to be added to the 2020/21 TNA, however as a direct result of Covid a staged approach to implementation was adopted 4.5 Knowledge, Information, Training & Education (KITE)

3  A revamped KITE site went live February 2021 providing an improved navigation and technology platform. 4.6 New eLearning packages  197 new e-learning packages have been developed over the last 12 months to support Covid and provided continuation of learning throughout the pandemic. 5.0 Clinical Skills and Resuscitation Service 5.1 Resuscitation  The delivery of Advanced Life Support courses for Adults, Pediatrics and Neonates has been affected by the availability of faculty and candidates. Priority places continued for cardiac arrest bleep holders.  Work continues on the city-wide implementation of Recommended Summary Plans for Emergency Care and Treatment (ReSPECT). Target completion date autumn 2021. 5.2 Undergraduate Training  Simulation and clinical skills training has continued for Medical Students.  Workshops replaced bedside teaching to meet learning objectives and competencies.  Curriculum planning underway for Aston Medical students here September 2021. 5.3 Clinical Skills  Some pop up training has occurred for clinical skills and training for FFP3 mask fitting continues. Fit testing has included Army support staff, redeployed staff into ICCU and students and staff. 5.4 Simulation  The newly formed Faculty of Simulation Based Education (FoSBE) has developed several work streams. . An initial scoping of SBE across the organisation is underway. . A sub group has been formed to examine how to develop debriefing skills across the workforce and to what extent. . Links established with Walsall looking at collaboration opportunities.  Embryonic discussions have taken place with the Centre for Defence Medicine in Lichfield originally around SBE, however other opportunities are being discussed.  Local immersive SBE sessions have been delivered in Oncology, Cardiology and Paediatrics, all led by Sim Fellows employed by RWT.  Planning for a region-wide IMT SBE programme is underway - delivery in August. 6.0 Leadership and Management 6.1 People Development  The following programmes have been developed during Covid to good feedback. . Learned Optimism and Positivity

4 . Happiness . PCM (Webinar version) . Workplace drama and conflict (Karpman) . Practical ways to build resilience  The forward focus will be developing resilience, psychological wellbeing and happiness; through delivery modalities of online, blended and classroom.  Wider people development and OD work includes: . Developing an RWT Coaching and Mentoring Pool. Delivering additional staff trained at levels 3, 5 and 7 in coaching and mentoring. . Working with an external provider to produce RWT bespoke Level 3 and 5 Leadership Apprenticeships. 6.2 Apprenticeships and Work based Learning  Functional Skills - Maths & English . Cohorts continue to be delivered remotely via MS Teams. Some learners find this delivery method challenging. Some learners have requested a break in learning due to Covid work pressures.  Apprenticeships . Creation of new apprentice vacancies continues to see a significant drop. . Staff development on apprenticeships remained steady for Level 6 and 7. . A number of learners had agreed learning breaks in December 2020. . The Mary Seacole programme has been included in some apprenticeship offers by Universities, mainly through Project Manager and Chartered Manager Apprenticeship programmes. Enrolment scoping is underway. . ‘Apprenticeship Incentives–Covid Recovery’: The Government incentive for hiring a new apprentice deadline has been extended from 31 Jan 2021 to 31 Mar 2021. Various restrictions still apply. . An ‘RWT Apprenticeship Hub’ newsletter has been launched in January. An interactive digital publication each quarter and listed on the Trust Newsletters page, Apprenticeships page and staff bulletin. 6.3 NHS Futures  Key successes for the team have been the conversion of face to face experiences into creative and innovative digital experiences as summarised below. #DiscoverNHS  World of Work Week in Engineering  NHS Futures @RWT YouTube Playlist  World of Work Week in Health & Social Care.  3600 Hospital tour  NHS Careers Virtual Work Experience  NHS Careers Virtual Work Experience – Special Educational Needs Schools 5  St John Ambulance Cadets – NHS Careers Presentation #ExploreNHS  AHP – Is it for me?  Surgical Virtual Q&A  ‘Ask Oli’  Virtual Work Experience – Insight Programmes #ChooseNHS  Get Into Hospital Services (Princes Trust)  Kickstart Programmes 7.0 SAS Doctors training  Doctors redeployed to the intensive care unit reported high morale and they all felt part of the team.  A TNA is underway to scope a two year Educational Programme.  SAS doctors who want to pursue the CESR route are well supported and have regular meetings to support their application process. 8.0 Physicians Associates (PAs): 8.1 Physician Associate Establishment Update  Currently 12 PAs are in post across multiple areas e.g. Acute Medicine, Gastro, and VI Practice; with 3 teaching fellow posts (a pioneering role).  Scoping work for new areas underway in Haematology, Oncology and Urology. 8.2 Universities and Career Development  Placements are planned for the University of Wolverhampton and University of Birmingham during 2021.  Unfortunately we are not able to accommodate placement requests from the University of Keele, as their programme is not flexible to fit placement availability at RWT; however building links with them via existing relationships continues.  With Clinical Teaching PAs in place, there is now a permanent resource and expertise to draw from in training the next generation of PAs. The team are working on a Career Framework for ‘growing our own’ and utilising the internal training portfolio to develop skills, knowledge and expertise further. 9.0 9.1 The Education and Training Annual Report for 2020-21  This has been completed and will be published on KITE 10.0 10.1 Walsall Collaboration  A shared service model is being finalised for the provision of Leadership training by RWT for Walsall Healthcare NHST from 1st April 2021.  The SLA to provide strategic support for Education and Training services by RWT for Walsall Healthcare NHST has increased to 2 days a week

6 12.1.1 Finance and Performance Committee minutes 19 February 2021 1 Finance+Performance Minutes 9.02.21 Agreed.pdf

J ` Minutes of the Finance and Performance Committee

Date Friday 19th February Venue 26Conferenceth Room, Hollybush House and via MSTeams Time 8.30am

Present: Name Role Mary Martin Non-Executive Director (Chair), RWT Junior Hemans Non-Executive Director, RWT Kevin Stringer Chief Finance Officer, RWT Prof. Ann-Marie Cannaby Acting Chief Operating Officer, RWT (part attendance) Simon Evans Chief Strategy Officer, RWT Sue Rawlings Non-Executive Director, RWT Alan Duffell Chief People Officer, RWT John Dunn Non-Executive Director, WHT

In Attendance: Name Role

Keith Wilshere Trust Secretary, RWT Tim Shayes Deputy Director of Strategic Planning & Performance, RWT Mark Worton Head of Financial Management, RWT Matt Butcher Head of Strategic Finance, RWT PA to Chief Strategy Officer and Strategic Advisor to the Trust Board, RWT Claire Richards (Minutes)

012/2021 Apologies for Absence Apologies were received from Gwen Nuttall and Katy Thorpe.

013/2021 Declarations of Interest There were no declarations of interest.

014/2021 Minutes of Meeting Held on 20/01/21 The minutes were agreed to be a true record.

015/2020 Introductions & Welcome Matt Butcher, Head of Strategic Finance, and Mark Worton, Head of Financial Management, were welcomed to the meeting whilst the Trust were awaiting a new Deputy Chief Finance Officer. K Stringer clarified that the Trust was in offer discussions with a Deputy CFO candidate at present.

016/2021 Action Points From Previous Meeting

016.01 Temporary Staffing Dashboard Report (Directorate FSO's) – Discussions have taken place and a mixture of bank and substantive posts are in place across the service. Bank is used to cover sickness/absence and also as a way to encourage new staff to the role. This provides flexibility to the service and is paid at the same rate. Action closed.

1

016.02 Self-Assessment Report – M Martin, S Rawlings and J Hemans met to discuss the findings of the Self-Assessment Report and circulated an update to the Committee. Action closed.

016.03 Independent Support for Urology Routine Treatments – The intention is still to utilise the independent sector, although this hasn’t been possible during Covid so will form part of the recovery plan instead. In addition to the updates the Committee will receive with the ‘Continued Impact of C19 on Performance’, the Board will also receive any proposal before it goes to tender. Action closed.

016.04 Strategic Objective Measures (LLOS) – James Owen and Dr Dowson are looking at the high level measures to go into the IQPR and we will report on these from 1st April. Action closed.

016.05 Financial Sustainability of the Estate – This item will be captured within the Capital Report going forwards. Action closed.

016.06 Strategic Objectives – M Martin asked the Committee members to send any further comments regarding the proposed objectives to T Shayes before the Board Development Session on 3rd February. Action closed.

016.07 Year End Plan – K Stringer will provide a verbal update on the Year End Plan as part of the Finance update. Action closed.

016.08 Charity Funding – This information has been circulated for information. Action closed.

017/2021 Governance

017.01 BAF Update – The following risks still remain as watching risks that the Finance & Performance Committee will continue to monitor.

017.01.01 Achievement of CIP – The CIP Programme would likely progress Quarter 2 next financial year, this is yet to be confirmed. Continue to monitor.

017.01.02 Achieving Financial Balance – Continue to monitor.

017.01.03 Maintain Financial Health Appropriate Investment to Patient – Continue to monitor.

017.01.04 Potential risks arising from Acute Collaboration – Continue to monitor. K Wilshere stated that he has added this possible risk within the report to board.

017.01.05 Potential risks arising from proposed ICP – Continue to monitor. K Wilshere stated that he has added this possible risk within the report to board.

017.01.06 Covid Restoration and Recovery Risk – A Cannaby stated that QGAC examine the risk currently but the performance risks need to be reported to Finance & Performance Committee. M Martin agreed that this was the case.

017.02 Terms of Reference – The Terms of Reference were circulated for amendment and comments. A number of minor amendments were made and an additional item was added as follows:

Item 20 – Changed to read ‘To receive and discuss updates regarding STP/ICS developments and requirements’.

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The Committee agreed that the existing strategic objectives would remain so that the ToR could be submitted to Trust Board for approval. The Strategic objectives will be updated following agreement at the Board Development Session in March.

S Evans queried which Committee would be reviewing updates from Wolverhampton Integrated Care Place (ICP). A Cannaby stated that a meeting has taken place to compile governance proposals for ICP and that reporting arrangements will be included.

The Terms of Reference were amended and submitted to Trust Board for approval.

018/2020 Performance

018.01 Continued Impact of Covid 19 on Performance – T Shayes provided highlights from the report and updated the Committee on current performance. The Trusts aspiration has been to manage any waves of Coronavirus without impacting the planned care operation. This aspiration was largely achieved until 14th January 2021, other than the partial, and subsequently full suspension, of orthopaedic operating at Cannock. The number of Covid patients and specifically the demand for staff in ICCU then resulted in almost all planned care being paused including screening, two week wait appointments, routine outpatients, routine endoscopy and the vast majority of surgery. Theatre capacity has been secured at Nuffield Wolverhampton to maintain some cancer surgery. The arrangements lasted beyond the end of January and are reflected in the data within the presentation. Services are now being reinstated as a matter of urgency (and as the number of Covid-19 inpatients continue to fall) with this depending on staff being released from the redeployment rota.

018.01.01 Current Waiting Lists – The number of patients awaiting planned treatment has remained broadly similar to before the pandemic although had started to reduce in the last 2-3 months. Since the curtailment of the planned programme, it has started to rise again. The more significant change has been in the waiting times with a significant rise in patients waiting over 18 weeks – mirroring the trend seen nationally and also 52 weeks. Waiting times are now improving consistently (up from 48.5% at the end of July 2020) and are now close to pre- pandemic performance although have dropped in month owing to the curtailment of the planned programme. T Shayes stated that discussions are taking place regarding the priority order for restoration.

018.01.02 Inpatient Activity – Day case and elective activity fell significantly from the 14th January in line with the corporate instruction. A small amount of day case activity continued but was isolated to urgent endoscopy, rheumatology and other ad hoc urgent day case activity from a range of surgical specialties. Almost all elective activity was curtailed other than the cancer activity at Nuffield and a very small amount of urgent surgery at new Cross.

018.01.03 Outpatient Activity – Referral rates have remained relatively static from the height of the crisis and have dropped further in the last couple of weeks – currently residing at around 55% of the normal level of demand being experienced at this time of the year. This reduction has contributed to the Trust’s waiting list remaining at the level it was before the pandemic but also negatively affects the 18 week compliance target. This trend is consistent across all of the main specialties.

There was a large drop in outpatient activity in month, although the trajectory was still achieved owing to the switch to virtual attendances in the latter part of the month, coupled with high activity at the start of the month.

018.01.04 Referral to Treatment Time (RTT) – In line with the significant reduction in activity, the overall waiting list size has started to rise again from 39,816, at the end of February 2020 to 40,363 at 3

the time of the report. The profile of the waiting list changed drastically although this was now returning to a similar profile to before the pandemic, with the exception of a wave of long waiting patients (43 weeks wait and above) which illustrated the 52 week challenge. A combination of both of these factors meant that performance had reduced from 83.74% in February to 71.09% (at the time of the report). This trend is mirrored across the country as seen the comparative data showed. Regrettably but inevitably, the Trust had also had 1,447 x 52 week breaches at the end of January, a target that was now being widely breached across the country

018.01.05 Diagnostic Activity – Diagnostics was significantly curtailed during the first wave of Covid-19, with the two largest areas of diagnostic activity (radiology and endoscopy) cancelling all routine work. However, radiology has continued through the third wave. Routine endoscopy had been curtailed (although urgent work continues) and was a priority for restoration when staffing allows. Other diagnostic areas continued to operate an urgent only service. Trusts have been asked to submit trajectories for these areas and have gone through the same confirm and challenge process as seen for admitted and outpatient care. Ultrasound remained under constant review and was of a particular challenge owing to the combined effect of increased demand (ultrasound demand has returned to pre-Covid levels unlike other modalities) and a lack of independent capacity available. There was a slight reduction in MRI and CT activity due to downtime of a scanner.

018.01.06 Cancer Services – After reducing significantly during Covid, there has been specific direction to maintain cancer services. The Trust had experienced significant demand in breast referrals due to patients being unable to access screening during the first wave. However, the report noted that RWT did appear to have one of the highest referral rates in the Black Country and demand had remained unaffected (in the most part) by the third wave.

Cancer services remain the priority for restoration with 2ww activity restoring and an increase in cancer surgery at New Cross. Cancer surgery has continued at the Nuffield Hospital although only equates to around 50% of normal cancer surgical treatments. T Shayes stated that the waiting list profile has started to follow the same trend as wave 1 and it is hoped that will be recovered over the coming weeks.

018.01.07 Next Steps – T Shayes stated that the focus was now on restoring and recovering services, some services have already been restored, including some two week wait activity, screening activity and a small amount of urgent surgery. Individual directorate meetings had taken place over the last week to plan recovery. T Shayes informed the Committee that the Trust is confident in the recovery of outpatients to get back to the levels achieved October and November 2020, which are the most normal figures since the pandemic. T Shayes stated that the position with elective and day cases was dependent on the requirements for the ICU bed capacity and the impact on the elective programme that can be run. Future updates will be included in the report.

018.01.08 A Cannaby informed the Committee that one of the biggest outliers during Covid 19 had been breast 2 week wait performance. A plan has been put in place to try to address this, however, mutual aid has been requested from surrounding Trusts in the interim and that this would be picked up via the STP. A Cannaby stated that a lot of work was being completed to examine capacity and demand to inform the way forward.

018.01.09 J Dunn queried what process was in place to form decisions on the prioritizing of 52 week wait patients against urgent cases. A Cannaby stated that throughout the pandemic conversations had taken place between clinicians and intensivists regarding the prioritizing of patients. However, the Trust is now looking into the possibility of completing harm reviews for the 52 week waits and all other patients within the Trust and how this is going to be prioritised. A Cannaby informed the Committee that the Trust has completed a review of patients on a clinical

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basis to identify those that would require ICU and those who would need to be referred to Nuffield but that she was keen to ensure robust governance was in place going forward. A Cannaby stated that Dr Odum is looking into the provision of a panel to review the prioritisation of 52 week wait patients and to ensure Directorate reviews are in place for the remaining patients.

018.01.10 S Rawlings queried whether the Trust was expecting an increase in referrals once patients feel safer following the administering of the vaccine. A Cannaby confirmed that this may be the case and stressed that it was key for hospitals to communicate and work together in a co-ordinated way to assist each other during this time to provide a service to patients.

018.01.11 M Martin queried whether the Trust had taken patients from out of area and from neighbouring Trusts to provide support. A Cannaby confirmed that RWT had received ITU patients from out of area and from neighbouring Trusts when possible. A Cannaby informed the Committee that neighbouring Trusts had assisted RWT with breast cases and that RWT had assisted neighbouring Trusts with skin cases. A Cannaby felt that there was a need to think about the referral process in the long term. J Hemans asked for clarification around the timeframe for examining internal capacity and demand. A Cannaby stated that the Trust would be in a position to see any problem areas within the next 2 weeks, an STP call is due to take place with Chief Operating Officers next week around mutual aid and that the STP will drive a longer term piece of work with Trusts working together.

The report was noted.

019.02 Contracting Round Verbal Update – S Evans informed the Committee that an ICS Meeting is due to take place on Friday 26th February and that there were no further updates at this stage.

020/2021 Financial Performance

020.01 Trust Financial Report – K Stringer provided an update as follows:

020.01.01 Income & Expenditure Position – K Stringer informed the Committee that the Trust was on plan, the breakdown is detailed below:

Income In Month YTD £’m £m

Block Payment 48.25 456.37 Other Income 10.50 93.17 Top-up Payment 1.18 26.99 Total 59.93 576.53 Expenditure 60.11 576.52 Surplus/(Deficit) (0.17) 0.01 Planned Surplus/Deficit) (0.28) (0.12) Variance to Plan 0.11 0.13

020.01.02 Cash – The cash balance as at 31st January 2021 is £67.4m.

020.01.03 Covid 19 Expenditure – The Trust incurred additional Covid-19 revenue costs of £2.17m in January.

020.01.04 Pay – K Stringer highlighted pay pressures as a concern. Pay was very high, which was driven in part by the impact of Christmas bank holidays (£0.4m) and additional bank and locum pay for 5

sickness/self-isolation cover and enhanced rates (£0.7m). The overspend on pay was offset by non-pay underspends, which were as a result of pausing the majority of elective inpatient activity.

020.01.05 CIP – £1.35m has been identified against a YTD target of £3.49m.

020.01.06 Forecast Outturn – The Trust had a £3.8m deficit plan for 2020/21 which was due to £3m shortfall on MSFT income and £0.8m shortfall on forecast non-NHS income. It has previously been reported that the MSFT shortfall has been corrected. It is now understood that the loss of non-NHS income (i.e. catering, car parking, R&D funding) will also potentially be funded and therefore the Trust is forecasting to breakeven at the end of the financial year. K Stringer clarified that the system is now instructing Trust’s to accrue for annual leave at year end (movement year on year) which may be an allowable deficit to the control plan or it may be funded and if funded it may be for an agreed number of days, however this is yet to be clarified. K Stringer stated that an STP report has been included within the papers for information.

020.01.07 J Dunn asked for clarification regarding the STP agreed overall deficit total. K Stringer informed J Dunn that the STP figure has been revised to £4.1m deficit with an expectation of reaching break even.

020.01.08 M Martin asked for clarification on the cash position as Trusts are no longer going to be funded in advance. M Martin asked for K Stringer’s view on the cash flow for the next 12 months and sought assurance that the Trust would be able to cope within reduced cash balances. K Stringer confirmed that the Trust will continue with the block/top up pay system for at least Q1 but the month in advance had not been confirmed as being re-activated. The Trust’s year end cash is anticipated to be £35 – £50m, which depends on a number of payments which are anticipated in March 2021. K Stringer stated that he would provide a cash flow forecast to Finance & Performance Committee in March.

020.01.09 M Martin raised the subject of Capital following the alerting risk that the Trust may break it’s CRL and asked how much of the CRL was secure. K Stringer informed the Committee that the Trust had received £9.3m funding for the modular build in April 2020. However, the 8 bed ICCU remains a risk as this is yet to be confirmed and that the centre are treating the emergency PDC £6.7m as a funding source. The Category 3 lab request totalling £750k cash and CRL is also yet to be confirmed. K Stringer stated that there is also a £7.7m CRL cover requirement from other providers within the STP so they will have to underspend their CRL, which will then be allocated to the Trust. K Stringer stated that this will cover the Pathology overspend and the 3.4m for the ICCU beds.

The Committee noted the report.

020.02 Budget Setting 21/22 – K Stringer stated that M Butcher has pulled together the budget setting paper, stating that due to the insufficient national information available in terms of funding a number of assumptions had had to be made. K Stringer asked the Committee to note the paper and progress with the STP at this stage.

K Stringer referred to the table at item 2.5 which displays a comparison for all providers in the Black Country using the current methodology, showing all in deficit. K Stringer stated that the methodology was a work in progress and would be revisited. K Stringer referred to items 3.13 and 3.14 which identified some of the pressures that the Trust will need to work through. K Stringer informed the Committee that the organisation are asking for significant support with cost pressure and service developments, stating that S Evans has a meeting taking place next week to discuss how some of the proposed developments are going to be dealt with. K Stringer felt that CIP savings will be required from Q2 onwards next financial year. 6

J Dunn expressed concerns regarding CIP requirements from Q2 stating that it would not offset the investment needs. K Stringer stated that this would depend on cash coming in from the CCGs and Commissioners and that the Trust was working on a 2% development figure. K Stringer clarified that the view of the centre is that no development should be taking place currently. K Stringer felt that the development figure may need to be adjusted but that it would be unrealistic to say that no development would be needed. J Dunn stated that there may be a possibility to obtain savings from collaborative working. K Stringer agreed with this suggestion. The Committee acknowledged that there would be challenges in engaging with operational teams whilst the focus was on restoration and recovery.

S Rawlings thanked the team for their hard work on producing the budget paper with the number of outstanding variables in play. S Rawlings asked how Trust financial management would be monitored/measured by the STP going forwards. K Stringer stated that the accountability framework is being managed by a regional body of providers and commissioners working together and that it would be difficult to manage financial performance against an STP control figure.

S Evans confirmed that RWT was currently liaising with WHT regarding improvement plans so that good practice can be shared and some synergy can be put into place.

The Committee noted the progress to date and agreed further actions to be taken.

020.03 Temporary Staffing Dashboard – Month 10 saw an increase in overall pay costs of £1,234k. Bank costs have increased by £797k from the previous month, the increase has been across all staff groups but particularly in Nursing & Medical staff in Division 1 & 2 due to COVID 19 pressures. Costs of £64k were incurred in month due to the enhanced bank rate which was introduced in January due to Covid pressures. Covid sickness pay incurred in month was £75k compared to £77k last month. Bank use has increased across all staffing groups due to the impact of the second wave of Covid 19.

J Hemans asked for clarification regarding sickness levels. A Duffell stated that the staff absence level (which includes covid quarantine and exclusions) is reported daily as is the normal sickness absence. A Duffell clarified that the current absence level is currently reported at 5.2%, 3 weeks prior the Trust was reporting 11%, so this has reduced considerably. The Trust’s normal sickness rate (not including covid figures) has remained consistent throughout, showing that the covid absence rates are the figures causing staff pressures.

K Stringer stated that the latest information guidance regarding the extension to shielding may impact on the reporting figures. K Stringer and A Duffell also agreed that there was a need for further discussions to take place about the removal of the premium bank payments by the end of the financial year.

The report was noted.

021/2001 Reports to Note

Due to current operational pressures the meeting duration and agenda items had been reduced and a number of reports had been submitted for information. M Martin asked the Committee to liaise with relevant Executive Lead against any of the papers to note if there were any issues that they wished to discuss outside of the meeting.

021.01 NHSI Monthly Return – The return was noted.

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021.02 Annual Work Plan – The work plan was noted.

021.03 Capital Report – The report was noted the report and acknowledged the funding challenges that were listed on the Trust Risk Register. The Committee noted the potential significant impact to both this year’s and future years’ capital programme proposals.

021.04 National & Contractual Standards (IQPR Extract) – The report was noted.

021.05 Cancer Action Plan – M Martin noted the significant deterioration in the Trust’s performance on cancer and stated that A Cannaby would be providing a separate briefing regarding this.

021.06 NIHR CRN West Midlands Report – M Martin noted the excellent work of NIHR CRN West Midlands in enrolling the most people into covid related research.

021.07 Supplementary Finance Report – The report was noted.

021.08 Financial Recovery Group Report – M Martin asked that Procurement CIP be included in future reports. K Stringer stated that M Worton had been asked to engage with Procurement to ensure that this was reconciled. K Stringer stated that he would bring back a more detailed report.

021.09 STP Finance Report – The report was noted.

22/2021 Any Other Business

022.01 Digital Pathology Business Case – K Stringer outlined the contents of the business case, stating that the West Midlands Cancer Alliance (WMCA) has obtained £9.6 Million in funding from NHS England to develop and implement a West Midlands integrated digital pathology solution. The implementation will commence in the first financial quarter of 21/22 and will take approximately 5 months to roll out across the West Midlands. The programme will deliver digital pathology to 12 laboratories organised into 4 regions within the West Midlands integrated digitalised pathology network where four tertiary centres, Lead Digital Laboratories (LDLs), based in Midlands 1 (Royal Wolverhampton), Midlands 3 (University Hospitals Birmingham), Midlands 4 (Wye Valley Trust) and North 8 (University Hospitals North Midlands) geographies and form the main connecting points of a regional networked digitalised diagnostic service. The integrated digital pathology solution will eventually allow the region to share workload, capacity shortfalls, and expertise and equally improve overall resilience of the pathology service. The Committee approved the business case to go to Trust Board and partners.

J Hemans stated that the business case was good and was happy to hear that there would be potential savings available. J Hemans asked if this would be shared with University Hospitals Birmingham. K Stringer stated that UHB have been the contracting lead for digital pathology.

022.02 PAS Replacement Outline Business Case (OBC) – K Stringer outlined the OBC case which was presenting an opportunity for RWT to move to an integrated Patient Administration System (PAS) and Electronic Patient Record (EPR) system with the ability to become interoperable with partner organisations, including Walsall Healthcare NHS Trust (WHT), to enable richer data sharing. It would be clinically advantageous to converge systems and have a truly interoperable system partly across the STP. K Stringer stated that the Full Business Case will be submitted to Trust Board in March. K Stringer stated that the preferred provider was not the most expensive option but it would have a re-occurring cost of £3m. K Stringer clarified that some benefits realisation would cover some of the costs but it was unlikely to recover the full cost. K Stringer 8

stated that if the business case was approved the affordability would need to be woven into cost pressure, service development and budget setting rounds going forwards. K Stringer stated that there were also concerns regarding the clinical management, understanding and ownership of the system and that this needed to be addressed. A discussion took place regarding this. K Stringer assured the Committee that implementation would take approximately 18 months which would allow sufficient time to liaise with clinicians and assign champions to take this forward. J Dunn extended an invitation to liaise with WHT regarding the clinical implementation process at WHT. K Stringer confirmed that Dr Odum had liaised with M Lewis regarding this.

J Hemans was happy to hear about the collaboration with WHT with this project and asked if this could be extended to include other neighbouring Trusts. K Stringer stated that unfortunately Dudley Group and Sandwell & West Birmingham had different PAS systems installed without an STP wide opportunity being presented. K Stringer felt that there would be an interface that would assist with this if required.

M Martin felt that this would be a good opportunity for the Trust and asked that a project team would be put into place for implementation. K Stringer assured the Committee that this would be the case.

The Committee approved the Outlined Business Case, with knowledge of the Full Business Case would be submitted to Trust Board.

022.03 Meeting Reflection – The Committee reflected on the meeting and agreed for the following items to be added to the Chairs Report:  Include approval of the 2 business cases being submitted to Trust Board.  Highlight that cash flow will be examined for the next 12 months.  Continue to highlight to Board that elements of CRL still need to be resolved before the year end.  Alert Board to the Budget paper and the challenges within the STP.  Highlight the 52 week wait position and the model that is being put into place to prioritise all patients.  Highlight cancer services and the need to work in cooperation to address performance issues

The Finance & Performance Committee Meeting was streamlined due to operational pressures and will continue to work in this capacity until notified otherwise.

023/2021 Date and Time of Next Meeting

The next Finance & Performance meeting will take place at 8.30am on Wednesday 24th March 2021 via MSTeams. Reports will be required by close of play on Friday 19th February 2021.

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12.1.2 Trust Management Committee minutes 19 February 2021 1 Minutes_Trust_Management_Committee_of_the_Board_19_February_2021 v1.4 vKW SF.docx

Minutes Trust Management Committee of the Board Date 19/02/2021 Time 13:30 - 15:30 Location MS Teams Virtual Meeting Chair David Loughton Attendees Nicki Ballard, Anna Blennerhassett, Ann-Marie Cannaby, Katherine Cheshire, James Cotton, Alison Dowling, Alan Duffell, Sally Evans, Simon Evans, Simon Fenner, Lindsay Ibbs-George, Lewis Grant, Emma Lengyel, Rosalind Leslie, David Loughton, Joanna Macve, Sultan Mahmud, Brian McKaig, Beverley Morgan, Gayle Nightingale, Jonathan Odum, Kate Shaw, Timothy, Shayes, Sian Thomas, Katy Thorpe, Kate Warren, Stew Watson and Keith Wilshere, Vanessa Whatley, Simon Evans, Cheryl Etches, Cathy Higgins, Nick Bruce

1 Apologies for absence - Kevin Stringer, Angela Davis, Dev Singh Lee Dowson

2 Declarations of interest

There were no new or changed Declarations of Interest.

3 Minutes of the meeting of the Trust Management Committee held on 22 January 2021 Lead Chair Action Approve

The Minutes were approved unchanged.

4 Matters arising from the minutes

There were no matter arising.

5 Action Points list Action reported as completed.

The one listed Action was noted as completed and closed.

6 Key Current Issues/Topic Areas None this month

7 Innovation Items

7.1 The Institute of Health Innovation Prof. Mahmud provided an overview that proposed harnessing the data asset base for the Trust in the future. He spoke about the importance of permissive leadership as a driver of change and a positive change culture. He spoke about the Trust hosting of the NIHR that was the best performing reseach network in the Country. He said all of those resourses needed to be focussed on a delivery programme to advance the organisation. Prof. Mahmud went on to speak about the potential to create an institute that would take the utilisation of data for the benefit of the Trust, partners and the City post-Covid. He said the asset base gave potential to attract further investment. He said that a focussed, dedicated team could increase the use of this valuable resource.

Ms Etches asked what the next steps were. Prof. Mahmud said the proposal would be shared and discussed across the Trust particularly with clinical staff and with Mr Evans and Mr Stringer regarding resource implications. He said the Trust had secured some external resource but that the proposal and programme required finalising.

Prof. Loughton asked for this to be summarised in a detailed pack for circulation.

Action: Prof. Mahmud provide pack to Mr Wilshere.

Dr Odum said he felt this was a great opportunity for the organisation and allowed the Trust to use the data sets that it had to the fulliest advantage. He said there would be questions asked and said it would be helpful for it to include an FAQ&A section. Prof. Mahmud noted the comment and agreed it was a good idea.

Action: Prof. Mahmud to include an FAQ&A section to the proposal.

8 By Exception Papers None this month

9 Monthly Reports

9.1 Integrated Quality and Performance Report Lead Chief Operating Officer Action to note

Prof. Cannaby highlighted that performance over the last month had deteriorated. She said the Trust had some issues in the emergency pathway relating to ambulance conveyances and the 4 hour target. She said the response and work that had been done around flow, discharge and the work with partners to try and recover the indicators. She summarised the decision made by senior clinians and senior managers to step down elective activity. She said the Trust had continued to do some surgery at the Nuffield Hospital but that had had an impact on waits and cancer performance. She said that at STP levle there had been concern about the Trust’s 2 week wait performance. She said there had been discussions with the STP COOs regarding possible mutual aid. She said that the work on restoration and recovery would be available soon.

Ms Whatley said there had been improvement in late observations and sepsis following CQI supported work. She said C-Sections had been very high at 28% however the acutity had also been very high and so was not unexpected. She VTE compliance remained low but with key changes regarding assessment and ensuring patients were given the correct treatment supported by the CQI Team. She said there had been an increase in C.Diff. Ms Etches asked about the mention of a formal process of reviewing the themes of complaints. She asked whether there were any themes emerging recently. Ms Whatley said communication remained the key area of concern. She said the wards had tried to improve communication making best use of the ipads. Ms Etches asked whether all areas had Ipads. Mr Bruce said all wards were issued with ipads at the peak in 2020. He said that he was aware that as time had gone by some had gone missing or were broken. He said if any area needed an ipad to let him know.

Action: Ms Whatley to forward a communication to Matrons to establish requirements for new/replacement Ipads.

Prof. Loughton said charitable funding was available to fund these if required. Ms Evans said the Trust had had some donated and more could be purchased.

9.2 Division 1 Quality, Governance and Nursing Report Lead Divisional Medical Director Action to note

The report was presented and accepted as read.

9.3 Division 2 Quality, Governance and Nursing Report Lead Divisional Medical Director Action to note

The report was presented and accepted as read.

9.4 Division 3 Quality, Governance and Nursing Report Lead Divisional Medical Director Action to note

The report was presented and accepted as read.

9.5 Executive Workforce Summary Report Lead Chief People Officer Action to note

Mr Duffell introduced the report and highlighted the following;  The Trust had increased it’s bank registered staff significantly.  The Trust had reached 70% for staff flu vaccinations.  The Trust had plenty of Covid Vaccination slots availble at Walsall for staff and he reiterated that staff should be encouraged to have the vaccination along with the 7000 staff so far vaccinated.

Prof. Loughton asked whether the figure included contractors. Mr Duffell said Carlisle staff were not included but they had been vaccinated and that it included agency and bank staff. Prof. Loughton asked that Carlisle and Synergy staff were included. Mr Duffell said they were incorpoated but for the purpose of national reporting they were not defined as staff at the Trust as they were not on ESR or directly employed and were not included in the headline figure. Prof. Loughton said the Trust was undertaking a comparision of flu and Covid vaccination rates and take up by BAME staff and others alongside data on the ethnic background of patients who had sadly died in the Trust.

9.6 NHS National Staff Survey Results Lead Chief People Officer Action to note Mr Duffell said the report was based on the raw data and not nationally reported at this point. He said Trust had remained the same or had improved in all areas. He highlighted the ‘recommendation as an organisation as a place to work’ had increased by 2% to 74%. He added that the ‘would you recommend this place for you or your family to recieve care again’ had increased by 1% to 78%. He said the national reporting was ancitipated on or around 11 March. Prof. Loughton said he wanted to move the to the staff survey next time round and wantd a meeting with the deputy COOs as wanted to discuss communications. Mr Wilshere asked all to note the embargo on sharing the information until after the national publication.

9.7 Chief Nurse (CNO) Nursing Report Lead Chief Nurse Action to note Ms Whatley highlighted that the report provided to the meeting was in a new format. She said there had been an increase in falls and C.diff that might be in line with the trends in the pandemnic seen in the first wave. She said vacancies had reduced to 9.3 whole-time equivalents for nursing both trained and untrained. She added that this included the additional capactiy that had been put in place. Prof. Loughton asked Ms Evans to prepare a press release on nurse recruitment for the Nursing Times and other publications.

Action: Ms Evans to prepare a press release on nurse recruitment

9.8 CNO Governance Report Lead Chief Nurse Action to note

9.9 Learning from Deaths Lead Chief Medical Officer Action to note Dr Odum highlighed that there were 333 deaths in January, higher than normally expected and that mirrored what was seen in wave 1 of Covid-19. He said the SHMI for the 12 month period had reduced to 1.018.

9.10 Finance Position Report - Month 10 Lead Chief Financial Officer Action to note 9.11 Capital Programme Update Lead Chief Financial Officer Action to note Mr Watson said the Trust had recieved the funding for the wards and expected to achieve the current CRL. He said the Trust was in negotiation with the STP about next years capital programme. Prof. Loughton asked about progress with the bed cleaning unit. Mr Watson said work was in progress with some challenges in the proposal being dealt with.

9.12 Financial Recovery Group Update Lead Chief Operating Officer Action to note

9.13 Innovation, Integration and Research Report Chief Innovation Integration and Research Officer Action to note

10 Statutory or Mandated Reports (1/4, 6 monthly and Annual)

10.1 Director of Infection Prevention Report Lead Chief Nursing Officer Action to note Ms Etches said within the Infection Prevention BAF there was a framework supplied by NHSEI that highlighted 2 red areas to be addressed. She said the first was in respect of the Trust’s ability to provide evidence of auditing patients’ use of face masks. She said there was nothing in place at the moment and that work would be initiated. She said the second was a suggestion that where there were HCSIs outbreaks that the Trust should undertake daily swabs of non- symptomatic patients but that from a laboratory basis this was not possible. She envisaged that would stay red other unless other committee members felt there was anything else that could reasonably be done. She said finally the HEPA filters for the staff rooms were anticipated for delivery in the next week.

Mr Duffell asked how other Trusts were dealing with the issue. Ms Etches said they too were not. She added the additional implications for the Trust hosted pathology services given worload from Walsall, Sandwell and Dudley et al.

10.2 The Green Plan Lead Chief Financial Officer Action to note Mr Waston said The Green Plan had been put in place to meet the requirements of the NHS to have a Board approved plan in place by March 2021 and to be zero carbon by 2040. He said it focussed on 3 areas - carbon emissions, air pollution and single use of plastics. Prof. Loughton asked whether the Trust had received planning permission for the solar farm. Mr Watson said was to go to the planning committee on the 12 March 2021. 10.3 Nursing System Framework (NSF) Milestone update and Annual Report 2020 Lead Chief Nurse Action to note Ms Whatley said the previous NSF was developed in 2018 and had ended in 2020 with quarterly progress reporting. She said that the pandemic had slowed the achievement of some of the milestones and any uncompleted had been carried forward to the new Framework. She said it had been re-named as the clinical systems framework with the inclusion of the AHP’s. She said this would build on the achievements of the last 2 years focused on excellence in care areas, workforce communication and retention of staff. She said there was really good co-working between Nursing and the AHP’s and leaders in those groups and were learning from each other.

10.4 Property Management Updates Lead Chief Financial Officer Action to note Mr Watson said the Trust was developing an updated space management policy to reflect the updated agile working policy. He said this was an area of focus to look at the fact that many staff were working from home and some of the space that could be maximised in those areas.

10.5 Cancer Services Lead Chief Operational Officer Action to note Dr Mathew reprised the impact on performance of staff redeployment and he referred to the planned process of restoration and recovery alongside decompression in looking after workforce as they came back to their home services. He said there had been some mutual aid particularly with the breast and dermatology pathways.

11 Business Cases Action To approve

11.1 Division 1

11.1.1 TA590 Fluocinolone Acetonide Intravitreal Implant for treating recurrent non-infectious Uveitis affecting the posterior segment of the eye Resolved Mr Evans recommended it be approved pending commisioners final sign off. This was agreed.

11.2 Division 2 - none this month

11.3 Division 3 - none this month

11.4 Corporate 4 - none this month 12 Outline/proposals for change None

13 Policies/Strategies

13.1 Policy Strategy Update Report Prof Loughton confirmed this was approved.

13.2 OP112 Profiling, Automated Decision Making and Artificial Intelligence Policy Prof Loughton confirmed this was approved

13.3 New Safeguarding Staff Experiencing Domestic Abuse Prof Loughton confirmed this was approved

13.4 IP04 Transportation and clean and contaminated instruments, equipment and specimens Prof Loughton confirmed this was approved

13.5 IP05 Linen policy Prof Loughton confirmed this was approved

14 Any new Risks or changed risks as a result of the meeting

15 AOB 15.1 Prof. Loughton outlined the changes to the Executive Team from 1 March 2021. He said Dr Odum and Dr McKaig (on an Interim basis) would become joint Chief Medical Officers with Dr Odum taking the responsibility of medical matters and clinical change across the STP. He said that Ms Palmer would become the Director of Midwifery and Ms Evans Director of Communication and Stakeholder Engagement with both attending the Board. He said that Prof. Field commenced his post as Chair of Walsall Healthcare on 1 March 2021.

15.2 Prof. Mahmud said the Trust had commenced work to secure resources to support the new EPR PAS system that would align RWT with Walsall running the same system. Mr Bruce said the Trust would have been replacing the PAS system and this would future proof the Trust.

15.3 Prof. Loughton thanked all for the work that they done throughout the pandemic.

Date and time of the next meeting 26 March 2021 The next meeting of the Trust Management Committee will be held on Friday 23 March at 1:30 pm. 12.1.3 Quality Governance Assurance Committee minutes 24 February 2021 1 Draft QGAC Minutes - February 2021.docx

The Royal Wolverhampton NHS Trust

Minutes of the Quality Governance Assurance Committee

held on the:

Date Wednesday 24 February 2021

Venue Virtual (via MS Teams due to COVID 19)

Time 2.00pm to 3.00pm

Name Role

Present: R Edwards (RE) - Chair Non-Executive Director M Arthur (MA) Head of Governance

A M Cannaby (AMC) Chief Nursing Officer

R Dunshea (RD) Non-Executive Director

Y Higgins (YH) Deputy Chief Nursing Officer

G Nuttall (GN) Chief Operating Officer

Dr J Odum (JO) Medical Director

A Pandyan (AP) Non-Executive Director

L Toner (LT) Associate Non-Executive Director

K Wilshere (KW) Company Secretary

Attendees:

Apologies:

S Field Chair of RWT D Loughton Chief Executive

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1 Chair’s Induction

The Chair welcomed everyone to this virtual meeting. She said it would be limited to an hour in view of COVID. Chair apologised for the cancellation of the January meeting, which had also been intended to be a short virtual meeting due to COVID. Following representations that the meeting would fall in the most intense week of COVID, Chair agreed to cancel the meeting. In future this would only be done after all members had been consulted.

1a Apologies for absence

Apologies were noted.

Declarations of Interest

There were no Declarations of Interest.

2 Minutes of Previous Meeting - Quality Governance Assurance Committee:

MA asked for the following update on page 5 on the minutes to include:

5522 - Roche consumables supply (COO) was noted for update in November 2020 this has been completed and the risk subsequently downgraded to the local risk register. This is reflected in the January 2021 TRR report reviewed virtually as January 2021 was stood down.

AP pointed out an error on page 11 item 4.1 “remove” should read “remote”.

The minutes of November’s meeting were accepted.

RESOLVED: Minutes of the Quality Governance Assurance Committee held in November 2020 were approved as a correct record.

3 Matters arising from the Minutes

The action log was updated accordingly.

4 Regular Reports

4.1 Integrated Quality & Performance Report – January – Y Higgins & A M Cannaby

YH advised the meeting of the following Quality updates from the above report:

Late observations have improved to 4.8% from 8.5%. YH mentioned that she did wonder if the indicator would deteriorate before it improved as the Trust is now doing more than one snap shot of data in month, with more real time data being used. A meeting was held with System C and it has been identified that more local operating procedures which are more in line with the Trust protocols within the system, may be needed. A CQI project has commenced.

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The meeting was informed that VTE compliance with assessment reduced slightly to 92.38% from 92.89%. For assurance the meeting was advised that there is focussed review of all VTE work streams and CQI projects to monitor the action plan.

In January there were five C-difficile cases compared to two in December.

Emergency Department monitoring has improved in month for Sepsis with 90% for screening and 85% for antibiotics within an hour.

Unfortunately the internal audit from Grant Thornton, which would be looking at the clinical pathways will not be able to be done in year now due to the COVID pandemic. This will be hopefully be rolled over to the next financial year.

C-Section rates have increased in month and the Trust remains higher than the national average of 28%. The Trust had double the normal figures of premature births within January and this has contributed to the C-section increase. YH informed the meeting that more emergency C-sections were undertaken due to the status of some of the patient’s physical health. It is hoped that this figure will reduce by next month.

Midwifery staffing ratio is currently at 1:30 in January compared to 1:32 in December.

AP asked, in regards to VTE percentages, what is the actual number of patients who are being missed. YH advised that the number of patients is in the hundreds rather than small figures. Effort is focussed on the Directorates where improvement is required. YH advised the meeting that in November 2020 the numerator was 8,264 over a denominator of 8,751 which equates to 94.3%.

AP mentioned that sometimes under the Midwife to Birth Ratio the figures are green for 27% and green for 28%, but amber for 30% whereas the target says “

RD commented that at nearly 40% the figure for January C-Sections was very high and asked if this was purely down to concerns over COVID. YH replied that following a conversation with the Head of Midwifery she was advised that it was multi-facetted. More women came in for interventions during the COVID period. Also there were a lot of premature labours, and this had also been observed in neighbouring regions. Some of the C-sections were undertaken due to the ladies having COVID.

RD asked about three maternal deaths which were linked to COVID. YH confirmed that some of the C-sections were undertaken due to some of the ladies having COVID and did have physical health problems. AMC advised that there was one maternal death and not three, two ladies were admitted into ICU. The maternal death was not COVID related, RD thanked AMC for the clarification and asked that this is noted at Trust Board.

RD enquired about the COVID outbreaks in wards / departments and asked what the reporting mechanism is for reporting for example will it be in this report or reported elsewhere. YH replied that this information will be produced in the STEIS Incident Report. The information is also reported to NHSE/I and via the Infection Prevention report. The meeting discussed YH further the possibility of having this data available in the IQPR and YH agreed to scope this.

RD noted that the Crude mortality had increased due to the COVID pandemic and asked when it will be known if the Trust is going to be an outlier. JO replied that the COVID deaths are excluded from the SHMI and mentioned that at the last data release SHMI had reduced a

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touch. It is, however, unclear when or if the deaths will be included in the analysis and he was therefore unable to answer RD’s question until the information is released to the Trust.

AMC assured the meeting that there is an Infection Control report which is discussed at Trust Board which contains COVID. The COVID deaths will be discussed at Private Board and AMC is hopeful that this will be short term.

AMC presented the Performance section of the paper to the meeting and advised that performance in January has deteriorated.

The meeting was reminded that during the first couple of weeks in January the Trust attempted to keep elective activity going, however this activity was severely reduced, paused or stopped in order for the organisation to respond to the requirement to increase ITU beds by 200%.

During January there were issues with ambulance conveyancing, deterioration in A&E performance. There were fewer ED attendances but a higher conversion rate to admissions due to patients arriving being sicker. The Trust also had to navigate an admission route if a patient was red or green for COVID. A lot of staff have also been off due to COVID. To help with the flow process the Trust has been concentrating on discharges together with partners in the Local Authority and this will be noted in the next IQPR.

AMC informed the meeting that some lists had gone ahead in the private hospital and also a few lists in the Trust which were an absolute emergency.

The meeting was advised that there were a number of discussions with NHSE/I in regards to 2-week waits. Delays in these have had an impact on waiting list times. For assurance AMC said that as soon as lists could commence they did. One area in which the Trust has particular delays is breast 2-week wait, however these services are running again and help has been sought across the STP.

JO emphasised the need to stand down surgery to create capacity and staffing for the Critical Care unit. Some urgent cancer and cardiac cases were undertaken.

AP raised concerns about the delay in identifying stroke patients (over 24 hours), AMC replied that tests and treatment would still happen within Emergency Department in a timely manner. The meeting was advised that due to Covid the Trust had to split the Stroke Ward, and it had to be closed because of Covid outbreaks. The meeting discussed the Stroke Ward and the AMC low uptake of the flu vaccine on the Stroke Ward. AMC agreed to review the figure and report back.

LT asked about the Community Nursing referrals and why are some patients refused. AMC explained how the system works and advised that patients are triaged correctly but with health needs have to be referred back to the correct setting i.e. Social Services. For assurance AMC mentioned that during the bed meetings discussions are held in regards to the Community situation. YH will be meeting soon with a neighbouring Trust who is bringing in an on-line community dashboard to see if there is anything that this Trust could use.

RD asked if the patients that were sent to private hospitals could have been sent to Cannock instead for electives. AMC advised that Theatres at Cannock had to be closed as the staff went onto wards or ITU.

RD enquired about who in the community could have pulse oximetry at home, YH advised that these were small numbers in the community at present, but growing. A national evaluation

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had been undertaken and the results were positive. A report would be out soon with the relevant details.

RE asked the members of the meeting to raise any queries in an e-mail to the relevant person(s).

Resolved: Report was accepted

4.1 Cancer Recovery Action Plan (RAP) January – For Information Only

RE advised that a meeting was held the previous day and all of the Non-Executive Directors received a valuable update on the Cancer recovery action plan.

AMC commented that a meeting would be held the following week to discuss ensuring the action plan would be returning to the levels it was last October / November.

4.2 Trust Risk Register – M Arthur

MA presented the Trust Risk Register (TRR) to the meeting and advised that the register has been maintained monthly.

MA advised the meeting of a new risk to the TRR which has just missed the deadline for the report. The risk is from Division 1 in regards to the cancellation of elective surgery due to COVID, this will be noted in more detail at the next presentation of the TRR.

Trust Risk Register Heat Maps – M Arthur

MA informed the meeting that YH and KW did the research in terms of finding the template. The heat map has been devised to provide a high level report on the management of risks, their assurances and gaps and the progression of the risks.

In future the plan is that only the Heat Map will be reported to Trust Board, with the Heat Map and the original TRR coming to this meeting in order for assurances to be reviewed and content signed off.

MA introduced the Executive Summary to the meeting and, by way of an example, took the meeting through Division 1's Heat Map report. Here it was noted that there was one high risk TRR, 5182, and eight amber risks. MA advised that the red risk had no positive assurances recorded, and also noted that the risk was coming up to two years old.

MA mentioned the eight amber risks, what stage they were currently at and what level of assurance was indicated.

KW advised the meeting of the Heat Map for the BAF and noted that the assurances levels in the TRR become controls and mitigation mapping in the BAF. For example in BAF risk SR13, there are levels of assurances for level one through to level three, however there are six negative assurances.

KW mentioned that this report is a high level summary and it should be a prompt to go into the detail of each risk if necessary. The general purpose of the report is to give the reader a quick overview of either BAF or TRR issues.

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RE assured the meeting that QGAC will carry on seeing everything on the TRR but the Trust Board will not. KW confirmed that the full BAF report will continue to the Private Board bi- monthly.

RD confirmed that he is favourable to the Heat Map from what he has seen. The meeting discussed further and agreed it was a good way forward to help everyone involved in updating the TRR and BAF to stay on top of what needs to be added and amended and to remove outdated and superseded actions.

Board Assurance Framework – K Wilshere

KW advised the meeting of the two BAF’s for noting (SR13 and SR14).

SR13 relates to Cancer performance and SR14 is COVID 19 and reflects the position known at the time of reporting. RE commented that neither had been updated recently and that there had been significant changes. KW agreed and advised that each BAF is updated at least every four weeks.

AMC commented that the risks were updated at least two weeks ago prior to submitting to NHSE/I.

The meeting discussed further potential updates which may be made.

RE asked how long the average wait was for the 2 week breast wait. AMC replied that there are approximately 360 people on the 2-week wait. Doctors and Nurses are doing additional clinics to help with the lists. Discussions are taking place with local Trusts to ascertain who can help. The average wait was 58 days, and has reduced to approximately 40+ days.

RE understood there had been an agreement, dating from 2019, that the STP would ensure that resources were shared for breast 2 week waits across the Black country. GN said Walsall may be able to help. Delays in the 2 week wait led to a bulge all the way along the pathway. Meeting agreed that the risks are to be accepted as stated in the report.

RE enquired if there were any updates on SR14, AMC replied that the numbers are reducing. The Trust is currently reducing the ICCU beds and seeing less patients in the organisation with COVID. Outbreaks over the last three weeks have been decreasing.

Resolved: Reports were accepted

5 Sub Group Reports

5.1 / 5.2 Quality & Safety Intelligence Group (QSIG) – January 2021

Please note there was no meeting in January due to operational pressures – papers were circulated to the Group members for comments.

5.3 / 5.4 Compliance Oversight Group (COG) - January 2021

Please note there was no meeting in January due to operational pressures – papers were deferred to February’s meeting.

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RE asked AMC and JO when these meetings would be re-instated. YH advised that there had been a COG meeting in February although the minutes and chair's report were not yet available, and QSIG would meet on 25 February. Reports on these meetings would come to the March QGAC.

6 Assurance Reporting / Themed Reviews

6.1 Mortality Update Report – Dr J Odum

The next Mortality Update Report is due to this Committee at April’s meeting.

7 Issues of Significance for the Trust Board

RE to produce a Chair’s report to be circulated to the Committee members for approval before submission to KW for Trust Board.

Matters for Audit Committee

No issues to escalate to Audit Committee.

8 Evaluation of Meeting – ALL

Good informative meeting

9 Any Other Business – ALL

AMC said that she would like to add an item to the March agenda: “harm and prioritisation of waiting patients from a quality perspective”. It was agreed that this will be a separate agenda item under item 5 of the agenda.

10 Date and time of Next Meeting:

The next meeting will be on

Date: Wednesday 31 March 2021 Venue: MS Teams Time: 2pm to 4pm

Apologies –

Additional Agenda Item: - Harm & patients waiting. To be included under Quality agenda item.

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COMMITTEES ACTION SUMMARY REPORT

ITEM Action to be taken raised from the Lead Committee Review Update meeting Date date

4.1 – RD enquired about the COVID outbreaks in YH 24.02.21 31.03.21 24.02.21 wards / departments and asked what the reporting mechanism is for reporting for example will it be in this report or reported elsewhere. YH replied that this information will be produced in the STEIS Incident Report. The information is also reported to NHSE/I and via the Infection Prevention report. The meeting discussed further the possibility of having this data available in the IQPR a YH agreed scope this .

4.1 – AMC to obtain number of staff who have had AMC 24.02.21 31.03.21 24.02.21 their flu vaccine on Stroke Ward.

Due to COVID 19, January’s meeting did not take place, therefore the actions were discussed and updated at the February meeting. 4.2 – Trust Risk Register VW 25.11.20 27.01.21 VH advised that this was in progress. RE asked VW 25.11.20 for a note to show amendment then action could be LT asked about the Mental Capacity act and closed. DoLS and the way it is set out in the register, 31.03.21 where an action plan is mentioned. This item was briefly discussed and VW agreed to amend.

4.1 – RE asked GN for an update on Tekihealth app GN 28.10.20 25.11.20 GN asked if this agenda item could be brought forward 28.10.20 which is being piloted at one care home to to the January 2021 meeting. enable remote monitoring of patients. GN replied that she has not had any feedback but 27.01.21 GN to respond prior to the next meeting. will obtain an update and feedback. 31.03.21

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4.1 – LT asked why the percentage of children who GN 28.10.20 25.11.20 GN advised the meeting that the Trust had been in 28.10.20 receive a 2 – 2.5 year review by the age of 2.5 discussion with the local authority on all of the years by the Health Visitors from April to performance metric, in regards to the recovery plan / August. GN replied that during the pandemic sign off and agreement. Progress is being made, a decision was made in regard to the Children however having reviewed all of the information with and not visiting them. GN assured the the local authority / public health, there is an issue with meeting that she is expecting this to show a the Trust denominator numbers which has been slow recovery in the coming months. The agreed with them and the Trust is in discussions Chair noted that at the previous meeting regarding a new trajectory. GN reported that October’s GN had agreed to provide a trajectory figures, not in the current IQPR report the percentage showing when this metric should start to now stands at 76% which is an improvement from improve. GN agreed to provide this September. It is believed that the 76% is information. underreported because of the denominator. GN is unable to give details of the denominator challenge is but it has been jointly agreed with the public health team and GN. The recovery plan is showing signs of improvement. RE pointed out that an entirely different, and improving, set of figures is included in the November IQPR, and said she would expect to have seen an explanation in the IQPR of why this series of figures had been changed. It was agreed to bring this forward to the January 2021 meeting where GN was asked to bring an explanation for why the figures have improved so much, and to ensure that the IQPR was suitably annotated.

27.01.21 GN to respond prior to the next meeting.

31.03.21

6.2 – Concerning Clinical Audit, JO offered to take JO 28.10.20 25.11.20 JO advised that this is a discussion which is still taking 28.10.20 this away and consider it. The move to QIPs place. Bring forward to the next meeting. would mean that parts of pathways were looked at, and national audits typically looked 27.01.21 JO mentioned that this is under discussion and due to at the whole of the patient pathway, but the the current pandemic has not been discussed to question of looking across care boundaries conclusion. A discussion regarding clinical audit will and ensuring patient and stakeholder be taking place as soon as possible. The discussions

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engagement at the different stages of the include CQI and the way QIPs are integrated into the audit cycle would require further programme. JO would present the outcome of these consideration. discussions at the April meeting.

28.04.21

6.2 - KW offered to help with devising a shorter KW 28.10.20 25.11.20 Bring forward to the next meeting. 28.10.20 format for reporting from this Committee to the Trust Annual Report. 27.01.21 KW advised that guidance is being waited for from the centre and there is a meeting next week with the authors who contribute to the annual report and KW will discuss at the meeting the option of a shorter format. KW mentioned that he has received notification the next year the Trust can opt out of reporting the quality account in the annual report.

31.03.21 Closed Agenda Items – To be removed at the next meeting

ITEM Action to be taken raised from the meeting Lead Carried Committee Update forward from Review date

6.3 – Trust Strategy & development of TS 25.11.20 27.01.21 RE mentioned that a Board Development session had 25.11.20 Strategic Objectives for 2021/22 & taken place and a follow up next week. beyond Close action The chair offered to be involved in further briefing on progress in December and this was agreed.

6.4 – AMC said the Trust had the standard AMC 28.10.20 25.11.20 VW advised that she had not received any update from 28.10.20 dataset from MBBRACE. She had had AMC, therefore would take this back and update via e- conversations with staff about data the mail. Trust had and data collected in the West Midlands and would bring a paper to a 27.01.21 YH advised that MBBRACE report is going to Private future Trust meeting. Board next week and work is on-going to look at revised maternity reporting to include the still-births, in-

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equalities and neo-natal deaths within our normal reporting.

6.3 – RE mentioned that in appendix 5, audit RE 24.06.20 29.07.20 RE confirmed by e-mail that she had already actioned 24.06.20 outcomes, she had noted a number of this, emailing JO, LT and MA on 29 June, with replies classifications which did not seem to from JO and MA, who provided existing criteria for the match the text, e.g. "fully compliant" classification, suggests additional criteria and also where there were matters requiring whether the classification should be reviewed e.g. at action. RE offered to provide examples directorate level. Bring forward at the next meeting. and JO asked if she would write to him and he would arrange for this to be In the absence of JO, RE asked for this action to be followed up. MA mentioned that a risk 30.09.20 brought forward. RE also asked the minute take to assessment will take place on the audits contact JO and ask for an update that were not completed due to COVID to prioritise future audit dates. CE sent an e-mail to JO on 2 October – awaiting reply once JO returns from leave.

JO updated the meeting and mentioned that the detailed 28.10.20 summary sent through by RE has gone to the Audit Team and they are working through each of the audits that RE highlighted and questioned the compliance rating. JO is hopeful to bring back to the meeting for review shortly. Bring forward

25.11.20 JO commented that he did not think this had been completed satisfactory. MA was to speak to one of the Healthcare Governance Managers, who confirmed that the reply has been sent and is waiting for JO to approve the response prior to it being sent to RE. JO to review and forward to RE. Bring forward to the next meeting.

JO advised that the Audit team have taken back through 27.01.21 the process and have revised largely in line with the suggestions made by RE. JO has sent to RE to review. Close action once circulated to meeting.

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Minutes of the Workforce and Organisational Development Committee

Date 22nd January 2021

Venue Via MS Teams

Time 10:30am

Present: Name Role

Sarah Allan Head of Resourcing

Rose Baker Associate Chief Nurse

Alan Duffell Director of Workforce

Roger Dunshea Non-Executive Director Rosi Edwards Non-Executive Director Simon Evans (Part) Chief Strategy Officer Junior Hemans (Chair) Non-Executive Director Lyndsey Ibbs-George Head of Hotel Services Daniela Locke Head of Workforce & Organisational Development Sultan Mahmud (Part) Chief Innovation, Integration & Research Officer

Adam Race Deputy Director of Workforce

In Attendance: Maria Dent Meeting Administrator Amanda Eagle Consultant, Deloittes (Observing)

Apologies: Sally Evans Director of Communications and Stakeholder Engagement Bal Everitt Head of Equality, Diversity & Inclusion Lewis Grant Deputy COO, Division 1 Sandra Roberts Divisional Manager, Estates & Facilities

Agenda Action Item No Standing Items J Hemans welcomed the members to the meeting and informed that given the current operational constraints, the agenda had been reduced and the Committee would receive key highlights only from the reports submitted.

In response to a query on whether the meeting was quorate, M Dent informed that the TORs stated that a Deputy COO was required to be in attendance, however, A Duffell stated that L Ibbs-George was in attendance and as Head of Estates and Facilities, was in fact an equivalent to the Deputy COOs and proposed therefore, that Committee was quorate from that perspective.

WOD Committee 22/01/2021 Page 1 of 8 Agenda Action Item No 1. Standing Items

1.1 Apologies for Absence As noted above. 1.2 Declarations of Interest No declarations were recorded. 1.3 Confirmation of the Minutes from the Last Meeting, 27th November 2020 The minutes from the 27th November 2020 were reviewed and agreed as a true record of the meeting.

J Hemans informed that there were a number of reports listed to note, one of which was the Executive Workforce Report, which due to the reduced agenda would not be reviewed in this meeting, however, these reports would be submitted and reviewed in detail at the next Trust Board meeting at the beginning of February.

1.4 Review of the Action Log The Action Log was reviewed, to note:

Action 2020/023 – National Staff Survey Results – update deferred until the next WODC meeting in March. A Duffell advised that the update this month would have provided an analysis on the Trust’s position against the previous year’s data, however, the full national benchmarked data would be available and reported on at the next meeting in March.

Action 2020/025 – Response to the National People Plan – item deferred until the next meeting in March.

1.4.1 Recruitment – Analysis Update Report (Action 2020/032) S Allan presented key highlights from her report which provided greater details on the recruitment of staff into RWT. She reported that for the 12 month period Sept 2019 to October 2020 the Trust had recruited 2,147 new starters. The data pulled from ESR showed that  32% of the new starters had joined RWT from elsewhere within the NHS and 21% of those had come from within the STP region, specifically from Dudley and Walsall NHS Trusts.  27% of new staff had not been previously in employment.  21% of new staff had previously been employed within the private sector.

S Allan informed that, as requested by the Committee, the report provided further data for the different staffing groups within the Trust, identified new starters recruited from within the NHS and included geographical data and STP breakdown.

R Edwards queried whether the junior doctor rotation figures had been included Action : within the data reported, and suggested that if these were taken out of the 2021/001 reporting data, this would provide a clearer view on the local impact. S Allan S Allan confirmed that the August figures did include junior doctors in training and agreed that this would be taken out and recirculated.

J Hemans commented that he would be interested for the data to include the

WOD Committee 22/01/2021 Page 2 of 8 Agenda Action Item No positions and posts that staff were appointed to. He also informed that following a discussion with the Lead of the Future Zones, it would be helpful to include the data around those staff recruited through the Princes Trust; S Allan informed that the Resources Team were now supporting recruitment with the Princes Trust and therefore, that data would be available for future reporting.

A Duffell commented that it was pleasing to note that the Trust had recruited a number of people who had previously not been in employment and, from a regional perspective, it was good to see that the Trust was able to provide opportunities to locally unemployed people.

R Dunshea queried whether the number of new starters over the 12 month period tied in with the turnover figures. S Allan advised that once the trainee figures were taken out, the data would correlate to the turnover figures and to the growth in the organisation as well.

It was agreed to bring back a further report on this information in 6 months which Action: would include a 12 month analysis of the data; R Dunshea proposed that this 2021/002 included reconciliation between the turnover figures and the data reported. S Allan

R Baker advised that as part of the future recruitments initiatives, the Trust was starting the Kickstart Programme which was a government proposal for those individuals who were on Universal Credit and who did not have any work experience. The team were looking to taken on a cohort of at least 27 to come in and join the administration staff on the wards and these were due to start within 4-6 weeks’ time. J Hemans proposed that the data on this group of staff was also included in the next update report.

2. Key Updates and Workforce Performance

2.1 Staff Vaccinations A Duffell provided an update on the Vaccination programme and informed that over 6,000 RWT staff members had been vaccinated and advised that the Trust had additional capacity and had called in staff from care homes and various other areas as well within the locality. He commented that overall, the programme had been running very well and a high number of staff had come forward to be trained and support the service.

3. Formal Review / Sign Off

3.1 Review of WODC Annual Planner J Hemans noted that the annual planner had been put forward for review by the committee ahead of formal sign off at the March meeting. He also requested that the Committee took the time to respond to the next Board Review as it was important that feedback was received to ensure that Committee remained proactive and dealt with key matters.

S Evans commented that in line with the agenda item on the Strategic Action: Objectives, it would be pertinent to determine at what point an update against 2021/003 those objectives was allocated to the annual plan. Following discussion, A Duffell proposed that, on a quarterly basis, an additional one page summary A Race update was included within the Executive Workforce report; J Hemans agreed to A Duffell

WOD Committee 22/01/2021 Page 3 of 8 Agenda Action Item No this proposal and commented that linking the culture and strategic objectives and M Dent values within this report would be valuable in monitoring and mapping the changes and progression through the Trust’s corporate values and cultural aspects.

3.2 Terms of Reference (TORs) J Hemans stated, that to fit in with the National People Plan, having spoken with A Duffell, he proposed that the Committee changed its title from Workforce and Organisational Development Committee (WODC) to People and Organisational Development Committee (PODC) which would align with the National People Plan. He put forward that the TORs were amended to reflect this proposal, to Action: which the Committee agreed. 2021/004 A Duffell A Race commented that the People Plan focussed on People and Culture and A Race questioned whether the TORS adequately covered the culture aspect. He suggested that an additional statement was added to support the purpose and M Dent responsibility of the Committee on culture. A Duffell proposed that further consideration would be given on this and the TORs would be updated ahead of bringing back to the next meeting for formal approval.

4. Strategic Focus Areas 4.1 Workforce & Organisational Development Strategic Objectives (2021-2022) A Duffell stated that it was recognised that the Trust was carrying out an organisational Trust wide strategy refresh and, in addition to that, the Trust Board had extended the current People and OD Strategy to the end of the financial year and there had been the intention to produce a revised People and OD strategy from the new financial year, however, given the recent pressures due to the Covid19 pandemic, this had been delayed until at least mid-way through 2021/2022. In the meantime, it had been agreed to identify some key strategic objectives to work towards and these in turn would support the development of the People and OD strategy.

A Race informed that he and Tim Shayes, Deputy Director of Strategic Planning & Performance, had worked together to produce the following objectives for the Committee to review :

 Maintain the lowest vacancy levels in the Black Country.  Increase the percentage of staff who deem the organisation has taken positive action on their health and  Improve overall employee engagement  Reduce the gap in engagement scores for BAME staff

R Edwards questioned whether other areas were included within the ‘reducing the gap on engagement scores for BAME staff’ such as equal access to education opportunities etc. A Race advised that the objective covered net promote and morale but suggested that WRES metrics could be included such disciplinary, access to non-mandatory training and representation. R Edwards welcomed this suggestion, stating that it was important to the Board to understand how staff felt on how they were being treated.

R Dunshea stated that he agreed with the overall approach and queried the level of ambition around the objectives on improving scores and whether these were around engagement or vacancy levels. A Race confirmed that these had not yet

WOD Committee 22/01/2021 Page 4 of 8 Agenda Action Item No been quantified given the current environment, but could be done by reviewing the staff survey and deciding on a range between the upper and lower quartile. Action : A Duffell proposed that the Committee started to consider what improvements it 2021/005 would like to see. R Dunshea responded that the Trust should take a risk and be A Race ambitious and even though the target may not be met, there would be some quantification around it. A Race noted the point made, however, he commented that the Committee needed to be mindful of the metrics that were measured by the staff survey given that the Trust has just completed one in Oct/Nov 2020 and the next survey would be scheduled for Oct/Nov 2021, and that these were 12 month objectives but there would only be 6 months to address.

J Hemans raised two points, one was around national reports around pay differentials between BAME staff and colleagues and queried whether a review on this could be carried out, the other was around setting a localised strategic objective around supporting training of unemployed people as the Trust was a key stakeholder within the region.

A Race advised that in regards to ethnicity pay gap, the Trust did not currently report in that area but did report on the gender pay gap. However, ethnicity pay could be reviewed as to whether this could be included for the end of year reporting on EDI. In regards to the second point, A Race commented that this Acton was a good point and agreed to explore this further with T Shayes on how this 2021/006 could be quantified and reported on. A Race

S Mahmud supported the proposal for an objective to actively support employment opportunities for local people and he queried whether there were any concerns over ethnic pay in the Trust. A Duffell informed that regardless of ethnicity, the Trust did not pay any individuals differently for the same role. The analysis to consider was around how many staff from a BAME background, compared to white, were actually in roles which were higher banded and at a higher level, and he understood that that this information was available national. D Locke agreed that nationally there had been comparison work carried out around the gender ceiling and there was a lot of information about people reaching certain levels. The other aspect that has been highlighted between Action: male and female pay was around other pay elements such as awards, bonuses 2021/007 and other additional pay which was being reviewed, as well as ethnicity and the D Locke Trust would be undertaking that comparison in addition to banding levels.

4.2 Black Internship Programme D Locke reported that the Trust had signed up to the Black Internship Programme. The application date had recently closed and the process was being managed by HDI UK centrally who were asking each partner organisation to be involved with the recruitment process. The programme covered a six week placement during the summer and focussed on black data scientists who were under-represented in the area of data science and research. In response to a query from J Hemans regarding supporting the interview process, D Locke advised that one person from the health science area had been identified. J Hemans advised that, depending on availability, he too would be interested in Action: supporting. A Duffell proposed that any other Committee member interested 2021/008 should inform D Locke. All

R Dunshea queried, in terms of the graduate experience and background, what graduates was the programme aimed for. He also stated that it would be important that the experience and structure of the programme was of a high standard as this was a fabulous opportunity to showcase the great work of the

WOD Committee 22/01/2021 Page 5 of 8 Agenda Action Item No Trust. D Locke advised that the internships were targeted to students in their final year or about to commence their final year at university, either undergraduate or graduate and targeted at people already working in a relevant field who were keen to transition into heath data science.

R Edwards questioned whether the placements were aimed for students who lived within the locality or would expenses be paid to cover travel and Action: accommodation. D Locke commented that the aim was for people to be able to 2021/009 access their local organisation and she understood that expenses were claimable but agreed to check as to whether travel to and from home would be claimable. D Locke

4.3 Employee Relations & Improving People Practices Update J Shillingford provided key highlights from the report presented which included an update on the Improving Practices work which she reported was continuous and ongoing.

To note on Improving Practices:

 The multiple person’s panels had been implemented, which was one of the recommendations from the Dido Harding report, and this provided a variety of decision makers. These had been working well, had not contributed to any delays and good feedback had been received from Staffside colleagues. These also provided some experience for those who had not previously sat on panels, which was another positive to this process.  Case assessment panels had been implemented. At the beginning of process, a small group, which included senior managers, Staffside reps, cultural ambassadors and an HR rep, reviewed the facts of the case to determine the route for that particular case and, if appropriate, taken through an informal route, making sure that there was no discrimination which was one of the WRES factors. A pilot had been running from the beginning of January and an evaluation on this would follow.  Some challenges were still faced around training in moving to virtual sessions, although as per normal winter practice, a number of training sessions had been put on hold.  There had been some challenges faced with holding hearings in person but to ensure the health and safety of all staff, the team had looked at the use of technology and the use of several rooms.  One action was still outstanding which was to implement the NMC guidance, but this had not yet been published however, once released this would be built into the routine policy review.

In response to a query raised by R Dunshea around the accessibility of HR colleagues for managers in order to provide support with any particular situation that may arise which may head off from the situation becoming a formal case, J Shillingford informed that the HR Advisory team were available and the teams were structured to support the different areas across the Trust. She also advised that there were a number of informal processes included within policy which supported early indicators to be acted on before reaching any formal process and she was more confident now that the Case Assessment panel had been set up that this was addressed.

L Ibbs-George informed the committee that from a management point of view, she had worked with a dedicated HR manager and assistants who provided

WOD Committee 22/01/2021 Page 6 of 8 Agenda Action Item No advice and monitored any casework. She advised that the HR team met with deputy managers on a monthly basis to follow up on ongoing cases and any new concerns or issues could be raised in this forum. She commented that her team were well supported.

4.4 Equality, Diversity & Inclusion Update D Locke provided key highlights from the report submitted, to note:  Bal Everitt has been appointed as the Head of EDI from the 2nd November 2020 and had started on pulling together the different factors and strands within this area of focus.  The NHSI draft Equality and Inclusion Strategy had been published and included a suggested action plan with short, medium and longer term actions, therefore a review of the Trust’s draft workforce EDI inclusion plan would be carried out to ensure alignment.  The draft plan has been shared with the Employee Voice Groups as it was important to receive their input, feedback and challenge.  The Cultural Ambassador Programme – three workshops had been scheduled with the HR Advisory team to undertaken a joint evaluation and review on how the programme was working in practice. However, due to clinical pressures, there had been some delay in holding he second workshop but it was hoped to reschedule this in March 2021.  Updates from the Employee Voice Groups had been included within the report.  A Task and Finish Group, chaired by S Allan, had been set up to review inclusive recruitment practices which was a priority for the Trust.  B Everitt was working with the Patient Experience Team regarding the equality impact analysis process and template.  Work was ongoing with colleagues in the Governance Team around the Relay Phone Service which supported individuals who had speech difficulties to ensure clear guidance to support both workforce and patient experience.

In response to a question raised by R Dunshea around the timetable and the preparation for an Inclusive recruitment policy and the changes and challenges required by all staff, D Locke informed that the timetable did need to be reviewed and stated that some of the actions and programmes spanned over a couple of years but needed to be broken down into tangible ways of taking forward as they needed to ensure there was engagement across the whole organisation. This was a cultural change overall and EDI needed to feature in the conversations around Strategy, followed by education. She stated that the national strategy had three principles : pact, inclusion and strategy which talked about challenge, education and support.

R Dunshea suggested that this subject was brought to a Board Development Action: session to ensure the Board were fully engaged. A Duffell proposed that rather 2021/010 than just a focus on inclusive recruitment, a wider session around the wider EDI agenda would be helpful to the Board. A Duffell

5. KEY RISKS 5.1 New Risks Following discussion, no new risks were identified.

WOD Committee 22/01/2021 Page 7 of 8 Agenda Action Item No 5.2 Board Assurance Framework (BAF) A Duffell commented that given the current organisation position due to Covid, there was no suggestion to make any changes to the BAF.

R Edwards queried why the risk had remained on the BAF as the target figure had been met and questioned whether the Committee was being overly cautious. A Duffell commented that the Committee had had several conversations about taking the risk off the BAF, however there had been some reservations from operational colleagues due to winter pressures with additional wards being opened as well as the impact of the covid pandemic. Following discussion, A Duffell suggested that unless there were any further changes and the figures Action : remained stable, at the next meeting, the Committee should consider taking a 2021/011 decision to downgrade this risk, the Committee agreed with this proposal. All

6. DOCUMENTS FOR INFORMATION ONLY 6.1 Equality and Diversity Bulletin

6.2 Minutes from the Operational Workforce Group

6.3 Minutes and Action Notes from the Attract and Retain Steering Group

6.4 Minutes from the Academy Steering Group

7. Any Other Business No additional items raised. 8. Date and time of Next Meeting 10:30am-12:30pm, 26th March 2021 Via MS Teams

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