Torbay and South Devon NHS Foundation Trust Public Board of Directors Anna Dart Lecture Theatre, Horizon Centre, Torbay Hospital, TQ2 7AA 7 March 2018 09:00 - 7 March 2018 11:30

Overall Page 1 of 253 AGENDA

# Description Owner Time

In case of fire - if the fire alarm sounds please exit the Anna Dart Lecture Theatre immediately in a calm and orderly fashion. On exiting, turn right and then left through the fire door and assemble in the car park by the Patient Transport Offices.

1 User Experience Story Information

2 Board Corporate Objectives Information

Board Corporate Objectives.pdf 7

3 PART A: Matters for Discussion/Decision

3.1 Apologies for Absence Ch Note

3.2 Declaration of Interests Ch Note

3.3 Minutes of the Board Meeting held on the 7th February Ch 2018 and Outstanding Actions Approve

18.02.07 - Board of Directors Minutes Public.pdf 9

3.4 Report of the Chairman Ch Note

3.5 Report of the Interim Chief Executive ICE Assurance

Report of the Chief Executive.pdf 33

3.6 Strategic Issues

Overall Page 2 of 253 # Description Owner Time

3.6.1 Devon Sustainability and Transformation Partnership DSI Update Report Information/Assurance

Devon STP Update.pdf 45

3.6.2 Annual Strategic Agreement with Torbay Council 2018-19 DSI and 2019-20 Approve

ASA with Torbay Council 2018-19 and 2019-20.pdf 57

3.6.3 Verbal Update on Progress on the Alternative Delivery Cllr Parrott Model for Children's Services Information/Assurance

4 Delivery Issues

4.1 DSI/DoF/DW Integrated Quality, Performance, Finance and Workforce OD Report - Month 10 Assurance

Integrated FPQW Report - Month 10.pdf 95

5 Governance Issues

5.1 Board Assurance Framework DoF Assurance

Board Assurance Framework.pdf 157

5.2 Feedback and Engagement Annual Report CN Information/Assurance

Feedback and Engagement Annual Report.pdf 171

6 Governors' Questions Ch Discuss

7 PART B: Matters for Approval/Noting Without Discussion

7.1 Reports from Board Committees Assurance

Overall Page 3 of 253 # Description Owner Time

7.1.1 Finance, Performance and Investment Committee - 27th RS February 2018 Information/Assurance

2018 02 27_FPI_Cttee_Report_to_Board.pdf 197

7.1.2 Quality Assurance Committee - 24th January 2018 Ch Information/Assurance

QAC 24.01.18 - Chair's Report.pdf 199

7.2 Reports from Executive Directors

7.2.1 Report of the Interim Chief Operating Officer ICOO Information/Assurance

Report of the Interim Chief Operating Officer.pdf 201

7.2.2 Antenatal and Newborn Screening CN Information/Assurance

Antenatal and Newborn Screening.pdf 209

7.2.3 Trust End of Life Annual Report CN Information/Assurance

Trust End of Life Report.pdf 215

7.2.4 Safe Staffing 6 Month Update CN Information/Assurance

Safe Staffing 6 Month Update.pdf 229

7.2.5 Getting it Right First Time MD Information/Assurance

GIRFT.pdf 245

7.3 Compliance Issues

7.4 Any Other Business Notified in Advance Ch

7.5 Date of Next Meeting - 9.00 am, Wednesday 11th April Ch 2018

7.6 Exclusion of the Public Ch

Overall Page 4 of 253 INDEX

Board Corporate Objectives.pdf...... 7 18.02.07 - Board of Directors Minutes Public.pdf...... 9 Report of the Chief Executive.pdf...... 33 Devon STP Update.pdf...... 45 ASA with Torbay Council 2018-19 and 2019-20.pdf...... 57 Integrated FPQW Report - Month 10.pdf...... 95 Board Assurance Framework.pdf...... 157 Feedback and Engagement Annual Report.pdf...... 171 2018 02 27_FPI_Cttee_Report_to_Board.pdf...... 197 QAC 24.01.18 - Chair's Report.pdf...... 199 Report of the Interim Chief Operating Officer.pdf...... 201 Antenatal and Newborn Screening.pdf...... 209 Trust End of Life Report.pdf...... 215 Safe Staffing 6 Month Update.pdf...... 229 GIRFT.pdf...... 245

Overall Page 5 of 253 Overall Page 6 of 253 BOARD CORPORATE OBJECTIVES

Corporate Objective:

1. Safe, quality care and best experience

2. Improved wellbeing through partnership

3. Valuing our workforce

4. Well led

Corporate Risk / Theme

1. Available capital resources are insufficient to fund high risk / high priority infrastructure / equipment requirements / IT Infrastructure and IT systems.

2. Failure to achieve key performance / quality standards.

3. Inability to recruit / retain staff in sufficient number / quality to maintain service provision.

4. Lack of available Care Home / Domiciliary Care capacity of the right specification / quality.

5. Failure to achieve financial plan.

6. Care Quality Commission’s rating ‘requires improvement’ and the inability to deliver sufficient progress to achieve ‘good’ or ‘outstanding’.

Board Corporate Objectives.pdf Page 1 of 1 Overall Page 7 of 253 Overall Page 8 of 253

MINUTES OF THE TORBAY AND SOUTH DEVON NHS FOUNDATION TRUST BOARD OF DIRECTORS MEETING HELD IN THE ANNA DART LECTURE THEATRE, HORIZON CENTRE, TORBAY HOSPITAL ON WEDNESDAY 7TH FEBRUARY 2018

PUBLIC

Present: Sir Richard Ibbotson Chairman Mrs J Lyttle Non-Executive Director Mrs J Marshall Non-Executive Director Ms V Matthews Non-Executive Director Mr P Richards Non-Executive Director Mr R Sutton Non-Executive Director Mrs S Taylor Non-Executive Director Mr J Welch Non-Executive Director Ms L Davenport Deputy Chief Executive Ms C Bessent Deputy Chief Nurse Mrs D Butler Deputy Director of Strategy Mr P Cooper Director of Finance Mrs L Darke Director of Estates and Commercial Development Dr R Dyer Medical Director Mrs J Falcão Director of Workforce and Organisational Development Mr J Harrison Deputy Chief Operating Officer Councillor J Parrott Torbay Council Representative

In attendance: Ms C Carpenter Member of the Public Mrs S Fox Board Secretary Ms J Gratton Joint Head of Communications Mr C Helps Interim Company Secretary

Governors: Mr R Bryant Mr P Coates Mrs C Day Mrs C French Mrs A Hall Mrs L Hookings Mrs B Inger (part) Mrs M Lewis

ACTION 01/02/18 Board Corporate Objectives

Noted.

PART A: Matters Discussion/Decision 02/02/18 Apologies for Absence

Apologies were received from the Director of Strategy and Improvement and Chief Nurse.

03/02/18 Declaration of Interests

Nil.

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04/02/18 Minutes of the Board Meeting held on the 6th December 2017 and Outstanding Actions

The minutes of the meeting held on the 6th December 2017 were approved as an accurate record.

05/02/18 Report of the Chairman

The Chairman reported the following to the Board:

 Mrs McAlinden had gone back to Northern Ireland with her husband and was taking a period of unpaid leave. Her husband was receiving palliative care and treatment. The Chairman was keeping in regular contact with Mrs McAlinden in respect of a possible return to office on a reduced hours contact over the next few months.

 The plans put in place to manage demand over the festive period had worked well and the Chairman wished to place on record his thanks to the teams who worked over that period.

 The Chairman visited Ashburton Hospital recently and on speaking to service users and staff felt that the hub was operating very well. He also commended the meeting room at the hospital for use by Board members.

 The Chairman spent some time shadowing a junior doctor working a shift at the end of January and reported that it was an extremely valuable experience. He was also pleased to receive positive feedback from both the junior doctor and his colleagues in respect of the Trust’s training programme.

06/02/18 Report of the Deputy Chief Executive

The Deputy Chief Executive highlighted the following:

 Both the Deputy Chief Executive and Chairman attended the recent Time to Talk Session which was part of a national programme to improve awareness of mental health needs and the importance of looking after the mental health as well as the physical wellbeing of staff. The event brought together staff from across the Trust who spoke about their experiences of mental health and the Board noted it has had a huge impact with many members of staff coming forward to speak about their experiences. The Deputy Chief Executive wished to place on record that Board’s thanks to Mr Paul Norrish for arranging this event.

 The Trust has found managing the winter period very challenging, but the experience has been made manageable due to having a robust Winter Plan in place. The Board should not underestimate the pressures that staff have had to face and how readily they have worked in a flexible manner when required.

 The A&E 4 hour performance at the end of December was 88.3% which was below trajectory. The Trust did meet the Quarter 3 trajectory target for the Emergency Department and was the only organisation in the South West to do this. Since January performance has been variable, and the focus has been on ensuring patients have been managed in a safe manner.

 Towards the end of the year the Trust had to make a difficult decision in respect of Riverview at Dartmouth and the establishment of a multi-agency Health and Wellbeing Hub at the site. Despite a lot of effort, the Trust had not Page 2 of 23 Public

18.02.07 - Board of Directors Minutes Public.pdf Page 2 of 23 Overall Page 10 of 253 been able to negotiate a lease value that was financially viable. This outcome was very disappointing for both the Trust and the Dartmouth community and the Trust and partners remain committed to finding an alternative solution.

 The CQC would be undertaking a well-led inspection of the Trust in early March, and as part of this would be undertaking some announced and unannounced inspections. The first inspections were due to take place on 13th and 14th February.

 The Trust has been successful, as part of the STP, to be part of a national imaging transformation programme. In addition, one of the Trust’s managers has been approached to provide support to the programme.

 The Trust’s Maternity Services has been highly rated by new mothers and was performing well compared to other NHS Trusts across the country, according to a new national survey.

Councillor Parrott queried the Trust’s performance over the winter period and the need to ensure patients were safe during periods of high demand, and asked if the Trust had found it necessary to seek help from other Trusts or they from the Trust. The Deputy Chief Executive explained that the benefit of the Winter Plan for the Trust’s system, and more widely in the STP, had meant that there was a process for engaging with the other NHS organisations when necessary with practical assistance provided – for example a soft divert when at OPEL 4.

Strategic Issues 07/02/18 Devon Sustainability and Transformation Partnership Report

Strategic Context

The Devon Sustainability and Transformation Partnership (STP) provides a single framework through which the NHS, local authorities and other health and care providers work together to transform health and care services. A single board update is now produced monthly following the Programme Delivery Executive Group (PDEG) meetings. This is the third update, following the meeting of PDEG on 15 December. Note there was no PDEG in January 2018.

The purpose of this report is to:  provide a monthly update that can be shared with Governing Bodies, Board, and other meetings in STP partner organisations;  ensure everyone is aware of all STP developments, successes, and issues in a timely way; and  ensure consistency of message amongst STP partner organisations on what has been endorsed at the Programme Delivery Executive Group (PDEG). All partner organisations in the STP are represented at senior level at PDEG.

Key Issues/Risks

Core Content Items included in this monthly update following the PDEG meeting held on 15 December are as follows:  Feedback from a meeting with Michael McDonnell, Director of Strategy, NHS England, on Accountable Care Systems.  Next steps for reviewing acute services.  Process for the review of Service Delivery Networks.  Paediatric surgery developments.  Next steps on developing STP estates and capital plans.  National developments and messages

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Risk As previously identified, the main risk to the Trust is having the leadership and clinical capacity to engage in and inform STP programmes and work streams on top of Trust and local system change programmes – this is being kept under review and a “do it once” approach for Devon is being pursued.

The Board noted the update report produced by the STP. The Board also noted the very live changing narrative in terms of Accountable Care Organisations and what this might mean for the Trust and its population. Sarah Wollaston MP has asked for an evidence-based review of the Government’s proposals and while this was taking place that Trust would be using that time to ensure its plans were the right ones for its population.

The Director of Estates and Commercial Development reported that as part of an STP bid for national funding, the Trust had submitted a bid for the emergency department and care centre. The Trust would learn by the end of March if the bid had been successful or not.

Mrs Lyttle stressed the need to help the public understand the Trust’s plans and to also ensure they understood the language used and what it meant. This was acknowledged. The Board was clear that any changes to its structure in terms of wider integration in the system was not privatisation and it was important this was widely understood.

Councillor Parrott reported that this was an issue that would be discussed at the Council’s Overview and Scrutiny Committee in March where he hoped it would be possible to help allay public concerns about privatisation of the NHS and gain clarity about the future structure locally.

The Deputy Chief Executive added that the Trust had a good opportunity, while the national debate was ongoing, to evidence the added value further development of the Trust’s integrated model would bring to the Trust’s population with close working with, in particular, Primary Care and the voluntary sector. In addition, in terms of supporting the STP, the Chairman made it clear that the best way the Trust can do this is by delivering its financial and performance targets.

Mrs Marshall asked if a solution had been found in respect of the substantive STP Chief Executive role and the Chairman explained that the STP had been discussing options but was not yet in a position to make these public.

The Chairman informed the Board that both he and the Deputy Chief Executive had been approached by the GMB in terms of a rumour that Torbay Hospital would be closing, this rumour had been strongly refuted and a statement also put on the Trust’s website.

The Board formally noted the progress of the Devon STP.

Delivery Issues 08/02/18 Integrated Quality, Performance, Finance and Workforce Report – Month 9

Strategic Context

2017/18 Operational and Financial Plan and Control Total: The Trust submitted an Operational Plan for 2017/18 to NHS Improvement (NHS I) which confirmed the commitment of the Board to ensure the Trust achieves the Control Total set by NHSI of achieving a £4.7m surplus by 31st March 2018.

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18.02.07 - Board of Directors Minutes Public.pdf Page 4 of 23 Overall Page 12 of 253 Sustainability and Transformation Fund: An allocation from the national Sustainability and Transformation Fund (STF) has been set aside for the Trust. The arrangements for allocating the STF for 2017/18 have been confirmed as follows:  70% is dependent on delivery of the Trust’s financial plan to deliver the agreed Control Total.  30% is dependent on delivery of both (a) A&E performance at Trust and / or STP level and (b) achievement of A&E operational mile stones (such as GP streaming).

These thresholds have been met in Quarters 1 and 2 and £2.04m has been received, and a further £1.75m accrued for Q3, though the value of the Q3 accrual is under review. The Trust delivered the required trajectory for 4 hour waits in ED in Q3. However, a previously unrecorded requirement to secure a level of patient streaming from ED to the on-site GP service has been assessed as not achieved, resulting in a potential loss of £525k of the accrued STF funding. All other aspects of the requirements as contained in the specification for GP streaming were achieved. The th Trust is considering its options in respect of the notification received on 24 January from NHS I that the Q3 STF for performance has not been secured.

Regulatory Context - NHS I Single Oversight Framework: The Single Oversight Framework (SOF) is used by NHS I to identify NHS providers’ potential support needs across the five themes of quality of care, finance and use of resources, operational performance, strategic change, and leadership and improvement capability. As previously reported NHS I have made changes to the SOF which applied from October 2017 onwards.

The underlying framework is unchanged and the performance of providers against the ‘Use of Resources’ metrics will continue to be made against the five themes set out above. Using this framework NHS I segment providers into one of four segments ranging from Segment One (maximum autonomy) to Segment Four (special measures).

The Trust has previously been assessed as being in Segment Two (targeted support), in response to concerns in relation to finance and use of resources. This rating is not expected to change as a result of the revisions to the SOF.

An additional performance metric, associated with the identification of patients who have dementia, has been added to the framework and has been included within the performance dashboard.

Key Issues/Risks

The key issues and risks to note are:

Finance:  Overall financial position: The financial position against NHSI Control Total for the 9 months to 31st December 2017 is a deficit of £0.83m against a planned deficit of £1.29m. In the month of December, a surplus of £760k has been achieved, which is £304k ahead of plan.

 Pay expenditure: Total pay costs are underspent against plan to Month 9 by £1.70m.

 Cumulative Savings Delivery: The Trust has delivered £30m against our year to date savings profiled target of £27.1m (including income Generation target); resulting in a £2.9m over-delivery.

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18.02.07 - Board of Directors Minutes Public.pdf Page 5 of 23 Overall Page 13 of 253  System Savings Plan Year End Forecast Out-turn Delivery: To achieve a 2017/18 surplus Trust control total of £4.7m, the Trust needs to deliver £40.74m cost reduction target, and a further income generation target of £1.33m (Total £42.1m). At the end of Month 9, the Trust has identified savings potential of £41.7m resulting in a £0.4m current-year shortfall.

 It is important to recognise that this scale of current-year forecast delivery represents a significant improvement on the achievements of previous years. Any slippage in delivery would, however, put the Control Total and £5.7m STF funding at risk, affecting liquidity and, in turn capital investment plans.

 The forecast recurrent delivery Full Year Effect (FYE) against the 2017/18 projects is £29.2m. Further mitigations are being scope that have the potential to improve this position slightly before the year end

 Use of Resources Risk Rating: NHS Improvement no longer publish a planned risk rating for Trusts, due to changes they have made to the risk rating calculation. However, at Month 9, the Trust had an actual use of resources risk rating of 3 (subject to confirmation by NHS Improvement). The Agency risk rating of 1 is a material improvement to the planned rating of 2.

 Capital Spend: A significant underspend against the revised approved budget exists at 31st December 2017. Scheme leads have been asked for assurance that the full year revised spend forecast of £10.6m will be delivered.

Summary of Performance Against Frameworks:

Framework Number RAG Rating at the end of Month 9 of KPIs Ambe Gree Red Not Rated r n National Performance 5 3 2 0 0 Standards (trajectory) Local Performance 1 23 10 1 11 Framework (no target set)

Community & Social 3 15 4 1 7 Care Framework (no target set

Quality Framework 19 Workforce 4 1 2 1 Framework

National Performance Indicators

Against the national performance standards, for Month 9 the Trust has delivered the following outcomes:  4 hour ED standard: In December the Trust achieved 88.3% of patients

discharged or admitted within 4 hours of arrival at accident and emergency departments. This is below the agreed Month 9 Operational Plan trajectory of

90.2% and below the 95% national standard.

The Q3 STF operational performance target was met with 91.4% against target of

91.32%. There is a risk being raised regarding the low number of patients accessing GP streaming which is the second operational performance requirement for delivery of Q3 STF. The operational performance criteria in Q4 is to achieve

95% in March 2018

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18.02.07 - Board of Directors Minutes Public.pdf Page 6 of 23 Overall Page 14 of 253 In December, the operational pressures and level of escalation increased moving into January, with performance to 23rd January showing 81.6% of patients being discharged from ED and MIU within 4 hours with six days declared at the highest level of escalation OPEL 4 and the remainder all at Opel 3. January trajectory is 89.9%. Admissions are marginally up on last year and every effort is made to bring forward senior clinical assessment and decisions to increase patient flow and de-escalate the system.

 RTT (target 92% / Trajectory 89.3%) - RTT performance has deteriorated in

December to 82.3% waiting less than 18 weeks from 83.7% in November. The

revised end of year target has been set at 86.1% which was the performance in

July 2017.

 Patients waiting over 52 week waits – Whilst the overall RTT 18 week position has deteriorated the plan to reduce the number of very long wait patients is starting to deliver. Although the number of patients over 52 weeks increased to 42 at the end of December (from 36 in November), this was anticipated and the planned reduction to 34 in January is on course to be delivered. The trajectory remains to achieve zero in March from 34 in January and 16 in February. Although the December trajectory was missed by 2, there is a strong degree of confidence that the January position of 34 will be achieved. The March delivery is at risk due to operational pressures currently being experienced. In January higher numbers of elective inpatient operations requiring beds have been stood down and this will need mitigating if the Trust is to deliver the March position of zero. Within the cohort of patients requiring treatment by 31st March to avoid a wait >52 weeks wait there are 39 elective patients who will require an inpatient elective bed on admission. Detailed mitigation plans are being developed to manage this risk.

 62 day cancer standard: 82.7% against the 85% national target, this is an improvement on last month (77.3%). The standard in Q3 NHS I assessment is predicted not to be met with 80.8% against the target 85%.

 Diagnostics: the number of patients waiting over 6 weeks has increased to 3.7% (2.4% last month) in December. MRI waiting times continue to present the highest number of long waits over 6 weeks. Mobile van visits are scheduled in January and February to support additional capacity.

 Dementia screening: Improvement to 65.5% (from 59% last month) against the 90% national standard. A drop in reported performance was forecast with the transition to the “Nerve Centre” clinical information tool which is being rolled out; a definitive timeline for this work is still awaited.

Local quality indicator performance variances to highlight

 Delayed Transfers of Care is becoming an area of national attention and is linked to securing the Better Care Fund. Performance in community hospitals has declined slightly with the number of delays increasing from 340 in November, to 348 in December against a target of 315. The Acute site showed a decrease in delays from 197 in November to 165 in December against a target of 64. Work is continuing with teams to make further improvements and keep delays to a minimum level.

 Follow up appointments waiting beyond the planned “to be seen by” date has increased from 6,308 by the end of November to 7041 against a target of 3500.

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18.02.07 - Board of Directors Minutes Public.pdf Page 7 of 23 Overall Page 15 of 253  C Difficile infections; 2 new acute infections were reported in December (0 in the community); 1 has been confirmed as a lapse in care.

Bed Closures due to Infection Control have fallen from 130 last month to 8 at the end of December. An increase in bed days lost is expected in January as there have been ward bays closed for infection control escalation.

The Board discussed the following:

 The Trust has struggled to meet it’s 4 hour standard with 88.3% being achieved in December which was below the agreed month 9 trajectory of 90.2% and below the 95% national standard. The Trust did meet the Quarter 3 STF target. There was, however, a risk due to performance against a target for GP streaming which had not been previously notified to the Trust. The Trust was in the process of appealing against this target. The Board expressed disappointment at this development, and was assured that the Trust was doing all it could to reverse the decision.

 Work continued to bring RTT performance back to trajectory and reduce 52 week waits. 18 week waits had deteriorated and stabilised at 81-82%, and over 52 week waits were slowly reducing.

 As part of the briefing on performance the Deputy Chief Operating Officer took the opportunity to response to a question from Mr Peter Coates (Governor):

“Given that the catchment area has an above average elderly population and that there are serious areas of deprivation my intuition suggest that referrals are unlikely to fall. Assuming this assumption is accurate is it possible to have monthly by speciality, the number of patients referred (split by elective and non-elective) and the number of patients processed plus the backlog at the end of each month?

This information will give assurance as to the progress in reducing the backlog by speciality and hopefully will get Torbay into the top half of the national backlog statistics.”

The Deputy Chief Operating Officer explained that the Trust did monitor referral activity and the impact on waiting lists down to speciality and patient level and that there was a risk in being able to get back to the previously agreed Board target of 86%. He added that there was still an aspiration, however, to meet this target.

 In terms of performance against Cancer targets, 3 pathways were particularly challenged – Urology, Colorectal and Lung. The Board noted that activity was taking place to bring forward the decision to treat in each pathway and when patients received their first treatment.

 The Board noted that there had been an instance of a patient waiting over 12 hours for admission to a bed in December and in January there had been a further 8 patients. The Deputy Chief Operating Officer assured the Board that a harm review had been undertaken for each patient and found that they did not experience any harm due to the wait.

 The Chairman asked the Deputy Chief Operating Officer for his view on the most important risk for the Trust and he said that it was difficult to put one above the other – reducing over 52 week waits; cancer standards; urgent care system; and management of the 4 hour flow.

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18.02.07 - Board of Directors Minutes Public.pdf Page 8 of 23 Overall Page 16 of 253  Mrs Lyttle raised a concern in respect of diagnostics and sustainability of the service. She said that she understood some mobile resources would soon be on site, but asked if, once that resource was no longer with the Trust, the service would be able to manage its workload. The Deputy Chief Operating Officer explained that part of the issue was because one of the Trust’s scanners failed on a regular basis and the need for the Trust to work with its commissioners to manage demand. It was noted that the Trust’s involvement in the STP-led imaging transformation programme might help the Trust’s situation. Mrs Lyttle added that, through the data reviewed at the Quality Assurance Committee, she was assured that patient safety and quality was not compromised by any delays.

 In respect of GP Streaming, Mrs Lyttle said that she understood that patients being seen through that initiative were not able to have their prescriptions filled by the Trust. The Deputy Chief Executive acknowledged this issue and said that it was one of capacity and that the second phase of the GP streaming work was to extend the Trust’s outpatient pharmacy so that it could provide prescriptions for patients from the GP streaming service.

 The Board noted the ongoing performance issues in relation to Dementia Find which were due to a technical issue between two IT systems. Whilst this was being resolved, a manual workaround had been put in place and therefore performance should start to improve.

 In respect of Workforce, the Trust experienced high levels of sickness in December mainly due to flu. The work to manage attendance continued with a reduction in the number of instances of short term sickness.

 The Trust continued to promote the need for staff to have the flu vaccine. The Chairman queried the perception that the flu jab was not effective against the strain of flu that was currently prevalent, and therefore staff did not see the benefit of having the jab and he asked if there was evidence that could be shared with staff in respect of its effectiveness. The Deputy Chief Nurse said that she understood that there was a difference in the vaccine administered by GPs and that issued to the Trust by the Department of Health. The Deputy DCN Chief Nurse was asked to gain clarity on this issue.

 The Workforce and Organisational Development Group agreed to put mandatory training on their risk register, with some training having been cancelled in December and January while the Trust was at OPEL 4.

 Mrs Lyttle raised a concern in terms of the pressure being placed on staff during the current increased level of demand and he asked for assurance that the Trust was supporting those staff. The Director of Workforce and Organisational Development provided assurance that work took place to ensure staff were being supported and had access to any support they required.

 The fact that the level of demand experienced over winter could become the new normal level of demand was discussed. The Deputy Chief Executive added that staff have suggested that as demand was always higher over winter, the Trust could consider annualised working arrangements and that this was being investigated. It was agreed that a review of winter would take place CEPA at the March Board Development session.

 The Trust had realised a surplus in month of £760,000 and year to date £304,000 better than plan. There was, however, still a gap in recurring savings. The Trust was ahead of CIP delivery for the year to date.

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18.02.07 - Board of Directors Minutes Public.pdf Page 9 of 23 Overall Page 17 of 253  Financial performance included the addition of some of the financial recovery  plan as previously discussed including the revaluation of the Trust’s estates. These actions have reduced the recovery action target from £8 to £6m.

 Financial performance did not yet take into account financial benefits if the Trust did meet its Control Total. Also, if the Trust did not succeed in having the decision in respect of the GP Streaming target for Quarter 3 reversed, it was noted that it would not lose any other STF income.

 The Director of Finance then referred to a question raised by a Governor about how the Trust reported on its financial performance and he explained that the Trust agreed its plan with NHSI at a fixed point of time in March of last year. The Trust’s budget tracked delivery of that plan but was flexed to reflect changes in delivery during the year. The biggest difference to the original plan was the £4m of income generated from the changes to the RSA, rather than an additional £4m to be found from cost reductions.

 Agency spend had reduced in December, but it was expected this would rise again in January.

 The Trust’s cash position was strong.

The Chairman reflected on the hard work that had taken place to achieve the Trust’s current financial position, and that the fact that the Trust’s target had almost been met needed to be acknowledged. He added that he felt the target for next year was not realistic or fair and that the Trust would struggle to maintain staff engagement to meet the challenge if it was not seen to be realistic.

The Board formally reviewed the document and evidence presented.

09/02/18 Staff Engagement and Communication Strategy Update

Strategic Context

To support a focused and co-ordinated approach a Staff Engagement and Communication Strategy was developed and endorsed by Board in August 2017. The strategy is underpinned by an evolving work programme.

This report seeks to provide the Board with assurance through an update on the progress made in implementing the work programme, and specifically include updates on:

- Purpose and values review - Achievement review - What matters to you staff engagement sessions - Back to the floor programme - Job shadowing - Local staff experience action plans - Randomised coffee trials - Front line job swap

Key Issues/Risks

Studies demonstrate a firm correlation between employee engagement and high organisational productivity and performance.

The Trust’s Human Resources Manager attended for this item and gave the Board an outline of the work and initiatives that had taken place in the last 6 months as detailed above.

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Mrs Marshall queried the Fab-O-Meter initiative and how when data was recorded could affect responses – for example by a junior doctor at the end of a long shift. The Human Resources Manager said that it was intended to use the tool to identify trends over a period of time.

The Deputy Chief Executive added that the resolution of issues could not always sit with managers, but that teams needed to look to resolve issues where appropriate and be enabled to do that. She added that staff needed to be able to understand how their job role was part of the Trust’s future direction of travel and to understand that direction of travel.

Ms Matthews agreed with this view, but raised a concern in terms of duplication of effort in terms of the number of ways the Trust now collected data, especially when staff were so busy. The Director of Workforce and Organisational Development acknowledged this issue, but said that some of the data collection exercises, such as the Annual Staff Survey, where taken at a point in time and could be 6 months out of date when the Trust received the data, whereas the Fab-O-Meter provided real time data which managers could act on immediately.

Mr Richards expressed concern that some of the language used could make the initiatives sound like management initiatives when teams needed to take control themselves with managers facilitating and encouraging team involvement. The Chairman added that feedback he received from front line staff was that middle managers were not as engaged as they should be, and he commended this as an action to take away from the meeting.

The Deputy Chief Nurse added that on the day patient care feedback was used in wards where staff received feedback the same day from patients and support was provided to line managers on how to feed back information from patient experience and incident reporting.

The Board formally reviewed the document and evidence presented.

Governance Issues 10/02/18 Organ Donation and Transplantation – Trust Performance

Strategic Context

The Trust has an organ donation committee consists of a core of the chair, the clinical lead for organ donation (CLOD) and the specialist nurse for organ donation (SNOD). In accordance with best practice guidelines laid down by NHS Blood and Transplant, the committee meets every 3-4 months with the following stated aims:

• To influence policy and practice to ensure that organ donation is considered in all appropriate situations, and to identify and resolve any obstacles to this.

• To ensure that a discussion about donation features in all end of life care, wherever located, wherever appropriate, recognising and respecting the wishes of individuals.

• To maximise the overall number of organs donated, through better support to potential donors and their families

• To engage the local community in education and discussion around the subjects raised by organ donation

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18.02.07 - Board of Directors Minutes Public.pdf Page 11 of 23 Overall Page 19 of 253 The Trust is judged on its performance in the ‘Potential Donor Audit’, a nationwide audit of all ICU and ED deaths, as well as the number of actual donations that take place in the hospital. The report of this audit is contained within the body of this report.

Key Issues/Risks

Our data for the 18 months to October 2017 shows 6 patients have proceeded to donate their organs following death on the Intensive Care Unit. This is entirely consistent with the numbers expected for a trust of our size and type. Of more relevance, however, is the referral rate of potential donors to the SNODs for consideration of organ donation. Our trust refers 93% of eligible patients to the service, compared to a national average of 86%. Our goal is to achieve 100% referral, and we are addressing this by systemic changes in the referral process on ICU, along with on-going programs for inter-professional education.

We are also better than the national average for the involvement of the SNOD in the family approach for organ donation, which has been shown to improve consent rates (71% for TSDNHSFT vs 57% nationally). However, there is much room for improvement in these figures, and we hope that the structures for earlier referral of potential donors should improve these in the current financial year.

The one metric from the most recent annual report in which we appear to be significantly below the national average is an approach rate of 20% (54% nationally). This measure is now recognised to not be a marker of quality practice and has been dropped from future reports.

We have plans to change our practice around where to provide end of life care (EOLC) to patients consented for organ donation to optimise retrieved organ function. This is being led by the ICU OD link nurse and one of the senior sisters and we hope to institute a change in policy that will see EOLC delivered in the theatre suite within the next 3 months.

We have established an on-going partnership with South Devon College to provide weekly education to their students around the subject of organ donation. A group of volunteer medical students, after training from the CLOD, visit the college in their free time on Wednesday afternoons to deliver a bespoke education package to up to 60 students at a time. This has been so well received that we have also provided similar sessions to the staff at the college.

We have made considerable progress with eye retrieval within the trust. A major change in personnel in the mortuary has meant that we now have the ability to retrieve eyes 7 days a week. We are now working on systems to improve the referral rate from the wards.

The Board noted the annual Organ Donation report, and the work that had taken place over the last year to improve performance, including improvements to retrieve tissue, and the experience for families affected. The Board noted that the Trust’s performance was in line with that expected for its size.

The Board formally reviewed the document and evidence presented.

11/02/18 Guardian of Safe Working Hours

Strategic Context

The new Junior Doctor contract was implemented in the Trust in line with the national implementation plan between August 2016 and August 2017. All junior doctors are now working on the terms and conditions of the new contract (with the exception of

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18.02.07 - Board of Directors Minutes Public.pdf Page 12 of 23 Overall Page 20 of 253 Trust doctors).

The Guardian of Safe Working Hours is a mandated post designed to provide support around implementation of the new contract and independent assurance in relation to the impact of the changes. A report of the Guardian is required at Trust Board on a quarterly basis.

Key Issues/Risks

 The report contains information with regard to exception reporting by junior doctors on the terms and conditions of the new contract.

 The level of reporting has risen, likely reflecting increased pressure on junior doctor activity in the early part of the winter. The level of completion of actions from the exception reporting is very low. An action plan will be drawn up by the new Guardian to improve completion.

 The Guardian of Safe Working has retired from her clinical position. Recruitment of a new Guardian has been delayed. The Director of Medical Education is providing cover in the interim pending a new appointment.

Board level engagement with Junior Doctors is being improved through shadowing by the Trust Chairman in the first instance.

The Board noted the report of the Guardian of Safe Working Hours.

The Medical Director drew the Board’s attention to the increase in reporting, which had reduced in the last reporting period.

The Medical Director also drew the Board’s attention to recent media coverage of a doctor who was convicted of manslaughter and then struck off the GMC. As part of the case against this doctor, junior doctor reflective writing was used and there were concerns about the impact this might have on junior doctors. The Secretary of State for Health has commissioned a report on this issue and the Medical Director said he was meeting with the Trust’s junior doctors later in the week to discuss any concerns they might have and provide support if necessary.

The Chairman asked if there was any way of making the exception reports any easier for doctors to complete and it was noted that it was a national document and any attempts to get it changed have been unsuccessful. The Chairman then asked if the contract could be made more gender neutral as it appeared to be disadvantageous to women. The Medical Director said that this issue had been raised during the consultation process, but the view of the Government was that although it was not as good for women as men, it was not different enough for it to be changed.

Mrs Lyttle queried the exception report data as the numbers did not appear to add up MD and the Medical Director said he would clarify the data.

The Board formally reviewed the document and evidence presented.

The Board is also formally acknowledged the commitment and achievements of the first Guardian of Safe Working to the role during the period of preparation for and implementation of the new junior doctor contract.

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18.02.07 - Board of Directors Minutes Public.pdf Page 13 of 23 Overall Page 21 of 253 12/02/18 Mortality Safety Scorecard

Strategic Context

The Safety Scorecard has been redesigned to provide focus on mortality. Other aspects of safety and quality of care are included in the Integrated Performance Report. This scorecard is reviewed at the Mortality Surveillance Group and is a key part of the assurance provided, alongside a new public facing mortality dashboard which was launched in December 2017. The mortality dashboard will contain the outcomes, learning and actions from individual mortality reviews, including an assessment of ‘avoidability’ of death. The aim is to include all patients. There is particular focus on patients with mental health problems and learning disability.

Key Issues/Risks

The Hospital Standardised Mortality Rate (HSMR) and Summary Hospital Mortality Index (SHMI) at TSDFT have been within the desirable range for our population over a prolonged period.

However, early in 2017 a divergence in HSMR and SHMI was identified. Detailed analysis of the reasons behind this has been undertaken with the support of Dr Foster and NHSI. The outcome of the deep dive has been discussed in detail at Quality Assurance Committee (QAC) in June 2017.

It is likely that changes in coding of admissions as a result of increasing ambulatory care is resulting in a reduction in coded comorbidities, affecting the standardisation of mortality data. It has been agreed that there should be a change in coding of ambulatory care patients to more accurately reflect their management. This will be in line with reporting in the other STP acute organisations. This change will not show through in our SHMI and HSMR data for some months because of the lag in mortality reporting.

Overall crude mortality shows a reduction over time. Dr Foster and NHSI support the view agreed at QAC that there is not an underlying problem in relation to mortality within the Trust, but that recording is affecting our reported rates.

The Medical Director presented the regular Mortality Safety Scorecard and reported that the Trust’s performance was good and below the national average. He added that increases in deaths would be seen and were expected over the winter months.

The Medical Director then drew the Board’s attention to the dashboard included as part of the report which was part of a new requirement to publish the number of avoidable deaths on the Trust’s public website. There was also an expectation that the data was reviewed at Board level. The Quality Assurance Committee had discussed this requirement and recommended that the Board should review the dashboard on a quarterly basis.

The Board formally reviewed the document and evidence presented.

The Board approved a recommendation that detailed discussion of the mortality surveillance process and the dashboard was undertaken at Quality Assurance Committee.

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18.02.07 - Board of Directors Minutes Public.pdf Page 14 of 23 Overall Page 22 of 253 13/02/18 Report of the Chief Nurse – Well-Led

Strategic Context

This paper presents an update on the CQC inspection process, focusing specifically on the well-led and use of resources assessment frameworks published by NHS Improvement and the CQC in June and August 2017.

The new Well-led framework for healthcare providers has a strong focus on financial and resource governance, and was developed jointly by CQC and NHS Improvement. The framework provides a single structure to enable CQC to assess and review the leadership, management and governance of an organisation.

The CQC uses the well-led framework for inspections and regulatory activity, and NHS Improvement uses it in its oversight / regulation and to support improvements in trusts. Trusts are encouraged to use the framework to carry out developmental reviews as part of our efforts for continuous improvement.

In June 2017, CQC and NHS Improvement tested the new trust-wide well-led inspection approach at three NHS trusts. NHS Improvement focused on assessing financial and resource governance, in the context of the sustainable delivery of services. Pilot inspections were not published as the purpose was to test the regulators new inspection methodology.

When CQC inspects the Well-led key question at the trust-wide level as part of the regular inspection programme they will take into account NHS Improvement’s assessment of trust’s performance. In particular, this includes NHS Improvement’s assessment of financial and resource governance within a trust.

Key Issues/Risks

The inspection will be undertaken during Winter pressure and at half-term.

Key risk areas identified:

 Operational management restructure – impact on staff  Ability to describe the Care Model going forward- impact on staff and stakeholders, including public.  Staff engagement and consistency in approach across the ICO.  External accreditation across the organisation is not mapped.

Outstanding areas identified:

 Visible leadership of leaders at every level  Trust strategies are aligned to local and national stakeholders. Close working with councils, primary care and STPs.  Appropriate interaction throughout governance structures. Clear routes for information flow.  Pride and positivity encouraged in the organisation, multiple routes to raise concerns, (FTSU guardians, Just Ask etc.)

The Deputy Chief Nurse presented this report and explained that it was based on output from work to review the Trust’s performance against the CQC well-led criteria. Taking the output of that work, and based on the fact that the CQC would be visiting at a time when the Trust was under pressure with very tired staff, the Chief Nurse’s view was that the Trust, on current evidence, would receive a ‘Requires Improvement’ rating.

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18.02.07 - Board of Directors Minutes Public.pdf Page 15 of 23 Overall Page 23 of 253 There was still work to do to improve some of the Trust’s amber ratings, and the paper detailed what was felt to be the main risks to the Trust’s score and the actions being taken to resolve those risks.

Weekly digests would start to be circulated to Board members which would detail the work taking place around the amber scores and areas of good practice and areas of risks. Mock interviews would also be taking place with Executive Directors.

The Board noted that it could expect an unannounced visit in the very near future and that the CQC had already given notice of announced visits to children and young people services and end of life services in the community.

The Deputy Chief Executive discussed the need to be able to bring evidence-based policies to life when being interviewed by the CQC, and how the Trust engaged with its clinicians etc as part of its decision-making process.

Mrs Lyttle raised a concern that, given the constraints on Non-Executive diaries, it might be difficult for Non-Executive Directors to be able to attend meetings with the CQC at short notice, and this was acknowledged. She also highlighted her concern in terms of succession planning. It was agreed this issue would be further discussed with the Deputy Chief Nurse outside of the meeting. JL/DCN

The Board formally reviewed the document and evidence presented.

14/02/18 Quality Account Improvement Priorities for 2018/19

Strategic Context

The Trust annual quality account is a statutory requirement. Each year the Trust engages with its key stakeholders to decide which 3-5 priorities the group will recommend for the Board to approve. These then will appear in the completed accounts approved by the Board in Spring.

Key Issues/Risks

Approval was required to meet required statutory deadlines.

The Board noted the work and engagement had had taken place to identify the following improvement priorities for the 2018/19 Quality Account that it was being asked to approve:

Safety: • Priority 1: winter pressures To collate, analyse and learn from clinical incidents, patient experience, and patient experience data (trolley waits/mixed sex accommodation during winter 17/18 in order to improve services during the 18/19 winter)

• Priority 2: Sepsis on inpatient wards To identify & treat any ward-based sepsis patients =<90 minutes

Effectiveness: • Priority 3: Outpatient redesign – yr. 2 To redesign and reduce the number of unnecessary outpatient appointments

Experience: • Priority 4: NHS Quicker Increase the use of NHS Quicker across Torbay & South Devon by both the local population and visitors (>20% increase from the baseline)

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18.02.07 - Board of Directors Minutes Public.pdf Page 16 of 23 Overall Page 24 of 253 Priority 5: HOPE programme: • Increase the number of people attending the HOPE programme and who benefit from improved outcomes to health and wellbeing

Mr Welch raised a concern that the priorities appeared to the acute based and the Medical Director said that this was not the intention, and that they were intended to be applied across the whole of the ICO.

The Board approved the five priorities for inclusion in the 2018/19 Quality Accounts as detailed above.

15/02/18 Governors’ Questions

The Board had received a question, as detailed below, from a number of Governors:

“Contrary to what we have previously been told, the recent letter from an A&E Consultant in Torbay to Whitehall, states that patient care is being compromised due to financial constraints. The Governors are seeking assurance as to whether this is a true reflection of the current status at Torbay A&E”

The Medical Director reported that the Trust’s lead Emergency Department consultant had asked him and the Chief Executive to approve him signing up to the letter that was printed in national newspapers outlining A&E consultants’ concerns about patient care being compromised by financial constraints. The Medical Director and Chief Executive supported him in signing the letter on the understanding that it supported the national position, but not one that was taking place in this Trust. He added that, although the A&E service had been very stretched over winter, it had felt that the department was managing and was not in crisis and patients had not been adversely affected by longer than ideal waits for treatment.

Councillor Parrott added that the Trust needed to be mindful of the fact that in recent months apparently distressed hospital workers who had been interviewed by media, had turned out to be party political activists seeking make gain from the situation. The Medical Director stated that there had been some staff who had found the demands placed on them difficult and that meetings were taking place so that the Trust could learn what it could improve in the future for those staff.

The Director of Finance reported that pay expenditure in the SDUs clearly showed that the Trust was not stopping spend on staff to keep within financial budgeted, as pay budges were overspend.

PART B: Matters for Approval/Noting Without Discussion Reports from Board Committees 16/02/18 Finance, Performance, and Investment Committee – 19th December 2017 and 30th January 2018

The Board noted the report and that a survey would be circulated to members for their views on the reporting format now that it had been in use for almost a year.

17/02/18 Quality Assurance Committee – 24th January 2018

Written report to be provided to the March meeting.

18/02/18 Audit and Assurance Committee – 26th January 2018

The Board noted that the Committee was still seeking further assurance on cybersecurity and other areas in IT.

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Strategic Context

The report provides the Board of Directors with an update on operational work programmes managed by the Chief Operating Officer.

Key Issues/Risks

Key points of note:

 Winter plans are in place supported by a Leadership Team reporting to the Chief Executive. Delivery of the 4 hour standard over the early festive period was strong however there have been challenges to delivery during January. Forecast delivery for January is 83.6% admitted or discharged within the 4 hour standard. This is the most significant variance from the monthly performance trajectory (Jan - 89.9%) this year.

 The National Urgent and Emergency Care Director has written to Trusts to inform the service that the National Emergency Pressures Panel has decided not to recommend an extension of the suspicion of elective activity beyond the end of January.

 The Care Model is developing to including changes in working practices and building partnerships with other organisations including mental health services

 The risks to delivery of the multi-agency Health and Wellbeing Centre in Dartmouth at Riverview have materialised and a new approach is now needed. The Trust and CCG remain committed to a solution for a H&WB Centre in the Town.

 Additional resources to increase domiciliary capacity in Torbay supported a more resilient service over December and into January.

The operational risks highlighted include:

 Delivery of NHSI Single Oversight Framework performance standards including 4 hour wait, RTT – 52 week, Cancer 62 day and diagnostic 6 week waits.  Increasing demand in ED impacting with risks to service resilience  Sustainability of MIU capacity and availability of radiographers  Compliance with HTA standards – Mortuary  Care home and domiciliary care capacity to support care at home  Clinical recruitment challenges affecting capacity in specialities including ED, Dermatology, Neurology, Histopathology, Endoscopy and CAMHS  Impact of extended hours for the medical take on RTT compliance in some specialities  Delays to follow up - high levels in Ophthalmology and Rheumatology  CIP plans are not yet fully at target with actions and cost pressure have emerged in year that require active management to mitigate risk to financial plan delivery  Emergency Duty Service resilience  Delays in mental health pathways  Failure to secure JAG accreditation following a self-assessment exercise in October 2017

The Board noted the report of the Deputy Chief Operating Officer and the highlighted operational risks to the Trust.

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18.02.07 - Board of Directors Minutes Public.pdf Page 18 of 23 Overall Page 26 of 253 The Board formally reviewed the report and considered the assurance provided then provide advice on any further actions to enhance the risk mitigation described in this paper.

20/02/18 Report of the Chief Nurse

Strategic Context

Safe Staffing Report - The purpose of this briefing is to provide information and assurance regarding the Nursing and Midwifery Safer Staffing levels over the previous month. On a monthly basis the number of planned nursing hours (based upon the agreed baseline safe daily staffing numbers for each ward) and actual nursing hours (the total number of nursing hours used each day) for each inpatient ward area is submitted to the national dataset. The model hospital dashboard has now been updated to show the national median data which suggests the Trust are in the best performing for cost-effectiveness.

CQC update - The CQC will be undertaking the well-led inspection on 6th, 7th and 8th of March 2018. The Provider Information Request (PIR) was submitted in November and this will inform areas for scrutiny. There will be a number of unannounced inspections between now and the well-led inspection which will also inform areas for focus. The final report is expected in May / June 2018 and will result in an updated Trust rating.

Carers strategy refresh - The Triangle of Care is an approach which recognises the importance of partnership with Carers in order to improve people’s outcomes and experiences. With supporting people at home being inherent in our model of care, the partnership and support of Carers is critical to its success. Carers Services across the STP footprint are working together to encourage a consistent approach to Carers – an overarching strategy - which includes adoption of the principles of the Triangle of Care and NHSE Memorandum of Understanding for Carers. The overarching strategy will then be embedded into Torbay’s Carers Strategy 2018-21, which is undergoing Carer engagement at the moment, ready for public consultation in the New Year.

Flu Status - There are circa 200 patients a week being tested for flu and about 30% of these patients are testing positive for either Flu-A or Flu-B. In early January we were doing about 300 flu tests per week. To date in Q4 around 1,200 flu tests have been done. Currently, there are about 10 infectious flu patients in the trust at any time. This has improved since the Xmas / New Year holiday.

Key Issues/Risks

Escalation ward has been operational through January.

The CQC are visiting at a time of escalation and reduced staff resilience.

Carer feedback nationally and locally suggests greater support required for this valuable unpaid workforce.

The impact of Flu has been managed and mitigated through the use of Warrington as a cohort ward. This has resulted in fewer general ward and bay closures.

The Board noted the report of the Deputy Chief Nurse, work that had taken place since the last Board meeting and key issues/risks to the Trust.

The Board formally reviewed the document and evidence presented.

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18.02.07 - Board of Directors Minutes Public.pdf Page 19 of 23 Overall Page 27 of 253 21/02/18 Report of the Director of Estates and Commercial Development

Strategic Context

To provide assurance to the Board on compliance with legislation, standards, and regulatory requirements, and to provide information on the assessed level of risk and management of same for Board consideration.

Key Issues/Risks

Estates Maintenance performance: The performance of both planned preventative and responsive maintenance has been challenged over the last few months as a result of an increasing workload on the service and some consequential significant change within the Estates department. A robust risk assessment process has provided assurance to the Executive and the Capital, Environment and Infrastructure Group (CEIG) that significant and high risks are and have been prioritised and actioned. This has meant staff have been focussed on completion of statutory PPMs (maintaining the safety of the built environment) to the detriment of the responsive estates indicators. Although recruitment is now up to the revised establishment, demand across all requests still exceeds the amount of resource available.

A review of demand and capacity is being undertaken to re-focus the workforce to meet statutory, mandatory and priority P1 and P2 activity related to patient safety, infection control and staff safety. This may well mean that lower priority jobs (P3 and P4) are unable to be considered for completion by the directly employed staff. The demand and capacity analysis and review of activity will be completed within the next four weeks. With the re-prioritisation and focus on statutory maintenance and priority response, performance in these areas will return to expected standards.

Fire Training: Percentage of staff undertaking mandatory fire safety training remains low and is below Trust requirements. Executive Directors have taken action informing Managers of the issue within their business units. The Fire Safety Officer continues to provide additional training as requested.

Estates failure – Special theatres: The poor condition of special theatres and consequent high risk of failure is well known to the Board. The Estates team have been unable to maintain the temperature of these theatres and consequently a clinical and operational decision has been taken to close theatre B as soon as possible. There are four theatres that are at high risk of failure. The replacement strategy:- that of two new theatres (built where old ICU was) have been designed this financial year and had been identified as a priority for funding in the 2018/19 capital programme. This will mitigate the increasing risk of theatre failure and loss of surgical activity.

The Board noted the report of the Director of Estates and Commercial Development, work that had taken place since the last Board meeting and key issues/risks to the Trust.

The Trust Board formally considered the risks and assurance provided within this report.

22/02/18 Report of the Director of Workforce and Organisational Development

Strategic Context

 To update the Board on the activity and plans of the Workforce and Organisational Development (OD) Directorate as reported to and assured by the Workforce and Organisational Development Group.(WODG).

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18.02.07 - Board of Directors Minutes Public.pdf Page 20 of 23 Overall Page 28 of 253  To provide the Board with assurance on workforce and organisational development issues.

Key Issues/Risks

 Sickness absence – the annual rolling rate of 4.07% at the end of November 2017 represents a further reduction from the high of 4.40% in January 2017. However, the month of November itself was reported at 4.58% which is the highest monthly figure of the year. This is against a target rate of 3.80% Early indications are that the month of December will show a further increase.

 The Trust is under planned agency expenditure. At Month 8 the spend was below plan by £1,707,000 and the Trust is on target to achieve the NHSI cap by the end of the year.

 Mandatory Training has been added to the risk register.

 Further information on the above is contained in the Integrated Performance Report.

The Board noted the report of the Director of Workforce and Organisational Development, work that had taken place since the last Board meeting and key issues/risks to the Trust.

The Board formally reviewed the document and evidence presented.

23/02/18 Report of the Director of Strategy and Improvement

Strategic Context

This report provides the Board with an overview of the key areas of development and activity for the Directorate. It highlights key areas of focus in the first section which include the development of the strategic refresh, the continued focus on strategic communication and engagement and an overview of the business planning framework.

The second section provides a summary of key outputs for quarter 3 and a forward view for quarter 4 for each of the departments, together with key performance indicators that reflects progress against important strategic objectives.

Key Issues/Risks

It is important the Board is assured that the Strategy and Improvement Directorate is best positioned to create, enable, and add value across the organisation and health and care system in one of the most challenging and complex periods the NHS has ever known. Expertise and capacity within the directorate must be focussed towards the organisation’s biggest strategic and delivery challenges to optimise the success of the organisation and support its sustainability.

The Board will play an important role in March when we will discuss and agree the strategic refresh framework and the development of a strategic narrative that connects and unites people around a story for our future.

The Board are asked to note the continued key risk in accessing the capital and revenue funds required to enable Information Technology Innovations that are critical to achieving our ‘tell my story once’ vision’.

The Board noted the report of the Director of Strategy and Improvement, work that had taken place since the last Board meeting and key issues/risks to the Trust. Page 21 of 23 Public

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The Board formally reviewed the document and evidence presented.

24/02/18 Report of the Medical Director

Strategic Context

Medical recruitment to the Trust remains a concern in a number of specialties, in the main reflecting national recruitment challenges.

The Medical Director has previously reported the areas of clinical service that are under particular challenge.

This report provides an update on recent senior medical recruitment and strategies to ensure continuity of service provision and maintenance of service quality and safety.

Key Issues/Risks

The report contains an update on:

1. recruitment of senior doctors to the Trust, vacancies and recent successful recruitment 2. The involvement of Torbay and South Devon Foundation Trust in the national approach to streamlining recruitment of doctors in training 3. The development of clinical networks as part of the Acute Service Review and/or the SEND collaborative as a response to recruitment difficulties and as a solution to the development of more resilient specialist services.

The Board noted the report of the Medical Director, work that had taken place since the last Board meeting and key issues/risks to the Trust.

The Board formally reviewed the document and evidence presented.

25/02/18 Compliance Issues

Nil.

26/02/18 Any Other Business Notified in Advance

Nil.

Exclusion of the Public

It was resolved that representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (Section 1(2) Public Bodies (Admission to Meetings) Act 1960).

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PUBLIC

No Issue Lead Progress since last meeting Matter Arising From 1 Identify lead NED for Emergency and Security. Ch Completed – Mr J Welch had taken on the 01/11/17 role 2 Detailed report to be provided to February meeting on the STP’s demand DSI February Update – the STP had not yet 06/12/17 management strategy published its demand management strategy.

3 Clarity to be provided on the potential differences between the flu vaccine DCN Completed – the Department of Health have 07/02/18 issued to the Trust from the Department of Health and that issued to GPs. recognised the difference between the vaccines issued to Trusts (trivalent) and GPs (quadrivalent) and have advised all trusts to purchase the quadrivalent vaccine for the 2018/19 season.

4 March Board Development Session to include a review of winter. CEPA 07/02/18

5 Safe Working Hours exception data to be clarified. MD 07/02/18

6 Discuss NED attendance at CQC interviews. JL/DCN 07/02/18

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MAIN REPORT

Report to Trust Board

Date 7 March 2018

Lead Director Interim Chief Executive Report Title Chief Executive’s Business Update

1 Trust Key Issues and Developments Update

Key Trust issues and developments to draw to the attention of the Board since the last Board of Directors meeting held in February are as follows:

Safe Care, Best Experience

Safely caring for our population this winter The challenge of providing safe care has continued as we have moved into February with high levels of flu and norovirus, staff shortages through recruitment challenges and sickness and reports of people not experiencing the timely care we would want for them. We have, again this month, had to declare OPEL 4 on a number of occasions – indicating that we are experiencing the most severe level of operational pressures right across our health and care system. Staff are following agreed escalation plans and procedures and, thanks to our new care model, we are able to cope better and provide a better service by supporting many more acutely unwell people in the community than would previously have been possible. We are also mobilising staff from support services to work with/on the front line in whatever capacity they can to maximise the resources we have available to us. We have continued to communicate important messages to the public via a wide range of channels including the media and social media. The messages have included advice on choosing appropriate services to meet healthcare needs, downloading the waiting time tracker NHSquicker, good hand hygiene to help avoid illness and not visiting hospitals when they might infect others. Our social media posts alone have reached tens of thousands of people. We have also continued with our campaign to share some of the positive feedback that we receive from patients and service users as part of our #ProudOfOurNHS campaign. We are using this hashtag on ICOn, our website and social media feeds to acknowledge the pressures and challenges facing the NHS, whilst celebrating the outstanding dedication of all our staff.

Comment: On behalf of the executive team, I would like to draw the Board’s attention to the additional effort that everyone is making. We realise that working this way is not sustainable and that people are very tired. We continue to focus on our ‘big 7’ priorities for winter, putting in place extra support wherever we can – including making our winter leadership team available 24/7.

Public

Report of the Chief Executive.pdf Page 1 of 11 Overall Page 33 of 253 Extreme weather at the beginning of March Due to the extreme winter weather conditions and red weather warning from the Met Office, we implemented our internal major incident plans on 1 March, so that we were able to continue to support urgent and emergency services. All non-urgent activity was cancelled for Thursday and Friday, including outpatient appointments and day surgery. In addition, the MIUs in Dawlish and Totnes and Castle Circus Health Centre had to close.

We were able to continue to provide a safe service due to so many of our staff who went well beyond what would have been expected to help keep urgent and emergency services running – working longer hours, sleeping in the hospital, supporting colleagues in other work areas. Our thanks to all our staff for their commitment and compassion.

In line with our policy all staff were asked to continue to report for work if it was safe for them to be able to do so or to report to their nearest hospital or health and wellbeing centre again if safe to do so. Other staff who were not on duty were also asked to report in if they were able.

We communicated with the public throughout so that they were aware of the situation and also to remind them to use services wisely and only attend the Emergency Department or call 999 in an actual emergency and to, as normal, use others services appropriate to their needs.

Health and Wellbeing Centre Development for Dartmouth: Update As the Board is aware, the development of a fit for purpose Health and Wellbeing Centre for the people of Dartmouth is a key priority for the Trust.

Following the breakdown of negotiations with the building owners to develop a health and wellbeing centre for Dartmouth at River View, we are now reviewing how to achieve an alternative health and wellbeing centre in Dartmouth. Our first step is to work with our partners and commissioners to revisit the services that need to be delivered so we can explore and develop what further options there are. Once our options appraisal is complete, we will share it with local stakeholders.

We remain committed to improving health care delivery, by focussing on what is important to people and have invested in services that are as close to home as possible with the expectation that more people can have their care needs better met out of a hospital. Dartmouth Clinic offers a wide range of outpatient clinics, including: audiology, bladder and bowels, community therapy, counselling, depression and anxiety services, Devon Carers, district nursing, ENT, heart failure, minor operations, physiotherapy and podiatry.

The investment into community services has included intermediate care services, investment into the voluntary sector and medical support. In the last three months, 58 people in Dartmouth have been supported by our intermediate care service that includes therapist and Nurses – of these five people required a short term placement in a residential care home. We are continuing to work with partner agencies and the owners of River View care home to ensure improvements highlighted in the recent CQC inspection are addressed and that residents’ needs are being met.

Well Led

CQC inspection The CQC Well-Led inspection will take place from 6 – 8 March 2018 and will focus specifically on the performance of the board and whether they are able to marshal the necessary information and intelligence to understand and be assured in regard to current performance, to plan at strategic and operational levels to improve services and to manage effectively the risks to Public

Report of the Chief Executive.pdf Page 2 of 11 Overall Page 34 of 253 delivery. Given the nature of the Well-Led inspection we are not expecting visits to all wards/sites. The CQC also visited on 13/14 February to inspect community paediatric services, young peoples’ services and community end of life care. At the same time a separate team of inspectors arrived and undertook an unannounced inspection focussing on outpatients, maternity services, acute End of Life Care and acute mental health services. During the week of 19 February the Trust also took part in the NHS I use of resources review which contributes to the CQC overall well led assessment.

As a learning organisation we welcome the review as it an opportunity to share areas of excellence as well as time to hold up a mirror and reflect on where we have more to improve. We know the inspectors are reviewing our services at a time of severe challenge and following a year of prolonged and significant change. We look forward to receiving their independent feedback so we can use to inform our improvement plans in our aspiration to be outstanding.

Delivering Today: 2017/18 Month 10 service delivery and financial performance headlines Key headlines for financial, operational, local performance, quality and safety and workforce standards/metrics for Month 10 from the integrated performance report to draw to the Board’s attention are as follows: Service delivery headlines  ED 4 hour wait standard: 83.82% of patients were discharged or admitted within 4 hours of arrival at accident and emergency departments in January. This is a fall on last month (88.34%) and is below the agreed Month 10 Operational Plan trajectory of 89.9% and below the 95% national standard. Performance has continued to decline in February  RTT trajectory: RTT performance has improved marginally in January with the proportion of people waiting less than 18 weeks increasing from 82.2% in December to 82.4% in January  Patients waiting over 52 week In addition the number of people waiting over 52 weeks is starting to reduce in line with plans; at the end of January 29 people were reported as waiting over 52 weeks against the plan of 34. The trajectory remains to achieve 16 at the end of February and zero at the end of March. The March delivery of zero 52 week waits is at risk due to operational pressures which are limiting the number of elective inpatient admissions. In January a higher number of elective inpatient operations were stood down; this is likely to continue whilst the urgent care pressures remain in the system. Teams are monitoring on a daily basis and implementing additional lists where possible to mitigate for this loss in capacity to deliver the March position of zero waiting over 52 weeks.  62 day cancer standard: 84.6% (validated 14 February 2018) against the 85% national target, this is a marginal improvement on last month (82.4%) but still below the national target. The standard in Q4 NHS I assessment is predicted to be met against the target 85%.  Diagnostics: The diagnostics waiting time 6 week standard was not met in January with 5.38% of people waiting over 6 weeks outside of the agreed tolerance of 3%. The greatest number of long waiting patients were for routine MRI with an increase in Echocardiography waits accounting for the greatest change in the January reported performance.  Dementia screening: The Dementia find standard was not met in January with 52.1% reported (last month 65.5%). As previously reported, a drop in reported performance was forecast with the transition to the “Nerve Centre” clinical information tool which is being rolled out; a definitive timeline for this work is still awaited.

Comment: Given the risks to patients relating to long waiting times, reducing treatment times, particularly for people on cancer pathways, continues to be an operational priority.

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Report of the Chief Executive.pdf Page 3 of 11 Overall Page 35 of 253 Financial Headlines  Overall financial position: The financial position against NHSI Control Total for the 10 months to 31 January is a surplus of £0.52m against a planned surplus of £0.57m. In the month of January a surplus of £1.31m has been achieved, which is £0.56m behind plan. (After the income reduction of Q3 ED STF, 75% of MARS accrued and a £200K hit on provisions)  Pay expenditure: Total pay costs are underspent against plan to Month 10 by £0.64m. (after the MARS accrual)  Cumulative savings delivery: The Trust has delivered £33.5m against our year to date savings profiled target of £32m (including income Generation target); resulting in a £1.5m over-delivery year to date  System savings plan forecast outturn: at the end of January the Trust identified savings potential of £42m resulting in a £0.1m current year shortfall against the £40.7m cost reduction target and income generation target of £1.33m required to achieve the Trust Control Total of £4.7m surplus; of this £30.1m is identified as recurrent FYE savings potential.

Comment: Based on our performance year to date, at month 10, the Trust had an actual use of resources risk rating of 2 (subject to confirmation by NHS Improvement). The Agency risk rating of 1 is a material improvement to the planned rating of 2. It is important to recognise that this scale of forecast delivery represents a significant improvement on the achievements of previous years. Any slippage in delivery would however put the control total and £5.7m STF funding at risk, affecting liquidity and, in turn capital investment plans. At this stage the Trust continues to forecast delivery of the control total excluding STF, although this is subject to the delivery of the recovery plan and mitigation of any further cost pressures. The delivery of plans to address remaining financial risk is ongoing and being monitored through the relevant Board Committees with risks escalated for Board discussion and decision.

Planning for 2018/19 The national NHS planning guidance released by NHS I on the 2nd February 2018 requires organisations to submit a refreshed narrative plan and financial, workforce and activity templates for 2018/19.

Draft submissions are required by noon on the 8th of March followed by final submissions by noon on the 30th April 2018. These submissions must include a clear statement as to whether, or not, the Trust Board accepts the control total issued by NHS I.

Teams are working to finalise the submission in conjunction with partners across the local South Devon and Torbay system and in line with agreed Devon STP approach. The FPIC has been briefed on the emerging position following the presentations at last month’s SDU business planning presentations to Board. The ‘Foreword’ has been used, as we did last year, to signal concerns in regard to the scale of the financial challenge faced by the Trust, the Control Total issued by NHS I and the need to balance these with the challenge of providing safe and sustainable care to the people we serve. in regard to performance trajectories and targets for 2018/19 the national planning guidance appears to be more permissive than in previous years in regard to some of the key targets.

Directors will update the Board in private session on the latest position so the Board can consider whether it is in a position to accept the 2018/19 control total in the March 8th submission.

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Report of the Chief Executive.pdf Page 4 of 11 Overall Page 36 of 253 Developing the Care Model Narrative We have a clear vision of how we provide care to support people to be able to live their lives how they wish and our care model is supporting this to happen. We have communicated this widely and now want to develop a clearer compelling narrative with supportive imagery that inspires our staff, stakeholders and local population. We, in partnership with the CCG, have been working with behavioural specialists, ICE Creates, to bring the narrative to life using imagery. In the last few months they have held workshops across South Devon and Torbay involving staff and partner organisations. This included an open session in the main entrance of Torbay Hospital which was open to anybody to come along and take part. During February they shared and checked out their insights that will inform the next stage of producing the imagery and narrative. The emerging narrative and imagery will be discussed at the March Board development session with an opportunity for Board contribution. Once finalised this will inform our communications and engagement activities.

Valuing our Workforce, Paid and Unpaid

Reflect and Connect We know that in order to provide the very best compassionate care to others we need to be compassionate towards ourselves. When we are so busy, doing this is a challenge, but this is vital to our wellbeing and the quality of care we provide. Some of us think best when we have time to connect with others and talk through our experiences. Some of us need a quiet space to think and reflect. The Executive Team is very keen to support our staff to access these opportunities, and have asked team leaders colleagues to create safe spaces where people can just be or can come together to talk and support each other.

One of Britain’s longest serving nurses retires after 66 years A Torbay Hospital nurse has retired after clocking up an astounding 66 years’ service for the NHS. Monica Bulman, a Registered General Nurse (RGN), worked on Hutchings ward at Torbay Hospital as part of the specialist outpatient surgical clinic team for Endoscopy. She is one of the oldest and longest serving nurses in Britain. Monica’s retirement, which took place on 22 February, coincides with national celebrations of the NHS 70th anniversary year. The NHS was launched on 5 July 1948 and Monica has worked for the NHS for 66 out of the 70 years since its creation.

NHSquicker App International recognition As previously reported, in January the NHSquicker App was launched across Devon and Cornwall. The free App, that shows live waiting times (and travel times) for the nearest ED and Minor Injuries Units, was the brainchild of the Health and Care IMPACT Network – a collaboration between healthcare organisations and universities across the South West. QI staff from the Trust (Susan Martin and Dr Andrew Fordyce) have driven its development with support from the University of Exeter. Susan Martin has successfully submitted a paper on the App’s development to the International Micro Systems festival in Jönköping and has been invited to present on behalf of the Impact network to an audience of QI practitioners.

Staff Flu Vaccinations All of our staff have been offered the opportunity of a free flu vaccination. Our peer vaccinators have run many clinics across the estate as well as vaccinating staff at their place of work to make it as easy as possible. Currently over 60% of staff have taken up the opportunity to protect themselves and others from the flu. Given the levels of flu in the community, teams continue to encourage those staff yet to take up the offer to come forward for immunisation.

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Report of the Chief Executive.pdf Page 5 of 11 Overall Page 37 of 253 Good news stories from our Service Delivery Units At the monthly quality and performance review meetings, as well as reviewing quality, safety, finance service delivery and workforce performance, Directors also encourage the SDUs to share developments or service improvements of which they are particularly proud or want to highlight as good practice to share with the Board.

 Histopathology: Following recruitment difficulties and retirements within the histopathologist workforce there has been collaborative work with the RD&E Hospital to transfer the breast histopathology work to their histopathology service. This is due to take effect on the 1st April 2018. No changes to the patient pathway are expected as a result of this change to this diagnostic element of the process.  Intensive care Unit first anniversary: On 27 February the Trust celebrated one whole year since our new, state-of-the-art Intensive Care Unit (ICU) opened at Torbay Hospital. The unit, which was made possible by the generous financial support of the Torbay League of Friends has treated almost 700 patients in the first year  Community services areas of excellence to share this month include Nigel’s story (patient video) describing the health and wellbeing support he had received which improved his life; successful approach to recruiting social workers in the Bay; homelessness project in Torquay and staff from the safeguarding teams have trained over 100 staff from the independent sector as a part of a rolling programme covering mental capacity act, deprivation of liberties and other important social care legislation.

2 Interim Chief Executive February Internal and External Engagement Internal External

• All Managers’ Meetings • Joint Executives’ Meeting with SDTCCG • Clinical Management Group • STP Chief Executives’ Meeting • Medical Staffing Committee • STP Programme Delivery Executive Group • Senior Midwives Team • STP CEO/COO/MD Meeting • Staff Drop in Sessions: • Chief Officer for Adult Care and Health, - Newton Abbot Hospital DCC • Chief Executive, Plymouth Hospitals Trust • Chief Executive, Brixham Does care • Brixham League of Friends

3 Local health and care economy developments

Partnership updates

Devon STP Update A separate paper included in the Board pack sets out the latest update from Devon STP following the last Programme Delivery Executive Group (PDEG) held on 16 February. Items include:

 STP transitional support arrangements  Risk Stratification Tool Implementation Plan

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Report of the Chief Executive.pdf Page 6 of 11 Overall Page 38 of 253  Acute Services Review update (phase 1 and 2018/19 priorities) and Dermatology clinical recommendations  Clinical Cabinet work plan  Finance planning: updates on Planning Guidance and the Naylor Review  Inequities review.

Partner updates

Silver surfer training in Torbay Healthwatch Torbay is delivering a free local programme of online health and social care training and support – aimed primarily at older people and voluntary community groups in Torbay. The ‘Digital Inclusion’ project is designed to reach a large number of front line volunteers, so that they have the skills to assist those lacking access to the internet to get and use online health and social care resources. The project will also offer one-to-one support to those aged over 50 so that they can receive advice and support in their own home and be shown how to register with local online resources such as self-referral systems, appointment-booking systems, and how to rate and review local services online

CQC reports on Plymouth integration plans CQC inspectors have praised Plymouth’s health and social care system for its “clearly articulated, long-established vision of integration.” Specifically looking at the link between health facilities and care providers, an investigation found that leaders had committed to a joined-up approach to care and worked cooperatively to implement it. The review was part of 20 targeted local reports currently being completed by the regulator at the request of health and social care secretary Jeremy Hunt and communities secretary Sajid Javid. Cornwall partnership Trust requires improvement England’s Chief Inspector of Hospitals has told Cornwall Partnership NHS Foundation Trust that it must make improvements in the quality of its services. Cornwall Partnership NHS Foundation Trust took over the provision of community health services previously provided by Peninsula Community Health Community Interest Company in April 2016 and this was the first inspection of the trust following that change. A team of inspectors from the Care Quality Commission visited Cornwall Partnership NHS Foundation trust as part of its comprehensive inspection programme. As a result of this inspection, CQC has rated the trust as Requires Improvement overall. CQC also rates all services on five key questions. It has rated the trust as Outstanding for Caring; Good for Responsive, and requires improvement for Safe, Effective and Well led

Former health minister to chair Somerset STP A former Department of Health and Social Care minister has been appointed as chair of a sustainability and transformation partnership. Stephen Ladyman will chair the Somerset STP after the departure of interim chair and current NHS Confederation chief executive Niall Dickson, who had been in post since January last year. Mr Ladyman is also chair of Somerset Partnership Foundation Trust – the county’s mental healthcare provider. He was elected as the Labour MP for South Thanet in 1997 and became a minister for communities at the DHSC in 2003. He went on to become a transport minister before losing his seat in 2010. Mr Ladyman joined Somerset Partnership FT in 2013.

4 National Developments and Publications Details of the main national developments and publications since the February Board meeting have been circulated to the Board regularly through the weekly developments update briefings.

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Report of the Chief Executive.pdf Page 7 of 11 Overall Page 39 of 253 There have been a number of items of particular note that I wish to draw to the attention of the Board as follows:

Focus on winter pressures:  NHS gives up on A&E target until 2019:NHS England and NHS Improvement say the health service has given up on hitting the key A&E target to treat 95% of patients within four hours for 2018/19. The target has not been met since July 2015 and winter pressures saw the rate dip to 85.1% in December. NHS documents declare that trusts are expected to hit 90% of performance in September, while the majority are expected to achieve 95% by March 2019.  January performance stats confirm ‘unprecedented’ winter: Responding to the publication of January A&E data which showed the highest ever number of emergency admission since data collection started, Chief Executive at NHS Improvement Ian Dalton said: “NHS staff across the country have worked exceptionally hard to meet the unprecedented challenges they have faced this winter. January saw the highest number of emergency admissions since the data collection began and, on top of this, hospitals had to manage a serious spike in flu cases. It is testament to NHS staff that they have treated, admitted or discharged more patients than ever before within the four hour target and I would like to say a huge and sincere thank you to staff for their efforts during an extremely challenging winter period. It is clear that hospitals have been under considerable pressure and emergency activity has justifiably taken precedence over elective work, although this is not a decision that hospitals take lightly. We are expecting demand for emergency activity to continue rising and local systems must plan for next year on this basis. They must use realistic figures and work as one to plan staffing levels, beds and capacity for 2018/19. This will help protect trusts’ ability to perform vital elective work.”  Norovirus leads to 800 bed closures: A spike in the number of norovirus cases saw more than 800 hospital beds being closed per day across the UK last week, according to official figures. NHS England also revealed that 10,800 patients had experienced waiting times of over 30 minutes when arriving at A&E by ambulance. The NHS 111 line received 335,900 calls in the week ending February 11, 18.3% up on the equivalent week last year. Bed occupancy remained high, at 95% for general and acute care beds and 85.5% for adult critical care beds. The official figures also showed 1,908 patients were placed in mixed-sex wards in January, the highest level since 2010, when the Government imposed a crackdown on the practice  Record levels of winter-related deaths forecast: The worst winter-related deaths crisis for almost two decades is expected this year. Public Health England warned flu is still circulating widely with more than 100 admissions to hospital in the past fortnight – and campaigners fear this winter could bring unprecedented numbers of deaths amid forecasts of severe cold weather into mid-March.

Government

 Secretary of State launches plan to address NHS prescription errors: The health and social care secretary Jeremy Hunt has advised that handwritten NHS prescriptions must end in response to a new report which found that errors involving dispensed medicines kill up to 22,300 patients a year. The report found that NHS staff make 237 million drugs errors every year, more than a quarter of which injure patients and cost up to £1.6bn.  Social care funding boost for councils: Communities Secretary Sajid Javid has said local authorities will receive an additional £150m for social care services, through an adult social care support grant. Rural authorities will receive an additional £16m to deliver services.

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Report of the Chief Executive.pdf Page 8 of 11 Overall Page 40 of 253  Nursing post-graduate bursaries scrapped: The DHSC has announced that postgraduate nurses, midwives and "allied health professional students" will no longer be exempt from tuition fees from August 2018.

Public Health England

Local authorities should ensure 100% offers of NHS Health Check for residents PHE Chief Executive Duncan Selbie, has called on local authorities to ensure that all local residents eligible for a free NHS Health Check get an invite to help tackle the 1 in 4 premature deaths in the country caused by Cardio Vascular Disease (CVD). The NHS Health Check is free for all adults in England aged 40-74, who have not yet developed CVD. CVD is a leading cause of disability and death in the UK, affecting around 7 million people and being responsible for 26% of all deaths in England – estimated to cost the NHS around £9 billion a year.

NHS Digital developments

NHS trusts assessed on cyber security fail inspection Every NHS trust assessed for cybersecurity vulnerabilities has failed to meet the standard required. In a parliamentary hearing about the WannaCry attack that disrupted parts of the NHS last year, DHSC officials said all 200 trusts had failed, despite increases in security provision. NHS Digital deputy chief executive Rob Shaw told the Commons public accounts committee on Monday that the agency, in assisting the Care Quality Commission, was conducting unannounced visits of some trusts up until the end of March.

Comment: the Trust had a visit in February and feedback is awaited. Investment in additional cyber security measures features in the Trust’s capital plan requirements.

NHS manager numbers return to pre-Lansley reform levels The number of senior managers working in NHS trusts and clinical commissioning groups has increased by more than a quarter since 2013 – and is now higher than before the reforms introduced by Andrew Lansley. The latest workforce data from NHS Digital shows overall the number of senior managers increased by 25 per cent between April 2013 – when the Health and Social Care Act 2012 took effect – and October 2017. This meant a rise of more than 2,000 full time equivalent employees. Other staff described as managers increased by almost 4,000 between April 2013 and October 2017 – growth of 22 per cent. Despite the growth since 2013, the total number of managers and senior managers employed by acute, community and mental health hospitals and CCGs is still lower than their recorded peak in 2010. Senior managers are down by 12 per cent and managers down by 14 per cent compared to 2010 levels – a total drop of more than 5,000 employees.

Salary data reveals NHS gender pay gap Figures from NHS Digital show that just five of the top 100 highest paid NHS consultants are female. Salary data from last year shows that the top male earner made over £730,000, while the top female earner – a radiologist - made £281,616. This places her 39th in the overall rankings and sees her as the only woman in the top 50 earners. The data shows the oldest male consultants were paid up to 22% more than their female counterparts, with an average 7% pay gap across all age groups.

Could this happen here?: The Medical Director is looking at how the Trust benchmarks and will provide a verbal update at the Board of Directors meeting.

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Report of the Chief Executive.pdf Page 9 of 11 Overall Page 41 of 253 National Audit Office 2,000 'high-priority' NHS letters lost in the system A report into the loss of NHS medical letters has revealed that 374,000 pieces of clinical correspondence which were not redirected as they should have been includes 1,811 “high priority items” such as screening or urgent test results. The total includes 162,000 medical documents that had been mistakenly sent to the outsourcing firm Capita. The backlog will cost an estimated £2.4m to clear.

Research

Public satisfaction with NHS at record low Public satisfaction with GP services has fallen to its lowest level since records began in 1983, according to the annual British Social Attitudes survey conducted by the National Centre for Social Research (NatCen). Satisfaction dropped seven percentage points to 65% in the 2017 study, making it the first time general practice has not been the highest-rated NHS service.

The survey also found dissatisfaction with the NHS overall has reached its highest level for a decade. The findings, collected by the National Centre for Social Research and analysed by the King's Fund and the Nuffield Trust, showed voters are increasingly concerned about staff shortages in the NHS, long waits to receive care and the amount of money given to health services.

5 Local Media Update

The Trust’s recent communications and media activity includes:

 Mail Online - Now paramedics are hired to work in A&E: Trusts in four counties advertise for emergency workers to plug staff shortages in departments – here  BBC Radio Devon, BBC Spotlight, Breeze FM – Nurse recruitment open day  Devon Live, Breeze FM - Maternity survey shows excellent feedback on care  Publicity for the Time to Talk event – seen on Facebook alone by thousands of people.  Continuing #ProudOfOurNHS – thank you video has now reached nearly 25,000 people  Devon Live – Liz Davenport responds to claims that developing an Accountable Care System may lead to Torbay Hospital closing– here  ITV Westcountry – Lisa Houlihan, Emergency Department Matron, was interviewed as part of the national release of the performance statistics. Lisa explained how we ensure safety continues despite the extreme pressure and that we our staff, right across the system, worked very hard to ensure this. A patient was interviewed who was very happy with our care.  Breeze FM, Radio Devon – Nurse Recruitment day included an interview with matron, Pat Searle - here  Devonlive - Mum left in agony claims hospital gave her the wrong medication – here Includes Trust statement  Devonlive - What has been in the impact of Paignton Hospital beds closure? – here There has been no increase in A&E admittance at Torbay Hospital in the over 65s – includes statement from the Trust  Devonlive - NHS rally planned by Labour and health unions for Torbay – here Includes a line from Liz Davenport saying those suggesting Torbay Hospital could close are wrong  Social Media – We have continued sharing some fantastic feedback as part of our #ProudOfOurNHS campaign. Please do have a look at it on Twitter and Facebook.

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Report of the Chief Executive.pdf Page 10 of 11 Overall Page 42 of 253  Social Media - We have continued to post on a wide variety of topics including looking after yourself in the cold weather, the HOPE programme and encouraging people to take part in our website survey. One post alone that marked the retirement on an 84 year old nurse at Torbay hospital has reached over 40,000 people and the number is continuing to rise.  Social Media - was used widely to communicate to the public during the severe weather at the beginning of March. Many messages of support were received.

6 Recommendation

The Board is recommended to review the report and consider implications on the Trust’s strategy and delivery plans.

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Report of the Chief Executive.pdf Page 11 of 11 Overall Page 43 of 253 Overall Page 44 of 253

REPORT SUMMARY SHEET

Meeting Date 7 March 2018

Report Title Devon Sustainability and Transformation Partnership Update

Lead Director Director of Strategy and Improvement

Corporate Objective  Safe, quality care and best experience  Improved wellbeing through partnership  Valuing our workforce  Well led

Corporate Risk/  Available capital resources are insufficient to fund high risk/high Theme priority infrastructure/ equipment requirements /IT Infrastructure and IT systems.  Failure to achieve key performance/ quality standards.  Inability to recruit/retain staff in sufficient number/quality to maintain service provision.  Lack of available Care Home/Domiciliary Care capacity of the right specification/quality.  Failure to achieve financial plan.

Purpose Information Assurance Decision

  Summary of Key Issues for Trust Board Strategic Context The Devon Sustainability and Transformation Partnership (STP) provides a single framework through which the NHS, local authorities and other health and care providers work together to transform health and care services. A single board update is now produced monthly following the Programme Delivery Executive Group (PDEG) meetings. This is the fourth update, following the meeting of PDEG on 16 February.

The purpose of this report is to:  provide a monthly update that can be shared with Governing Bodies, Board and other meetings in STP partner organisations;  ensure everyone is aware of all STP developments, successes and issues in a timely way; and  ensure consistency of message amongst STP partner organisations on what has been endorsed at the Programme Delivery Executive Group (PDEG). All partner organisations in the STP are represented at senior level at PDEG.

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Devon STP Update.pdf Page 1 of 11 Overall Page 45 of 253 Key Issues/Risks Core Content Items included in this monthly update following the PDEG meeting held on 16 February are as follows:  STP transitional support arrangements  Risk Stratification Tool Implementation Plan  Acute Services Review update (phase 1 and 2018/19 priorities) and Dermatology clinical recommendations  Clinical Cabinet work plan  Finance planning: updates on Planning Guidance and the Naylor Review  Inequities review.

Risk As previously identified, the main risk to the Trust remains having the leadership and clinical capacity to engage in and inform STP programmes and work streams on top of Trust and local system change programmes – this is being kept under review and a “do it once” approach for Devon is being pursued.

Recommendations The Board is asked to note the progress of the Devon STP

Summary of ED STPs are increasingly being seen by NHSE as the gateway for Challenge/ performance and access to capital and transformation funding. It is Discussion essential that the Trust is fully engaged within the Devon STP, influencing and informing STP strategy development and implementation.

The Devon STP is moving towards having a single strategic commissioner for NHS services across the county by April 2018. As part of this direction of travel, some functions such as communications and finance will be integrated into the strategic commissioner early (in 2018/19) while PDEG supported the preferred option to ‘ring fence’ the transformation part of the STP team within the strategic commissioner.

All of the Executive director team, together with many of our lead clinicians and heads of service, are involved in some way in the STP – either through direct leadership of programmes or membership of the respective programme boards/workstreams/professional working groups and enabler programmes.

The aspirations and ambition of the STP regarding a more Integrated Health and Care System and Integrated Care Model are absolutely aligned with and supported by the Trust’s own strategy and place –based “home first” shared vision.

The Trust’s business planning for 2018/19 needs to align with the overall STP plan and return

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Devon STP Update.pdf Page 2 of 11 Overall Page 46 of 253 Internal/External Any requirements for internal and external engagement and consultation Engagement inc. arising from the above projects will be led by Andrew Millward, System Public, Patient & Lead Director of Communications & Engagement and delivered through Governor the STP Communications and Engagement group. There will be a single, Involvement consistent and co-ordinated approach across Devon.

Our joint heads of communication, Corinne Farrell and Jacqui Gratton are fully engaged with the work of the STP Communications and Engagement group.

Equality & Diversity A key principle of the STP is equity of access to health and care for Implications patients across Devon. There is also a focus on achieving parity of mental and physical health considerations.

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Devon STP Update.pdf Page 3 of 11 Overall Page 47 of 253

Boards, Governing Bodies and Local Authority Update to meetings of Devon STP partner organisations

Date February 2018

Title Monthly Update Report on Devon’s STP

Introduction

The purpose of this regular report is to:

 Provide a monthly update that can be shared with Governing Bodies, Board and other meetings in STP partner organisations.

 Ensure everyone is aware on all STP developments, successes and issues in a timely way.

 Ensure consistency of message amongst STP partner organisations on what has been endorsed at the Programme Delivery Executive Group (PDEG). All partner organisations in the STP are represented at senior level at PDEG.

Content

This is the fourth Update Report, and covers developments from the PDEG meeting held on Friday, 16 February 2018. Items covered this month include:

1. STP transitional support arrangements.

2. Risk Stratification Tool Implementation Plan.

3. Acute Services Review update (phase 1 and 2018/19 priorities) and Dermatology clinical recommendations.

4. Clinical Cabinet work plan.

5. Finance planning: updates on Planning Guidance and the Naylor Review.

6. Inequities review.

Devon STP Update.pdf Page 4 of 11 Overall Page 48 of 253

1. STP transitional support arrangements

Over the last two years a central team has worked to support the STP, funded initially by the Success Regime and NHS England contributions.

The team has played a key role in the STP, which has been a positive catalyst for Devon. The STP has helped leaders build a collaborative and system approach across the NHS and local government. As a result, Devon is in a stronger position in which to further integrate services for the benefit of patients and service users.

In order to support the development of a new Integrated Care System for Devon, the same principles that supported the setting up the STP still apply.

PDEG received an update from a meeting of the Organisational Design steering group that the future direction of travel would be to integrate this team into the new single, strategic commissioner.

As part of this direction of travel, some functions such as communications and finance will be integrated into the strategic commissioner early (in 2018/19) while PDEG supported the preferred option to ‘ring fence’ the transformation part of the STP team within the strategic commissioner.

The STP team will provide the following functions:

. System Medical Director (and leadership of Clinical Cabinet). . System governance and agenda planning for PDEG and other system meetings. . Support for system HR leadership. . Programme delivery and programme management (PMO).

2. Risk Stratification Tool Implementation Plan

Following a presentation to PDEG of the Integrated Care blueprint in November 2017, part of the agreed actions was the implementation of a risk stratification tool for the Devon system.

This risk stratification tool will be used to identify at-risk individuals and patterns of need across Devon. It will also be used to inform, monitor and evaluate the implementation of new models of care, preventative work and early intervention.

The risk stratification element relies on a linked dataset that will support commissioning for outcomes, commissioning at a local level, analysis of population health and costs. The objectives of the risk stratification roll out are to:

. Raise awareness across the health, care and wellbeing system. . Agree and establish information governance arrangements. . Establish data infrastructure and flows. . Establish standard reporting arrangements. . Establish practice-based, place-based and strategic applications of model.

Devon STP Update.pdf Page 5 of 11 Overall Page 49 of 253

The approach, integrating the electronic frailty index with system-wide health and care linked data, was developed by Exeter GP practices, NEW Devon CCG, the Royal Devon and Exeter NHS Foundation Trust, the South West Academic Health Science Network and the Public Health and Adult Social Care teams in Devon County Council.

PDEG members agreed to nominate a senior lead for this important tool in their own organisation. Work on this tool will be taken forward in the next two months.

3. Acute Services Review update (phase 1 and 2018/19 priorities) and Dermatology Clinical Recommendations

Phase 1 review and approach for 2018/19

ASR 1 proposed a set of ‘Best Care for Devon’ standards along with clinical recommendations based on a selection of services which had risks around service sustainability and variation in outcomes and offer of service.

When these were published it was indicated that further services would be reviewed following phase 1. Whilst significant information was collected to inform the generation of clinical recommendations, the ASR programme proposes the collation of a core set of data to support a final review and handover along with consistency in data collection for 2018/19 hypothesis work.

Following the completion of ASR 1, the programme team are currently assessing the deliverability of the clinical recommendations in terms of workforce and finance. Presently, due to the additional workforce needed to run the proposed stroke recommendations, there are no savings that flow from ASR 1.

In parallel, the team will also be reviewing the other specialities that would benefit from adopting a networked approach. To set the financial context for clinical leaders, each specialty will be asked to consider how they could redesign their service so as to fall within the ‘Model Hospital’ lower quartile spend and this will begin to outline the scale of opportunity from 2019/20 onwards.

For all reviews (phase 1 and 2018/19 priorities) a full summary of information (including finances) is being collated.

In addition to this, information will be gathered on all current service issues and potential issues across all provider organisations. This summary will be presented for review to ASR leads to prepare recommendations which will be considered by the STP through the standard governance process.

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Dermatology clinical recommendations

The current review of Dermatology services was initiated outside of the Acute Services Review. It began as an exploration of mutual aid initiated following discussions between Derriford Hospital and the Royal Devon & Exeter. Examination of scenarios for improved joint working and service pressures quickly led to the inclusion of all four acute Trusts, commissioners and GP representation.

The review group gained a mandate to proceed on that basis from the Clinical Cabinet. Dr Adam Morris became sponsoring Medical Director for dermatology on behalf of the Clinical Cabinet. There was recognition that Dermatology shows a number of the characteristics of services that were included in ASR1, that the solutions are based on Service Delivery Networks and that a multi-organisational governance route would be needed for such solutions to be pursued.

Subject to due diligence, a Level 3 Delivery Network was recommended across Northern, Eastern Devon, and South Devon and Torbay, with a level 1 Network relationship from Plymouth into that Network. A Level 3 Delivery Network is where the total service for Devon is delivered by a single/lead provider and would be commissioned directly from that provider.

Additionally, there may be a case for a Network between Plymouth and Cornwall.

PDEG members agreed that further work was required to fully and finally understand the benefits and sustainability of the recommended Level 3 network relative to a Level 2 network before an absolute commitment is made. As a reminder, a Level 2 Delivery Network has cross-site delivery of all or some provision of service.

4. Clinical Cabinet update / work plan

The Clinical cabinet, chaired by Dr Rob Dyer, has worked up a detailed forward plan on the issues and topics that will be considered at its future meetings. A copy of this work plan can be seen at Appendix One.

5. Finance planning: updates on Planning Guidance and the Naylor Review

Planning Guidance

PDEG were briefed on the impact of the recently published planning guidance on our STP plan for 2018/19.

Planning guidance was delayed nationally due to changes announced in the budget in November 2017.

In the absence of the national guidance, the Devon STP continued the planning process for 2018/19 to ensure production of the most robust plan possible to ensure delivery. This included the agreement of a set of planning principles that have led to the development of the latest plan, with a timeline to complete the process.

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‘Refreshing NHS Plans for 2018/19’ was issued by NHS England on 2 February 2018. Some of the key factors in it include:

. The introduction of a Commissioning Sustainability Fund, together with revised CCG control totals. This is worth an additional £25 million for Devon if financial control totals are met. . Release of existing resources previously held back. . Release of new resources to CCGs. . Clarification of expectations relating to A&E and RTT targets. . The expectation that all organisations will achieve their respective control totals, and that planning will continue until this is achieved.

PDEG noted the developments, and supported the production of a revised plan to meet the expected timescales and requirements.

The new savings requirement for 2018/19 would be £167.7 million.

Government’s response to the Naylor review of estates

Key points from the government’s response to the Naylor review, and its implications for STP local plans, were discussed at PDEG.

Robert Naylor’s report, ‘NHS Property and Estates: Why it matters for patients’ was published in March 2017. It made 17 recommendations to government, the majority of which have been accepted as set out in their response which was published in January 2018.

Key headlines from the government’s response:

. The 2 for 1 incentive of public funds to match disposal receipts was rejected. . A Property Board has been established that oversees rather than merges the work of existing NHS property organisations (NHS Property Services and CHP), and will be supported by NHS Improvement. . NHS Trusts will now be able to bank land receipts for use at a later date to fund STP priorities. . Capital receipts from properties owned by NHS Property Services will continue to be pooled at a national level.

Other implications for STPs needing capital:

. There is a requirement to produce an STP prioritised capital investment plan covering primary and secondary care. . There needs to be clear estates representation and accountability within STP governance arrangements. . There is a need to develop ambitious disposals plans. The government has made initial assessments of opportunity for areas, and for Devon this is “over £20 million”. . Any new business cases need to demonstrate a clear understanding of lifecycle costs and reduced backlog maintenance liabilities. Background

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6. Inequities review

PDEG members were updated on the work being undertaken to prepare for place- based budgets and to rebalance the consumption of resources across Devon.

Initial work was based on 2015/16 financial data and this has now been refreshed with 2016/17 data and 2017/18 plan. The overall picture is that greater levels of resource are focused on the populations of North and East than they are on the West. The population of Southern Devon and Torbay still receive a greater level of resources than their funded level.

The localities consuming greater than their respective allocations reflect the overspend positions of the two CCGs in Devon.

Work is also being undertaken to assess the impact of social care spend, specialised services and primary care, however, there are challenges as follows:

Social care . Devon County Council, which spans all four localities, does not utilise the same localities as health. . The three local authorities do not report expenditure in consistent ways, so it is difficult to disaggregate at locality level. . Social care expenditure is subject to means testing, so any analysis would only include the publicly funded elements.

Specialised Commissioning . The specialised commissioning funding formula cannot be disaggregated below the level of the CCGs, therefore it is currently not possible to set a locality based resource limit. . Activity and cost data is not routinely available at a population level as NHS England monitor expenditure at provider level only.

As specialised commissioning expenditure only accounts for 13% of total CCG expenditure, any underlying imbalance of resource consumption is likely to be immaterial when compared to the drivers described above. Work is on-going, and it is anticipated that locality-based analysis and place-based budgeting for specialised commissioning should be available by 2019/20 when the local system takes on more responsibility for this area.

The important next stages agreed at PDEG include:

. Ensuring plans to develop Local Care Partnerships (LCPs) and place based budgets, as part of the new Devon Integrated Care System, are drawn up in to address inequities and, importantly, ensure we return to living within the capitated budget for our total and individual populations as part of this. . Current observed gap between capitated budget for CCG commissioner services and current consumption will be addressed through progressing the STP delivery plans like integrated care and standardised thresholds. . The overall commissioning strategies for the two CCGs need to address and manage any inequities as a vital next step as part of the establishment of LCPs.

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Appendix One: Clinical Cabinet Forward Planner

Meeting Agenda item Overview of Item Owner CC Lead SRO date item 8th Learning Programme Dave McAuley Paul Caroline Taylor/ March Disabilities Update Paul O’Sullivan O’Sullivan Paul O’Sullivan Simon Polak Planned Care Programme John Finn Alison Update – Update John Renninson Diamond/John Cancer Work Finn programme (diagnostics) Financial Angela Sarah Andy Robinson Principles Hibbard Brampton Update

Strategy Programme Paul O’Sullivan Sonja Mairead Refresh Update Jenny McNeill Manton McAlinden/Sonja Manton Service Rob Rob Dyer Ann James Delivery Dyer/Emma Networks – Herd/Warwick final Heale proposals 18/19 Emma Rob Dyer Not confirmed Ambulatory Herd/Rob Care Dyer hypothesis CYP Programme Sharon Matson Jo Olsson Programme Update Update

Meeting Agenda item Overview Item CC Lead SRO date of item Owner 12th Strategy Programme Sonja Sonja Mairead April Refresh (Focus Update Manton Manton McAlinden/Sonja on 18/19 Paul Manton priorities) O’Sullivan Jenny McNeill Innovation John Exchange McCormick / Stuart Monk Workforce Programme Ralph Piers Tetley Update Howle Digital work Programme Ralph John Andy stream update Update Howle/John McCormick Robinson/Nick McCormick Hopkinson/John McCormick Meds Bryan management – Foreshew Biosimilar’s and Rheumatology OD Programme For Emma Rob Dyer Nick Roberts – input into discussion Herd/Rob ACS/Strategic Dyer commissioning

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Meeting Agenda item Overview of Item CC Lead SRO date item Owner 10th May ICM Update Programme Charlotte Em Em Wilkinson- Update Ives/Em Wilkinson- Brice Wilkinson- Brice Brice

Primary Care Online Paul Baker Nick Nick Roberts/ Primary care Roberts Mark Procter offer Future items - potential SC or LCP intentions around primary care prescribing ASR 18/19 Programme Emma Herd Rob Dyer Ann James/Rob priorities Update Kevin Baber Dyer

Mental Programme Jo Turl Helen Smith Melanie Health Update Walker/ Simon Tapley Planned Care Programme John Finn Alison Update - STP Update Warwick Diamond/John GIRFT work Heale Finn

Meeting Agenda item Overview of Item Owner CC Lead SRO date item 14th June Learning Programme Dave Caroline Taylor/ Disabilities Update McAuley Paul O’Sullivan Update Paul O’Sullivan Digital Work Programme Ralph John Andy stream update Update Howle/John McCormick Robinson/Nick McCormick Hopkinson/John McCormick Prevention Programme Giles Colton Caroline Phil Norrey work stream Update Dimond update Specialised Sunita Berry Sunita Berry commissioning (links to ASR?) priority areas OD Work Programme Paul Nick Sonja stream Update O’Sullivan Roberts Manton/Paul O’Sullivan

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REPORT SUMMARY SHEET

Meeting Date 7th March 2018

Report Title Annual Strategic Agreement with Torbay Council 2018/19 and 2019/20

Director of Strategy and Improvement Lead Director Chief Operating Officer

Corporate Objective Safe, quality care and best experience

Improved wellbeing through partnership Corporate Risk/ Available capital resources are insufficient to fund high risk/high priority Theme infrastructure/equipment requirements/IT Infrastructure and IT systems

Failure to achieve key performance standards Inability to recruit/retain staff in sufficient number/quality to maintain service provision Lack of available Care Home/Domiciliary Care capacity of the right specification/ quality. Failure to achieve financial plan Delayed delivery of integrated care organisation (ICO) care model Purpose Information Assurance Decision



Summary of Key Issues for Trust Board Strategic Context The Annual Strategic Agreement (ASA) is negotiated with the Torbay Council

annually. It describes the services and functions the Trust will deliver on behalf of the Council and forms an adjunct to the Section 75 Partnership Agreement under which services and legal duties are delegated from the Council to the Trust. The original Partnership agreement was established as services and duties were first transferred from the Council to Torbay Care Trust in 2005. The Partnership Agreement was refreshed in 2012, when Torbay and Southern Devon Health and Care Trust was established, and novated to Torbay and South Devon NHS Foundation Trust on the 1st October 2015. Funding for the services escribed within the ASA is included within the terms of the revised Risk Share Agreement (RSA2) agreed with the Council and CCG in 2017. The Board has previously received the ASA for discussion in private Board on the 7th February. The ASA has since been formally adopted by the Council at a full Council meeting on the 22nd February 2018. The Board is now able to receive and formally adopt the ASA in public session.

Public

ASA with Torbay Council 2018-19 and 2019-20.pdf Page 1 of 38 Overall Page 57 of 253 Key Issues/Risks The attached ASA for the period 2018/19 and 2019/20 has been drafted in

partnership with commissioning colleagues from the Council with input from colleagues in the Trust’s operational, community, professional practice and finance functions. The ASA reflects the service developments planned in 2018/19, including phase 2 of care model as it will impact in community services, as well as the financial pressures within the health and care system in Torbay. The KPIs which are attached to this Agreement reflect national performance metrics for adult social care services as set out in the ‘Adult Social Care Outcomes Framework’ (known as ASCOF) and also includes indicators which track the impact and benefits of the care model. The ASA has been discussed and endorsed by the Trust Executive. Whilst there are risks associated with the Trust taking accountability for the delivery of social care services this is a key enabler in the Trust being able to provide integrated care services at a local level in Torbay. Additionally:  there are specific exclusions within the ASA (section 6.2) under which the Council has agreed to fund any additional settlement agreed or instructed in the part two decision on the judicial review appeal.

 A number of specific risks pertinent to expenditure, which could therefore impact on RSA2,are also noted (section 6.4) including: • Scale of required savings • (insufficient) Capacity and quality in the domiciliary care market • Sufficiency and pricing in the care home market • Community support for change • Impact of case law re Deprivation of Liberty Safeguards • Pressures in out-of-hours Emergency Duty service • Increasing complexity of needs • Increasing referral rates due to the increasing age of the population Recommendations The Board is asked to:

 Approve the Annual Strategic Agreement 2018/19 and 2019/20.

Summary of ED The ASA has been reviewed and approved by both the Community SDU and Challenge/Discussion Executive team; it is in line with our strategic intent and support the shared

aspirations between local partners to strengthen and deepen the level of integration in our services. Internal/External The ASA has been negotiated between officers of the Trust and the Council, Engagement inc. reviewed by the Adult Social Care Programme Board and subject to consultation Public, Patient & under the Standing orders of the Council. Governor Involvement In addition specific developments planned during 2018/19 (such review of eligibility criteria for social care services) will be subject to specific and appropriate consultation. Equality & Diversity Implications None.

Public

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Annual Strategic Agreement

Between:

Torbay Council and Torbay and South Devon NHS Foundation Trust

For the delivery of:

Adult Social Care April 2018 to March 2020

Draft 3.1 09/02/2018

Adopted by Torbay Council at a full meeting of the Council Held 22nd February 2018 To be Adopted by TSDFT at a meeting of the Trust Board to be held 7th March 2018.

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Contents 1 Introduction ...... 5 1.1 Scope of the Agreement ...... 5 1.2 Summary of services to be provided ...... 5 2 ASC Commissioning Priorities ...... 6 2.1 New Model of Care ...... 6 2.2 Autism ...... 7 2.3 Learning Disabilities ...... 7 2.4 Social Care Workforce ...... 9 2.5 Enhanced working between the commissioning functions ...... 9 2.6 Housing and Care ...... 9 2.7 Safeguarding Adults ...... 9 2.8 Carers ...... 9 3 Current Services ...... 10 3.1 Activity Baseline and Planning Assumptions ...... 10 3.2 Projected activity ...... 11 3.3 Operational Delivery, Monitoring & Oversight ...... 11 3.4 Impact on quality, activity and cost including cost improvement ...... 11 3.5 Adult Social Care Workforce ...... 11 3.6 Safeguarding ...... 12 3.7 Delivery and Performance Management: Adult Social Care Services ...... 13 4 Service developments ...... 14 4.1 Social Care Workforce Plan ...... 14 4.2 Strengths Based Approach ...... 15 4.3 New Approaches to Person Centred support Planning ...... 15 4.4 Wellbeing Coordinators ...... 16 4.5 Self-Directed support – including direct payments...... 16 4.6 Care Model Implementation ...... 16 4.7 Services for people with learning disabilities including Autism ...... 17 4.8 Residential and Day Services for Older People ...... 17 4.9 Reviews ...... 17 4.10 Key Milestones ...... 17 5 Quality Assurance ...... 17 5.1 National: CQC (Care Quality Commission) ...... 17 5.2 Local: Torbay and South Devon NHS FT ...... 18 6 Finance and Risks ...... 18

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 4 of 38 Overall Page 60 of 253 6.1 Financial Risk Share ...... 18 6.2 Care Home Fees Judicial Review Appeal ...... 18 6.3 Better Care Fund ...... 18 6.4 Efficiency Risks ...... 18 6.5 Risks pertinent to Adult Social Care expenditure include ...... 18 7 Client Charges ...... 19 7.1 Power to Charge ...... 19 7.2 Residential and Non Residential Charges ...... 19 7.3 Carers ...... 19 7.4 Universal Deferred Payments ...... 20 8 Governance ...... 20 8.1 Adult Social Care Programme Board (ASCPB) ...... 20 8.2 Consultation, engagement and involvement process ...... 21 8.3 Programme Management ...... 21 8.4 Key Decisions ...... 21 8.5 Governance of other decisions ...... 22 8.6 Governance of Placed People ...... 22 8.7 Risk Share Oversight Group ...... 22 8.8 Individual Roles and Responsibilities ...... 23 8.8.1 Torbay Council Executive Lead Adults and Children ...... 23 8.8.2 Director of Adult Social Services ...... 23 8.8.3 Deputy Director of Adult Social Services ...... 23 8.8.4 Deputy Chief Executive and Chief Operating Officer ...... 23 8.8.5 Organisational Roles and Responsibilities...... 23 8.9 Emergency cascade ...... 23 8.10 Annual Audit Programme ...... 23 Appendix 1: Carers’ Strategy – to follow after consultation & agreement at ASCPB – Consultation and finalisation expected mid- April 2018 ...... 25 Appendix 2: Performance Measures: ...... 26  Adult Social Care Outcomes Framework (ASCOF) ...... 26  Better Care Fund ...... 26  Local Measures ...... 26 Appendix 3: Trust Wide Improvement and Savings Plans – to follow once endorsed via ASCPB ...... 27 Appendix 4: Summary of the Adult Social Care Outcomes Framework for Torbay ..... 28 Appendix 5: Eligibility Criteria – to follow after consultation & agreement at ASCPB and to be presented to Policy Development and Decision Group March 2018 ...... 29 Appendix 6: Strategic and Micro-commissioning functions ...... 30 Appendix 7: Emergency Cascade ...... 32

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1 Introduction

The Annual Strategic Agreement (ASA) is refreshed and agreed annually between Torbay Council (the Council) and Torbay and South Devon NHS Foundation Trust (the Trust). The ASA is aligned with the Council’s Corporate Plan and the Trust’s Operational Plan.

The ASA is set in the context of the Risk Share Agreement established between the Council, the Trust and South Devon and Torbay Clinical Commissioning Group (the CCG).

It should also be noted and considered within the context that the Council and the Trust and CCG are working as part of the Devon wide Sustainability and Transformation Partnership (STP). The organisations continue to evidence their strong partnership role in working on both local and Devon solutions to use resources to best effect.

There is an aspiration for the Trust to become a Local Care Partnership during 2018/19 as part of the governance of an Accountable Care System for Devon.

1.1 Scope of the Agreement

The scope of this agreement is Adult Social Care (ASC) services provided for the population for which Torbay Council is accountable. This will include the statutory duties and obligations in respect of the delivery of ASC services for people who are resident in Torbay but will also include people placed in accommodation in other areas of the country where national policy dictates that the Council remains the accountable authority.

In addition to the services described in this Agreement, the Trust provides other services, including those commissioned by the CCG, NHS England specialist, dental, and screening teams.

Torbay Council also commissions additional services from the Trust including, the Drug and Alcohol Service and the Lifestyles, Health Visiting, and School Nursing service which are commissioned by the Council’s Public Health team.

Within the integrated approach of the Torbay care system the parties work jointly to ensure effective and efficient delivery of services. The Trust hold the budget for areas such as Autism, Learning Disabilities and Mental Health. Aspects of these are delivered through other organisations such as Devon Partnership Trust. The system partners will collaborate to ensure a continuous improvement approach to the delivery of care. Roles and responsibilities will be part of iterative work within 2018/19

1.2 Summary of services to be provided

The services provided under this agreement will include:  Provision of information and advice to people enquiring about ASC services;  Assessment of need for social care services, including the provision of rehabilitation and reablement services, and an Emergency Duty Service;

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 7 of 38 Overall Page 63 of 253  Commissioning and monitoring individual packages of care, including case management assessments under the Mental Capacity Act, Deprivation of Liberty safeguarding and engagement in Court proceedings;  Monitoring of the quality, performance, and cost of services provided by Trust staff and other providers;  Safeguarding the needs of adults and older people living in Torbay. This includes delivery of Torbay Council’s operational safeguarding responsibilities, servicing the Torbay Adult Safeguarding Board, investigations of individual safeguarding concerns and whole homes investigations;  Voluntary and Community Sector development and coordination in support of independence, self-care, enablement and improved quality of life;  Ensuring that services are provided in a cost effective way whilst still offering the choice to which people are entitled;  Collection of income for chargeable services, including and assessment of an individuals’ financial circumstances and ensuring that people are receiving any welfare benefits to which they are entitled;  The collection, collation and submission of activity information and performance returns as required operationally, by the Council and to meet local, regional and national statistical returns;  The collection, collation and submission of financial returns and budget reports as required operationally, by the Council and to meet local, regional and national statistical returns;  Benchmarking Torbay Council’s performance and cost against similar Local Authority areas, England and the South West;  Input to JSNA and housing needs assessment as required to ensure strategic commissioning plans and market management is based on relevant, accurate, quality and timely data;  Procurement and monitoring and management of the local market, within the strategic approach set by the Council/CCG Joint Commissioning Team and Market Management Group, to ensure sustainable, good quality services;  Delivery of agreed plans including Trust Wide Improvement Projects and those agreed through the BCF including the commitments to optimise the application of the Disabled Facilities Grant.

2 ASC Commissioning Priorities

The Council’s Corporate Plan (2015-2019) includes the following commissioning priorities for 2018-2020. It is the Trust’s responsibility to ensure these are underpinned by timely and accurate data collection and information provision including, finance and performance management information on independent and community voluntary sector contracts and Service Level Agreements held by the Trust:

2.1 New Model of Care

 Wellbeing Co-ordination in place, offering strengths based conversations and signposting to support people to maximize resilience and self-care  introduction of a new model of support planning, using a partner to deliver person centered support plans developed with people by planners with lived

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 8 of 38 Overall Page 64 of 253 experience  Living Well@Home development programme being a market wide programme in support of the new model of care;  Implementation of the NHS Standard contract for Care Homes and development of outcomes based contracting options;  Accommodation-based, care and support strategy;  Outcomes based specification for extra care housing and procurement of supported living, to maximize independence ;  Support the development of a vibrant voluntary and community sector within the context set by commissioners  Reducing demand through prevention and innovation  New approaches to assessment and the introduction of Individual Service Funds in order to maximize choice and reduce costs in care packages.

These will be supported by the development of a detailed approach to Information and Advice provision (in relation to ASC services), a strategic plan for the support of enablement of individuals by the use assistive technology alongside a refreshed strategy for the development of the Voluntary and Community Sector.

2.2 Autism

 Provide Autism awareness training for Trust staff who come into contact with people with autism;  Ensure that staff of organisations and agencies commissioned by the Trust who come into contact with people with autism have appropriate training;  Provide specialist training for key staff in the trust who come into contact with people with autism;  Undertake assessments under the Care Act for adults;  Key partner and in the development and delivery of the Joint Learning Disability and Autism Strategy and action plan, following the ADASS Peer Review.  a sustainable supported living market for people with Autistic Spectrum Disorder diagnosis through procurement of Supported Living Shared Hours and Supported Living 1:1 Hours contract

2.3 Learning Disabilities

 Focus on people living full and independent lives, where secure homes and fulfilling lives are a priority;  Help people and let them know what options they have to help them achieve their goals;  Improved accessibility to community services for those people who have a learning disability;  Improve access to employment and housing;  Key partner and in the development and delivery of the Joint Learning Disability and Autism Strategy and action plan, following the ADASS Peer Review.  secure a sustainable supported living market for people with a Learning Disability diagnosis through procurement of Supported Living Shared Hours and Supported Living 1:1 Hours contract

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 9 of 38 Overall Page 65 of 253 Mental Health The Council has statutory responsibilities for providing services to eligible people with poor mental health under the Mental Health Act 1983 and NHS and Community Act 1990, which are delegated to the Trust. These include:

 Approval and provision of ‘sufficient’ numbers of Approved Mental Health Practitioners (AMHP);  guardianship under section 7;  Financial and Budgetary responsibilities for the whole Mental Health budget, including activity below assigned to DPT.

Devon Partnership Trust will be directly commissioned under a Service Level Agreement by Torbay and South Devon NHS Foundation Trust as part of the section 75 agreement between TSDFT and the Council. Devon Partnership Trust will be commissioned to operationally deliver these under 65 social care mental health services in Torbay. This is in compliance with Torbay Council’s statutory duties under the Care Act, Mental Health Act and other relevant legislation, including:

 Aftercare under section 117;  Care management services, including operational brokerage of social care packages.

Contract management of Devon Partnership Trust will be undertaken by Torbay Council, Strategic Commissioning Support for this arrangement will be provided by Torbay Council’s Joint Commissioning Team. Professional Practice oversight of AMHP needs to be defined and agreed. This arrangement will be governed by this ASA and a contract between DPT and the Trust.

The priorities for the commissioned service in 2017 to 2018 extend into 2018 / 19 and are outlined in the Adult Mental Health, Joint Delivery Plan between the Council, TSDFT and DPT. Close working with other commissioners such as the CCG will see this developed and monitored through Social Care Programme Board Quarterly performance and finance reports will be submitted to the ASCPB. A governance structure is in place with the Council, the Trust and DPT. Greater alignment of this work will be required during the 2018/19 financial year through the development of the Mental Health ACS. It is envisaged greater alignment of governance and strategic approach will be agreed through this structure. It is expected that during this period employment of the Approved Mental Health Practitioners will transfer from the Council to DPT.  Trust finance team support for improvement plan and development and implementation of cost improvement projects. Torbay Council Commissioners to agree improvement plan and development of cost improvement projects with DPT  Support for integrated personal care planning and brokerage including implementing and embedding systems plans.

 Review and redesign of all current assigned staff roles within the Adult Mental Health contract to ensure value for money and focused approach to delivering better outcomes for people with mental ill health.  a sustainable supported living market for people with a Mental Health diagnosis through procurement of Supported Living Shared Hours and Supported Living 1:1 Hours contract

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 10 of 38 Overall Page 66 of 253 2.4 Social Care Workforce

 Ensure sufficient professional leadership and support to changes to the workforce and implementation of new ways of working;  Develop capacity within the workforce to deliver the services and provide contingency working and engagement in co-producing new approaches to care work e.g. Trusted Assessor models.

2.5 Enhanced working between the commissioning functions

 Continued development of working arrangements for clarity of roles and responsibilities with the growing independent and voluntary sector;  Supporting engagement with independent and voluntary sector providers through the multi-provider forum and associated groups.

2.6 Housing and Care

This commissioning function in support of the new model of care will be led by the Council in support of its system partners Implement the homelessness prevention plan:  Re-commissioning of accommodation based and outreach support for single homeless and young peoples’ homelessness support services and young parents service;  Implement the Devon protocol to support joint action on improving health through housing;  Accommodation-based care and support plan;  Better use of equipment, home improvements, grants and technology including, disabled facilities grant in line with BCF planning;  Homelessness strategy delivery including, prevention and early intervention and alternatives to temporary accommodation and improved hospital discharge.

2.7 Safeguarding Adults

The Trust will deliver operational safeguarding duty on behalf of Torbay to:

 Prevent abuse and neglect wherever possible, understand the causes of abuse and neglect, and learn from experience;  Ensure all organisations embed learning from incidents and case reviews;  Improve multi-agency practice and processes to improve individual safety planning as part of care and support plans and safeguard adults in a way that supports choice and control and improves their lives;  Provide information and promote public awareness to enable people in the community to be informed so that they know when, and how, to report suspected abuse;  Work with strategic commissioners and in partnerships with independent and community voluntary sector organizations to identify and address issues early preventing escalation through focused service improvement planning to reduce and streamline the number of current safeguarding processes.

2.8 Carers

In line with the priorities established through the redesign of Carers services the Trust will deliver operational duties to support carers on behalf of Torbay to:

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 Provide Carers Assessments / Health and Wellbeing Checks for Carers of Adults  Provide support to maintain Carers’ health and wellbeing  Provide Carers’ advocacy;  Promote identification and support of Carers across the wider health/social care community;  Provide support to commissioners about market development to meet the needs of Carers and those of the people they care for  Ensure Carers performance indicators are met.  Take steps to address reduced performance in the Personal Social Services Survey of Adult Carers in England 2016-17;  Implement the Carers Strategy (Appendix 1)

In 20181/9 a review of Carers Services will be undertaken, this will include a period of consultation with the public. Any decisions on changes to services will be made following this consultation and be managed through the Adult Social care Programme Board.

3 Current Services

3.1 Activity Baseline and Planning Assumptions

The Trust will be providing, under the terms of this agreement, long term packages of care to adults and older people with social needs. In the table below this activity is broken down across localities / teams and by value of the packages of care (initial business planning baseline).

Table 1: Activity Baseline Assumptions for 1st April 2018 Adults & Older People Mental Mental Health Health Learning Paignton & Total Under Over Disability Torquay 65 65 Brixham Type of Care and Support Plans Packages of Care Under £120 per week 54 19 47 236 186 542 (at home) Care Under between £121 & £999 per 41 24 244 245 251 805 week (at home) Care Under £1,000 per week (Residential 36 130 82 174 165 587 based) Care over £1,000 per week (at home & 3 5 79 4 5 96 residential based) Full Cost Care - 21 1 14 18 54 (Residential based) Full Cost Care (at - 12 2 49 49 112 home) Total 134 211 455 722 674 2,196

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3.2 Projected activity

As part of the Trusts’ business planning process the Trust’s Community Service Delivery Unit (Community SDU) will formulate plans to deliver the capacity required in 2018/19 within the parameters of the Trust’s business planning process and the associated savings requirements.

The service development and saving plan work streams developed through this processes by the Community SDU will report to the Adult Social Care Programme Board (ASCPB) with governance, assurance and approval being provided through this board as appropriate and applicable.

3.3 Operational Delivery, Monitoring & Oversight

Delivery will be monitored through local operational meetings, the Community SDU Board, the Trust Board and the ASCPB against financial run rates and performance targets.

The Trust will operate autonomously to take any management action is necessary to correct performance which can be taken within the parameters of this Agreement. However, should exceptional circumstances arise, through excess demand or other external factors not taken into account when the budget allocations underpinning this agreement were made, the impact and any corrective actions will be discussed through the ASCPB

The indicators are to be agreed in the light of the December 2017 out-turn figures and the relevant service and business planning processes. Performance indicators for the service will be those set nationally, under the ASC Outcomes Framework (ASCOF), or agreed locally. A description of the ASCOF indicators is set out in Appendix 2 and includes details of the performance and benchmarking information against each Key Performance Indictor along with performance measures produced following the review of work with Professor John Bolton.

3.4 Impact on quality, activity and cost including cost improvement

A programme of improvement and savings plans will be developed by the Trust for approval through the Adult Social Care Programme Board and attached as Appendix 3

3.5 Adult Social Care Workforce

The provision of integrated health and social care services through local multidisciplinary teams has proved to be an effective model for delivery, able to respond to customer needs swiftly, facilitate rehabilitation, and avoid admissions to residential care and hospital where ever possible. However, the existing model relies on a level of staff resources which will not be sustainable in future given the additional demands. An alternative model is being designed which will have an impact on how staff are deployed.

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 13 of 38 Overall Page 69 of 253 The new care model will be built on a strengths based approach, aligning entirely to the model in use within the voluntary sector and Integrated Personal Commissioning. Adopting this approach across social care, health services, and the private, voluntary and independent sectors will bring a synergy of approach not previously seen. For social care this is building upon the previous ‘Personalisation Strategy’. This is being developed with initiatives e.g. Strengths Based Working and Making Every Contact Count (MECC) and will underpin a more from time based and care based provision to outcomes based commissioning.

3.6 Safeguarding

The Trust will continue to deliver the delegated responsibilities of Torbay Council regarding Safeguarding Adults. The Care Act 2014 put Safeguarding Adults into a statutory framework for the first time from April 2015. This placed a range of responsibilities and duties on the Local Authority with which the Trust will need to comply. This includes requirements in the following areas:

 Duty to carry out enquiries;  Co-operation with key partner agencies;  Safeguarding Adults Boards;  Safeguarding Adult Reviews;  Information Sharing;  Supervision and training for staff.

Accountability for this will sit with the Torbay Safeguarding Adults Board (TSAB). This is a well-established group that will provide a sound basis for delivering the new legislative requirements. The Board will incorporate the requirements into its Terms of Reference and Business Plan for 2017/18, ensuring that all relevant operational and policy changes are in place for April implementation.

Regular performance analysis from all partner agencies will be reported to the TSAB to give a clear picture of performance across the agencies. The Council will ensure high level representation on the Board by the Director of Adult Social Services and Executive Lead for Adult Social Care.

In order to maximise capacity Torbay SAB will work closely with the Devon SAB with an increased number of joint sub-committees and shared business support. In addition to this, to provide internal assurance that the Trust is fulfilling its Safeguarding Adult requirements, the Board will have a sub-committee which will oversee performance. This will have a particular focus on training and performance activity.

The Council has signed up to the national initiative of ‘Making Safeguarding Personal’. This is an exciting initiative designed to measure Safeguarding Adult performance by outcomes for the individual, rather than the current reliance on quantitative measurement of timescales for strategy meetings and case conferences. This is now in place.

The Trust also has delegated responsibility as a provider of ASC services to ensure that it participates as a full partner in the TSAB and meet all regulatory requirements in safeguarding adults and children.

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 14 of 38 Overall Page 70 of 253 3.7 Delivery and Performance Management: Adult Social Care Services

The present arrangements for ASC delivery through an integrated health arrangement delivered by the ICO have been benchmarked against similar authorities in its family group (comparator group). The results show in 2016/17 Torbay spends around £363 per head of adult population, compared to an average of £348 for our comparator group (this is the net current expenditure from 2016/17 Adult Social Care Finance Return (ASC-FR) - per head of adult population). It is to be noted that the integrated nature of the Torbay’s system whilst delivering better outcomes for people does mean that direct comparisons do not always provide an unambiguous picture. The work and benchmarking as provided by Professor John Bolton illustrates the benefit of the additional analysis and benchmarking. With this in mind a series of additional measures reflecting the challenges put forwards by Professor Bolton are included within the performance indicators and will be attached as Appendix 2.

Torbay performs very well in the following area: Excellent  Service user reported quality of life  Service user reported social contact  Service user reported control over daily life  Carer reported ease of finding information

And well in these areas: Good  Service user reported ease of finding information  Service user reported satisfaction with care & support  Coverage of reablement service  Reablement not followed by long term social care support  Delayed transfers of care from hospital

Opportunities for improvement are as follows  Permanent admissions to residential and nursing care for 18-64 years olds  Adults with a learning disability in paid employment

Audit South West’s January 2017 audit report looking at the Trust’s care assessment process has confirmed that “the Trust’s arrangements for the assessment of the care needs of referred individuals, and determination of eligibility to receive publicly funded care and support is in line with the Care Act 2014 and are appropriate. Staff are able to access a range of training and operational support mechanisms to help them discharge these key responsibilities.”

Appendix 4 provides further detail in respect of the areas above – Summary of Adult Social Care Outcomes Framework for Torbay (Jan 2017)

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 15 of 38 Overall Page 71 of 253 1 Torbay’s family group of comparator authorities are groups of authorities that central government consider have similar patterns of deprivation and age profiles etc. N.B. It should be noted that the ASA applies to the delegation of authority and activity in respect of ASC and does not include Children’s services. The ICO’s use of funds to deliver these services should therefore focus on ASC when comparisons are made with other authorities. [Torbay and South Devon NHS Foundation Trust Final Internal Audit Report: Care Assessment Process Report Reference: TSD08/17 January 2017 Source Page 34 CIPFA Local Authority budget comparator profile Torbay Comparator Report November 2016 Source ASCOF and Personal Social Services: Expenditure and Unit Costs, England - 2015-16: http://www.content.digital.nhs.uk/catalogue/PUB22240 ]

4 Service developments

Key developments in the way ASC services are provided, and any changes in what services will be provided, are outlined in the following paragraphs. Where appropriate the planning and implementation of these changes will involve internal and external consultation with key stakeholders as set out in the Decision Tracker which is managed through the ASCPB. Where appropriate the Decision Tracker will also clarify accountability for decision making in these developments.

The new care model will target resources to those in greatest need and provide a universal service to allow people to be as independent as possible and be connected with their local community. The new care model will require significant change and we will need to ensure that we support staff and managers through complex change.

To support the resilience and sustainability of services, we will work closely with the independent and voluntary sector in relation to co-production of solutions that provide solutions for ‘what matters to me’.

The Ageing Well Programme has piloted a number of initiatives and the evaluation of these will offer additional input for the further development of services that provide alternatives to traditional social cares services, increase the independence of people and encourage preventative measures and behaviours. Areas that will be addressed include Information and Advice, Assistive Technology and community building.

The development of the new model of care, the on-going focus on enablement and support for a strengths based approach with clients is further underpinned by a revised Eligibility Criteria which will be attached as Appendix 5 once formally agreed by the Adult Social Care Programme Board.

4.1 Social Care Workforce Plan

Delivery of Care Act compliance is a key deliverable for our social care staff and in 2018/19 we will develop and implement a workforce plan for social care services which focuses on:

 Working in partnership with our community, addressing the issues faced by our most vulnerable members;  Revisiting our approach to ensure we are inclusive with users, carers and community organisations – using strengths based approaches as our principal theoretical approach and operating model;

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 16 of 38 Overall Page 72 of 253  Promoting the reputation of social work in Torbay through engagement with users and the co-design of our approach;  Supporting staff to reach their potential using a capability framework; responding to the Social Work health check and by providing support to improve resilience;  Delivering a high quality, safe and well respected service through use of quality, safety and governance processes.

In 2016/17 TSDFT undertook the Social Work Health Check. The health check indicated that there are arrangements in place for structures such as flexible working, staff welfare services and exit interviews. Despite increasing allocation lists, Social Workers did not report unmanageable caseloads or sickness due to stress. However, stress is a constant issue for Social Work. Although Social Workers do find time to attend training, and they find it useful, they feel it needs improvement in terms of specialist areas and opportunities for professional development.

These key areas were identified as performance and improvement priorities:

 Reducing the amount of process and computer inputting  Improving training & CPD  Clarifying arrangements for supervision  Focusing on wellbeing and resilience

These areas have been addressed via an action plan in 2017/18. In 2018/19 a strategic approach is sought to the supporting infrastructure and the legacy system that is PARIS.

4.2 Strengths Based Approach

The Care Act 2014 requires local authorities to consider the person’s own strengths and capabilities, and what support might be available from their wider support network or within the community to help in considering what else other or alongside the provision of care and support might assist the person in meeting the outcomes they want to achieve. In practice, this means operationalising strengths based approaches into the care model.

A strengths based approach is being embedded and scaled up within the new Health and Wellbeing Teams. It will become the golden thread which runs through all our interactions with people, both in terms of how we approach care and support in our teams and how our teams in turn approach care and support with the people they serve. To support the deployment of a strengths based approach we have developed the following principles for the implementation:

 We will empower staff to use their skills and experience;  We will let go of care management approaches;  We will focus on community involvement;  We will concentrate on the assets and strengths of the people who use our services, our staff and our partners.

4.3 New Approaches to Person Centred support Planning

During the course of 2018/19 the Trust will continue to explore new approaches to undertaking support planning. This will include furthering existing schemes for people

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 17 of 38 Overall Page 73 of 253 with learning disabilities and undertaking wider proof of concept work in partnership with independent, voluntary and third sector organisations.

4.4 Wellbeing Coordinators

The Wellbeing Coordination service has been in place since July 2016 and is now well embedded as part of the Health and Wellbeing Teams across Torbay. The Trust is working with partners to look at the evaluation of this program in relation to outcomes which reduce reliance on statutory services. This is an evolving project which is being co-designed and developed between statutory and voluntary sector providers and is funded from the Ageing Well Lottery Fund.

4.5 Self-Directed support – including direct payments

Self-directed support using initiatives such as Individual Service Funds alongside Direct Payments will be encouraged. An infrastructure will be developed to support this, enabling people to identify their options, make informed decisions and have mechanisms that make the right thing to do the easy thing to do.

An example of this is the implementation of Direct Payment cards that took place in 2016/17.

The personal assistant market was a focus of development in 2017/18 and is now well established. The priority for 2018/19 is a refresh of the Direct Payment policy, in order to fully embed a flexible and personalised approach. This refresh will be managed through the Adult Social care Programme Board.

4.6 Care Model Implementation

Health and wellbeing teams referred to in the Operational Plan will be providing a range of functions details of which are below:

 Encourage self-care, healthy lifestyles and maintain independence  Help to grow community assets/develop resilience;  Assessment, support planning and professional social work support;  Provide rehabilitation;  Provide nursing care;  Integrated medical management of people with complex co-morbidities;  Reactive care coordination of people with deteriorating complex health issues and frail elderly;  Continue to imbed and mainstream Learning Disabilities and working with the voluntary sector to support the delivery of this  Proactive care co-ordination of people with complex needs and frail elderly;  Proactive integrated long term conditions support;  High quality discharge support from hospital to home, integrated planning and seamless handover of care;  Development of a fully integrated out of hospital care system for Torbay and South Devon, providing onward care which is focused on improving independence.  Provide falls prevention services;  Provide palliative care as part of end of life care pathway.

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 18 of 38 Overall Page 74 of 253 In addition to the Trust’s internal governance structures the impact of these changes on community based care roll-out will be monitored and assured through the ASCPB in respect of the community activity

4.7 Services for people with learning disabilities including Autism

On the 12th and 13th of October 2017, Torbay Council and the Trust took part in a Learning Disability Peer Challenge Review; which was an opportunity for all partners to understand what we do well, areas for improvement and will support us together in setting our strategic aims and delivery for Learning Disability services for the next three years.

As part of the next stage of this process, an action plan has been developed, with the participation of key partners and will focus on the 5 key areas that have emerged from the Peer Review Team visit:  Information and Needs Assessment  Training and Employment User  Engagement and Partnership Board  Commissioning and Market for the Future  Working in Partnership

The Trust will be a key partner in the delivery of this plan.

4.8 Residential and Day Services for Older People

Market management strategy to support and shape the local market for ASC will be produced and led by council commissioners.

4.9 Reviews

In 2017/18 the Quality Assessment and Improvement Team was formed by The Trust. This team focusses on all residential and nursing reviews, offering support to homes on key improvement issues. The feedback from homes has been very positive and in 2018/19 a review will be undertaken to ensure that the team has sufficient clinical leadership and can meet review targets.

4.10 Key Milestones

These are to be agreed, in line with the performance indicators and Trust Wide Improvement initiatives, through the ASCPB and then monitored and assured by the ASCPB throughout the year.

5 Quality Assurance

5.1 National: CQC (Care Quality Commission)

The Commission will make sure health and social care services provide people with safe, effective, and compassionate high-quality care and encourage care services to improve. They monitor, inspect, and regulate services to make sure they meet fundamental standards of quality and safety and publish what they find, including performance ratings to help people choose care.

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 19 of 38 Overall Page 75 of 253 5.2 Local: Torbay and South Devon NHS FT

The Trust will provide quality assurance of both its own integrated business activity and the services it commissions on behalf of the community. A quality and safety report reports all social care quality, safety, and performance metrics quarterly. Interim performance monitoring is via the ASCPB; which receives performance reports and updates on ad hoc issues.

A Quality Assurance Framework has been developed and is now in use with independent and voluntary sector providers to provide assurance in regard to the quality of care provided to people in their own homes and in care homes

6 Finance and Risks

6.1 Financial Risk Share The Risk Share Agreement (RSA) (Appendix 9) was developed as part of the transaction creating the ICO, and took effect from its inception on 1st October 2015. A revised Risk Share Agreement was agreed October 2017. The share of financial risk going forward is a function of the wider performance of the Trust, rather than specifically in relation to Adult Social Care. The financial baseline from the Council and the CCG, the commissioning funders of the ICO, are set out in the revised Risk Share Agreement, known as RSA2.

6.2 Care Home Fees Judicial Review Appeal

The Council has agreed to fund any additional settlement agreed or instructed in the part two decision on the judicial review appeal.

6.3 Better Care Fund

The Better Care Fund is dealt with within the Section 75 agreement. The Improved Better Care Fund (iBCF) and Disabled Facilities Grant are hosted by the Council and have governance structures which reflect this and the allocation of spend. The focus of the iBCF will continue to be on those initiatives that encourage the development of the new model of care and transformation of adult social care provision. Appendix 10 provides a list of schemes within the Improved Better Care Fund that have been approved

6.4 Efficiency Risks

 Delivery of the Trust-wide Improvement programme

 Levels of agency and temporary staff costs

 Increasing costs of medical technologies

 Rate of expenditure in both ASC and Place People

 Delayed delivery of financial benefits arising from the implementation of the revised care model 6.5 Risks pertinent to Adult Social Care expenditure include

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 20 of 38 Overall Page 76 of 253  Scale of required savings

 (insufficient) Capacity and quality in the domiciliary care market

 Sufficiency and pricing in the care home market

 Community support for change

 Impact of case law re Deprivation of Liberty Safeguards

 Pressures in out-of-hours Emergency Duty service

 Increasing complexity of needs

 Increasing referral rates due to the increasing age of the population 7 Client Charges

7.1 Power to Charge

With the introduction of the Care Act, the Council now has a ‘power to charge for services’ whereas previously, there was a ‘duty to charge’ for long term residential/nursing care and a ‘power to charge’ for non-residential care.

The Council has made the decision to utilise the ‘power to charge’ for both residential and non-residential services. The Trust will discharge this power on behalf of the Council and in doing so will apply sections 14 and 17 of the Care Act and the Care and Support (charging and assessment of resources) regulations 2014.

7.2 Residential and Non Residential Charges

Charges for residential services will be amended each April as directed by the Department of Health new rates. In addition to this, charges can also be amended in light of increases to the cost of care.

Charges per unit of care for non-residential care services will be set in accordance with the Council’s charging policy.

Client contributions are based on the level of care a person requires and an assessment of their financial circumstances, including capital and income. The Trust will ensure that individual financial assessments are updated at least annually (but more frequently where the financial circumstances of an individual service user are known to have changed during the course of the year).

Consequently the charges made to an individual may change in the course of a year if there are changes in their financial circumstance or the level of care they require. The Trust will ensure that all clients in receipt of a chargeable service receive a full welfare benefit check from the Finance and Benefits team and an individual financial assessment in person for new assessments where possible.

There is no charge for Intermediate Care or Continuing Health Care services.

7.3 Carers

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 21 of 38 Overall Page 77 of 253 Services provided specifically to carers will, in principle, not be subject to a charge but this will remain under review dependent upon resource allocation. These are services provided directly to the carer (rather than the person that they care for) which include open access services such as Carers Emergency Card and Carers Education Courses, and simple services provided as a result of an assessment including emotional support or one-off direct payments for a carer’s break.

The Carers Strategy will be subject to consultation in the final quarter of 2017/18 and implemented during 2018/19 and attached as Appendix 1.

7.4 Universal Deferred Payments

The Care Act 2014 established a requirement for a universal deferred payments scheme which means that people should not be forced to sell their homes in their lifetime to pay for the cost of their care.

A deferred payment is, in effect, a loan against the value of the property which has to be repaid either from disposal of the property at some point in the future or from other sources. The scheme has now been running since April 2015 as all councils in England are required to provide a deferred payment scheme for local residents who move to live in residential or nursing care, own a property and have other assets with a value below a pre-determined amount (currently £23,250). They must also have assessed care needs for residential or nursing care.

The Council’s deferred payments policy is now fully implemented as part of the policy the Trust has the ability to recover any reasonable costs it may incur in setting up and reviewing a Deferred Payment Arrangement in addition to the cost of any services provided. These management costs may be included in the deferred payment total or be paid as and when they are incurred.

The interest rate payable on deferred payments is advised by the Department of Health and changed every six months. Interest will be added to the balance outstanding on the deferred arrangement on a compound daily basis, in accordance with the regulations.

8 Governance

8.1 Adult Social Care Programme Board (ASCPB)

The text of this section remains current however the Terms of Reference and membership of the ASCPB will be revised and agreed to ensure the ASCPB continues as an effective governance board within the developing system structures.

The ASCPB remains the contract management Board for this Agreement. The ASCPB will drive ASC and improvement plans. Its Terms of Reference cover the following areas:

 To assist the development of the strategic direction of ASC services supporting the new context faced by the Council and Trust in terms of public sector reform, reducing public resources and potential devolution;  To receive regular reports and review progress against transformation and cost improvement plans differentiating between those areas incorporated within the budget settlement and any cost pressures over and above this;  To receive reports and review performance against indicators and outcomes

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 22 of 38 Overall Page 78 of 253 included in the ASA providing and/or participating in regular benchmarking activities;  To monitor action plans against any in-year areas of concern, raising awareness to a wider audience, as appropriate;  To discuss and determine the impact of national directives translating requirements into commissioning decisions for further discussion and approval within the appropriate forums. This will include the initial list of service improvement areas planned for 2017-19 and onwards;  To discuss and develop future ASAs; co- ordinate the production of the Local Account.  To receive and review the progress of the Trust Wide Improvement Plans impacting on ASC  To escalate issues of concern or delivery to the Contract Review meeting and the RSOG as appropriate

The ASCPB governance framework is under review. In the interim the ASCPB will report and escalate issues which cannot be resolved within the ASCPB, to the Joint Executive Group; additionally the ASCPB reports to the Adults and Public Health Monitoring Group for oversight by elected Members.

8.2 Consultation, engagement and involvement process

As the Accountable Authority the Council will lead consultation processes where the need for change is being driven by the needs and requirements of the Council beyond those of delegated activities to the Trust. The Trust is committed to supporting the consultation and engagement processes the Council undertakes in relation to service changes recognising the Council’s statutory duty and good practice.

As a provider the Trust will engage all stakeholders in service redesign and quality assurance including, playing an active role with Torbay Council Health Overview and Scrutiny Committee. Additionally the Trust will be engaged with the CCG Locality Teams where the primary focus will be on consultation in regard to NHS services.

Where service changes will result in variation in the level or type of service received by individual service users, the Trust will comply with statutory guidance on the review/reassessment of care needs and ensure that those service users affected are given appropriate notice of any changes.

The Council, the Trust, and the CCG will continue to support the role of Healthwatch and the community voluntary sector in involving people who use services in key decisions as well as service improvement and design. The Council also expects the Trust to engage actively with service users and the voluntary sector in Torbay in developing new service solutions. This will apply irrespective of whether the service changes are driven by the necessities of the current financial environment or the need to ensure the continual evolution and development of services.

8.3 Programme Management

Oversight of delivery and programme management for the programmes of work set out in this Agreement will be provided through the Trust’s Programme Management Office. Delivery will monitored through standing internal meetings (such as the Community SDU Board), and reported for assurance to the ASCPB.

8.4 Key Decisions

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 23 of 38 Overall Page 79 of 253 Whilst this agreement places accountabilities on the Trust for the delivery and development of ASC Services, the Trust may not act unilaterally to make or enact decisions if they meet the criteria of a ‘key decision’ as described in the standing orders of the Council or are included in a list of ‘Reserved Items’ shared between the parties as part of the agreement.

This requirement reiterates section 22.3 of the Partnership Agreement under which services were originally transferred from the Council to Torbay Care Trust. Key decisions must be made by the Council in accordance with its constitution. In Schedule 8 of the Partnership Agreement a key decision is defined as a decision in relation to the exercise of council functions, which is likely to:

 Result in incurring additional expenditure or making of savings which are more than £250,000;  Result in an existing service being reduced by more than 10% or may cease altogether;  Affect a service which is currently provided in-house which may be outsourced or vice versa and other criteria stated within schedule 8 of the Partnership Agreement.

In addition when determining what constitutes a key decision consideration should be given to the possible level of public interest in the decision. The higher the level of interest the more appropriate it is that the decision should be considered to be a ‘key decision’.

8.5 Governance of other decisions

Governance of other decisions will vary according to the scope and sensitivity of the decision being made. To ensure clarity about whether decisions are to be taken by the Trust, Council, or CCG and at what level the decision should be taken a ‘Decision Tracker’ has been developed and will be managed through the ASCPB.

The Council will take the lead in reviewing, managing and updating the Decision Tracker throughout the year.

8.6 Governance of Placed People

With the advent of Risk Share Agreement 2 being signed in 2017 Placed People Governance sits within the structure of the present monitoring and decision making arrangements which include ASCPB and Joint Executive meetings.

8.7 Risk Share Oversight Group

The Risk Share Agreement (RSA) (Appendix 9) describes the framework for the financial management of the multi-year investment by health and social care commissioners for the services provided by the Trust. The RSA sits alongside the NHS Standard Contract and this Agreement. Whilst does not override the quality or administrative elements it does supersede all financial components.

The implementation of the RSA will be monitored by the Risk-Share Oversight Group (RSOG), which includes senior officer representation from the Council and Directors from the Trust and CCG, to provide strategic oversight of the RSA.

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 24 of 38 Overall Page 80 of 253

8.8 Individual Roles and Responsibilities

8.8.1 Torbay Council Executive Lead Adults and Children The role of Executive Lead is held by an elected Member of Torbay Council. As part of their duties they will sit as the Council’s representative on the Trust Board to provide oversight, challenge, and liaison.

8.8.2 Director of Adult Social Services The role of Director of Adult Social Services (DASS) is a statutory function, and is fulfilled by a senior officer of the Council who is accountable for all seven responsibilities of the role set out in statutory guidance dated May 2006. However responsibility for Professional Practice and Safeguarding are delegated to the Deputy DASS employed within the professional practice directorate of the Trust.

8.8.3 Deputy Director of Adult Social Services The role will provide professional leadership for social care services and lead on workforce planning, implementing standards of care, safeguarding, and support the running of the ASCPB. The role also oversees the Deprivation of Liberty Safeguards and Guardianship arrangements in Torbay.

8.8.4 Deputy Chief Executive and Chief Operating Officer The role will provide provider executive input and oversight as part of the governance structure for the contract.

8.8.5 Organisational Roles and Responsibilities The partnership working inherent within the Torbay model is supported by further clarification of the organizational roles pertaining to the local authority as the commissioning partner of the contract and the Trust as the providing partner including commissioning responsibilities within its delegated activities. A range of activities for reference is included in Appendix 6 – Strategic and Micro-commissioning functions.

8.9 Emergency cascade

Please see Appendix 7 for details of Torbay Council’s Emergency Planning Roles in Council’s Emergency cascade. The Trust will be expected, through best endeavours, to identify social care senior officers to be part of emergency cascade, to coordinate delivery of ASC in an emergency situation.

8.10 Annual Audit Programme

Audit South West (ASW) as the Internal Audit provider to Torbay and South Devon NHS Foundation Trust will undertake the following actions and requirements:-

 Consult with the Director of Adults Services (DAS) of Torbay council on proposed internal audit coverage;  Provide to the DAS copies of assignment reports that relate to control arrangements for Adult Services;  Provide an annual report to the DAS on the adequacy and effectiveness of the overall system of internal control for the Trust, and in particular, those areas

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 25 of 38 Overall Page 81 of 253 directly affecting Adult Services. Detail is included in Appendix 8

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 26 of 38 Overall Page 82 of 253 Appendix 1: Carers’ Strategy – to follow after consultation & agreement at ASCPB – Consultation and finalisation expected mid- April 2018

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 27 of 38 Overall Page 83 of 253 Appendix 2: Performance Measures:  Adult Social Care Outcomes Framework (ASCOF)  Better Care Fund  Local Measures Date included in this draft is derived from 2016/17 returns a revised position will be agreed on the basis of 2017/18 Month 9 figures and to reflect the new Care Model.

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 28 of 38 Overall Page 84 of 253 Appendix 3: Trust Wide Improvement and Savings Plans – to follow once endorsed via ASCPB The table below summarises Trust and System wide savings workstreams and projects where they impact on Adult Social Care and Unit Cost Improvement

TO BE PROVIDED BY ICO MARCH 2018

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 29 of 38 Overall Page 85 of 253 Appendix 4: Summary of the Adult Social Care Outcomes Framework for Torbay January 2017 UPDATED VERSION TO BE INSERTED POST MONTH 9

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 30 of 38 Overall Page 86 of 253 Appendix 5: Eligibility Criteria – to follow after consultation & agreement at ASCPB and to be presented to Policy Development and Decision Group March 2018

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 31 of 38 Overall Page 87 of 253 Appendix 6: Strategic and Micro-commissioning functions Drafting Note: These are to be reviewed and approved via the ASCPB during 2018/19

Torbay Torbay and Council South Strategic Function/role lead Devon Trust Commissio ASC ning function function MICRO COMMISSIONING OF PROVIDERS, PROCUREMENT AND BROKERAGE

STRATEGIC COMMISSIONING FUNCTION Market shaping and developing new providers to fill gaps in provision and oversight of decommissioning  plans Market Position statement and Joint Strategic Needs  Assessment Market mapping  Gap analysis  Analysis of sufficiency of supply  Manage provider failures and market exits   Strategic Commissioning Strategy  Proactive strategy to develop the market as a whole  Market engagement with provider market as a whole  Run Multi Provider Forum for all providers with  strategic themes Joint commissioning arrangements with partner  organisations and other areas Lead on co-design of new service models with   providers and stakeholders Develop population outcome based commissioning  approach for market Develop and c-produce Payment by Results  mechanisms that encourage sound outcomes Co-ordinate user and carer engagement and  consultation Contract review and performance management of ASC  Review budget for ASC and sign-off cost improvement  plans related to ASC Develop and implement operational commissioning  plans Overarching sub contracts between Trust and other  ASC providers, e.g. Care homes, community care Prepare and agree individual service specifications  Develop and monitor outcome based commissioning   approach for each provider at service level Develop personal outcome based commissioning for  each service user Contract management & performance review of  independent & voluntary sector including, grant funding Proactive quality assurance of individual providers  including, develop/implement service improvement

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ASA with Torbay Council 2018-19 and 2019-20.pdf Page 32 of 38 Overall Page 88 of 253 Torbay Torbay and Council South Strategic Function/role lead Devon Trust Commissio ASC ning function function plans Achieving value for money from providers including,  cost improvement planning Procurement of ASC providers  Manage provider failures and market exits including, for  service users and relatives/carers involved Individual contracts for care packages  Brokerage/purchasing processes and brokerage of  individual care packages Direct payments and personal budgets  Lead and manage safeguarding processes including,  Whole Provider/Provider of concern/quality concerns Resolution of Safeguarding incidents and  implementation of lessons learned Run and co-ordinate forums for specific provider areas  with operational focus e.g. forums for care homes Collection, collation and regular reporting of data on  need, demand, supply, cost, workforce and performance (Trust and sub-contractors) with interpretation and presentation Benchmarking of cost/performance of services – own  and sub-contracted Management of pooled budget to achieve value for  money and cost improvement

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Adult Services Primary Contacts Name/Title Emergency Role Communication with contracted providers of Frances Mason, Care and Support for vulnerable people. Head of Availability and co-ordination of needs Partnerships, assessment. Safeguarding vulnerable adults People and and serious case review including Housing authorisation of deprivation of liberty under Mental Capacity Act. The role will provide professional leadership for social care services and lead on Joanna workforce planning, implementing standards Williams, Deputy of care, safeguarding and support the running

Director of Adult of the ASCPB. The role also oversees the Social Services Deprivation of Liberty Safeguards and Guardianship arrangements in Torbay.

Adults Services Secondary Contacts Assessment and placement, access to Robin services, medication and packages of care Willoughby, and place of safety for older people with poor Lead AMHP mental health Sharon O’Reilly, Assessment and placement, access to Manager Older services, medication and packages of care

Person Mental and place of safety for people under 65 with Health Team poor mental health.

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Appendix 8: Annual Audit Programme

Background

For Torbay Council, Internal Audit is a statutory service in the context of The Accounts and Audit (England) Regulations 2015.

From April 2013, organisations in the UK public sector are required to adhere to the Public Sector Internal Audit Standards (the Standards). Internal Audit for Torbay & South Devon NHS Foundation Trust is delivered by Audit South West.

Internal Audit Plans

When preparing the internal audit plan for Torbay and South Devon NHS Foundation Trust it is expected that Audit South West will:

 Consider the risks identified in Torbay Council's strategic and operational risk registers that relate to Adult Services;  Discuss and liaise with Directors and Senior Officers of Torbay Council regarding the risks which threaten the achievement of the Council's corporate or service objectives that relate to Adult Services, including changes and / or the introduction of new systems, operations, programs, and corporate initiatives;  Take account of requirements to support a “collaborative audit” approach with the external auditors of Torbay Council;  Consider counter-fraud arrangements and assist in the protection of public funds and accountability;  Support national requirements, such as the National Fraud Initiative (NFI) which is run every two years.

Draft plans, showing proposed audits covering Adult Services should be shared and agreed with Torbay Council's Director of Adult Services (DAS). The DAS should also be made aware of planned audit reviews that will provide overall assurance that control mechanisms operated by the Trust, but that are key to the workings of Adult Services, are working effectively (e.g. audits of key financial systems (payroll, payments, income collection etc.), and corporate arrangements (e.g. procurement, information governance etc.)).

The Audit Plan will not be a "tablet of stone" and changes may be required or advised during the year.

Internal Audit work

Internal audit work should be completed in accordance with the PSIAS. Proposed briefs for work covering ASC should be shared with the DAS prior to fieldwork commencing.

Reporting – Assignments

The DAS will be provided of copies of all final reports that specifically relate to Adult Services. The DAS will also be provided with early sight of draft reports for which the audit opinion is "fundamental weaknesses" or similar. The Director of ASC will also be

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Reporting – Annual Report

Audit South West will provide the Council with an annual assurance report on the adequacy and effectiveness of the overall system of internal control for the Trust, and in particular, those areas directly affecting Adult Services. It is noted that this assurance can never be absolute. The most that the internal audit service can do is to provide reasonable assurance, based on risk-based reviews and sample testing, that there are no major weaknesses in the system of control.

The report should provide:

• A comparison of internal audit activity during the year with that planned, placed in the context of Adult Services; • A summary of significant fraud and irregularity investigations carried out during the year and anti-fraud arrangements; and • A statement on the effectiveness of the system of internal control in meeting the Council’s objectives.

Together with a summary of the performance indicators set for internal audit and performance against these targets.

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Appendix 9: Risk Share Agreement (RSA2)

Risk Share Agreement signed Sept 17.pdf

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Appendix 10: List of Improved Better Care Fund Schemes Approved by BCF Working Group

Project Name Approved Extension of TSDFT Care Home Education and Support Team (CHEST) (DPT- note also apvd by DCC) Approved - with conditions Mental Health and DPT (MSB) Approved Proud to Care South West Approved Leadership development in care homes Approved Development of the out of hospital care system Approved IPC Approved Transition Worker Approved Health Care Videos Approved Market Analysis for Care Homes (see also Transformation Funding) Approved LD Peer Review Approved Non-injured fallers Approved City & Guilds Accreditation Approved Low Cost Packages / Eligibility Criteria - Age UK Approved

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REPORT SUMMARY SHEET

Meeting Date 7th March 2018

Report Title Integrated Finance, Performance, Quality and Workforce Report: Month 10 (January 2018)

Lead Director Director of Strategy and Improvement Director of Finance

Corporate Objective  Safe, quality care, and best experience  Improved wellbeing through partnership  Valuing our workforce  Well led

Corporate Risk/  Available capital resources are insufficient to fund high risk/high priority Theme infrastructure/equipment requirements/IT Infrastructure and IT systems.  Failure to achieve key performance standards.  Inability to recruit/retain staff in sufficient number/quality to maintain service provision.  Lack of available Care Home/Domiciliary Care capacity of the right specification/ quality.  Failure to achieve financial plan.  Delayed delivery of integrated care organisation (ICO) care model.

Purpose Information Assurance Decision



Summary of Key Issues for Trust Board

Strategic Context 2017/18 Operational and Financial Plan and Control Total: The Trust submitted an Operational Plan for 2017/18 to NHS Improvement

(NHS I) which confirmed the commitment of the Board to ensure the Trust achieves the Control Total set by NHS I of achieving a £4.7m surplus by 31st March 2018. Sustainability and Transformation Fund: An allocation from the national Sustainability and Transformation Fund (STF) has been set aside for the Trust. The arrangements for allocating the STF for 2017/18 have been confirmed as follows:  70% is dependent on delivery of the Trust’s financial plan to deliver the agreed Control Total.  30% is dependent on delivery of both (a) A&E performance at Trust and / or STP level and (b) achievement of A&E operational mile stones (such as GP streaming) These thresholds have been met in Quarters 1 & 2 and for Q3 the financial element. The Trust is appealing the Q3 notification of non-achievement of the Public

Integrated FPQW Report - Month 10.pdf Page 1 of 61 Overall Page 95 of 253 performance element, however in line with the notification only £3.94m has now been recognised in the accounts. NHS I are assessing Trust financial performance using the pre STF Control Total position. So the notification of non-achievement at Q3 on the performance element of the SFT does not impact on the assessment of financial performance.

Winter funding allocations: The Trust received on 15th December details of the allocation of winter funding allocations as set out below: The funding has been allocated nationally in two tranches. Firstly, acute Trusts will be allocated funds on a ‘fair shares’ basis to reflect the cost of emergency and urgent elective activity across winter that is already in operational plans and is being incurred by providers. The allocation is based on emergency services activity in Trusts with a Type 1 A&E. This will enable a corresponding improvement in the reported Month 7 forecast outturn financial position. The second tranche of funding has been the subject of discussions between individual Trusts, their NHS I Regional Director and the National Director of Urgent and Emergency Care. This additional winter funding is for new initiatives to improve A&E performance over winter and should be spent on the specific schemes set out below. Where the schemes involve the purchase of beds either in the acute provider or the community, the level of expenditure has to be agreed with the Regional Director before it is committed. Table 1 – funding allocated to Torbay and South Devon

Purpose of funding Value

Tranche 1 To reflect existing costs of winter in plans. £600 000 Expectation of corresponding improvement in M7 forecast position

Tranche 2 provide additional Dom Care, additional Rapid £396 000 Response capacity and additional voluntary sector capability; up to 15 beds per day released for management of acute patients

Development of a front door Rapid Assessment £102 000 and Discharge Service (RADS); 5 per day - based on current performance of 7 patients seen per day and a 70% discharge rate

In totality we expect the schemes in Tranche 2 to £498 000 ensure you at least maintain your YTD, 92.4%, performance in Q4

Regulatory Context - NHS I Single Oversight Framework: The Single Oversight Framework (SOF) is used by NHS I to identify NHS providers’ potential support needs across the five themes of quality of care, finance and use of resources, operational performance, strategic change, and leadership and improvement capability. As previously reported NHS I have made changes to the SOF which applied from October 2017 onwards. The underlying framework is unchanged and the performance of providers against the ‘Use of Resources’ metrics will continue to be made against the five themes set out above. Using this framework NHS I segment providers into one of four segments ranging from Segment One (maximum autonomy) to Segment Four (special measures).

Public

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The Trust has previously been assessed as being in Segment Two (targeted support), in response to concerns in relation to finance and use of resources. This rating is not expected to change as a result of the revisions to the SOF. An additional performance metric, associated with the identification of patients who have dementia, has been added to the framework and has been included within the performance dashboard.

Key Issues/Risks The headlines for Month 10 performance against the financial, operational, quality, change, and workforce frameworks established by the Trust are set out

in Section Two of the attached Integrated Performance Report, with the full performance frameworks being set out in Section Three, and underpinned by the attached Dashboard and Data Book. The key issues and risks to note are: Finance:  Overall financial position: The financial position against NHS I Control Total for the 10 months to 31st January 2018 is a surplus of £0.52m against a planned surplus of £0.57m. In the month of January a surplus of £1.31m has been achieved, which is £0.56m behind plan. These figures take into account the reduction of the Q3 STF funding (due to the known issues associate with performance and developments within ED), 75% of MARS has been accrued and a £200K reduction on provisions.  Pay expenditure: Total pay costs are underspent against plan to Month 10 by £0.64m (after the MARS accrual).  Cumulative Savings Delivery: The Trust has delivered £33.48m against our year to date savings profiled target of £32.01m (including income Generation target); resulting in a £1.47m over-delivery year to date.  System Savings Plan Year End Forecast Out-turn Delivery: To achieve a 2017/18 surplus and achieve the Control Total excluding STF, the Trust needs to deliver £40.74m cost reduction target, and a further income generation target of £1.33m (Total £42.1m). At the end of Month 10, the Trust has identified savings potential of £41.95m resulting in a £0.15m current year shortfall. It is important to recognise that this scale of current year forecast delivery represents a significant improvement on the achievements in previous years. Any slippage in delivery would however put the plan and £2.04m STF funding at risk, affecting liquidity and, in turn capital investment plans. The forecast recurrent delivery Full Year Effect (FYE) against the 2017/18 projects is £30.1m. In addition, we believe there is a potential further £1.5m to £3.0m of FYE mitigation, which we are scoping with a view to add before the end of the financial year.  Use of Resources Risk Rating: NHS I no longer publish a planned risk rating for Trusts, due to changes they have made to the risk rating calculation. However, at Month 10, the Trust had an actual use of resources risk rating of 2 (subject to confirmation by NHS I). The Agency risk rating of 1 is a material improvement to the planned rating of 2.  Capital Spend: A significant underspend against the revised approved budget exists at 31st January 2018. A further £1m of capital expenditure slippage was reported to NHS I Scheme during January 2018. Scheme leads have been asked for assurance that the full year revised spend forecast of £9.6m will be delivered.

Public

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Framework Number RAG Rating at the end of Month 9 of KPIs Red Amber Green Not Rated

National Performance 5 4 1 1 0 Standards (trajectory)

Local Performance 23 12 0 10 1 Framework (no target set)

Community & Social 15 4 0 7 3 Care Framework (no target set)

Quality Framework 19 8 2 7 2 (no target set)

Workforce 4 2 1 1 0 Framework

National Performance Indicators Against the national performance standards, for Month 10 the Trust has delivered the following outcomes:  4 hour ED standard: In January the Trust achieved 83.82% of patients discharged or admitted within 4 hours of arrival at accident and emergency departments. This is a fall on last month 88.34% and is below the agreed Month 10 Operational Plan trajectory of 89.9% and below the 95% national standard. Performance to 20th February shows 79.62% of patients being discharged from ED and MIU within 4 hours in February.  RTT (target 92% / trajectory 89.3%): RTT performance has improved in January to 82.51% waiting less than 18 weeks from 82.2% in December.  People waiting over 52 weeks: The number of people experiencing very long waits is starting to reduce in line with plans with 29 people reported as waiting over 52 weeks at the end of January against the target of 34. The trajectory remains to achieve no more than 16 people waiting over 52 weeks by the end of February and zero at the end of March. The March delivery of zero is at risk due to the current operational pressures which are limiting the number of elective inpatient admissions. In January higher numbers of elective inpatient operations requiring beds have been stood down with this continuing into February whilst the urgent care pressures remain in the system. Teams are monitoring on a daily basis and implementing additional lists where possible to mitigate for this loss in capacity to deliver the March position of zero waiting over 52 weeks.  62 day cancer standard: 85.6% (as at 20th February 2018) against the 85% national target, this is an improvement on last month (82.4%). The standard in Q4 NHS I assessment is predicted to be met against the target 85%.  Diagnostics: The diagnostics standard is not met and increased to 5.38% over 6 weeks outside of the agreed tolerance of 4%. The greatest number of long waiting patients over 6 weeks are for routine MRI with an increase in Echocardiography waits the greatest change in the January reported performance. Public

Integrated FPQW Report - Month 10.pdf Page 4 of 61 Overall Page 98 of 253  Dementia screening: The Dementia find standard is not met in January with 52.1% reported (last month 65.5%). A drop in reported performance was forecast with the transition to the “Nerve Centre” clinical information tool which is being rolled out; a definitive timeline for this work is still awaited. Local quality indicator performance variances to highlight  Delayed Transfers of Care is becoming an area of national attention and is linked to securing the Better Care Fund. Performance in community hospitals has improved from 348 in December, to 272 in January against a target of 315. The Acute site showed an increase in delays from 165 in December to 218 in January against a target of 64. Work is continuing with teams to make further improvements and keep delays to a minimum level.  Follow up appointments waiting beyond the planned “to be seen by” date decreased in January with 6,630 compared to 7,041 reported in December.  C Difficile infections; 1 new acute infection is reported in January (0 in the community); this is not reported as a lapse in care.  Bed Closures due to Infection Control have increased from last month with 198 bed days lost in January from infection control bed closures.

Recommendations The Board is asked to:  consider the assurances provided in the main report;  challenge the performance achieved; and  agree the further actions necessary to ensure delivery.

Summary of ED Executive Directors: Challenge/Discussion Finance: While the position remains challenging Directors are working with corporate and operational teams to ensure delivery of the year end position. Performance: Pressures within the urgent care system continue and are illustrated by a reduction of performance against the 4 hour wait target, the high level of bed occupancy and reduction in levels of RTT activity as surgical admission have had to be stood down. The exceptional pressures experienced this winter will be reviewed as plans are developed for winter 2018/19. Overall it is noteworthy that despite the pressures the Trust is currently experiencing there is evidence that the changes in community services are impacting and enabling the current pressures to be managed more effectively than they could have been previously. Workforce: The spike in workforce numbers in December has been noted by the Executive team and the factors behind this unexpected shift are being investigated. Quality and Performance Reviews: were held on the 22nd February 2017 to review progress with the SDU leadership teams with particular focus on:  Projected financial outturn.  The RTT position at speciality level.  The number of people waiting over 52 weeks at speciality level.  The number of people with overdue follow up appointments

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Equality & Diversity N/A Implications

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MAIN REPORT Integrated Finance, Performance, Quality, and Workforce Report

Date of Board Meeting: 7th March 2018

Reporting Period: Month 10

Data Up To : 31st January 2017

Version Control

Version Meeting Date of Circulation Date of Meeting Owner This Version

Draft 1 Trust Executive 16/02/18 20/02/18 Paul Procter ☒

Ann Wagner Published Report FPI Committee 23/02/18 27/02/18 Paul Cooper ☒ Ann Wagner Published Report Trust Board 2/3/18 7/3/18 Paul Cooper ☒

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Contents

1. Introduction and Contents: 1

2. Performance Headlines: . Finance Headlines: 2 . Operational Headlines:  NHS Single Oversight Framework 3  Local Performance Indicators 3  Community and Social Care 4 . Quality Summary 4 . Workforce Summary 5

Attached as Part 2 of the Report (in a single PDF): . Finance Focus . Operational Performance Focus . Quality Focus . Workforce Focus

Attached as Appendix (as a separate PDF): . Dashboard

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1. Introduction and Context Financial Context: Operational and Financial Plan, Control Total and Sustainability and Transformation Fund Purpose For 2017/18 the Trust submitted an Operational and Financial Plan to NHS The purpose of this report is to bring together the key areas of delivery Improvement (NHS I) confirming our intention to achieve the £4.7m Control (including financial, service delivery, quality and safety, change, and Total and deliver required service performance standards to secure our workforce) into a single integrated report to enable the Finance, designated share of the national Sustainability and Transformation Fund Performance, and Investment Committee (FPIC) to: (STF).  Take a view of overall delivery, against national and local standards Delivery of the Control Total relies on the Trust, with its system partners, and targets, at Trust and Service Delivery Unit (SDU) level. delivering a Systems Savings Plan of £40.7m and an additional Income Plan of  Consider risks and mitigations. £1.3m. This leaves a system deficit of around £13m that the CCG is currently  Determine whether the Committee is assured that the Trust is on track holding on behalf of the system. to deliver the key milestones required by the regulator and will therefore secure Sustainability and Transformation Funding (STF) and In addition to financial delivery, access to a 30% of the STF funding, allocated ultimately retain our license to operate. to the Trust for 2017/18, is also dependent on delivery of service standards relating to the national ED 4 hour wait standard and new GP streaming arrangements which had to be in place by October 2017. Report Format The main detail of the report, which follows from the Performance Summary Regulatory Context: NHS Improvement Single Oversight Framework set out below, is contained in a separate PDF file Performance Focus Reports. The Single Oversight Framework is used by NHS I to identify NHS providers The Focus Reports are split into four main sections of Finance Focus; with potential support needs across the five themes of quality of care, finance Operational Focus; Quality Focus; and Workforce Focus and are supported by and use of resources, operational performance, strategic change and the following appendices: leadership and improvement capability.

Appendix 1: Board Dashboard (PDF file) Against this framework NHS I have segmented providers into one of four categories ranging from Segment One (maximum autonomy with no support needs identified) to Segment Four (providers in special measures). This Performance Summary and the Focus Reports have been informed by discussions and actions at: The Trust has been assessed by NHS I as being in Segment Two (providers  Executive Director scrutiny (20th February 2018) offered targeted support). This rating was in response to concerns raised in  Service Delivery Unit Quality and Performance Review meetings (22nd 2016/17 in relation to finance and use of resources. As part of the targeted February 2018) support, Mark Hackett was initially commissioned by NHS I to help improve the Trust’s financial sustainability, efficiency, and compliance with sector  Finance, Performance, Investment Committee (27th February 2018) controls such as agency costs. The Trust was expected to secure its own support for 2017/18 and agreed to continue using Mark Hackett for a time

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limited period (until end of September 2017) to provide targeted support to 75% of MARS has been accrued and a £200K reduction on the delivery of our 17/18 financial plan. Mark Hackett’s assignment has now provisions. completed.  Pay expenditure: Total pay costs are underspent against plan to Month Updated Single Oversight Framework 10 by £0.64m (after the MARS accrual). An updated Single Oversight Framework (SOF) has been released by NHS I for  Cumulative Savings Delivery: The Trust has delivered £33.48m against implementation from M7 and this report has been updated to reflect changes our year to date savings profiled target of £32.01m (including income in the SOF. The SOF has been updated to reflect changes in national policy Generation target); resulting in a £1.47m over-delivery year to date. and standards, other regulatory frameworks and the quality of performance  System Savings Plan Year End Forecast Out-turn Delivery: To achieve a data as well as feedback and lessons learned from operating the framework. 2017/18 surplus and achieve the Control Total excluding STF, the Trust There are no changes to the underlying framework and the five themes of needs to deliver £40.74m cost reduction target, and a further income quality of care; finance and use of resources; operational performance; generation target of £1.33m (Total £42.1m). At the end of Month 10, the strategic change and leadership and improvement capability. The only Trust has identified savings potential of £41.95m resulting in a £0.15m material change is the inclusion of the Dementia Find metric into the list of current-year shortfall. indicators used to monitor operational performance. It is important to recognise that this scale of current-year forecast The triggers for potential intervention remain unchanged based on failure of a delivery represents a significant improvement on the achievements of national operational standard for two or more consecutive quarters, previous years. Any slippage in delivery would however put the plan and however, where there is an agreed trajectory of improvement this will be £2.04m STF funding at risk, affecting liquidity and, in turn capital taken into account when determining any actual underlying support need. investment plans. The forecast recurrent delivery Full Year Effect (FYE) against the 2017/18 2. Performance Headlines: Month 10 (January 2018) projects is £30.1m. In addition, we believe there is a potential further £1.5m to £3.0m of FYE mitigation, which we are scoping with a view to Key headlines for financial, operational, local performance, quality, safety, add before the end of the financial year. and workforce standards/metrics for Month 10 to draw to the Committee’s attention are as follows:  Use of Resources Risk Rating: NHS I no longer publish a planned risk rating for Trusts, due to changes they have made to the risk rating Financial Headlines calculation. However, at Month 10, the Trust had an actual use of  Overall financial position: The financial position against NHS I Control resources risk rating of 2 (subject to confirmation by NHS I). The Agency Total for the 10 months to 31st January 2018 is a surplus of £0.52m against risk rating of 1 is a material improvement to the planned rating of 2. a planned surplus of £0.57m. In the month of January a surplus of £1.31m  Capital Spend: A significant underspend against the revised approved has been achieved, which is £0.56m behind plan. These figures take into budget exists at 31st January 2018. A further £1m of capital expenditure account the reduction of the Q3 STF funding (due to the known slippage was reported to NHS I Scheme during January 2018. Scheme issues associate with performance and developments within ED), 2

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leads have been asked for assurance that the full year revised spend  62 day cancer standard: 84.6% (validated 14 February 2018) against the forecast of £9.6m will be delivered. 85% national target, this is a marginal improvement on last month (82.4%) but still below the national target. The standard in Q4 NHS I Operational Headlines: NHS Improvement Single Oversight assessment is predicted to be met against the target 85%. Framework  Diagnostics: The diagnostics standard is not met and increased to 5.38% Against the national performance standards, for Month 10 the Trust has over 6 weeks outside of the agreed tolerance of 4%. The greatest number delivered the following outcomes: of long waiting patients over 6 weeks are for routine MRI with an increase in Echocardiography waits the greatest change in the January reported  4 hour ED standard: In January the Trust achieved 83.82% of patients performance. discharged or admitted within 4 hours of arrival at accident and emergency departments. This is a fall on last month 88.34% and is below  Dementia screening: The Dementia find standard is not met in January the agreed Month 10 Operational Plan trajectory of 89.9% and below the with 52.1% reported (last month 65.5%). A drop in reported performance 95% national standard. was forecast with the transition to the “Nerve Centre” clinical information tool which is being rolled out; a definitive timeline for this work is still Performance has continued to decline in February; the A&E Performance awaited. Predictor (which is circulated daily) for the 16th February shows 81.29% of patients being discharged from ED and MIU within 4 hours. Operational Headlines: Local Performance Indicators

In addition to the national operational standards there are a further 23  RTT: RTT performance has improved marginally in January with the indicators agreed locally with the CCG, of which 12 were RAG rated RED in proportion of people waiting less than 18 weeks increasing from 82.2% in January 2018 (11 RED RAG rated in December). The indicators RAG rated RED December to 82.4% in January. are summarised in Table 1:

In addition the number of people waiting over 52 weeks is starting to Table 1: Local Performance Indicators RAG Rated RED reduce in line with plans; at the end of January 29 people were reported Standard/ Last month This month as waiting over 52 weeks against the target of 34. The trajectory remains Standard target Month 9 Month 10 to achieve 16 at the end of February and zero at the end of March. The March delivery of zero 52 week waits is at risk due to operational Cancer 2ww urgent GP referral >93% 76.0% 77.6% pressures which are limiting the number of elective inpatient admissions. In January a higher number of elective inpatient operations were stood Cancer – 31 day wait from decision >96% 98% 91.43% down, this appears likely to continue whilst the urgent care pressures to treat to first treatment remain in the system. Teams are monitoring on a daily basis and implementing additional lists where possible to mitigate for this loss in Cancer 62day wait from screening >90% 100% 80% capacity to deliver the March position of zero waiting over 52 weeks.

3

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Standard/ Last month This month Table 2: Community and Social Care Framework RAG Rated RED Standard target Month 9 Month 10 Last month This month Target Standard Month 9 Month 10 RTT waits over 52 weeks: 0 42 29 Delayed transfers of care bed days 64 days per 165 218 On the day cancellations for (acute) month <0.8% 1.6% 0.9% elective operations Number of permanent care home <617 634 629 placements Cancellations not readmitted 0 1 13 within 28 days Bed occupancy 80-90% 92.4% 93.1% Ambulance handovers > 30 0 181 271 minutes: Community hospitals admissions 214 252 276 (non-stroke) Ambulance delays > 60 minutes 0 18 18 Of the remaining indicators, 7 were rated GREEN and 4 indicators do not yet have an agreed target. A&E patients (ED only): >92.9% 84.0% 77.2% Quality Headlines Trolley waits in A&E > 12 hours 0 1 8 There are 19 Local Quality Framework indicators in total of which 8 were RAG from decision to admit rated RED for January (compared to 4 for December) as follows: Care plan summaries % completed within 24 hrs of discharge >77% 67.9% 67.7% Table 3: Local Quality Indicators RAG Rated RED weekdays: Last month This month Standard Target Care plan summaries % completed Month 9 Month 10 >60% 25.6% 28% Reported incidents – Major and within 24 hrs discharge weekend: <6 0 6 catastrophic Of the remaining indicators, 10 were rated GREEN and 1 indicator does not Pressure ulcer avoidable harm 0 1 2 yet have an agreed target. category 3+4 (1 month in arrears) Strategic Executive Information 0 2 9 Operational Headlines: Community and Social Care Summary System (STEIS) reported incidents VTE – risk assessment on There are 15 Community and Social Care indicators in total of which 4 were admission (community) >95% 69.4% 92.1% RAG rated RED in January 2018 (4 in December 2017) as follows:

4

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Last month This month attendance, and the rate still remains above target. The target the Trust Target Standard Month 9 Month 10 set itself was 3.80% for the end of March 2017 which has been rolled Medication errors – catastrophic forward into 2017/18. 0 0 2 harm – SC to review In addition to the workforce KPIs there are 2 further workforce indicators that are being tracked to provide assurance to the Board: Infection control bed closures <100 8 198 . Workforce Plan - The workforce plan aims to have 5001.3 staff in post at the end of the financial year. At the end of January 2018 there was an Hand Hygiene >95% 95% 89% significant increase in the WTE in post by 91.23 against plan. This is being Follow ups past to be seen date investigated further to understand the increase. 3,500 7,041 6,630 (excluding Audiology): . Agency Expenditure - Agency expenditure at Month 10 is overachieving against plan by £1,553,000 and remains on target to achieve the NHSI cap Of the remaining 11 indicators, 7 were rated GREEN, 2 AMBER and 1 does not by the end of the year. have an agreed target.

Workforce Headlines Of the four workforce KPIs on the current dashboard one is RAG rated Green, two RAG rated Amber, and one RAG rated Red as follows: . Turnover (excluding Junior Doctors): GREEN - the Trust’s turnover rate was 12.09% for the year to January 2018. This is a small decrease from last month however is within the target range of 10% to 14%. . Mandatory Training rate: AMBER – At the end of January 2018 the overall mandatory training rate was 82.79% against the target of >85%. This represents a small reduction in performance which had been static at 83% for the last six months. . Appraisal rate: AMBER - At the end of January 2018 the appraisal rate was 78%, which is a slight reduction on the previous month, however this has been attributed to the winter operation pressures. Appraisal rates remain below the overall target of 90%, consequently further support is being offered to departments and delivery units to help achieve improvements. The accountability and oversight framework will be utilized to support and drive improvements. . Staff sickness/absence: RED - The annual rolling sickness absence rate of 4.09% at the end of December 2017 represents a small deterioration in 5

Integrated FPQW Report - Month 10.pdf Page 13 of 61 Overall Page 107 of 253 Integrated Performance Report

February 2018 - reporting period January 2018 - Month 10

Section 1 Finance

Section 2 Performance NHSi performance metrics Local performance metrics Community and social care metrics Quality Metrics Workforce metrics

Integrated FPQW Report - Month 10.pdf Page 14 of 61 Overall Page 108 of 253 Finance Focus

Page 2 Summary Of Financial Performance Page 3 Summary Of Financial Performance (2) Page 4 Income Page 5 Income (2) Page 6 Pay Expenditure Page 7 Pay Expenditure (2) Page 8 Non Pay Expenditure Page 9 Forecast Page 10 Financial Position by SDU Page 11 Financial Position by SDU (2) Page 12 Items Outside of EBITDA Page 13 Balance Sheet Page 14 Cash Page 15 Capital Page 16 Activity Page 17 Continuous Improvements Program (CIP) Page 18 Continuous Improvements Program (CIP) (2)

Integrated FPQW Report - Month 10.pdf Page 15Page of 61 2 Overall Page 109 of 253 Summary of Financial Performance Current Performance Key Points  The Trust has a £0.30m surplus for the period to 31st January 2018, which is £0.42m behind budget. This reflects the stepped increase in saving targets with no significant reduction in expenditure run rates, increased income and the loss of the Q3 urgent care STF. Excluding the income and expenditure not used by NHS Improvement in their assessment framework and against the published 'Control Total', a surplus of £0.52m is recorded; virtually on budget year to date. NHS Improvement is measuring Trust financial performance against the Control Total excluding STF; on this metric the Trust is £0.48m better than plan.  The Trust has recorded a surplus of £1.31m in the month, £0.56m below the budgeted level. The Trust has developed a recovery plan focusing on income recovery, technical accounting solutions and recovery of CIP schemes that have Re- Budget Actual Variance slipped. To date the Trust has transacted a revised asset lives valuation Plan for Catego for for to Annual Annual improving the year to date position by £1.1m, reflected the benefit of additional Period risation Period Period Budget Plan Budget contract income secured from Commissioners and taken £250k of the Tranche 2 £M £M £M £M £M £M £M winter pressure monies to offset costs being incurred. Delivering further income Income 342.27 4.27 346.54 345.95 (0.59) 410.62 416.83 gains and CIP recovery actions are critical to securing the financial element of Pay (182.73) (3.20) (185.93) (185.29) 0.64 (217.32) (222.23) STF at Q4. There remains a significant risk in securing the Q4 performance STF Non Pay (142.79) (4.13) (146.92) (148.37) (1.45) (169.30) (174.27) given the challenge the Trust has seen in securing the Q3 performance element. EBITDA 16.75 (3.06) 13.69 12.29 (1.40) 24.00 20.33  Pay run rates have increased by £0.98m in month; £0.23m within agency, mainly Financing Costs (16.04) 3.06 (12.97) (11.99) 0.99 (19.24) (15.58) due to the opening of the Flu Ward. and the provision for MARS . SURPLUS / (DEFICIT) 0.71 0.00 0.72 0.30 (0.42) 4.76 4.76  There has been a £0.48m reduction in non pay expenditure run rates mainly NHSI Exclusions (0.14) 0.00 (0.14) 0.22 0.37 (0.17) (0.17) within the purchase of out of hospital placements.  The CIP target for the nine months to 31 January 2018 is £32.01m, against which Plan Adjusted Surplus / (Deficit ) 0.57 0.00 0.57 0.52 (0.05) 4.58 4.58 a total of £33.48m has been delivered; a favourable variance of £1.47m. Remove STF Income (4.47) 0.00 (4.47) (3.94) 0.52 (5.83) (5.83)  The burden of savings requirement continues to increase from this point in the Variance to Control Total (Excl STF) (3.90) 0.00 (3.90) (3.42) 0.48 (1.25) (1.25) year, reducing the run rate of expenditure, decreasing the deficit and ultimately resulting in a surplus position. Run rates will need to reduce or income levels Cash Balance 5.01 4.74 (0.27) 6.17 increase at a rate more significant than that seen in the first 10 months of this Capital Expenditure 24.31 (13.86) 10.45 4.42 (6.03) 29.58 financial year if the Control Total is to be achieved.  The current forecast of CIP delivery for the full year is £41.95m against a target KPIs (Risk Rating) YTD Plan YTD Actual of £42.1m. It is critical that plans are executed to full effect for the Control Total Indicator Rating Rating excluding STF to be achieved.  The Trust continues to forecast delivery of control total excluding STF, subject to Capital Service cover rating 3 3 the delivery of recovery actions to cover the residue of cost pressures identified Liquidity rating 4 3 at the outset of the year. STF on financial performance would then be pyable but STF in Urgent Care remains at risk. I&E Margin rating 2 2  The Trust's Finance Risk Rating has risen in M10 to a 2, though this is marginal I&E Margin variance rating N/A 2 and there is risk in sustaining the rating. Agency rating 2 1 Finance Risk Rating N/A 2

Integrated FPQW Report - Month 10.pdf Page 16Page of 61 3 Overall Page 110 of 253 Summary of Financial Performance Month 10 Year to date

Re- Current Re- Current Categoris Current Current Month Plan for Categoris Budget for Variance to Prior Month Month ation of Month Month Variance to Period ation of Period Actual for Budget Variance Annual Annual Plan Plan Budget Actual Budget YTD Plan YTD Period YTD YTD YTD Change Plan Budget £M £M £M £M £M £M £M £M £M £M £M £M £M £M Operating income from patient care activities 29.71 0.81 30.52 32.52 2.00 297.14 7.33 304.47 304.24 (0.23) (2.23) 2.00 356.04 364.87 Other Operating income 4.80 0.09 4.89 3.99 (0.90) 45.13 (3.06) 42.06 41.71 (0.36) 0.54 (0.90) 54.59 51.96 Total Income 34.52 0.89 35.41 36.51 1.09 342.27 4.27 346.54 345.95 (0.59) (1.68) 1.09 410.62 416.83

Employee Benefits - Substantive (17.03) (0.93) (17.96) (18.82) (0.86) (176.84) (3.77) (180.61) (180.96) (0.35) 0.52 (0.86) (210.73) (216.29) Employee Benefits - Agency (0.36) 0.05 (0.32) (0.52) (0.20) (5.89) 0.57 (5.32) (4.34) 0.98 1.18 (0.20) (6.60) (5.94) Drugs (including Pass Through) (2.96) (0.04) (3.00) (2.73) 0.27 (29.70) (0.36) (30.06) (26.69) 3.37 3.10 0.27 (35.62) (36.05) Clinical Supplies (1.94) (0.08) (2.02) (2.10) (0.08) (20.28) (0.68) (20.96) (20.84) 0.12 0.30 (0.19) (24.11) (24.94) Non Clinical Supplies (0.41) (0.01) (0.41) (0.28) 0.13 (4.05) 0.03 (4.02) (3.38) 0.64 0.51 0.13 (4.86) (4.85) Other Operating Expenditure (8.34) (0.17) (8.52) (9.49) (0.97) (88.76) (3.12) (91.87) (97.46) (5.59) (4.73) (0.86) (104.70) (108.42) Total Expense (31.04) (1.19) (32.23) (33.93) (1.70) (325.52) (7.33) (332.85) (333.66) (0.82) 0.89 (1.70) (386.62) (396.49)

EBITDA 3.48 (0.29) 3.18 2.57 (0.61) 16.75 (3.06) 13.69 12.29 (1.40) (0.80) (0.61) 24.00 20.33

Depreciation - Owned (1.14) 0.30 (0.84) (0.76) 0.08 (11.41) 2.98 (8.43) (7.18) 1.25 1.17 0.08 (13.69) (10.12) Depreciation - donated/granted (0.07) 0.00 (0.07) (0.05) 0.01 (0.69) 0.00 (0.69) (0.53) 0.16 0.15 0.01 (0.83) (0.83) Interest Expense, PDC Dividend (0.48) (0.00) (0.48) (0.46) 0.02 (4.77) 0.08 (4.68) (4.64) 0.04 0.02 0.02 (5.72) (5.63) Donated Asset Income 0.08 0.00 0.08 0.01 (0.07) 0.83 0.00 0.83 0.36 (0.47) (0.40) (0.07) 1.00 1.00 Gain / Loss on Asset Disposal 0.00 0.00 0.00 (0.01) (0.01) 0.00 0.00 0.00 0.06 0.06 0.06 (0.01) 0.00 0.00 Impairment 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 (0.06) (0.06) (0.06) 0.00 0.00 0.00

SURPLUS / (DEFICIT) 1.87 0.00 1.87 1.31 (0.56) 0.71 0.00 0.72 0.30 (0.42) 0.15 (0.56) 4.76 4.76

Adjusted Plan Position Donated Asset Income (0.08) 0.00 (0.08) (0.01) 0.07 (0.83) 0.00 (0.83) (0.36) 0.47 0.40 0.07 (1.00) (1.00) Depreciation - Donated / Granted 0.07 0.00 0.07 0.05 (0.01) 0.69 0.00 0.69 0.53 (0.16) (0.15) (0.01) 0.83 0.83 Impairment 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.06 0.06 0.06 0.00 0.00 0.00 Adjusted Plan Surplus / (Deficit) 1.86 0.00 1.86 1.35 (0.51) 0.57 0.00 0.57 0.52 (0.05) 0.46 (0.51) 4.58 4.58

NHSI Adjustment to Control Total Remove STF Income (0.68) 0.00 (0.68) (0.68) 0.00 (4.47) 0.00 (4.47) (3.94) 0.52 0.00 0.00 (5.83) (5.83) Variance to Control Total Excluding STF 1.18 0.00 1.18 0.67 (0.51) (3.90) 0.00 (3.90) (3.42) 0.48 0.46 (0.51) (1.25) (1.25)  The position for Month 10 is a surplus of £1.31m, which is £560k behind the budgeted position (£1.87m surplus) before NHSI exclusions.  Cumulatively the Trust surplus is £0.30m against a budget surplus of £0.72m.  Income is ahead of budget by £1.09m in Month 10 and behind budget cumulatively by £0.59m, with the majority of this relating to SCG Pass through Payments and the loss of the Performance STF at Q3. The Trust is appealing this decision.  Pay expenditure is £1.06m higher than budget in Month 10 and £0.63m lower than budget cumulatively. This reflects the phasing of budgets and savings targets.  Non-pay expenditure is £0.64m higher than budget in Month 10 but £1.45m higher than budget cumulatively, again reflecting phasing of budgets and savings targets.  The challenge increases considerably as the year progresses to reduce costs, secure the increased funding and meet savings targets in order to achieve the control total excluding STF. CIP plans have been identified and we must continue to focus on ensuring their complete delivery along with the management of the residual cost pressures identified in final budget setting and arising during the year for the Control Total excluding STF to be achieved.

Integrated FPQW Report - Month 10.pdf Page 17Page of 61 4 Overall Page 111 of 253 Income Current Performance Key points

 Overall Operating Income from Patient Care Activities is behind plan by £0.23m. This has improved from being £2.23m behind plan in Month 9.

 The reason for this large movement is that the Trust has included Year to Date - Month 10 Previous Month Variance to Recategorisa Variance to 10/12ths of the increase in funding from STP CCG's £2m relating to Operating Income Plan Budget Actual Budget - Change tion of plan Budget (adv)/+fav Devon IBCF and Risk Share Agreement income reflecting improved system savings plan income. The month 10 position also includes £'m £'m £'m £'m £'m £'m £'m £250k of the Tranche 2 Winter Pressures funding, making a total Contract Healthcare 251.22 3.15 254.37 253.83 (0.53) (2.23) 1.69 Council Social Care (inc Public Health) 35.95 3.99 39.93 40.17 0.23 0.02 0.21 positive movement of £1.9m. The Trust is assuming that the Client Income 7.98 0.20 8.18 8.18 (0.00) (0.02) 0.03 Tranche 2 Winter Pressure funding is payable irrespective of the ED Private Patients 1.40 0.02 1.43 1.42 (0.00) (0.02) 0.02 Other Income 0.59 (0.02) 0.57 0.64 0.07 0.02 0.05 4 hour performance but based on delivery of the schemes the bid Operating Income from patient care activities 297.14 7.34 304.48 304.24 (0.23) (2.23) 1.99 Other Income 33.55 (3.47) 30.08 30.17 0.09 0.56 (0.47) was against. Research and Education 7.11 0.41 7.52 7.60 0.08 (0.01) 0.09 Sustainability & Transformation funding 4.47 0.00 4.47 3.95 (0.53) (0.00) (0.52) Other operating income 45.13 3.06 42.07 41.71 (0.36) 0.55 (0.90)  This is offset by a £0.2m reduction in contract healthcare income as Total 342.26 4.28 346.54 345.95 (0.59) (1.68) 1.09 a result of a reduction in 'Pass Through' activity of £0.22m, a reduction in Outpatients of £0.18m and in elective activity by £0.4m. Year to Date - Month 10 Previous Month Variance to There is a offsetting positive movement of £0.6m in non-elective Recategorisa Variance to Contract income by Commissioner Plan Budget Actual Budget - Change tion of plan Budget activity. (adv)/+fav

£'m £'m £'m £'m £'m £'m £'m  The overall improvement in contract healthcare income is therefore South Devon & Torbay Clinical Commissioning Group 139.23 3.10 142.32 143.11 0.79 (0.04) 0.83 £1.69m. North, East & West Devon Clinical Commissioning Group 4.36 0.01 4.37 5.43 1.06 0.18 0.89 NHS England - Area Team 6.60 0.08 6.68 5.73 (0.95) (0.81) (0.14) NHS England - Specialist Commissioning 25.40 0.13 25.53 24.20 (1.33) (1.19) (0.14) Other Commissioners 6.21 (0.06) 6.15 5.94 (0.21) (0.43) 0.22  At Commissioner level, in-month variances are marginal except for South Devon & Torbay Clinical Commissioning Group (Placed NHS England contracts. The NHS England Specialist Commissioning People and Community Health) 67.29 0.07 67.36 67.37 0.01 0.01 0.00 Other Commissioners 2.14 (0.18) 1.96 2.05 0.08 0.06 0.03 contract has moved by a further £0.13m behind plan, largely relating Operating Income from patient care activities 251.22 3.15 254.37 253.83 (0.53) (2.23) 1.69 to reduced pass through income. The NHS England Local Area Year to Date - Month 10 Previous Month Variance to contract is a further £0.14m behind plan, with Outpatients being the Recategorisa Variance to MEMO - CCG Block Adjustment Plan Budget Actual Plan - Change tion of plan Budget biggest movement at £0.1m. (adv)/+fav £m £m £m £m £m CCG Block adjustment (7.42) 0.39 (7.04) (5.42) 1.61 2.49 (0.88)

Integrated FPQW Report - Month 10.pdf Page 18Page of 61 5 Overall Page 112 of 253 Income

Year to Date - Month 10 Previous Month Other Operating Income is behind budget by £0.36m. This has moved on Variance to Recategorisa Variance to Other Operating Income Plan Budget Actual Plan - Change the previous month as a result income associated with winter pressures, tion of plan Budget (adv)/+fav recorded as Other Operating Income last month switching to Income from Patient Care Activities. Beyond that, key variances are: £m £m £m £m £m £m £m  Systems Savings plan income is behind plan by £2.07m for the year R&D / Education & training revenue 7.11 0.41 7.52 7.60 0.08 (0.01) 0.09 to date. On a full year basis £5.4m is forecast against a target of Site Services 1.82 0.06 1.88 1.90 0.02 0.02 (0.01) Revenue from non-patient services to other bodies 4.50 (1.32) 3.19 3.19 (0.00) (0.09) 0.09 £7.2m. Recovery in this income is forecast . Sustainability Transformational Funding (STF) Income 4.47 0.00 4.47 3.95 (0.53) (0.00) (0.52)  Income earned by Torbay Pharmaceuticals is £621k less than Risk Share Income 2.92 (2.92) 0.00 0.00 0.00 0.00 0.00 budget. The Torbay Pharmaceuticals Board has agreed a recovery Misc. other operating revenue 24.31 0.70 25.01 25.09 0.08 0.63 (0.55) plan that will deliver the planned contribution despite this Total 45.13 (3.06) 42.06 41.71 (0.36) 0.55 (0.90) reduction.  R&D and Education income ahead of budget by £79k  E Prescribing income received is £12k more than planned  Overachievement of CIP £1.12m

The Trust has accrued £3.98m of income from South Devon and Torbay CCG as agreed and provided by the CCG in Month 10, relating to System Wide Savings schemes advised, delivered and passing to the Trust. STF funding of £3.94m has been accrued and included in the year to date figures, reflecting anticipated receipt for Months 1 to 10. This excludes the Q3 A&E income of £525k, the loss of which is being appealed.

Integrated FPQW Report - Month 10.pdf Page 19Page of 61 6 Overall Page 113 of 253 Pay Expenditure Current Performance Key points  To reflect the latest budgeted position, there has been a year to date adjustment to month 10 of £3,267k to reduce the SSP savings target categorised as pay in the annual plan, and which is now replaced with additional income following conclusion of Risk Share Agreement negotiations. The chart to the left therefore presents a more realistic reflection of the extent to which run rates of expenditure now need to reduce for target to be achieved.

 Based on this, total pay costs are showing an underspend against budget for the year to date by £0.64m and over spent by £1.06m in Month 10. The Month 10 position includes a provision for MARS costs of £0.54m.

 Substantive and Bank pay costs are overspent by £0.35m, and agency costs are underspent by £0.98m.

 In setting the annual plan, agency budgets were set in line with the agency cap. Work in the period between then and final budget setting achieved a significant reduction in forecast agency spend, requiring a 'budget transaction', held in reserves, to maintain the integrity of the plan. As a consequence, when reviewed at service level, the main area of overspend in substantive costs shows in reserves. At Service Delivery Unit (SDU) level, there are underspends within most SDUs except in Research and Development which is £84k overspent and Independent Sector £91k overspent.

 The agency underspend is reflected in Reserves, offset by overspends in all areas of Medicine (£1.65m), Community Services (£0.65m) in Public Health CAMHS, Women and Child’s Health (£0.42m). This continues to reflect the filling of vacancies achieved through the redeployment of staff affected by bed closures, made possible through the care model implementation.

 Run rates in substantive and bank pay have increased overall by £0.75m from the previous month, of which £0.54m is the provision for MARS within substantive (substantive increased £0.81m and bank decreased £0.06m). Main Re- areas of substantive increase are within Medicine (Care of the Elderly & Plan for Categorisati Budget for Actual for Variance to Annual Emergency) and Radiology. Period on Period Period Budget Annual Plan Budget £M £M £M £M £M £M £M  Agency run rates, have increased during January by £0.23m, mainly within Medical and Dental (46.04) 2.47 (43.57) (42.12) 1.45 (55.23) (52.24) registered nursing staffing in Medical Services, as a result of the maintenance Nursing and Midwifery (76.95) 0.49 (76.46) (73.85) 2.62 (91.62) (91.00) of escalation capacity throughout the month. Other Clinical (39.49) (1.56) (41.05) (37.91) 3.13 (47.33) (49.30) Non Clinical (20.25) (4.60) (24.85) (31.41) (6.56) (23.14) (29.69) Total Pay Expenditure (182.73) (3.20) (185.93) (185.29) 0.64 (217.32) (222.23)

Integrated FPQW Report - Month 10.pdf Page 20Page of 61 7 Overall Page 114 of 253 Pay Expenditure Agency Spend Cap Agency staff costs in Month 10 across all staff groups is £0.52m, and £4.34m for the year to date. This is £1.55m lower than the NHSI plan and agency cap of £5.89m.

 Medical agency spend is £2.34m for the year to date which is £0.07m higher than the £2.27m plan.

 Nursing Agency spend for the year to date is £1.08m, being £1.93m lower than the £3.02m plan. Spend in the month increased by £0.1m as a result of the opening of escalation Agency - All Staff Groups Q1 Q2 Q3 January YTD 2017-18 capacity on Warrington Ward.

£m £m £m £m £m  The full year forecast as at Month 10 is £5.24m, £1.32m Agency Plan 2017/18 (NHSI Ceiling) lower than the NHSI cap of £6.56m. Planned Agency Cost (2.78) (1.53) (1.22) (0.36) (5.89) Total Planned Staff Costs (56.96) (54.75) (53.64) (17.39) (182.73)  This continues to reflect the filling of vacancies achieved % of Agency Costs against Total Staff Cost 5% 3% 2% 2% 3% through the redeployment of staff affected by bed closures made possible through the care model implementation, and Agency Actual Costs 2017/18 further supported by on-going review of Agency Agency Cost (1.39) (1.31) (1.12) (0.52) (4.34) requirement, implementing tighter control on Agency use, Actual Staff Cost (55.82) (55.48) (55.28) (19.41) (185.98) staff flexibility and other initiatives. % of Agency Costs against Total Staff Cost 2% 2% 2% 3% 2%

Agency Cost vs Plan 1.39 0.22 0.10 (0.16) 1.55  Although the Trust remains within the agency cap overall, % of Agency Costs against Total Staff Cost -2% 0% 0% 1% -1% individual price rates for Nursing and Medical staff are all above NHSI individual shift rates. Agency - Nursing Q1 Q2 Q3 January YTD 2017-18  Actual staff cost for the purposes of calculating the NHSI £m £m £m £m £m agency cap is based on gross cost of £185.98m prior to Agency Nurse Staff Cost (0.40) (0.22) (0.28) (0.19) (1.08) deducting capitalised staff cost of £0.69; the net amount is Actual Registered Nurse Staff Cost (13.59) (13.15) (13.34) (4.68) (44.75) £185.29m. % of Agency Costs against Nursing Staff Cost 3% 2% 2% 4% 2%

Integrated FPQW Report - Month 10.pdf Page 21Page of 61 8 Overall Page 115 of 253 Non Pay Expenditure Current performance Key Points  Drugs, Bloods and Devices - Underspent by £3.37m mainly due to pass through drugs and devices (£2.76m) for which income is similarly reduced in the NHS England/ NEW Devon CCG contracts.  Clinical Supplies – Total underspend of £0.11m; £0.26m in Surgery, £0.06m Women and Child’s Health, £0.15m Hospital Services with offsetting overspends in Estates Contract Maintenance, Community Services and Torbay Pharmaceuticals. Although underspent against budget, previous reports have highlighted an increase in run rates since the beginning of the financial year. Run rates have stabilised somewhat, with expenditure £80k Re- Plan for Categorisati Budget for Actual for Annual Annual above budget in the month. Period on Period Period Variance Plan Budget  Non Clinical Supplies – Total underspend of £0.64m; £0.40m in Estates, £'M £'M £'M £'M £'M £'M £'M £0.06m Hospital Services and £0.16m Health Informatics Team. Run rates Drugs, Bloods and Devices (29.70) (0.36) (30.06) (26.69) 3.37 (35.62) (36.05) Clinical Supplies & Services (20.23) (0.68) (20.91) (20.80) 0.11 (24.05) (24.88) have reduced further by £0.05m on the previous month mainly in Estates, Non Clinical Supplies & Services (4.04) 0.03 (4.02) (3.37) 0.64 (4.85) (4.84) External Service Agreements. Other Operating Expenditure (24.98) (4.82) (29.80) (33.52) (3.72) (28.74) (34.97)  Placed People (including Continuing Healthcare) - Over spent by £0.56m, ASC (Independent Sector & In House LD) (37.35) 0.30 (37.05) (38.33) (1.29) (44.51) (44.09) mainly in Adult Individual Patient Placements and reflecting an unachieved Placed People (Incl Continuing Healthcare) (26.49) 1.40 (25.09) (25.65) (0.56) (31.52) (29.43) savings target. Total Non Pay Expenditure (142.79) (4.13) (146.92) (148.37) (1.45) (169.30) (174.27)  Adult Social Care - Over spent by £1.29m mainly as a result of a shortfall in the delivery of the Systems Savings Plan and overspend within the Torquay Zone area placements.  Other Operating Expenditure - Over spent by £3.72m reflecting: o Premises - underspent by £0.04m, with run rates decreasing by £0.01m on last month. o Purchase of social care - overspent by £1.87m due to Systems Savings Plan shortfall (savings target phased from month 4 onwards). o The placed people reduction in Month 10 reflects the detailed review of accruals requested by Finance, Performance and Investment Committee, updating the assessment to reflect latest information. o Other £2.62m overspent – allocation of cost pressures savings targets (£1.74m), Torbay Pharmaceuticals miscellaneous expenditure (£0.24m), Women and Child's Health (£0.13m), Surgical Services (£0.12m) and Medical Services (£0.13m). o Purchase of Healthcare is £0.40m overspent- Women and Children's Health for Radiology and Lab Test outsourcing (£0.14m) and Community Service intermediate care (£0.24m), with an overall decrease in Purchase of Healthcare run rate of £0.06m from the previous month. o Underspends in Education and Training (£0.53m); Bad debt Provision (£0.47m), Establishment (£0.13m), mainly office stationery, telephone, marketing, postage & Clinical Governance, and Lease expenditure.

Integrated FPQW Report - Month 10.pdf Page 22Page of 61 9 Overall Page 116 of 253 Forecast

Forecast Variance Over the past 5 months, a forecast risk to the Control Total of £6.5m before Forecast position with mitigations Plan £m £m £m mitigations and Risk Share has been reported. Income Gross 403.02 402.44 (0.58) Early indications at Month 10 are that the forecast gap (prior to mitigations yet Planned CIP 8.60 13.04 4.44 to be actioned) is now £4.01m. The finance teams have been testing the Net position 411.62 415.48 3.86 forecast but operational teams, focused on operational pressures in recent weeks, have yet to fully review and sign off the latest position. Pay Gross (236.82) (241.73) (4.91) The Month 10 forecast includes the costs for six weeks of an escalation ward. Planned CIP 19.50 18.81 (0.69) Any variation from that will impact on the spend and need for mitigation Net position (217.32) (222.91) (5.59) actions in-order to achieve the Control Total (excluding STF).

Non Pay Mitigations to close the gap take account of iBCF, CCG income and Tranche 2 Gross (203.61) (202.08) 1.53 Winter pressures monies. The Trust has also reflected the increased building Planned CIP 13.90 10.09 (3.81) Net position (189.71) (191.98) (2.28) life into the capital charge calculation, both in the current and forecast positions. Total net position 4.59 0.58 (4.01)

Mitigations:- NHSI require the Tranche 1 winter pressure monies to improve the forecast by Recovery Actions Plan 3.49 3.49 £600K, which the Trust had previously assumed would be part of the STF Incentive Fund 0.04 0.04 mitigation actions. Receipt of this and Q4 performance STF is dependent on NHS Winter pressure Fund - Tranche 1 0.60 0.60 achievement of the 95% ED performance in month 12 which is at risk. NHSI are now monitoring the Trust on the Control Total excluding STF income; this Variance Against Plan 4.59 4.71 0.12 position shows a forecast deficit of £0.64m against a planned deficit £1.28m, £0.64m better than plan. Removal of STF Income (5.83) (5.31) 0.53 Removal STF Incentive Fund 0.00 (0.04) (0.04) There is however significant risk on the Urgent Care performance at Month 12 Original Plan Exceeded Control Total (0.04) 0.00 0.04 achieving the requirement for receipt of the Tranche 1 Winter Pressure Fund (£600k) and STF Performance Q4. Variance Against Control Total Excluding STF (1.28) (0.64) 0.64

Integrated FPQW Report - Month 10.pdf Page 23Page of 6110 Overall Page 117 of 253 Financial Position by SDU Key Drivers

Re- The year to date position is a surplus of £0.30m against a Plan for Categoris Budget Actual for Variance Annual Annual budget surplus of £0.72m. Period ation for Period Period to Budget Forecast Plan Budget £'M £'M £'M £'M £'M £'M £'M £'M Forecast (before mitigating action) is showing a Trust wide Trust Total Position surplus of £0.58m, being £4m behind the planned surplus of Income 337.05 5.38 346.41 346.31 (0.10) 411.05 404.36 416.17 £4.58m (adjusted plan). The £4m gap is before mitigations and Pay (186.41) 0.07 (186.35) (185.29) 1.05 (222.91) (222.84) (222.85) assuming that all identified CIP schemes deliver in full. Non Pay (146.47) (1.71) (150.22) (148.37) (0.19) (188.62) (174.82) (179.33) Financing Costs (16.87) 3.06 (13.81) (12.35) 1.46 (5.44) (20.24) (16.58) Further analysis by at SDU level can be seen in the following tables. SSP Plans 13.41 (6.80) 4.67 0.00 (2.64) 5.43 18.30 7.34 Trust Surplus / (Deficit) 0.71 0.00 0.72 0.30 (0.42) (0.50) 4.76 4.76

NHSI Exclusions (0.09) 0.00 0.00 0.16 0.25 1.08 (0.17) (0.17) Variance Against Plan Surplus / (Deficit) 0.62 0.00 0.72 0.46 (0.17) 0.58 4.58 4.58 Re- Plan for Categoris Budget Actual for Variance Annual Annual Period ation for Period Period to Budget Forecast Plan Budget £'M £'M £'M £'M £'M £'M £'M £'M Underspend is related to the in year over achievement of savings from the Community decommissioning of Community Hospitals; Lower than anticipated IC bed placement Income 0.81 0.01 0.82 1.33 0.51 1.66 0.97 0.98 numbers. Phasing of CIP is also a factor in the YTD position with phasing loaded Pay (35.17) 0.60 (34.57) (32.35) 2.22 (39.14) (41.83) (41.11) towards end of the year whilst savings have been achieved from M1. Non Pay (9.24) 2.37 (6.87) (7.28) (0.41) (8.75) (10.99) (8.01) Financing Costs (1.51) 0.02 (1.48) (1.47) 0.01 (1.77) (1.81) (1.77) Surplus / (Deficit) (45.10) 3.01 (42.10) (39.77) 2.33 (48.00) (53.66) (49.91)

Re- Plan for Categoris Budget Actual for Variance Annual Annual Period ation for Period Period to Budget Forecast Plan Budget £1.3m overspend entirely ASC driven with £775k of this due to unachieved TWIP. Difference of circa £525k is now largely driven by an overspend in residential care, £'M £'M £'M £'M £'M £'M £'M £'M driven by price based pressures from a large backdated fee uplift. Income to offset ASC (Independent Sector & In House LD) this is captured in support & reserves. An under recovery of residential client income Income 8.25 (0.00) 8.25 8.40 0.15 9.93 9.90 9.90 has also had an adverse effect, with this not matched to an equivalent drop in Pay (1.09) 0.24 (0.85) (1.04) (0.18) (1.24) (1.31) (1.02) expenditure due to high unit costs across Torquay offsetting the saving in income. Non Pay (37.35) 0.30 (37.05) (38.33) (1.29) (45.86) (44.51) (44.09) Surplus / (Deficit) (30.18) 0.54 (29.65) (30.97) (1.32) (37.17) (35.92) (35.21)

Re- Plan for Categoris Budget Actual for Variance Annual Annual Period ation for Period Period to Budget Forecast Plan Budget Unachieved TWIP is the key driver behind the £490k overspend where adverse £'M £'M £'M £'M £'M £'M £'M £'M market conditions has made it very difficult to achieve any price based savings. In Placed People (includes Continuing Healthcare) addition to this, Adult IPPs is overspent by £500k entirely due to growth in the Income 0.02 0.00 0.02 0.00 (0.02) 0.00 0.02 0.02 number of high cost cases. The above has been partially offset by savings in CHC Pay (1.03) 0.21 (0.82) (0.73) 0.09 (0.94) (1.24) (0.99) South Nursing Homes and Intermediate Care. Non Pay (26.49) 1.40 (25.09) (25.65) (0.56) (30.73) (31.52) (29.43) Surplus / (Deficit) (27.51) 1.61 (25.89) (26.38) (0.49) (31.67) (32.74) (30.40)

Integrated FPQW Report - Month 10.pdf Page 24Page of 6111 Overall Page 118 of 253 Financial Position by SDU

Re- Key drivers Plan for Categoris Budget Actual for Variance Annual Annual Period ation for Period Period to Budget Forecast Plan Budget Continued overspends within clinical ward areas, which include costs associated with specialling/increased ward dependency and the flu escalation ward which has £'M £'M £'M £'M £'M £'M £'M £'M remained open during January. On-going cover of vacancies with bank and agency Medical Services at a premium cost. Some underspending pay budgets converted to recurring TWIP Income 76.38 (0.74) 75.63 73.81 (1.82) 88.91 91.47 90.50 schemes in year now leaving vacancy factor largely unachieved. Underspends Pay (35.01) 0.21 (34.80) (38.03) (3.23) (45.39) (41.84) (41.62) against pass through drugs and devices are offset with an underachievement of Non Pay (24.81) 1.81 (23.00) (21.73) 1.28 (26.04) (29.66) (27.49) contract income. Surplus / (Deficit) 16.55 1.28 17.83 14.06 (3.77) 17.49 19.98 21.39

Re- Clinical Contract income down due to continued reduced levels of elective surgery Plan for Categoris Budget Actual for Variance Annual Annual and ICU still not yet fully operational to planned level. Ward overspends within Period ation for Period Period to Budget Forecast Plan Budget clinical ward areas, primarily on specialling costs and sickness. This partially offset £'M £'M £'M £'M £'M £'M £'M £'M with underspends in ICU and Theatres. Non pay underspend in PTP drugs and Surgical Services clinical supplies. Offsetting an increasing overspend in Health at Home Income 66.64 (4.97) 61.67 60.64 (1.03) 72.29 79.12 73.14 Rheumatology Drugs. In month 7 Elective care and Drugs QIPP targets where Pay (40.31) 0.51 (39.80) (39.39) 0.41 (47.50) (48.28) (47.66) allocated reducing our over all surplus. Non Pay (15.54) (2.79) (18.34) (17.38) 0.96 (20.89) (18.59) (21.94) Surplus / (Deficit) 10.78 (7.25) 3.53 3.87 0.34 3.90 12.24 3.54 Re- Plan for Categoris Budget Actual for Variance Annual Annual Period ation for Period Period to Budget Forecast Plan Budget £'M £'M £'M £'M £'M £'M £'M £'M Unachieved SSP savings targets partially offset by continued underspends against Women's, Children's, Diagnostics and Therapies vacant posts mainly in Radiology & therapies that are difficult to recruit to. Radiology Income 39.73 (1.93) 37.80 37.67 (0.12) 45.23 47.38 45.12 consultant vacancies partially offset by outsourcing services to external providers Pay (31.98) 1.12 (30.86) (31.18) (0.31) (37.51) (38.31) (36.95) shown against non pay Non Pay (7.28) 0.11 (7.17) (7.64) (0.47) (9.26) (8.68) (8.56) Financing Costs 0.00 0.00 0.00 (0.00) (0.00) (0.00) 0.00 0.00 Surplus / (Deficit) 0.46 (0.70) (0.24) (1.14) (0.90) (1.54) 0.39 (0.39)

Re- Favourable income variances within Education and Health Informatics are covering Plan for Categoris Budget Actual for Variance Annual Annual the under recovery within Torbay Pharmaceuticals, Research and the lower than Period ation for Period Period to Budget Forecast Plan Budget anticipated donated asset income. £'M £'M £'M £'M £'M £'M £'M £'M Pay underspends across corporate areas due to vacancies being held, however the Corporate Services effect of the latest MARS scheme has been incorporated into the forecast and this Income 145.23 13.01 158.25 160.49 2.25 193.03 175.49 196.50 has reduced the anticipated pay underspend. These reduced underspends and non Pay (41.82) (2.83) (44.64) (42.59) 2.05 (51.20) (50.03) (53.50) pay underspends are contributing to the achievement of TWIP targets. The rate of Non Pay (25.75) (4.91) (30.66) (30.37) 0.30 (47.09) (30.86) (36.74) non pay underspending has slowed, due to increased expenditure within Health Financing Costs (15.36) 3.04 (12.33) (10.88) 1.45 (3.68) (18.44) (14.80) Informatics projects, and the introduction of a £200K injury benefit provision relating Surplus / (Deficit) 62.30 8.32 70.62 76.66 6.04 91.07 76.17 91.46 to a new case.

Re- Plan for Categoris Budget Actual for Variance Annual Annual Period ation for Period Period to Budget Forecast Plan Budget £'M £'M £'M £'M £'M £'M £'M £'M SSP income behind planned year to date position by £0.96m SSP Plans Pay and non pay forecast adverse variance due to original SSP target £11m; Income 6.05 (1.11) 4.94 3.98 (0.96) 5.43 7.26 1.66 £3.06m of non pay budget has now been transferred to Independent Sector / CHC. Pay 3.68 (3.27) 0.41 0.00 (0.41) 0.00 5.52 0.62 Non Pay 3.68 (2.42) 1.26 0.00 (1.26) 0.00 5.52 2.01 Surplus / (Deficit) 13.41 (6.80) 6.61 3.98 (2.64) 5.43 18.30 4.28

Integrated FPQW Report - Month 10.pdf Page 25Page of 6112 Overall Page 119 of 253 Items Outside of EBITDA

Key points Year to Date - Month 10 Previous Month YTD

Movement in Plan Actual Variance Variance Variance • Donated asset income is £0.5m adverse to £m £m £m £m £m plan, due to a delay in these capital projects.

Operating income/expenditure outside EBITDA This variance does not affect performance Donated asset income 0.83 0.36 (0.47) (0.40) (0.07) against the control total. Depreciation/Amortisation (12.10) (7.71) 4.39 4.00 0.40 Impairment 0.00 (0.06) (0.06) (0.06) 0.00 • Depreciation/Amortisation is £4.4m Total (12.10) (7.77) 4.33 3.93 0.40 favourable to plan, largely due to the reassessment of asset lives done in 2016/17, Non-operating income/expenditure the reduced level of capital expenditure in Interest expense (excluding PFI) (1.40) (1.34) 0.05 0.05 0.01 2017/18 and the adoption of the Alternative Interest and Contingent Rent expense (PFI) (1.51) (1.47) 0.03 0.03 0.00 Useful LIfe Methodology of the RICS. PDC Dividend expense (1.87) (1.83) 0.04 0.04 0.00

Gain/loss on disposal of assets 0.00 0.06 0.06 0.06 (0.01) Other 0.00 0.01 0.00 0.00 0.00 Total (4.77) (4.58) 0.19 0.18 0.01 Total items outside EBITDA (16.87) (12.35) 4.52 4.11 0.41

Integrated FPQW Report - Month 10.pdf Page 26Page of 6113 Overall Page 120 of 253 Balance Sheet Key Points

Year to Date - Month 10 Previous Month YTD Movement in Plan Actual Variance Variance • Non-current assets are £24.9m lower than planned, principally due to Variance the reduced levels of 2016/17 asset revaluation and 2017/18 capital £m £m £m £m £m

Non-Current Assets expenditure. Intangible Assets 11.20 8.81 (2.39) (2.29) (0.10) Property, Plant & Equipment 173.81 154.23 (19.58) (18.35) (1.23) • Cash is £0.3m adverse to Plan, as explained in the commentary to the On-Balance Sheet PFI 18.19 14.74 (3.45) (3.45) (0.01) Other 1.85 2.36 0.50 0.50 0.00 cash flow statement. Total 205.05 180.13 (24.92) (23.59) (1.33) • Other Current Assets are £8.2m higher than Plan, largely due to Current Assets Cash & Cash Equivalents 5.01 4.74 (0.27) 4.77 (5.04) income received in arrears £5.4m (STF £1.9m, NHS England £0.9m, Other Current Assets 25.03 33.26 8.23 5.61 2.62 NEW Devon £0.8m, Torbay Council £0.9m, Devon Country Council Total 30.04 38.00 7.96 10.38 (2.42) Total Assets 235.09 218.13 (16.96) (13.21) (3.75) £0.9m) and NHS Litigation Authority insurance premiums paid in advance £1.2m. Current Liabilities Loan - DH ITFF (7.12) (6.90) 0.22 0.22 0.00 PFI / LIFT Leases (0.73) (0.76) (0.04) (0.04) 0.00 • Trade and Other Payables are £3.8m higher than Plan, largely due to Trade and Other Payables (30.08) (33.90) (3.81) (6.08) 2.27 payments on account from Torbay Council £3.0m and a favourable Other Current Liabilities (2.51) (2.71) (0.20) (0.03) (0.17) change in the phasing of payments by the local CCG, partly offset by Total (40.44) (44.27) (3.83) (5.93) 2.10 Net Current assets/(liabilities) (10.40) (6.27) 4.13 4.45 (0.32) the paying down of the capital creditor. This reflects the slowing of debt settlement within the NHS at present as seen in current assets Non-Current Liabilities Loan - DH ITFF (71.28) (59.60) 11.67 10.45 1.23 above. PFI / LIFT Leases (19.65) (19.64) 0.00 (0.01) 0.02 Other Non-Current Liabilities (3.94) (4.51) (0.57) (0.42) (0.16) • DH loans (non-current) are £11.7m lower than Plan, largely due to Total (94.86) (83.76) 11.11 10.02 1.09 Total Assets Employed 99.79 90.10 (9.69) (9.12) (0.56) the delay in obtaining approval for new loans.

Reserves • PDC reserves are £0.4m higher than plan due to receipt of PDC Public Dividend Capital 61.87 62.29 0.42 0.42 0.00 Revaluation 46.23 36.13 (10.10) (10.10) 0.00 relating to the GP streaming project. Income and Expenditure (9.03) (8.62) 0.40 0.40 0.00 Total 99.79 90.10 (9.69) (9.12) (0.56)

Integrated FPQW Report - Month 10.pdf Page 27Page of 6114 Overall Page 121 of 253 Cash Current Performance Key points • The actual opening cash balance was £1.6m favourable to the planned opening cash balance. • Cash generated from operations is £4.5m adverse, largely due to the variance against control total excluding the favourable variance relating to depreciation (£4.4m), which is a non-cash item. The risk to in month cash balance is growing and the need to closely manage debtor / creditor positions is becoming more critical and requires working with Risk Share partners.

• Debtor movements are £7.5m adverse, including income received in Year to Date - Month 10 Previous Month YTD Movement arrears £5.4m. Plan Actual Variance Variance in Variance £m £m £m £m £m • Creditor movements are £3.5m favourable largely due to payments on Opening Cash Balance (incl Overdraft) 3.00 4.64 1.64 1.64 0.00 account from Torbay Council £3.0m and the phasing of payments by Cash Generated From Operations 16.75 12.29 (4.46) (3.56) (0.90) the local CCG, partly offset by the paying down of the capital creditor. Working Capital movements - debtors 2.79 (4.72) (7.51) (4.89) (2.62) Working Capital movements - creditors (0.23) 3.24 3.47 5.74 (2.27) Capital Expenditure (accruals basis) (24.31) (4.42) 19.89 17.60 2.29 • Capital expenditure is £19.9m favourable, largely due to reduced loan Net Interest (2.46) (2.22) 0.24 0.10 0.14 drawdown and the delay in starting schemes. Loan drawndown 12.26 0.67 (11.58) (10.36) (1.23) Loan repayment (3.33) (3.33) 0.00 0.00 0.00 Finance lease recognition 0.00 0.69 0.69 0.69 0.00 • Loan drawdown is £11.6m adverse, largely due to the delay in Finance lease repayment 0.00 (0.10) (0.10) (0.10) (0.00) obtaining approval for new loans. PDC Dividend paid (1.12) (1.03) 0.10 0.10 0.00 • Other cash flows are £2.2m adverse, largely due to the delay in Other 1.69 (0.95) (2.63) (2.18) (0.45) planned sales of surplus assets. Closing Cash Balance (incl Overdraft) 5.01 4.74 (0.27) 4.77 (5.04)

Integrated FPQW Report - Month 10.pdf Page 28Page of 6115 Overall Page 122 of 253 Capital Current Performance Key Points

Year to date Mth 10 - Based upon Operational Full Year Plan Operational Plan. Capital expenditure plan of £29.58m, dependent Plan (March 17) upon: - Variance to  New Independent Trust Financing Facility (ITFF) loans Plan Budget Actual Plan Revised F'cast Variance Budget totalling £14.7m, £m £m £m £m £m £m £m  Planned sale of Community properties and Kemmings Close totalling £4.1m, Capital Programme 24.31 10.45 4.42 (6.03) 29.58 9.62 (19.96)  Delivery of NHSI revenue control total and consequently full Significant Variances in Planned Expenditure by Scheme: access to STF. HIS schemes 6.15 2.66 0.88 (1.78) 7.38 1.96 (5.42) Current position: - Estates schemes 15.54 4.54 1.50 (3.04) 19.03 3.95 (15.08)  Asset disposal proceeds in 2017/18 will be less than planned. Medical Equipment 1.22 1.36 0.72 (0.64) 1.46 1.47 0.01  Forecast underspend in (non-cash) depreciation charge being Other 0.00 0.91 0.72 (0.19) 0.00 0.90 0.90 used to offset other cost pressures which have cash requirements. PMU 0.97 0.98 0.60 (0.38) 1.16 1.19 0.03  Planned loans not secured. Contingency 0.43 0.00 0.00 0.00 0.55 0.15 (0.40)  Consequently, in order to maintain solvency, the Trust's Anticipated slippage 0.00 0.00 0.00 0.00 0.00 0.00 0.00 actual capital expenditure in 2017/18 will be substantially Prior Year schemes 0.00 0.00 0.00 0.00 0.00 0.00 0.00 less than that planned. Total 24.31 10.45 4.42 (6.03) 29.58 9.62 (19.96)  Value of approved schemes to date totals £12.6m.  No spend on ED/UCC and Theatre schemes is now forecast as loans will not be in place during 2017/18. Funding sources  Full year forecast expenditure now £9.6m Secured loans 0.00 0.65 0.67 0.02 0.00 0.67 0.67 Actions outstanding Unsecured loans 12.26 0.00 0.00 0.00 14.71 0.00 (14.71)  Present Quality Impact Assessment to the Trust Board for Finance Leases 0.00 0.00 0.87 0.87 0.00 0.87 0.87 those schemes that were planned for progression in 2017/18 Disposal of assets 2.87 0.61 0.00 (0.61) 4.00 0.88 (3.12) but which are not currently part of the prioritised schemes. PDC 0.00 0.00 0.35 0.35 0.00 0.90 0.90 Charitable Funds 0.83 0.83 0.36 (0.47) 1.00 1.00 0.00 Internal cash resources 8.35 8.36 2.17 (6.19) 9.87 5.30 (4.57) Total 24.31 10.45 4.42 (6.03) 29.58 9.62 (19.96)

Integrated FPQW Report - Month 10.pdf Page 29Page of 6116 Overall Page 123 of 253 Activity Activity variances to plan -Month 10 Activity variances for M10 and M9 against the contract activity plan are shown in the table opposite. In M10, elective activity broadly matched plan but, F-ups activity dropped 1,800 behind plan, New's increased to 252 ahead of plan. The main variation is against elective inpatients (18% behind plan, 16% last month) and outpatient follow up appointments (8% behind plan, 8% last month).

At treatment function level the greatest variance is in Orthopaedics with 197 inpatient cases behind plan (£954k). This position reflects the continuing focus to reducing costs and limiting activity to workforce plan. A number of decisions have been taken to not replace clinical staff in particular some 'training and middle grade' posts at this time. It is noted that the newly introduced therapy led interface services have been successful in reducing the conversions to surgery.

For follow ups, the specialty with greatest variance against plan is Dermatology 3,580 appointments behind plan (£455k).

The underperformance against commissioned elective activity plan has been escalated as a concern. The underperformance is one of the factors behind the deteriorating RTT performance. This is currently being reviewed. The committee is asked to note: • The activity plan is based on the assessment of actual capacity and therefore does not include any historical waiting list initiative activity. • Risk Share Agreement mitigates any immediate income risk. • Activity underperformance is contributing to cost savings on non pay consumable items. • Risk remains that reduced elective activity will increase waiting times and impact on RTT performance and patient experience, see graphs opposite. • The RTT risk and assurance group are maintaining the performance oversight with the RTT position and forecast reviewed at individual team level. • Referrals over a rolling 12 month period are remaining at historical levels . • The winter plan to escalate bed capacity and medical cover during December / January and beyond is having a further impact on elective activity.

Integrated FPQW Report - Month 10.pdf Page 30Page of 6117 Overall Page 124 of 253 CIP Delivery: Current Mth, Cumulative & Forecast a) Current Month and Cumulative to Current Month Delivery against Target a) Current Month and Cumulative to Current Month Delivery against Target Summary>

-Current Month Shortfall: £0.9m

-Cumulatively Surplus: £1.47m

Commentary> The current month shortfall is reflective of the incremental phasing of the CIP Target not reflecting the actual delivery phasing. The more important indicator is the Cumulative position, which remains in Surplus.

b) Year End Forecast Delivery against Target and Recurrent FYE forecast delivery. b) Year End Forecast Delivery against Target and Recurrent FYE forecast delivery.

Target: The CIP target shown is £42.1m. This comprises £41.7m of CIP and £1.3m of Income Generation Saving proposals.

Target: £42.1m Yr End Forecast Delivery: £42.0m Shortfall: £0.1m

F/Cast 18/19 Recurrent FYE of 17/18 projects: £30.1m reported, but with mitigations to potentially increase in quarter 4 (See main report covering commentary)

Risk: Presumes all schemes listed deliver (See Delivery Assurance)

Integrated FPQW Report - Month 10.pdf Page 31Page of 6118 Overall Page 125 of 253 CIP- Delivery Assurance - Yr end delivery forecast- c) CIP Delivery Assurance- Route to Cash (c) CIP Delivery Assurance:- Route to Cash

The vast majority of the £42.0m forecast delivery has a proven route to cash, i.e: £40.7m (97% of forecast delivery total) with the remaining £1.3m (3% of forecast delivery total) identified as having a route to cash analysis in progress.

d) CIP Delivery Assurance:- Pipeling stage (d) CIP Delivery Assurance:- Pipeline stage

Of the projects comprising the £42.0m forecast delivery:

£41.8m (99.5%) are either Complete, and delivering savings or in "Delivery" stage whereby the project is finalised but savings awaited. Nb: Projects categorised as "Abandoned with delivery" are showing delivery realised prior to abandonment £0.2m (0.5%) relates to schemes in outline or in detailed plan stage. However these projects are constantly being reviewed to scope delivery potential.

This demonstrates a very strong level of delivery assurance.

Integrated FPQW Report - Month 10.pdf Page 32Page of 6119 Overall Page 126 of 253

Operational Performance Focus

Month 10 - January 2018

Page 2 Summary of Performance Page 3 RTT (Referral to Treatment Time) Page 4 4 hour standard for time spent in the Emergency Department and MIU's Page 5 Cancer Standards Page 6 Diagnostic Waits Page 7 Other Performance Exceptions Page 8 Social care performance metrics Page 9 Community metrics

Integrated FPQW Report - Month 10.pdf Page 33 of 61 Overall Page 127 of 253 Performance Summary NHSI Operational Plan indicators (Month 10) A+E: The STF operational performance trajectory in January is not met. The target set for winter incentive funding is an aggregate level of 92.4% in Q4 and 95% in March for STF operational performance payment. RTT: The RTT trajectory is not met - plans to prevent further deterioration have been agreed and to maintain 82% to end of March 2018. Cancer: The standard for urgent suspected cancer referral and treatment within 62 days has been met in January. Diagnostics: The diagnostics standard is not met and increased to 5.38% over 6 weeks outside of the agreed tolerance of 4%. Dementia: The Dementia find standard is not met in January.

4 hour ED standard: In January the Trust achieved 83.82% of patients discharged or admitted within 4 hours of arrival at accident and emergency departments. This is a fall on last month 88.34% and is below the agreed Month 10 Operational Plan trajectory of 89.9 % and below the 95% national standard. 4 hour standard for time spent in the Emergency Department and MIU's Performance to 20th February 2018 shows 79.62% of patients being discharged from ED and MIU within 4 hours.

RTT (Target 92% / Trajectory 89.3%): RTT performance has improved in January to 82.51% waiting less than 18 weeks from 82.2% in December.

Patients waiting over 52 weeks: The number of very long wait patients is starting to reduce in line wiith plans with 29 reported at the end of January against the target of 34. The trajectory remains to achieve 16 at the end of February and zero at the end of March. The March delivery is however at risk due to operational pressures currently being experienced and limiting the number of elective inpatient admissions. In January higher numbers of elective inpatient operations requiring beds have been stood down with this continuing into February whilst the urgent care pressures remain in the system. Teams are monitoring on a daily basis and implementing additional lists where possible to mitigate for this loss in capacity to deliver the March position of zero patients waiting over 52 weeks.

62 day cancer standard: 85.6% (validated 14 February 2018) against the 85% national target, this is an improvement on last month (82.4%). The standard in Q4 NHS I assessment is predicted to be met against the target 85%.

Diagnostic waits: The diagnostics standard is not met and increased to 5.38% over 6 weeks outside of the agreed tolerance of 4%. The greatest number of long waits are for routine MRI, with an increase in Echocardiography waits being the greatest change.

Integrated FPQW Report - Month 10.pdf Page 34 of 61 Overall Page 128 Pageof 253 2 NHSI Indicator - Referral to Treatment Specialties with highest numbers of patients over 18 weeks RTT Incomplete RTT > 18 weeks Submitted Spec IPDC OP % < 18wk Total Trauma & Orthopaedics 367 103 76.33 470 Urology 205 112 73.89 317 Upper Gastrointestinal Surgery 208 64 61.96 272 Cardiology 17 235 78.57 252 Ophthalmology 193 52 87.21 245 Gastroenterology 139 57 85.17 196 Pain Management 49 128 68.11 177 Rheumatology 7 153 75.42 160 Neurology 2 158 70.91 160 Respiratory Medicine 152 73.7 152 Colorectal Surgery 67 50 79.47 117 Oral Surgery 50 59 91.1 109 Grand Total 1430 1706 82.5 3136

At the end of January 82.5% (82.2% last month) of patients waiting for treatment had waited 18 weeks or less at the Trust from initial referral for treatment. This is assessed as RED however is an improvement on last month and follows seven months of reducing performance. Improvements have been seen across the non-admitted pathways whilst the impact from reduced admissions for routine elective inpatient admissions remains a risk for upper GI , Urology and Orthopaedics.

As part of the STP planning guidance a revised M12 performance of 82% has been agreed and this is to be used as the baseline of activity forecasts in 2018_19. An assessment has been made by specialty and this confirms that the revised trajectory can be achieved from current plans however there is an increased risk due to the continued operational pressures from emergency admission pathways to these plans. We remain committed to remove all over 52 week wait patients by 31st March 2018.

Monitoring patients waiting longer than 52 weeks: At the end of January, 29 patients (target 34) were waiting longer than 52 weeks (42 in December) with a target reducing to 16 in February and zero by the end of March. Risks to this plan have increased with the emergency operational pressures resulting in a loss of routine elective operating for patients requiring inpatient admission. Within the cohort of patients needing to be treated by 31st March 2018 there are 21 patients (39 last month) that will require inpatient admission.

Governance and monitoring: All RTT delivery plans are reviewed at the bi-weekly RTT and Diagnostics Assurance meeting chaired by the Deputy Chief Operating Officer (DCOO) with the CCG Commissioning Lead in attendance.

Integrated FPQW Report - Month 10.pdf Page 35Page of 61 3 Overall Page 129 of 253 NHSI indicator - 4 Hours - Time spent in Accident and Emergency Department

The STF trajectory for Accident and Emergency waiting times is not achieved in January with 83.82% of ED and MIU attenders discharged or transferred within 4 hours against the trajectory of 89.9%. Thresholds for access to performance related (tranche 2) winter funding allocations have been confirmed with an aggregate performance of 92.4 %4 in hour Q4 setstandard as our for local time target spent. As in at the 20 Emergencyth February itDepartment is confirmed and that MIU's this level of performance cannot be achieved in Q4 due to the performance reported to date. The performance related winter funding allocation would be in addition to the original STF operational performance threshold of 95% in March 2018 for the 30% operational performance element of STF.

January performance was impacted by continued winter pressures with the urgent care system being in escalation of OPEL 3 or higher for 28 days compared to just 4 days in November (6 days at OPEL 4). Patient flow and access to inpatient beds being the critical constraint. The escalation ward consisting of 22 beds remained open throughout January. Escalation status June July August September October November December January Opel 1 15 30 15 4 12 15 6 0 Opel 2 10 1 11 9 14 11 11 2 Opel 3 5 0 4 17 5 4 13 23 Opel 4 0 0 1 0 0 0 1 6

Management of flu across inpatient wards remained a challenge, however, with early testing the impact has been managed well along with on-going infection control measures. The additional domiciliary care capacity commissioned in December continued and has supported timely discharge and on-going support of patients at home. Intermediate care bed capacity and home support has been maintained at planned levels. Operational pressures and escalation have continued into February 2018 with operational performance of 79.62% to 20th February 2018.

12 hour Trolley wait - In January eight patients are reported as having a trolley wait from decision to admit to admission to an inpatient bed of over 12 hours. These all occurring on the 1st (7) and 2nd (1) January 2018. A full harm review and Root Cause Analysis has been completed and no harm found; this adverse event was reported to NHSI.

Integrated FPQW Report - Month 10.pdf Page 36 of 61 Page 4 Overall Page 130 of 253 Cancer treatment and cancer access standards January 2018 Cancer standards - Table opposite shows the January performance (at 13th

CWT Measure Target February): Note these figures are provisional and may change as final Total Performance

Within Target validation and data entry is completed for national submission, 25 working Breached Target Breached

14 Day - 2ww referral 93% 878 254 1132 77.6% days following the month close.

14 Day - Breast Symptomatic referral 93% 75 5 80 93.8% Three cancer treatment time standards have not been met. 31 Day 1st treatment 96% 161 15 176 91.5% Urgent cancer referrals 14 day 2ww: At 77.6% this position is improving 31 Day Subsequent treatment - Drug 98% 88 1 89 98.9% from last month (76.3%). Dermatology is the main specialty that requires 31 Day Subsequent treatment - Radiotherapy 94% 81 4 85 95.3% improvement. Locum cover is now in place to support additional urgent 31 Day Subsequent treatment - Surgical 94% 32 1 33 97.0% clinics and patients are being booked within 14 days. 31 Day Subsequent treatment - Other 21 0 21 100.0% 31 day diagnosis to treatment: 91.4% against the target of 96%. 62 day 2ww / Breast 85% 86.5 14.5 101 85.6%

62 day Screening 90% 4 1 5 80.0% 62 day screening: 80.0% against 90% target. Note the low numbers influence the delivery of this standard with a single patient not meeting the standard in January. NHSI monitoredLong waits Cancer - patients 62 day over standard 104 days: The 62 day referral to treatment standard is forecast to be met in January (85.6%) standard 85%. This remains provisional as potential for delayed data entry and pathology results can be added together with any patients referred to other trusts and not tracked not meeting the target. Plans are in place to support reduction in wait time across the Lung and Urology pathways through pathway redesign and reducing diagnostic phase of pathway. However there are an increasing number of Skin patients exceeding the time to treatment.

Cancer - Patients waiting >104 days from 2ww Longest waits greater than 104 days

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Cancer not discounted n/a n/a n/a n/a n/a n/a 9 6 4 7 12 13 15 The most recent guidance from NHS E is that there will be a zero tolerance Confirmed cancer n/a n/a n/a n/a n/a n/a 4 4 2 5 4 1 9 Total waiting >104 days from 2ww 14 14 9 10 18 17 13 10 6 12 16 14 24 on the number patients who have confirmed cancer and receive treatment

30 after 104 days from December 2017. To facilitate our early warning of

25 these patients reaching 104 days a 90 day trigger has been established in

20 internal monitoring reports and these patients to be further reviewed at

15 MDT. This validation and escalation process is seeing a reduction in the 10 longest waits with confirmed cancer, however, there remain pathways 5 greater than 104 days being tracked from urgent referral where cancer has

0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 not been ruled out. Total waiting >104 days from 2ww

Integrated FPQW Report - Month 10.pdf Page 37Page of 61 5 Overall Page 131 of 253 NHSI indicator - Patients waiting over 6 weeks for diagnostics The number of patients with a diagnostic wait over 6 weeks increased in January with 191 (5.38% of total waiting) from 134 (3.73%) in December. The highest number of patients with long waits have been identified in MRI with 75 (81 last month) patients over 6 weeks. The continued mobile MRI van visits have helped to stabilise the number waiting and starting to see an overall reduction. CT has seen an overall reduction in numbers waiting with staff being flexed to run additional weekend sessions. The largest increase was for Echocardiography waiting numbers and those now waiting over six weeks. This is from staff sickness and reduced capacity and a focus on resources to support ward 4 hour standard for time spent in the Emergency dischargesDepartment. The and team MIU's have now arranged locum backfill for five days a week with all new patients referred are being listed to be seen in six weeks and the backlog reducing. There continues to be pressures from increasing demand across many areas with demand management and options to increase capacity reviewed as part of the 18_19 business planning.

Overall Diagnostic waits > 6 weeks (as percentage of total waits)

Integrated FPQW Report - Month 10.pdf Page 38Page of 61 6 Overall Page 132 of 253 Other Performance Exceptions Ambulance handovers Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Handovers > 30 minutes 123 62 110 56 98 183 104 180 150 88 124 181 271 Ambulance Handover Handovers > 60 minutes 22 10 4 6 2 4 12 17 10 6 5 18 18 >30 minutes trajectory 30 30 30 30 30 30 30 30 30 30 30 30 30 The number of ambulance handovers delayed over 30 minutes remains 300 above planned levels. The increase in January (271 from 181 in December) 250

200 is a reflection of pressures on patient flow across the system with patients

150 being held in ED waiting for admission to hospital beds impacting on 100 ambulance delays in offloading and handing over patients.

50

0 Regular meetings with the Ambulance Trust continue to manage these Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Handovers > 30 minutes Handovers > 60 minutes >30 minutes trajectory operational challenges. The longest delays being those over 60 minutes are being managed with clinical prioritisation and escalation processes in place. The number of handovers over 30 minutes is higher than the same period last year.

Care Plan Summaries completed with 24 hours of discharge - Weekday

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Discharges 1258 1230 1355 1079 1239 1204 1179 1268 1239 1269 1251 1104 1161 Care Planning Summaries (CPS) CPS completed within 24 hours 2004 1883 2234 1674 1905 1925 1803 1787 1746 1825 1821 1625 1716 % CPS completed <24 hrs 63% 65% 61% 64% 65% 63% 65% 71% 71% 70% 69% 68% 68% Target 77.0% 77.0% 77.0% 77.0% 77.0% 77.0% 77.0% 77.0% 77.0% 77.0% 77.0% 77.0% 77.0% Improvement remains a challenge to complete CPS's within 24 hours of

90% discharge, 68% achieved in January for weekday discharges against the 80% internal target for improvement of 77%. The challenges remain with the 70% 60% manual processes and duplication of information already recoded. The 50% 40% strategy is to reduce the manual entry requirements and demands on 30% 20% junior doctor time by increasing the automatic transfer of data from 10% existing electronic records. 0% Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 % CPS completed <24 hrs Target The current performance is an improvement over the same period last year.

Integrated FPQW Report - Month 10.pdf Page 39Page of 61 7 Overall Page 133 of 253 Social Care and Public Health Metrics

Torbay Social Care KPIs 2017/18 2017/18 Comment full year YTD Outturn target target YTD % clients receiving self-directed support 92% 92% 92% On target Below target. Performance remains static but target is increasing. Performance expected to % clients receiving direct payments 28% 27.6% 25.2% improve through use of 'My Support Broker' and work with the voluntary sector.

Below target. Clients in care homes are now being reviewed by location rather than date for % clients receiving a review within 18 months 93% 93% 88% efficiency. Many clients at home are being reviewed by 'My Support Broker' and these are also done in the most efficient order rather than date order. Timeliness of social care assessment 70% 70% 79% OnSafeguarding target work has also impacted review work. No. of permanent care home placements (snap shot) 617 621 629 Within agreed tolerance Permanent admissions (65+) to care homes per 100k On target 599.0 599.0 465.0 population (BCF) (rolling 12 month) Carers receiving needs assessment, review, information, On target 43% 35.8% 38.1% advice, etc. % carers receiving self directed support 85% 85% 82% Within agreed tolerance

% of high risk adult safeguarding concerns where On target 100% 100% 100% immediate action was taken to safeguard the individual % Adults with learning disabilities in settled On target 75% 75% 76% accommodation Below target. These are delays for Torbay residents by any NHS organisation with around Number of days of delayed transfers of care (BCF) 2,439 1,521 2,450 60% reported by TSD NHS Trust. Torbay continues to perform well compared to National and regional benchmarks.

The Social Care and Public Health metrics relate to the Torbay LA commissioned services. Comments against indicators are shown in the dashboard above. The metrics and exceptions are reviewed at the Torbay Social Care Programme Board (SCPB), monthly Executive Quality and Performance Review meetings and Community Board. The headline risks currently being managed are: • Nursing and residential home market and capacity; • Domiciliary care provider not meeting service level demand and contract queries raised; • Continuing Health Care (CHC) for placed people volume and price pressures.

17/18 Performance Measures 17/18 YTD 17/18 YTD Public Health Year End Target Actual The headline messages for Public Health performance are: Target • CAMHS - waiting times from referral to assessment and commencement of Public Health Services treatment remain good. CAMHS - % Urgent referrals seen within 1 week 68% 68% 86% • Health visiting - The metric is reporting 84% compliance however the service CAMHS - % patients waiting under 18 weeks at month end [B] 92% 92% 100% confirm that no new birth visits have been missed. Babies in the Special Care % of face to face new birth visits within 14 days * 95% 95% 85% Unit may not be reviewed. The team are continuing to work to improve the Children with a child protection plan * [B] .. 160 reporting with the use of the new PARIS system. 4 week smoking quitters Q2 ** [B] 100 156 • Children with Child protection plan reduced - last month 198 Opiate users - % successful completions of treatment Q2 ** [B] 8.3% 7.9%

Integrated FPQW Report - Month 10.pdf Page 40Page of 61 8 Overall Page 134 of 253 Community Services The Community Hospital Dashboard highlights Community Hospital admissions remain over plan. The bed occupancy is 93% and length of stay remaining constant at 11 days. The impact from the overall reduction in bed numbers in both the acute and community settings is being closely monitored. Winter resilience planning includes programmes to increase the use of intermediate care and support the domiciliary care capacity to support timely discharge and alternatives to community and acute bed based care. It is noted that delayed discharges from community setting has reduced from a peak in September. MIU attendances are in line with plans. There have been no unexpected consequences following the closure of Paignton and Brixham MIU's. Waiting times in MIU's are being maintained with a median time of 46 minutes. Community based services highlights Nursing Community nursing and outpatients activity is tracking the same levels of activity as last year, in line with target.

Intermediate Care (IC) placements The year to date average length of stay 17/18 Performance Measures 17/18 YTD 17/18 YTD YTD Variance Year End in IC placements remains above target and remains at 17 days. Teams have Target Actual No. % Target been focusing on reviewing all patients with a longer length of stay. There Community Based Services remains variation between different zones in the utilisation of IC and the Nursing activity (F2F) 199,889 167,578 170,339 2,761 2% percentage of referrals that convert to placement, this is being reviewed as Therapy activity 74,545 62,121 55,289 6,832 11% part of the wider ICO evaluation work. Outpatient activity 98,399 82,011 81,872 139 0% No. intermediate care urgent referrals [B] 3,041 2,538 1,809 729 29% No. intermediate care placements 1,665 1,393 917 476 34% Delayed Transfers of Care (DToC) Intermediate Care - placement average LoS [B] 12 12 17.4 5 45% January is reporting a fifth consecutive month of reducing delays. Maintaining low levels of delayed discharges remains a key operational goal and is a good indicator that system process to discharge patients from a hospital setting continue to work well. DToC levels remain higher than the same period last year. There is scope for improvement and teams continue to focus on early escalation of potential delays. A detailed review of DToC process , system capacity, and delays is underway to understand more closely the causes and give assurance to the board and system partners.

Integrated FPQW Report - Month 10.pdf Page 41Page of 61 9 Overall Page 135 of 253 Quality Focus

Page 11 Summary Of Quality Page 12 Mortality Page 14 Infection Control Page 15 Incident Reporting Page 16 Exceptions

Integrated FPQW Report - Month 10.pdf Page 42Page of 6110 Overall Page 136 of 253 Quality and Safety Summary

Quality and Safety Summary

The following areas of performance are noted:

1. The Hospital Standardised Mortality Rate (HSMR) remains in a positive position for the months of February to August (please note Dr Foster has a three month data lag). October data has a rate of 86.6 which is good and remains below the 100 average line. The overall yearly mortality is in line with the Trusts Unadjusted Mortality and the DH's Summary Hospital Mortality Index (SHMI).

As well as viewing the top line mortality figure any Dr Foster mortality alerts are also reviewed on a monthly basis, firstly between Coding and Clinical Risk and subsequently at the Mortality Surveillance Group and Quality Improvement Group.

2. Incident reporting continues to be well supported and all areas of the Trust are reporting within expectations. Themes and issues are collated on a monthly basis and can be viewed via the Trust wide QIG Dashboard and help inform the 5 point Safety Brief and Clinical Alert System. A new monthly Datix Digest has also been produced and the second edition includes a top 10 themed review of each SDU. This is also sent out via ICO News to the ICO

It is noted that January is reporting 9 STEIS reportable incidents. The details are outlined in the following report. All serious incidents are reported on the Strategic Executive Information System (STEIS) and via the National Reporting and Learning System upload. Serious incidents are managed in the Service Delivery Units and are presented to the Serious Adverse Events group for learning and sharing Trust wide. This group has links with the Improvement and Human Factors teams.

3. Infection Control are reporting a low number of bed days lost from infection control measures in December with 8 days lost compared to 130 in November and 68 in December 2016. There is one Clostridium Difficile (CDT) reported and this confirmed as a lapse in care. Hand hygiene audits remain high at a 96% compliance rate. It is noted that Norovirus has been present in the Hospital in January and the number of bed days lost increased.

4. The Venous thromboembolism (VTE) drop in compliance has been noted and escalated to the Medical Director and will be included for discussion at the forthcoming Quality and Performance Review meeting .

Integrated FPQW Report - Month 10.pdf Page 43Page of 6111 Overall Page 137 of 253 Quality and Safety - Mortality

Trust wide mortality is reviewed via a number of different metrics however, Dr Foster allows for a standardised rate to be created for each hospital and, therefore ,this is a hospital only metric. This rate is based on a number of different factors to create an expected number of monthly deaths and this then is compared to the actual number to create a standardised rate. This rate can then be compared to the English average, the 100 line. Dr Fosters mortality rate runs roughly three month in arrears due to the national data submission timetable and,therefore, Dr Foster mortality has to be viewed with the Trusts monthly unadjusted figures. The latest data for Dr Foster HSMR is showing a low relative risk of 86.6, which is positive and mirrors the general trend of the Trust. Mortality does have a cyclical nature and tends to rise during the colder months. This may start to manifest in the coming months.

Summary Hospital Mortality indicator (SHMI)

The SHMI data reflects all deaths recorded either in hospital or within 30 days of discharge from hospital. The data is released on a quarterly basis and the latest data release from the DH is July 16 - June 17 and records the Trusts at 83.9. The SHMI has remained low for a sustained period of time.

A score of 100 represents the weighted population average benchmark.

Integrated FPQW Report - Month 10.pdf Page 44Page of 6112 Overall Page 138 of 253 Quality and safety - Infection control Number of Clostridium Difficile cases

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 In January there is one Cdiff reported, this is not a lapse Acute 1100211201521 Community 0100001000000 in care (acute).

6 For the year to date of the 16 total cases reported to date 5 9 have been assessed as a lapse in care. 4

3 Each reported case of c-diff undergoes a Root Cause 2 Analysis. Learning from these is used to inform feedback 1 to teams and review of systems and processes. 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Acute Community

Infection Control - Bed Closures (acute)

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 The Infection Control Team continue to manage all cases Acute 116 0 6 24 24 12 18 18 12 30 130 8 198 of potential infections with individual case by case 250 assessment and control plans. 200

150 In January there has been a number of ward bays closed from infection control measures as seen in the graph 100 opposite. 50

0 Hand hygiene compliance scores have dropped in the last Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 few months with 89% recorded in January. Acute

The number of patients in hospital with confirmed flu are reported as part of the winter reporting to NHSI. The graph opposite summarises the daily submissions . The opening of Warrington Ward as part of the winter escalation plans together with its allocation as dedicated flu ward over New Year made a significant contribution to Flu figures the containment of flu cross infection.

Integrated FPQW Report - Month 10.pdf Page 45Page of 6113 Overall Page 139 of 253 Quality and safety - Incident Reporting and Complaints Reported Incidents - Major and Catastrophic

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Trustwide 201240131300 12 The Trust reported 6 serious incidents in January.

14

12 The incident review process established that the cause 10 was not related to any failure in patient care and that no 8 harm caused to the patient. 6

4

2

0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Trustwide STEIS Reportable Incidents The Trust reported 9 incidents on STEIS from across the Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 STEIS - reportable incidents 2449447835226 ICO in January. The incidents are:

10 9 2 Pressure ulcer grade 4 in the Community 8 7 3 falls on wards resulting in fractured neck of femurs 6 1 Diagnostic delay in ED 5 4 1 Suicide of a pateint recieiving NHS care 3 2 1 overdose of a service user 1 1 Deterorating patient incident 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 All incidents have followed normal reporting procedures STEIS - reportable incidents and are being investigated with feedback to the patients Formal complaints

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Acute 20 23 29 11 25 21 25 14 17 27 17 13 32 Community 9 3 5 2 7 10 8 8 5 11 7 4 2 Formal Complaints Total 29 26 34 13 32 31 33 22 22 38 24 17 34 Target 60 60 60 60 60 60 60 60 60 60 60 60 60

70 The number of formal complaints are shown in the table

60 opposite. Reporting can be variable with less reported in 50 December and this is evident in the data. January's 40 complaint numbers are showing a rise in acute hospital 30 and this needs to be observed for any trend. All 20 complaints are investigated and shared with area/locality 10 for leaning. 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Acute Community Target

Integrated FPQW Report - Month 10.pdf Page 46Page of 6114 Overall Page 140 of 253 Quality and Safety - Exception Reporting Dementia Find: The NHS I Single Oversight Framework (SOF) includes Dementia screening and referral as one of the NHSI priority indictors.

The Dementia Find in January deteriorated to 52.1% from 65.5% in December.

The switch to recording on Nerve Centre is in the process of being rolled out and is currently affecting the recorded performance as the data is unable to be accurately extracted. Longing work with the supplier to resolve.

Follow ups 6 weeks past to be seen date (excluding Audiology) Follow ups: The number of follow ups waiting for an Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 6+ weeks past to be seen date 5512 5518 5548 6429 6550 6999 7209 7496 7477 6790 6308 7041 6630 appointment greater that six weeks past their 'to be seen by date' in January reduced to 6630 from 7041. 8000

7000 6000 Agreed actions to target the areas with the greatest number are 5000 being monitored through the RTT Risk and Assurance Group. 4000 3000

2000 The Quality Assurance Group are maintaining oversight on 1000 processes to identify and mitigate clinical risk against patients 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 waiting beyond their intended review date. 6+ weeks past to be seen date Specialties with the greatest numbers of patients waiting Row Labels Sum of Patients longer than six weeks are shown in the table opposite with OPHTHALMOLOGY 3320 Ophthalmology having the highest number. These are across RHEUMATOLOGY 841 a number of common disease pathways and appropriate clinical DERMATOLOGY 431 risk and review measures are in place. UROLOGY 305 PAEDIATRICS 291 ORTHOPTICS 288 ORAL SURGERY 218 CARDIOLOGY 209 COLORECTAL SURGERY 143

Integrated FPQW Report - Month 10.pdf Page 47Page of 6115 Overall Page 141 of 253 Workforce Focus

Page 17 Summary Of Workforce Page 18 Workforce Plan Page 19 Workforce Plan Page 20 Sickness Absence Page 21 Turnover Page 22 Appraisals and Training Page 23 Agency

Integrated FPQW Report - Month 10.pdf Page 48Page of 6116 Overall Page 142 of 253 Workforce - Workforce Plan Planned Staff In Post 16/17 17/18 18/19 19/20 20/21 21/22 The table opposite shows the planned In-post In-post In-post In-post In-post In-post Prof Scientific and Tech 293.27 291.93 286.43 279.43 273.43 273.43 substantive staff in post and planned Additional Clinical Services 1069.54 1067.50 1049.50 1036.76 1032.76 1032.76 temporary workforce over the next five years Administrative and Clerical 1290.56 1239.22 1146.22 1142.22 1138.22 1136.22 by staff group. Allied Health Professionals 403.74 403.05 376.97 368.60 367.59 367.59 Estates and Ancillary 390.66 339.53 339.53 339.52 339.53 339.53 This plan takes into account the effect of the Healthcare Scientists 91.46 91.46 91.46 91.46 91.46 91.46 Medical and Dental 433.73 433.73 433.73 433.73 433.73 433.73 care model, trust wide improvement Nursing and Midwifery Registered 1189.81 1133.36 1090.36 1075.18 1070.27 1070.27 programmes, reductions in the vacancy factor Students 1.49 1.49 1.49 1.49 1.49 1.49 etc.

Substantive Staff Total 5164.27 5001.28 4815.70 4768.40 4748.49 4746.49

Bank Prof Scientific and Tech Bank Additional Clinical Services 154.00 50.00 40.00 30.00 30.00 30.00 Bank Administrative and Clerical 24.36 7.22 7.22 5.42 5.42 5.42 Bank Allied Health Professionals 1.20 1.00 1.00 1.00 1.00 1.00 Bank Estates and Ancillary 43.13 12.78 12.78 9.58 9.58 9.58 Bank Healthcare Scientists Bank Medical and Dental Bank Nursing and Midwifery Registered 29.00 15.00 10.00 10.00 10.00 10.00 Bank Students

Bank Workers Total 251.69 86.00 71.00 56.00 56.00 56.00

Agency Prof Scientific and Tech 6.25 1.25 1.25 1.25 1.25 1.25 Agency Additional Clinical Services Agency Administrative and Clerical 4.00 Agency Allied Health Professionals 6.25 1.25 1.25 1.25 1.25 1.25 Agency Estates and Ancillary Agency Healthcare Scientists Agency Medical and Dental 17.00 16.20 16.20 16.20 16.20 16.20 Agency Nursing and Midwifery Registered 40.00 26.00 26.00 26.00 26.00 26.00 Agency Students

Agency Workers Total 73.50 44.70 44.70 44.70 44.70 44.70

Integrated FPQW Report - Month 10.pdf Page 49Page of 6117 Overall Page 143 of 253 Planned Workforce 2017/2018 Workforce - Plan v Actual Staff Group 31/03/2017 30/04/2017 31/05/2017 30/06/2017 31/07/2017 31/08/2017 30/09/2017 31/10/2017 30/11/2017 31/12/2017 31/01/2018 28/02/2018 31/03/2018 In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post The table opposite shows the planned Add Prof Scientific and Technic 293.27 293.16 293.05 292.94 292.87 292.80 292.43 292.33 292.22 292.11 291.99 291.93 291.93 substantive WTE changes from the Additional Clinical Services 1,069.54 1,069.36 1,069.26 1,069.12 1068.99 1068.87 1068.71 1068.52 1068.33 1068.10 1067.88 1067.66 1067.50 Administrative and Clerical 1,290.56 1,287.98 1,285.41 1,282.83 1278.65 1275.20 1271.76 1266.60 1261.44 1256.28 1250.27 1244.25 1239.22 opening position at the 31 March 2017 for Allied Health Professionals 403.75 403.57 403.63 403.63 403.46 403.46 403.46 403.30 403.30 403.30 403.11 403.11 403.05 each month of the financial year until the Estates and Ancillary 390.66 388.09 385.53 382.96 378.79 375.37 371.94 366.80 361.66 356.52 350.53 344.54 339.53 Healthcare Scientists 91.46 91.46 91.46 91.46 91.46 91.46 91.46 91.46 91.46 91.46 91.46 91.46 91.46 31 March 2018. Medical and Dental 433.73 433.73 433.73 433.73 433.73 433.73 433.73 433.73 433.73 433.73 433.73 433.73 433.73 Nursing and Midwifery Registered 1,189.81 1,184.86 1,182.22 1,178.54 1175.14 1171.75 1167.46 1162.37 1157.28 1151.20 1145.27 1139.34 1133.36 Students 1.49 1.49 1.49 1.49 1.49 1.49 1.49 1.49 1.49 1.49 1.49 1.49 1.49 The plan is to reduce the overall Planned Substantive Staff Total WTE 5,164.27 5,153.71 5,145.79 5,136.70 5,124.59 5,114.14 5,102.45 5,086.61 5,070.92 5,054.20 5,035.74 5,017.52 5,001.28 headcount to 5001 WTE substantive staff

Actual Workforce 2017/2018 in post at the end of the financial year. Staff Group 31/03/2017 30/04/2017 31/05/2017 30/06/2017 31/07/2017 31/08/2017 30/09/2017 31/10/2017 30/11/2017 31/12/2017 31/01/2018 28/02/2018 31/03/2018 In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post Add Prof Scientific and Technic 295.47 297.23 296.89 294.47 298.28 286.21 286.06 278.68 286.70 281.92 292.11 This table also shows the outturn against Additional Clinical Services 1,073.29 1,070.59 1,075.01 1,076.72 1,068.81 1070.32 1068.69 1059.85 1055.60 1059.49 1091.59 the plan at the 31 March 2017 and for Administrative and Clerical 1,292.95 1,268.78 1,265.77 1,267.43 1,258.83 1259.13 1256.09 1244.10 1244.19 1230.87 1250.64 Allied Health Professionals 405.45 401.10 402.55 400.26 401.56 403.33 403.50 396.19 395.15 391.76 404.09 each month of the year to date. Monthly Estates and Ancillary 392.86 380.83 378.78 375.22 375.56 372.50 368.07 363.74 368.03 365.91 368.77 WTE against plan will continue to be Healthcare Scientists 91.85 92.27 91.47 90.47 91.13 88.13 89.13 94.23 85.93 86.93 85.77 Medical and Dental 435.50 456.88 452.43 451.28 488.13 468.13 467.03 465.11 463.99 458.94 465.75 monitored and included in this Integrated Nursing and Midwifery Registered 1,196.66 1,178.26 1,174.32 1,173.08 1,161.42 1161.89 1166.97 1168.77 1160.94 1154.69 1168.25 Performance Report each month. Students 1.50 2.50 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 Actual Substantive Staff Total WTE 5,185.53 5,148.43 5,139.21 5,130.91 5,145.74 5,111.65 5,105.54 5,070.66 5,060.52 5,030.52 5,126.97 0.00 0.00 The outcome at the end of January 2018 Planned V Actual 2017/2018 Staff Group 31/03/2017 30/04/2017 31/05/2017 30/06/2017 31/07/2017 31/08/2017 30/09/2017 31/10/2017 30/11/2017 31/12/2017 31/01/2018 28/02/2018 31/03/2018 for substantive WTE staff is a reduction of In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post In-post 58.56 FTE year to date aganst the year Add Prof Scientific and Technic -2.20 -4.07 -3.84 -1.53 -5.41 6.59 6.37 13.65 5.52 10.19 -0.12 Additional Clinical Services -3.75 -1.23 -5.75 -7.59 0.18 -1.45 0.02 8.67 12.74 8.62 -23.70 target of 162.99 by the end of March Administrative and Clerical -2.39 19.20 19.64 15.41 19.82 16.07 15.67 22.50 17.26 25.41 -0.37 2018. This is 91.23 behind of the plan for Allied Health Professionals -1.70 2.48 1.08 3.37 1.90 0.13 -0.04 7.11 8.15 11.54 -0.98 Estates and Ancillary -2.20 7.26 6.75 7.74 3.23 2.87 3.87 3.06 -6.37 -9.39 -18.24 January. Further analysis is being Healthcare Scientists -0.39 -0.81 -0.01 1.00 0.33 3.33 2.33 -2.77 5.53 4.53 5.69 undertaken to investigate the increase Medical and Dental -1.77 -23.15 -18.70 -17.55 -54.40 -34.40 -33.30 -31.38 -30.26 -25.21 -32.02 Nursing and Midwifery Registered -6.85 6.60 7.91 5.46 13.72 9.86 0.49 -6.40 -3.66 -3.49 -22.98 Students -0.01 -1.01 -0.51 -0.51 -0.51 -0.51 1.49 1.49 1.49 1.49 1.49 The increase in Medical and Dental staff Variance Substantive Staff Total WTE -21.26 5.27 6.58 5.79 -21.15 2.49 -3.10 15.94 10.40 23.68 -91.23 0.00 0.00 Medical and Dental staff numbers from April 2017 includes the adjustment for hosting a cohort of GP Trainees numbers from April 2017 includes the Total year reductions to date are 58.56 as at the end of December towards the 162.99 target by the end of March 2018 and 91.23 behind plan adjustment for hosting a cohort of GP Trainees.

Integrated FPQW Report - Month 10.pdf Page 50Page of 6118 Overall Page 144 of 253 Workforce - by staff group Staff in Post by staff Group

Table 1 Staff Group 2015 / 09 2015 / 12 2016 / 03 2016 / 06 2016 / 09 2016 / 12 2017 / 03 2017 / 04 2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 Add Prof Scientific and Technic 274.87 271.26 270.11 269.99 282.27 285.36 295.47 297.23 296.89 294.47 298.28 286.21 286.06 278.68 286.70 281.92 292.11 The tables opposite show the WTE in Additional Clinical Services 1,016.24 1,028.82 1,039.05 1,035.41 1,058.88 1,071.48 1,073.29 1,070.59 1,075.01 1,076.72 1,068.81 1,070.32 1,068.69 1,059.85 1055.60 1,059.49 1,091.59 Administrative and Clerical 1,345.55 1,340.31 1,342.79 1,347.28 1,340.26 1,343.18 1,292.95 1,268.78 1,265.77 1,267.43 1,258.83 1,259.13 1,256.09 1,244.10 1244.19 1,230.87 1,250.64 post figure by staff group for each Allied Health Professionals 403.03 405.49 398.12 395.43 397.08 404.03 405.45 401.10 402.55 400.26 401.56 403.33 403.50 396.19 395.15 391.76 404.09 Estates and Ancillary 389.95 392.72 389.27 403.99 399.86 402.69 392.86 380.83 378.78 375.22 375.56 372.50 368.07 363.74 368.03 365.91 368.77 month from September 2015, the Healthcare Scientists 92.69 89.80 91.59 89.89 93.75 92.39 91.85 92.27 91.47 90.47 91.13 88.13 89.13 94.23 85.93 86.93 85.77 month before the Integrated Care Medical and Dental 425.99 418.77 414.22 408.00 437.41 434.01 435.50 456.88 452.43 451.28 488.13 468.13 467.03 465.11 463.99 458.94 465.75 Nursing and Midwifery Registered 1,182.09 1,187.12 1,197.97 1,178.16 1,192.73 1,207.26 1,196.66 1,178.26 1,174.32 1,173.08 1,161.42 1,161.89 1,166.97 1,168.77 1160.94 1,154.69 1,168.25 Organisation (ICO) commenced, up to Students 5.69 5.69 5.09 5.09 3.90 2.90 1.50 2.50 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 Grand Total 5,136.11 5,139.99 5,148.21 5,133.23 5,206.14 5,243.31 5,186.13 5,148.43 5,139.21 5,130.91 5,145.74 5,111.65 5,105.54 5,070.66 5,060.52 5,030.52 5,126.97 January 2018. Table 2 Staff Group 2015 / 09 2015 / 12 2016 / 03 2016 / 06 2016 / 09 2016 / 12 2017 / 03 2017 / 04 2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 Bands 1 - 7 4461.09 4478.25 4492.38 4487.66 4531.51 4570.31 4525.20 4467.81 4462.16 4456.01 4434.46 4421.27 4418.27 4385.30 4376.00 4353.44 4453.69 Table 1 shows current whole time Band 8 and Above 249.02 242.97 241.61 237.57 237.22 238.99 225.36 223.74 224.62 223.62 223.15 222.15 220.25 220.25 220.53 218.13 207.53 M&D 425.99 418.77 414.22 408.00 437.41 434.01 435.57 456.88 452.43 451.28 488.13 468.23 467.03 465.11 463.99 458.94 465.75 equivalent staff in-post by staff group Grand Total 5,136.11 5,139.99 5,148.21 5,133.23 5,206.14 5,243.31 5,186.13 5,148.43 5,139.21 5,130.91 5,145.74 5,111.65 5,105.54 5,070.66 5,060.52 5,030.52 5,126.97 from September 2015 (prior to the Table 3 Staff Group 2015 / 09 2015 / 12 2016 / 03 2016 / 06 2016 / 09 2016 / 12 2017 / 03 2017 / 04 2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 ICO commencing) to December 2017. Bands 1 - 7 86.86% 87.13% 87.26% 87.42% 87.04% 87.16% 87.26% 86.78% 86.83% 86.85% 86.18% 86.49% 86.54% 86.48% 86.47% 86.54% 86.87% Band 8 and Above 4.85% 4.73% 4.69% 4.63% 4.56% 4.56% 4.35% 4.35% 4.37% 4.36% 4.34% 4.35% 4.31% 4.34% 4.36% 4.34% 4.05% M&D 8.29% 8.15% 8.05% 7.95% 8.40% 8.28% 8.40% 8.87% 8.80% 8.80% 9.49% 9.16% 9.15% 9.17% 9.17% 9.12% 9.08% Grand Total 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Table 2 shows the number of staff by

Table 4 pay bands. Those staff in band 8 are Staff Group 2015 / 09 2015 / 12 2016 / 03 2016 / 06 2016 / 09 2016 / 12 2017 / 03 2017 / 04 2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 Non-Executive Directors 14.00 7.00 6.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 8.00 predominantly in management roles. Grand Total 14.00 7.00 6.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 8.00 Table 5 Staff Group 2015 / 09 2015 / 12 2016 / 03 2016 / 06 2016 / 09 2016 / 12 2017 / 03 2017 / 04 2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 Table 3 shows the same pay bands by Chief Executive 2.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 ratio. Clinical Director - Medical 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Director of Nursing 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Finance Director 2.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 Other Directors 3.00 3.00 4.50 4.61 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 Tables 4 and 5 show the number of Grand Total 9.00 7.00 8.50 8.61 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 8.00 Notes: In addition to the 9.00 WTE Executive Directors shown above in 2015/09 there were 2 further Senior Managers as TSDHCT acting in Non-Executive Directors and Executive Director Roles and remunerated accordingly. A further 2 Directors from SDHFT at 2015/09 were also covering Director Roles at TSDHCT Executive Directors over the same At 2015/09 the role of Medical Director at TSDHCT was vacant In total across SDHFT and TSDHCT there would normally have been a compliment of 14.00WTE Executive Directors period. Medical and Dental staff numbers from April 2017 includes the adjustment for hosting a cohort of GP Trainees Total year reductions to date are 58.56 as at the end of January towards the 162.99 target by the end of March 2018 and 91.23 behind plan

Integrated FPQW Report - Month 10.pdf Page 51Page of 6119 Overall Page 145 of 253 Workforce - Sickness absence

Rolling 12 month sickness absence rate - (reported one month in arrears)

• The annual rolling sickness absence rate of 4.09% at the end of December 2017 is the first increase in the rolling absence for a year. This is against the target rate for sickness of 3.80%.

• The sickness figure for the month of December was 4.78% which is an increase from 4.58% in November and the highest monthly sickness total since January 2017 and the third monthly increase in a row however this increase was predicted and due to normal seasonal trends.

• The Attendance Policy has been ratified and a programme of training for managers and awareness sessions for staff is being rolled out.

• A Health and Wellbeing Charter is being developed.

• The Absence Action Plan is reviewed and monitored by the Workforce and OD Group.

Integrated FPQW Report - Month 10.pdf Page 52Page of 6120 Overall Page 146 of 253 Workforce - Turnover All Staff Turnover All Staff Rolling 12 Month Turnover Rate

The following graph shows that the Trusts turnover rate was 12.09% for the year to January 2017. This is an reduction from last month's 12.53% and within the target range of 10% to 14%.

The recruitment challenge to replace leavers from key staff groups remains significant.

RGN Turnover RGN Rolling 12 Month Turnover Rate

This recruitment challenge includes Registered Nurses due to the supply shortage as reported elsewhere and for which the Trust has a long term capacity plan to address, which maximises the use of all supply routes including overseas recruitment, return to nursing, growing our own etc.

The turnover rate for this staff group has continued to stay within the target range of 10% to 14% but reduced in January to 12.29%

The January overall turnover for RGN's is aligned to the 12 month plan of 56.5 FTE reduction in RGN's.

Integrated FPQW Report - Month 10.pdf Page 53Page of 6121 Overall Page 147 of 253 Workforce - Appraisal and training Achievement Review (Appraisal): The Achievement Review rate % Achievement Rate for January is at 78.46% against a target rate of 90% and is a 100% decrease from December (80.80%). This decrease has been 90% 82% 82% 82% 82% 82% attributed to the winter operational pressures and the ability to 79% 81% 81% 81% 81% 81% 78% 80% be able to release managers and staff. Managers are provided 70% with detailed information on performance against the target.

60% Achievement 50% Rate Members of the HR team are contacting individual managers to discuss progress in areas that are particularly low and offer 40% Target additional support. 30% 20% Achievement Review rates are also an agenda item for discussion 10% at senior manager meetings and Quality and Performance Review 0% meetings.

Jul-17 Jan-18 Jun-17 Oct-17 Apr-17 Feb-17 Sep-17 Dec-17 Aug-17 Nov-17 Mar-17 May-17 Statutory and mandatory training - The Trust has set a target of 85% compliance as an average of nine key statutory and mandatory training modules. The graph shows that the current rate has only changed slightly from 82.71% for December 2017 to 82.79% in January 2018.

An action plan to further improve the rate has been developed and progress against plan will be monitored through the Workforce and OD Group.

Individual modules that remain below their target are detailed in

Module Target Performance Information Governance 95% and above 73.10% Conflict Resolution 85% and above 83.66% Fire Training 85% and above 75.56% Infection Control 85% and above 75.17% Manual Handling 85% and above 75.57%

Integrated FPQW Report - Month 10.pdf Page 54Page of 6122 Overall Page 148 of 253 Workforce - Agency Agency Spend as at Month 10: The Trust's annual cap for agency spend, set by NHS I, for the next two years is £6.58 million per year. The table below shows the current agency spend by staff group for 2017/18 compared to the total agency expenditure plan. As at Month 10 the Trust is overachieving

Scientific, Therapeutic and Technical Agency continued: Radiography have used Agency Advanced Practitioner Ultra sonographer to cover off vacancies in both the AHP and Consultant groups. This is under close review pending recent recruitment. There will be a lead in period for the newly recruited team members. It is anticipated that agency will reduce and possibly cease from late January. Following the outcome of an inspection the Mortuary has an action plan in place which includes recruiting permanently to a Band 5 position. The recruitment process has been instigated and it is anticipated that the agency will cease by the end of

Nursing and HCA Bank and Agency: The table to the left shows the split between agency and bank for nursing and HCA shifts. The use of nursing agency increased significantly in January 2018, primarily due to the operational winter pressures, which included an additional ward being opened. In addition during January 2018 the equivalent of 72.6 WTE Bank RGNs were used. Nursing & HCA: Bank and Agency Usage All Healthcare Assistant shifts are filled through the internal Apr May Jun Jul Aug Sep Oct Nov Dec Jan bank. In January 2018 the equivalent of 141.9 WTE Bank HCAs 17 17 17 17 17 17 17 17 17 18 WTE Requested 210 218 224 229 238 248 242 186 192 231 Medical and Dental Agency: The use of medical agency is WTE Covered by Bank 178 183 194 200 206 209 200 154 153 176 mainly attributable to a number of consultant vacancies and WTE Covered by Agency 17 18 15 13 9 9 12 12 14 24 gaps in the junior doctor rotas. The Medical Bank is supporting WTE Unassigned 15 18 15 16 23 29 30 21 26 30 the gaps in the junior doctors rotas, which has reduced the cost Total WTE Covered 195 200 209 213 215 218 212 166 166 201 of agency for this staff group. The Trust is also part of the STP Medical Agency Group which is Scientific, Therapeutic and Technical Agency: The largest use of agency in this staff reviewing the number of agencies used (currently in the region group is CAMHS, which is currently part of a national project, which includes funding for of 50) in order to reduce and then actively work with those agency staff. agencies to reduce rates. In addition the Trust/STP is working The other areas using agency include cardiology, radiography and mortuary. In with a recruitment agency to support with 'hard to fill' posts. Cardiology there has been increased levels of sickness and vacancies within the team

Integrated FPQW Report - Month 10.pdf Page 55 of 61 Overall Page 149 of 253 Integrated FPQWReport -Month 10.pdf FINANCE FINANCE INDICATORS - LOCAL NHS I - FINANCE AND USE OF RESOURCES 4 4 4 4 4 3 2 1 4 4 4 4 4 4 4 4 Corporative Objective Well Well led Valuing our workforce Improved wellbeing through partnership Safe, Quality Care and Best Experience ShareRisk actual income to date cumulative (£'000's) Distance from NHSI Control total (£'000's) Capital spend - Variance from PBR Plan - cumulative (£'000's) CIP - Variance from PBR plan - cumulative (£'000's) Agency - Variance to NHSI cap - EBITDA Variance from PBR Plan - cumulative (£'000's) Overall Use of Resources Rating Plan Variance from agency ceiling Margin I&E Variance from Plan Plan Margin I&E Plan Liquidity Plan Capital Service Cover Corporate Objective Key Objective Corporate 2 1 1 4 Target 2017/2018 [STF] denotes standards included within the criteria for achieving the Sustainability and Transformation Fund Transformation and Sustainability the achieving criteria for the within included [STF] standards denotes average monthly the on isbased rating RAG indicators) & contract performance (operational indicators, date to year For* cumulative 13 13 month trend -1.32% 17176 -7083 -2354 -9934 8389 4 1 3 4 3 4 2 3 3 4 Jan-17 -12.922 -1.28% 18254 -7924 -3518 8637 4 1 3 4 2 4 2 3 3 4 Feb-17 -15310 -1.27% 17324 -9549 -2430 9107 4 1 3 4 2 4 2 3 3 4 Mar-17 NOTES 3.03% 2116 -173 -236 -562 234 3 4 1 1 4 4 4 4 4 4 Apr-17 2.72% 4021 1093 -261 -579 581 3 4 1 1 4 4 4 4 4 4 May-17 2.38% 1696 6106 1392 -192 389 3 4 1 1 4 4 4 4 4 4 Jun-17 2.00% 1247 7708 -479 -124 822 3 4 1 1 4 4 4 4 4 4 Jul-17 2.00% 9560 1942 -732 997 -98 3 3 1 1 4 4 4 4 4 4 Aug-17 11689 1.41% 1475 1503 -543 3 3 1 1 4 4 4 4 4 4 0 Sep-17 Performance Report - JanuaryPerformance 2018 13770 1.27% -1123 3114 1201 3 2 1 1 4 3 4 4 4 4 0 Oct-17 14723 1.09% -2545 3711 89 3 2 1 1 3 3 4 4 3 4 0 Nov-17 Overall Page 150 of253 17672 1.05% -3560 2813 495 3 2 1 1 3 3 4 4 3 4 0 Dec-17 19886 0.89% -4464 2263 -15 Page 56 of61 2 2 1 2 2 2 4 3 3 3 0 Jan-18 n/a n/a n/a n/a n/a n/a

2 2 1 2 2 2 4 3 3 3 Year to date 2017/18 Integrated FPQWReport -Month 10.pdf LOCAL PERFORMANCE FRAMEWORK 1 FRAMEWORK LOCAL PERFORMANCE 2017) FROM OCTOBER SINGLEFRAMEWORK (NEW OVERSIGHT NHS PERFORMANCE I - OPERATIONAL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Corporative Objective Cancelled patients not treated within 28 days of cancellation * On the day cancellations for elective operations Mixed sex accomodation breaches of standard RTT 52 week wait incomplete pathway Cancer - Patient waiting longer than 104 days from 2ww Cancer - 62-day wait for first treatment - screening Cancer - 31-day wait for second or subsequent treatment - Surgery Radiotherapy Cancer - 31-day wait for second or subsequent treatment - Cancer - 31-day wait for second or subsequent treatment - Drug Cancer - 31-day wait from todecision treat to first treatment breast patients Cancer - Two week wait from referral to date 1st seen - symptomatic Cancer - Two week wait from referral to date 1st seen Number cases of Difficile Clostridium - Lapse of care - (ICO) * Dementia - Find - monthly report Diagnostic tests longer than the 6 week standard Cancer - 62-day wait for first treatment - 2ww referral RTT Trajectory Referral to treatment - % Incomplete pathways <18 wks - A&E trajectory [STF] - A&E patients seen within 4 hours [STF] <18 (year) <0.8% >90% >94% >94% >98% >96% >93% >93% >90% >85% >92% >92% >95% <1%

0 0 0 Target 2017/2018 13 13 month trend 100.0% 92.3% 97.7% 94.7% 95.5% 89.3% 96.2% 59.9% 84.2% 93.1% 87.6% 92.0% 86.9% 1.1% 2.9% 15 1 0 0 Jan-17 100.0% 100.0% 96.7% 96.0% 98.0% 94.6% 97.0% 65.8% 91.6% 93.3% 87.8% 92.0% 89.2% 0.7% 1.6% 17 14 1 0 0 Feb-17 100.0% 100.0% 100.0% 96.2% 99.4% 96.2% 98.0% 67.8% 88.0% 93.3% 87.5% 92.0% 94.2% 0.6% 1.7% 17 1 0 9 0 Mar-17 100.0% 100.0% 96.9% 96.4% 99.2% 54.8% 83.6% 58.9% 87.2% 87.2% 87.2% 89.0% 94.4% 0.9% 3.4% 18 10 0 0 0 Apr-17 100.0% 100.0% 87.0% 93.5% 99.4% 97.8% 81.8% 60.6% 85.1% 87.5% 87.6% 90.0% 90.1% 1.4% 2.2% 18 18 2 0 2 May-17 100.0% 100.0% 98.3% 97.0% 97.1% 94.8% 86.5% 54.9% 84.0% 88.0% 86.4% 91.0% 92.3% 0.6% 2.8% 21 17 7 0 0 Jun-17 100.0% 100.0% 95.3% 97.2% 98.8% 74.0% 74.3% 52.8% 86.8% 88.9% 86.1% 92.0% 93.9% 0.7% 3.0% 15 13 4 0 1 Jul-17 100.0% 100.0% 100.0% 100.0% 98.6% 17.1% 65.3% 62.4% 79.2% 89.4% 85.2% 92.5% 93.2% 0.6% 7.3% 19 10 3 0 2 Aug-17 100.0% 98.1% 91.1% 98.9% 69.7% 61.1% 81.8% 85.7% 89.8% 84.0% 93.5% 89.9% 98.7% 1.0% 3.9% 16 3 0 6 0 Sep-17 Performance Report - JanuaryPerformance 2018 100.0% 95.2% 87.1% 95.8% 95.5% 94.7% 63.1% 78.6% 83.9% 90.7% 84.0% 92.0% 92.8% 1.1% 3.2% 26 12 4 0 0 Oct-17 100.0% 100.0% 100.0% 94.6% 95.0% 95.1% 70.4% 59.0% 77.4% 89.9% 83.7% 92.2% 92.9% 0.7% 2.4% 36 16 3 0 3 Nov-17 Overall Page 151 of253 100.0% 100.0% 100.0% 97.7% 98.0% 93.2% 76.0% 65.5% 82.4% 89.3% 82.2% 90.2% 88.3% 1.6% 3.7% 42 14 1 0 1 Dec-17 91.48% 95.3% 80.0% 93.8% 77.6% 52.1% 85.6% 90.1% 82.5% 89.9% 83.8% 97.0% 98.9% 0.9% 5.4% Page 57 of61 29 24 13 0 0 Jan-18 97.5% 95.9% 79.7% 73.8% 62.3% 83.5% 90.1% 82.5% 89.9% 91.3% 96.0% 97.2% 99.8% 1.0% 3.7% 29 24 40

0 9 Year to date 2017/18 Integrated FPQWReport -Month 10.pdf LOCAL PERFORMANCE FRAMEWORK 2 FRAMEWORK LOCAL PERFORMANCE 1 1 1 1 1 1 1 1 1 1 Corporative Objective Clinic Clinic letters - timeliness % specialties within 4 working days Weekend Care Planning Summaries % completed within 24 hours of discharge - Weekday Care Planning Summaries % completed within 24 hours of discharge - Number cases of Difficile Clostridium - (Community) Number cases of Difficile Clostridium - (Acute) * Trolley waits in A+E > 12 hours from todecision admit - A&E patients seen within 4 hours community MIU - A&E patients seen within 4 hours DGH only Ambulance handover delays > 60 minutes Handovers > 30 minutes trajectory * Ambulance handover delays > 30 minutes >80% >60% >77% >95% >95% <3

0 0 0 0 Target 2017/2018 13 13 month trend 100.0% 95.5% 30.3% 62.8% 81.4% 123 22 30 1 0 2 Jan-17 100.0% 72.7% 28.7% 65.3% 84.3% 10 30 62 1 1 0 Feb-17 100.0% 86.4% 23.7% 60.7% 91.5% 110 30 0 0 0 4 Mar-17 100.0% 72.7% 27.9% 64.5% 91.8% 30 56 0 0 0 6 Apr-17 100.0% 81.8% 33.4% 65.0% 85.1% 30 98 2 0 0 2 May-17 100.0% 81.8% 28.1% 62.5% 88.1% 183 30 1 0 0 4 Jun-17 100.0% 86.4% 33.6% 65.4% 90.5% 104 30 12 1 1 0 Jul-17 100.0% 86.4% 33.8% 71.0% 89.9% 180 30 17 2 0 0 Aug-17 100.0% 90.9% 38.5% 71.0% 85.5% 150 30 10 0 0 0 Sep-17 Performance Report - JanuaryPerformance 2018 100.0% 86.4% 25.1% 69.5% 89.7% 30 88 1 0 0 6 Oct-17 100.0% 90.9% 35.9% 68.7% 90.0% 124 30 5 0 0 5 Nov-17 Overall Page 152 of253 100.0% 90.9% 25.6% 67.9% 84.0% 181 30 18 2 0 1 Dec-17 100.0% 81.8% 28.0% 67.7% 77.2% 271 Page 58 of61 30 18 1 0 8 Jan-18 100.0% 85.0% 30.8% 67.3% 87.3% 1435 300 15 98

1 9 Year to date 2017/18 Integrated FPQWReport -Month 10.pdf QUALITY QUALITY LOCAL FRAMEWORK 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Corporative Objective Follow ups Follow 6 ups weeks past to be seen date Audiology) (excluding Stroke patients 90% spending of time on a stroke ward Fracture Neck Of Femur - Time to Theatre <36 hours Hand Hygiene Infection Control - Bed Closures - (Acute) * Safer Staffing - ICO - Nightime (registered /nurses midwives) Safer Staffing - ICO - Daytime (registered /nurses midwives) Hospital standardised mortality rate (HSMR) - 3 months in arrears Medication errors - Total reported incidents (trust at fault) Medication errors resulting in moderate to catastrophic harm - (Community) VTE assessment on - admission Risk - (Acute)VTE assessment on - admission Risk Formal Complaints - Number Received * Teams QUEST (Quality Effectiveness Safety Trigger - Tool) Red Rated Areas / (Reported to CCG and CQC) Strategic Executive Information System (STEIS) Never Events (1 month in arrears) Avoidable New Pressure Ulcers - Category 3 + 4 * Reported Incidents - Major + Catastrophic * Safety Thermometer - % New Harm Free 90%-110% 90%-110% (full year)(full <100% >80% >90% >95% >95% >95% >95% 3500 <100 N/A <60 <6 9 0 0 0 0 Target 2017/2018 13 13 month trend 128.8% 101.3% 82.9% 76.9% 98.7% 95.4% 95.3% 96.6% 5512 98% 116 53 29 2 2 0 0 1 2 Jan-17 99.5% 91.8% 90.9% 84.6% 97.6% 93.5% 94.7% 98.1% 5518 95% 48 26 0 0 2 0 1 1 4 Feb-17 96.2% 92.8% 89.1% 76.1% 95.5% 96.1% 94.7% 98.0% 5548 94% 64 34 1 6 1 0 0 0 4 Mar-17 110.6% 97.2% 89.2% 69.2% 94.4% 97.6% 93.4% 97.3% 6429 97% 24 51 13 2 1 0 0 1 9 Apr-17 100.0% 95.7% 57.1% 79.3% 97.4% 96.5% 93.7% 96.1% 6550 99% 24 76 32 4 1 0 1 0 4 May-17 100.8% 100.0% 76.3% 84.5% 86.1% 98.5% 93.6% 97.3% 6999 91% 12 37 31 0 0 0 1 0 4 Jun-17 97.4% 98.4% 95.6% 82.4% 95.6% 96.9% 92.4% 95.9% 7209 96% 18 64 33 1 1 0 0 0 7 Jul-17 101.6% 77.7% 95.5% 86.0% 71.0% 94.7% 92.9% 96.3% 7496 95% 18 43 22 3 0 0 2 0 8 Aug-17 100.0% 101.4% 85.5% 77.1% 73.5% 80.0% 88.0% 96.0% 7477 99% 12 68 22 1 0 0 0 0 3 Sep-17 Performance Report - JanuaryPerformance 2018 105.2% 105.8% 100.0% 86.6% 79.4% 68.6% 92.3% 97.2% 6790 98% 30 63 38 3 0 0 0 0 5 Oct-17 104.2% 101.7% 100.0% 83.3% 76.3% 92.6% 96.4% 6308 96% 130 48 24 0 0 0 1 0 2 Nov-17 Overall Page 153 of253 106.6% 105.6% 72.5% 71.4% 69.4% 88.9% 97.1% 7041 95% 42 17 0 8 0 0 2 1 2 Dec-17 105.2% 105.8% 100.0% 84.4% 92.1% 93.0% 96.2% 6630 89% 198 n/a Page 59 of61 59 34 6 2 0 1 9 Jan-18 101.3% 100.7% 94.7% 80.7% 92.1% 96.6% 6630 95% 551 266 474 n/a n/a 20 53 5 0 7 3 Year to date 2017/18 Integrated FPQWReport -Month 10.pdf COMMUNITY & SOCIALCOMMUNITY FRAMEWORK CARE 3 1 1 1 1 1 1 1 1 3 3 1 3 2 1 Corporative Objective Community Hospital - Admissions (non-stroke) Community Hospital - Admissions Intermediate Care - urgentNo. referrals DOLS (Domestic) - Open applications at snapshot CAMHS - % of patients waiting under 18 weeks at month end Bed Occupancy was taken to safeguard the[NEW] individual Safeguarding - Adults % of concernsrisk high where immediate action in arrears) Opiate users - %completions of treatmentsuccessful (quarterly 1 qtr 4 Week Smoking Quitters (reported quarterly in arrears) Children with a ProtectionChild Plan (one month in arrears) Number of Permanent Care Home Placements trajectory Number of Permanent Care Home Placements Carers trajectory Assessment Carers Completed Assessments year to date Clients receiving Self Directed Care of referral of Adult Social Timeliness Care within assessed 28 days Assessment Number of Delayed Transfer of Care (Acute) Number of Delayed Discharges * (Community) (Year end) (Year end) 16/17 16/17 Avg 16/17 Avg 80% - 90% <=617 NONE NONE NONE NONE NONE >92% 100% >90% >70% 40% 113 315 SET SET SET SET SET 64 Target 2017/2018 13 13 month trend 100.0% 100.0% 88.7% 33.3% 35.8% 92.2% 69.8% 310 199 593 191 620 636 179 n/a n/a 39 Jan-17 100.0% 100.0% 86.1% 36.7% 37.0% 92.5% 70.7% 278 151 609 189 619 636 223 n/a n/a 41 Feb-17 100.0% 96.3% 88.2% 40.0% 38.3% 92.0% 71.2% 7.8% 258 149 597 157 219 617 642 310 138 Mar-17 100.0% 88.7% 89.7% 92.0% 78.8% 3.6% 4.4% 205 164 603 231 639 634 142 202 n/a n/a Apr-17 100.0% 83.7% 91.3% 92.8% 72.9% 7.2% 8.7% 241 174 601 240 637 629 144 n/a n/a 72 May-17 100.0% 94.1% 88.4% 10.8% 17.0% 92.6% 73.9% 7.8% 261 247 177 599 272 239 635 619 230 Jun-17 100.0% 92.0% 80.7% 14.3% 20.7% 92.8% 74.6% 225 225 182 608 238 633 634 159 n/a n/a Jul-17 100.0% 100.0% 89.2% 17.9% 24.8% 92.9% 75.9% 211 253 182 574 248 631 637 185 n/a n/a Aug-17 100.0% 98.4% 93.2% 21.5% 31.1% 93.6% 77.2% 8.4% 445 242 155 579 254 629 638 172 80 Sep-17 Performance Report - JanuaryPerformance 2018 100.0% 100.0% 92.7% 25.1% 33.9% 93.1% 78.3% 401 241 191 596 235 627 632 177 n/a n/a Oct-17 100.0% 100.0% 93.2% 28.7% 34.5% 93.2% 79.1% 340 224 202 603 198 625 637 197 n/a n/a Nov-17 Overall Page 154 of253 100.0% 98.9% 92.4% 32.3% 35.9% 92.8% 79.1% 7.9% 348 252 177 609 176 623 634 156 165 Dec-17 100.0% 100.0% 93.1% 35.8% 38.1% 92.3% 79.0% 272 276 205 610 621 629 218 n/a n/a Page 60 of61 Jan-18 100.0% 92.4% 35.8% 35.9% 92.8% 79.1% 98.9% 2717 2406 1809 1849 7.9% 609 621 629 198 156 Year to date 2017/18 Integrated FPQWReport -Month 10.pdf CHANGE FRAMEWORK CHANGE FRAMEWORK MANAGEMENT WORKFORCE 3 2 2 2 3 3 2 Corporative Objective Hospital Hospital Stays > 30 Days - (Acute) Average Length of Stay - - (Acute)Emergency Admissions Number - (Acute)of Emergency Admissions Turnover (exc12 months Jnr Rolling Docs) Mandatory Compliance Training Appraisal Completeness Staff / sickness Absence (1 month arrears) 12 months Rolling 10% - 14% <3.8% >85% >90% Target 2017/2018 13 13 month trend 11.51% 85.00% 78.00% 4.40% 3036 3.3 19 Jan-17 12.39% 85.41% 79.00% 4.36% 2754 3.2 18 Feb-17 12.66% 84.90% 81.40% 4.33% 3155 3.0 25 Mar-17 12.00% 84.00% 81.42% 4.27% 2840 2.9 7 Apr-17 12.73% 84.00% 81.00% 4.23% 3148 3.0 32 May-17 12.30% 83.86% 81.66% 4.19% 3101 2.9 21 Jun-17 12.64% 83.00% 81.66% 4.17% 3111 2.7 24 Jul-17 12.37% 83.00% 81.00% 4.14% 3040 2.9 19 Aug-17 12.39% 83.00% 82.00% 4.11% 3030 2.9 32 Sep-17 Performance Report - JanuaryPerformance 2018 12.32% 83.00% 82.00% 4.09% 3232 2.8 34 Oct-17 12.34% 83.00% 82.00% 4.07% 3130 2.7 28 Nov-17 Overall Page 155 of253 12.53% 83.00% 81.00% 4.09% 3175 2.7 28 Dec-17 12.09% 82.79% 78.00% 3259 3.1 Page 61 of61 41 Jan-18 12.09% 82.79% 78.00% 31066 4.09% 266 2.9 Year to date 2017/18 Overall Page 156 of 253

REPORT SUMMARY SHEET

Meeting Date 7 March 2018

Report Title Board Assurance Framework

Lead Director Director of Finance

Corporate Objective Well led

Corporate Risk/ All Theme Purpose Information Assurance Decision

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Summary of Key Issues for Trust Board This report provides the Board of Directors with the reviewed version of the Strategic Context Board Assurance Framework (BAF) as at attachment one for approval.

The BAF continues to receive detailed reviews and any changes are reflected in the attached document. Further scrutiny and enhancements will continue to take place throughout the year by the Risk Group, Executive Team and various committees.

On 26 January 2018, the Audit and Assurance Committee meeting received an updated BAF. Two Corporate Level Risks (1050 and 1159) were highlighted to the Committee for a more in-depth review.

At least two deep dive reviews continue to take place at each meeting of the Audit and Assurance Committee (except May’s meeting), the Quality Assurance Committee (QAC) and Finance, Performance and Investment Committee (FPIC).

A completed schedule of Deep dives for 2017 was also submitted as an assurance to the committee.

A ‘heat map’ to summarise the Board Assurance Framework on one page, supported by the detail can be found as at attachment two.

The next full review of the BAF is scheduled to be presented to the Audit Assurance Committee on 13 April 2018

The overarching corporate risk themes are as follows: Key Issues/Risks 1. Available capital resources are insufficient to fund high risk / high priority infrastructure / equipment requirements / IT Infrastructure and IT systems. 2. Failure to achieve key performance / quality standards. 3. Inability to recruit / retain staff in sufficient number / quality to maintain service provision. 4. Lack of available Care Home / Domiciliary Care capacity of the right specification / quality. 5. Failure to achieve financial plan. 6. Care Quality Commission’s rating ‘requires improvement’ and the inability to deliver sufficient progress to achieve ‘good’ or ‘outstanding’. Public

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Risks are grouped under these headings in the Corporate Risk Register, with detail carried through to ensure there is a clear link with the operational risk management systems and to enable clear description of planned management actions.

Recommendations 1. The Board of Directors reviews, comments and accepts the reviewed version of the Board Assurance Framework as at attachment one. 2. The Board of Directors discusses whether any new strategic risks need to be incorporated onto the Board Assurance Framework.

The Executive Team have considered the balance of risk associated with the Summary of ED capital programme, concluding that the Trust is no longer in a position to restrict Challenge/Discussion capital spend within generated cash resources. The capital requirements – estates, equipment and IT – hold too much risk to make that possible. This has been the trigger to conversations with NHS Improvement intended to secure access to external capital funding.

The focus on service delivery risks within the BAF has also been discussed. In considering developments in the planning cycle for 2018/19 the Executive Team are keen to consider, and include where applicable, wider strategic risks to the organisation. The Audit and Assurance Committee endorsed this ambition.

As a general point, the Executive Team tasked the Risk Group with ensuring that there are clear action plans in place for items listed as ‘potential sources of assurance’ such that benefits are crystallised as soon as possible.

The Board Assurance Framework and supporting risk registers should identify Internal/External all possible issues against the Trust’s ability to deliver its strategic and Engagement inc. supporting objectives. If equality and diversity are key business objectives as Public, Patient & per patient, client, public, service user and governor involvement, then these Governor would be recorded on one of the risk registers and/or Board Assurance Involvement Framework. A governor observer regularly attends the Audit and Assurance Committee, Finance, Performance and Investment Committee and Quality Assurance Committee.

Equality & Diversity None identified. Implications

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MAIN REPORT

Report to Board of Directors

Date 7 March 2018

Lead Director Director of Finance

Report Title Board Assurance Framework

1. Background Information

1.1 The Board Assurance Framework (attachment one) is reviewed primarily by the Audit and Assurance Committee and the Board of Directors. Accountability for recording the information is with the Executive Leads. The Company Secretary oversees the Board Assurance Framework and key risk registers e.g. Surgical Services Delivery Unit. The Corporate Risk Register will be reviewed regularly by the Executive Team e.g. following a Risk Group meeting.

1.2 Assurance may be recorded within the risk registers, but more importantly is that assurance is captured within the Board Assurance Framework. The risk registers are reviewed primarily by the different Groups/Service Delivery Unit and the Risk Group. Accountability for capturing the information is with the Service Delivery Units or Departmental Leads.

2. Positional Update

2.1 The Risk Group continues to conduct deep dives at its monthly meetings, eg. Medical Service Delivery Unit, Torbay Pharmaceuticals and Health Informatics Services.

At the last meeting, the Risk Group challenged some of the recent risks identified by the Executive Team rather than individual SDUs. The Risk Officer continues to look at risk themes at each meeting using a combination of soft intelligence from Executive Directors\SDU leads and analytical information from Datix e.g. risks, incidents as well as using reports like CLICC and deep dives.

At the most recent meeting of the Risk Group a deep dive was conducted for the Women’s, Children’s, Diagnostics and Therapies Division. The SDU management team were requested to review Maternity risks currently sitting below corporate level, to ensure that this remained appropriate when triangulated with reported incidents.

2.2 Key Performance Indicators (KPI’s) for the Risk Group are better than target and are therefore not a cause for concern or escalation.

2.3 The weekly Executive Team meeting continues to receive a report from the Risk Group after every meeting.

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Board Assurance Framework.pdf Page 3 of 13 Overall Page 159 of 253 2.4 A development session on risk management with Service Delivery Units and departmental leads has been arranged for 28 November 2017 was productive, further building understanding and developing the risk management culture within the Trust. The Chief Operating Officer / Deputy Chief Executive and Director of Finance are the lead directors. Teams were able to feedback on systems and processes, and the Risk Team will work with teams to amend where appropriate.

2.5 The Director of Finance, Director of Strategy and Company Secretary met on 10 January 2018 to discuss the current Board Assurance Framework, options for including more strategic risks following the recent Board development session and the opportunity for an annual review of its style and structure taking on board best practice from other trusts. The product of this meeting will be reflected in the updated framework for 2018/19.

2.6 Since the last Board meeting a new section (section 3) has been created to show detailed changes since the BAF’s last review.

3. Audit of Detailed Changes

Corporate Theme 1 : Available capital resources are insufficient to fund high risk / high priority infrastructure /equipment requirements / IT Infrastructure and systems

DRM ID Title Observation 1050 Special Theatres Updated following in depth discussion at FPIC. Ventilation. Capacity reduced to one of two theatres, with lists reallocated.

1083 Insufficient Capital Funding No change. and Backlog of Maintenance. 1159 Current IT Systems & New Assurance: Infrastructure Will Not Meet Ctrl 4-5 £110k capital approved at FPIC to Future Demands. invest before 31 March 2018 in cyber security to mitigate 11 out of the 12 outstanding May 2017 CareCERTS by October 2018. £90k capital approved from April 2018. £252k revenue approved from April 2018. New Potential Assurance: Ctrl 5-6 Following discussion at CIEG there is a possibility of an integrated finance capital and revenue identification process that does not mean we have capital approved for IT schemes which cannot be spent due to there being no approved revenue. New Gap in Assurance Ctrl 4-5 All but one of the 12 CareCERTS addressed by October 2018. 1231 Failure to Raise Sufficient New Assurance: Capital. Ctrl 1-3. RSA functioning providing additional income to support financial recovery plan. Update Potential Assurance: Ctrl 1-3. Board released second Capital tranche, but items with revenue consequences held pending assurance on control total delivery. Public

Board Assurance Framework.pdf Page 4 of 13 Overall Page 160 of 253 Ctrl 1-3. £4.0m additional forecast reduction required to achieve control total. Ctrl 1-3. CCG agreed SSP delivery increase by £1.5m

Corporate Theme 2 : Failure to achieve key performance / quality standards

1070 Achievement of 4-Hour Removal of Controls 7-8 Standard. Replaced with: 7. Trial for 'see and treat' during FAB week. 8. Trial completed for RADS project - aim for improvements in early discharge.

Assurances adjusted.

1101 Medical Retina Demand. New Assurance: Ctrl 2. Mega clinics now running Monday and Tuesday. Saturdays have now been converted to reduce the Medical Retina backlog. Updated Actual Assurance: FROM: Ctrl 8. ‘Two more pieces of equipment have arrived and been installed’ TO: Ctrl 8. ‘Three out of four pieces of equipment have arrived and been installed’ Updated Potential Assurance FROM: Ctrl 8. Last piece of equipment purchased. TO Ctrl 8. Last piece of equipment purchased but on hold due to IT resource prioritisation. 1110 Follow up Appointments are New Potential Assurance: Followed up in Agreed Ctrl 1. Each speciality to review "Lost to follow Timescales. up" 1266 Poor Patient Experience and Control 3 updated. Quality of Care. Gap In Control 3. removed. 1815 High Quality Patient Tracking New Assurance: to Avoid any Unnecessary Ctrl 1-2. Managed leave arrangements to CWT Breaches. ensure minimal staffing away at one time to maximise staff capacity. 1998 Human Tissue Act 2004 Non- No change. Compliance.

Corporate Theme 3 : Inability to recruit / retain staff in sufficient number / quality to maintain service provision

1697 Difficulty in Recruiting Service No change Critical Staff.

Corporate Theme 4 : Lack of available Care Home / Domiciliary Care capacity of the right specification / quality

1695 Mears Personal Care Delivery, DRM ID No 1974 (12) linked to this risk. Failure Concerns Across New Controls:

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Board Assurance Framework.pdf Page 5 of 13 Overall Page 161 of 253 Torbay & South Devon. 12..Incidents that our staff report relating to care homes in the Torbay Localities (Torquay, Paignton & Brixham) are notified to TSDFT QAIT Team for investigation and interventions as required. 13. Incidents that our staff report relating to Mears in the Torbay Localities (Torquay, Paignton & Brixham) are notified to Cathy Williams, Jon Anthony, Nigel Sutton and Emma Bewes. 14. Non safeguarding concerns incidents relating to MEARS (or a sub-contractor of MEARS) are notified to MEARS via their secure NHS email address for them to investigate and respond to David Hickman within 14 working days using an agreed template. 15. Incidents relating to MEARS (or a sub- contractor of MEARS) which raise possible Safeguarding concerns incidents are notified to the persons in control 13 and also to the TSDFT safeguarding alert email address in the 1st instance for triage prior to provider notifications.

New Assurances: Ctrl 10. Judy Saunders has completed on-site visit with Mears to support their recruitment processes. Follow up visit also planned. Ctrl 11-14 Daily monitoring of incidents and escalation of Mears related incidents are managed my CSDU Clinical Governance Lead. David Hickman. (New) Ctrl. 15. Breach of contract notice has been issued. Resulted in fortnightly meetings. Ctrl 1 -17 Due to the level of concerns, decision has been made to put the service into a "Whole service safeguarding process" under a S42 process.

Corporate Theme 5 : Failure to achieve financial plan

1223 Financial Sustainability Risk Reduction in linked risks score: Rating. DRM ID No 75 (CLR) Viability of Care Homes and Nursing Homes. (12 down from 16) New Assurance: Ctrl 1-10 New RSA Signed New Gaps in Assurance: Ctrl 1-10. SDU asked for forecast run rate reduction plans for £5m. (New) Ctrl 1-10.CCG asked for SSP deliver to be improved to plan further £1.5m. (New)

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Board Assurance Framework.pdf Page 6 of 13 Overall Page 162 of 253 1236 Increase in Overspends on the New Assurances: Independent Sector. Ctrl 6. Outcome of judicial review consultation process. Judicial review ruled in the Council’s favour. Ctrl 1-10. Fran Mason has secured on-going nursing Home provision in Torbay

New Gaps in Assurances: Ctrl 1-10. SDU asked for forecast run rate reduction plans for £5m. Ctrl 1-10.CCG asked for SSP deliver to be improved to plan further £1.5m. 1239 Failure to Secure Better Care New Control: Fund Monies. 14. New risk share agreement signed with CCG and Council. New Assurance: Ctrl 1-14 Quarter 1 & 2 achieved. Ctrl 14. Agreement Signed. New Gaps in Assurances: Ctrl 1. Forecast requires further £6.5m of financial improvement to achieved Control total. Ctrl 1-4. SDU's asked to populate £5m additional actions to address. Ctrl 11. CCG asked to push SSP schemes for full delivery.

Corporate Theme 6: CQC rating 'requires improvement' and the inability to deliver sufficient progress to achieve 'good' or 'outstanding'

1095 Safer Care - No Delays in ED. New Control: 10. SWAST and ED initiative with use of 'expected cards' to highlight if patients could be directed elsewhere e.g. AMU/EAU3.

The Risk Officer is in the process of collecting new assurances for this control. 1504 Delays to Mental Health No change. Pathways.

3. Attached to this Report

Attachment one - Board Assurance Framework Attachment two - Board Assurance Framework Heat Map

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Board Assurance Framework.pdf Page 7 of 13 Overall Page 163 of 253 Attachment three 2018-01-15 BAF Report Final.xlsx

A Datix Risk Module Report Actual Risk Details Assurances ID Sub-Objective Organisational Description Controls in place Gaps in Control Actual Assurances in Place on Existing Controls Potential Assurances on Existing Controls Gaps in Assurances on Existing Controls Objectives

Rating Rating Senior (Initial) Responsible (Current) Risk Type Risk Risk OwnerRisk Department Officer

1050 Corporate Theme 1 : 1. Safe, Quality Care and 25 Cause: Due to age and condition of plant etc possible major 1. Enhanced maintenance / normally scheduled Planned 5. Lack of sufficient capital funding. 25 Ctrl 1. Detailed maintenance and engineering performance Ctrl 3. Revised/approved contingency plan. Ctrl 1. Regular maintenance being undertaken but Available capital Best Experience failure in Special Theatres (Acute). Preventative Maintenance (PPM.) 6. No option to replace equipment in the short-term. data and records, held on the electronic backtraq system. Live Ctrl 4. Capital Infrastructure and Environment Group report to serviceability of unit is not guaranteed. resources are insufficient 2. Plan in place to replace theatres (medium to long term). and real time performance of the mechanical and electrical Finance, Performance and Investment Committee. Ctrl 1. Maintenance access to plant is poor and heat trimmer to fund high risk / high Effect: Loss of Surgical Activity happening regularly. 3. Operational contingency plan in place. systems shown on the electronic Building Management System batteries giving independent temperature to each theatre are priority infrastructure 4. Monitoring, reporting and escalation of critical failure. (BMS). Annual insurance inspection, Annual authorised non operational. System temperature has been set to give /equipment requirements Linked to Risk: engineer assessment of systems. optimum temperature to theatre A, with theatre B not attaining / IT Infrastructure and DRM ID No 1473 Maintenance of Inpatient Theatres & DSU & suitable temperature at times. (Updated with correct locations) systems Ophthalmic Theatres (12) Ctrl 2. Design fees funded in the phase 1 capital released. Air Ctrl 2. No approval of business case to replace theatres given DRM ID No 2101 Failure of Temperature Control in Theatre handing in recovery scheduled to be funded in the second at this point in time. B.(12) (New) tranche of capital. Scheme to replace the theatres will not Callcut, Rae Callcut, proceed other than to final design in 2017/18 due to lack of Estates Estates Operations

Corporate Level Risk Level Corporate capital and non approval of the business case for a loan sat with NHS England for approval. Director of Estates (Lesley Darke) of Estates (Lesley Director

1083 Corporate Theme 1 : 1. Safe, Quality Care and 25 Cause: Lack of available capital funding to spend on backlog 1. Risk assessment, prioritisations and approval process in 11. Still waiting to identify appropriate capital allocation to 25 Ctrl 2. Robust planned preventative maintenance regime in None identified. Ctrl 6. Future Board decision to provide more funding. Available capital Best Experience, 4. Well maintenance and contingency for Estates emergency place to manage highest risks. High risk elements prioritised in reverse deteriorating trend and reduce current catastrophic risk place. resources are insufficient Led. expenditure. the capital programme. level. Ctrl 3. Scheduled Finance reports provided to Board and to fund high risk / high 2. Robust planned preventative maintenance regime in place. 12. Insufficient funds allocated to reduce risks. Executive Team through the Finance, Performance & priority infrastructure Effects: 3. PPM performance and critical failures reported and 13. Equipment and plant is failing and cannot always be Investment Committee. /equipment requirements A. Failure of key plant or building fabric resulting in impact on monitored monthly via Capital Infrastructure and Environment repaired. Ctrl 3. Scheduled Financial reports provided to the Board by / IT Infrastructure and service delivery. Group, Finance, Performance and Investment Committee, the Executive Team. systems B. Harm to individual staff, patients or member of the public Infection Prevention and Control, exceptions to the Board of Ctrl 3. Scheduled development reports provided to the Board from deteriorating infrastructure. Directors. and Executive Team by the Senior Business Management 4. Responsible Persons in post (statutory). Group. 5. Rolling programme for testing in place. Ctrl 3. Scheduled Infrastructure and Environment reports 6. Capital allocation identified to deliver action plan. provided to Board and Executive Team by the Infrastructure 7. Annual review of system management by externally and Environment Group. appointed Authorising Engineer. Ctrl 1,3,7,8,9. Scheduled Progress and KPI's reports provided 8. Asset register in place. to Board and Executive Team as depicted in the Governance

Estates 9. Estates Strategy presented to Private Board in May 2016. Reporting Structure including but not limited to: 10. Board has approved plan based on actively considered - PPM performance and critical Darke, Lesley Darke, risks versus maintaining a cash balance. failures reported monthly Corporate Level Risk Level Corporate - exceptional reporting to Board. - Monthly monitoring of departmental PPM records in place.

- Patient environment issues reported to infection - Prevention Darke) of Estates (Lesley Director & Control Committee. Ctrl 4. Responsible Persons in post (statutory) Ctrl 5. Rolling programme for testing in place. Ctrl 1,6. Capital allocation identified to deliver action plan. Ctrl 10. Approved plan.

1159 Corporate Theme 1 : 4. Well Led. 20 Cause: Lack of available capital funding to spend on IT 1. ICT Strategy with supporting policies and procedures e.g. Ctrl's 5.6.7 Insufficient funds allocated to reduce risks. 16 Ctrl 1. ICT Strategy in place and approved every four years. Ctrl 1. External assessment as part of Digital Roadmap/STP Ctrl 3. Upgrade current key systems to mitigate effect. Available capital infrastructure and IT Systems. Business Continuity Plans Ctrl 2. Service Desk user surveys. programmes. resources are insufficient 2. Well-developed IM&T service. Ctrl 4. Information Asset Support Team Manager processes. Ctrl 5-7. Finance monthly capital expenditure reports. to fund high risk / high Effects: 3. Upgrade current key systems to mitigate effect. Ctrl 4. Agenda's, reports and minutes/notes. Ctrl 5-6 Following discussion at CIEG 15/11/2017 there is a

priority infrastructure Gary Hotine, A. Failure of key IT infrastructure and IT systems resulting in 4. IT Projects and Programme governance in place and linked Ctrl 4-5 £200k capital and £252 revenue approved at possibility of an integrated finance capital and revenue /equipment requirements impact on service delivery. to organisation's executive groups. IM&IT Group reports, November FPIC to invest in cyber security to only mitigate the identification process that doesn't mean we have capital / IT Infrastructure and B. Lack of cyber security investment may expose the Trust to reports to Finance, Performance and Investment Committee. 12 outstanding May 2017 CareCERTS. New approved for IT schemes which cannot be spent due to there

systems Risk Level Corporate risk of fines equal to 4% of Turnover or £ capped at £17M 5. Investment planning to maintain and develop infrastructure Ctrl 5. IT Projects Group minutes and IT Projects Dashboard being no approved revenue. (New) following a successful cyber-attack similar to the May 2017 capacity. Ctrl 6. Annual capital plan (infrastructure). Ctrl 8-9. HIS Board/IM&IT Group regarding system failures. "Wannacry" attack. NHS Digital (for NHS England) are 6. Continued IM&T Strategic investment. Risk assessment Ctrl 7. Annual capital plan (projects). Escalated to Board via Finance, Performance and Investment

IT Operations and Informatics and IT Operations highlighting the number of CareCERTs they have mandated based on need and prioritised accordingly. Ctrl 8. HIS TeamTalk minutes. Committee. that Trusts have mitigated. We currently have 12 unmitigated 7. Continual review of emerging technology and adoption Ctrl 10. Internal Audit Reports e.g. IT Projects Cradle to Grave and are flagging as an outlier regionally. where suitable. (Feb 16) Information Asset Owner Business Continuity 8. Minimising critical failure. Planning (Oct 14) Note: Our plans are predicated on an on-going capital 9. Management of failure. Ctrl 11. Action plan in place and monitored/reviewed by the investment plan to ensure optimum performance of service. 10. Internal audit reviews Information Governance Steering Group. 11. Actions following Information Commissioners Office visit Ctrl 1-11 IA Report - SDU Governance arrangements. (May Linked to Risks: (Sept 2015). 2017). DRM ID No 1158 Malware Attack. (15) Ctrl 1-11 . Risk deep dived at Finance, Performance and DRM ID No 1161 Meeting the Information Governance Investment Committee meeting on 28/11/2017. (New) standards set by Connecting for Health, supported by Monitor. (15) DRM ID No 1162 Business Continuity and Information Security. (8) DRM ID No 1168 National Programme for IT HSCIC. (25) up from (20) DRM ID No 1172 Quickest Access to Diagnosis and Treatment.

(8) Wagner) (Ann Improvement and Strategy DRM ID No 1173 Strategic Hardware Platform. (16) DRM ID No 1174 Increasingly Software Companies Are Changing Their Licensing. (16) DRM ID No 1181 Unauthorised Staff May Have Inappropriate Access. (3) DRM ID No 1183 Cost Pressure Relating To Support of IHCS. (9) DRM ID No 1719 IM & T Strategy to Support Care Model Delivery (5) DRM ID No 1723 Lack of Shared or Centralised Care Records Across the System. (9)

1231 Corporate Theme 1 : 4. Well Led. 25 Cause: Financial position or national capital restrictions limit 1. All measures to maintain I&E performance. 4. Board to approve most significant capital risks with a limited 25 Ctrl 1-3. NHS Improvement indicating over commitment to Ctrl 1-3. Board has approved a critical list of capital for 2017/18 Ctrl 1-3. Assurance over CIP full CIP delivery, ability to access Available capital ability to access Loans or PDC. 2. Relationship management with ITFF. capital programme pending confidence in revenue position. current capital allocation nationally. Currently looking unlikely in April. ITFF loan finance. resources are insufficient 3. Savings Risk High given target levels. 5. Trust needs revised capital plan based on liquidity position that loan applications will be released. Driver to consider other Ctrl 1-3. Board released second Capital tranch, but items with Ctrl 1-3. £6.5m additional forecast reduction required to to fund high risk / high Effect: Inability to fund necessary infrastructure developments. and to agree solution with NHS I. funding mechanisms such as PFI to keep investments 'off revenue consequences held pending assurance on control total achieve control total. priority infrastructure 6. Draft Heads of Terms requires CCG to pay cash based on balance sheet'. delivery Ctrl 1-3. SDU asked for forecast reduction plans for £5m. /equipment requirements Linked to DRM ID 2013 Medical Devices Rolling £18m System wide savings plans being covered. Ctrl 1-3. RSA Now signed. Ctrl 1-3. CCG asked for SSP delivery increase by £1.5m. / IT Infrastructure and Replacement Program (15) (New) 7. CCG recovering cash based on SSP delivery. (New) systems Finance Cooper) Muskett, Rodney Corporate Level Risk Level Corporate Investment Group (Paul (Paul Group Investment Finance, Performance and and Performance Finance,

Board Assurance Framework.pdf Page 1 of5 Page 8 of 13 Overall Page 164 of 253 Attachment three 2018-01-15 BAF Report Final.xlsx

ID Sub-Objective Organisational Description Controls in place Gaps in Control Actual Assurances in Place on Existing Controls Potential Assurances on Existing Controls Gaps in Assurances on Existing Controls Objectives

Rating Rating Senior (Initial) Responsible (Current) Risk Type Risk Risk OwnerRisk Department Officer

1070 Corporate Theme 2 : 1. Safe, Quality Care and 25 Cause: Patient demand exceeding capacity within the ED 1. Good data analysis available - ED dashboard linked with 9. Safer bundle piloted in all areas which are applicable - not 20 Ctrl 1. Scheduled performance, progress and KPI report Ctrl 1. Combined patient flow action plan. None Identified. Failure to achieve key Best Experience department. control room - good and accurate weekly data sheets produced same monitored process in all ward areas. provided to Executive Team and Board via Quality Assurance performance / quality to monitor performance. 10. Programme of bed configuration started but not yet Committee. Progress reports distributed to governors. standards Effect: Failure of the 95% standard, poor patient experience 2. New medical O drive - to allow other specialities (Medicine) complete. Ctrl 1. Up-to-date action plan. and possible adverse clinical outcomes as patients not cared to be monitored in same way as ED - pressures easier to 11. Phlebotomy resource limited due to sickness and Ctrl 4-5,7. Agenda's, papers, minutes/notes.

Houlihan, Lisa for in the correct environment. identify earlier. recruitment issues Ctrl 2. After Action Reviews (AARs) post incidents 3. Escalation policy in place. 12. Linkage of the overcrowding risk score not formally linked Ctrl 3. Up-to-date policies and procedures Emergency Services Emergency Corporate Level Risk Level Corporate Linked to Risk: 4. 3 x daily control meetings with real-time information and to the escalation policy. Need for better OPEL linked Ctrl 8. Up-to-date on call executive rota DRM ID No 1242 Poor Patient Experience in ED. (15)(Closed) appropriate management responses. escalation. CQC self-assessment DRM ID No 1264 Delays to first clinician. (12) 5. Ward discharge coordinators have daily meetings to review 13. Potential new pressure will be added to department until all Ctrl 1,7. External independent assessment (Oct 16) ward discharges. available/allocated MIU's have radiology cover for full opening Ctrl 1-8. IA Report - SDU Governance arrangements. (May 6. AMU re-provided on Level 2 from 21/03/16 to divert hours, meaning patients can be consistent re-directed or 2017), Assurance level satisfactory. medically expected patients from ED. encourage to self present for appropriate conditions. - Update Ctrl 1-8. Positive CQC report - August 2017 (see documents) 7. Trial for 'see and treat' during FAB week 13/11 - 20/11) MIU NAH Radiology cover 7/7 (Opening hours 9-5. Ctrl 1-8. Risk deep dived at Quality Audit Committee meeting 8. Trial completed for RADS project - aim for improvements in on 24/01/2018. (New)

early discharge. OfficerDavenport) (Liz Operating Chief

1101 Corporate Theme 2 : 1. Safe, Quality Care and 20 Cause: Inability to meet Medical retina demand for follow-up 1. Reviewing patients to ensure clinical priority is achieved in 10. Despite putting control in place there are still 4000 patients 16 Ctrl 1-3.Patients all have an allocated consultant responsible Ctrl 1.Continued work to increase capacity for the patients most Ctrl 4. Continued growth in demand may outstrip new capacity. Failure to achieve key Best Experience patients within sub-specialties within ophthalmology. appointments but unable to reduce this number without waiting passed to be seen by date. for their care. at risk. performance / quality affecting other sub-specialties backlogs. Number is gradually 11. Capacity levels still fluctuate over bank holidays and Dr Ctrl 1-4. The list of patients are regularly sent to the consultants Ctrl 1. Action Learning Set with GP's and Commissioners standards Effect: Increased risk of loss of vision for patients not seen on a coming down. holidays. so that they are aware of the delays. discussing progress and further work that can be done to help. timely basis. 2. Running additional clinics including virtual clinics. 12.Not enough clinic rooms, equipment staff. (New) Ctrl 1. The list of patients are monitored at sub-specialty level Ctrl 8. Last piece of equipment being purchased, but delayed 3. We now include the clinic accommodation at Newton Abbot to ensure higher risk patients are prioritised. due to IT resource prioritisation. (Updated) within our timetables which will enable improved utilisation. Ctrl 2. Mega clinics now running Monday and Tuesday. 4. We have instigated a timetable review and meetings are on Saturdays have now been converted to reduce the Medical going. Retina backlog. 5. Utilisation of clinic activity within Newton Abbot Ctrl 2-3. Work to increase the accommodation has been 6. Established clinic timetable. completed and extra clinics are now running. 7. PTL monitoring and tracking in place. Ctrl 5. Agenda's, Minutes and Reports from these meetings. 8. Extra clinical space is now complete and new equipment is Ctrl 6. Completed the timetable with the new rooms, this being purchased. control is in place and working effectively. Ophthalmology

Westacott, Derren 9. Virtual clinics now running in trial phase to establish best use Ctrl 7. Weekly PTL meeting. Corporate Level Risk Level Corporate of the time and equipment as well as issues with other sub- Ctrl 8. Three out of fours pieces of equipment have arrived and specialties. been installed. (updated) Ctrl 9. We are currently running at about 90% of expected final

capacity. OfficerDavenport) (Liz Operating Chief Ctrl 1-9 IA Report - SDU Governance arrangements. (May 2017), Assurance level satisfactory.

1110 Corporate Theme 2 : 1. Safe, Quality Care and 16 Cause: Lack of a robust follow-up appointment process across 1. Documented / updated process in place. 5. Long-term IT solution. 16 Ctrl 1. Approved process. Ctrl 1. Each speciality to review "Lost to follow up" None identified. Failure to achieve key Best Experience, 4. Well the Trust. 2. Random sample of 2,500 outpatient records identified some 6. Systematic report for all patients with a follow-up Ctrl 2. All patients identified as lost to follow up have had a root Ctrl 2. Routine reporting from PAS. performance / quality Led. failures in the old system. No failures identified in the new 7. Completed review of 1,509 day case records to identify any cause analysis completed. Ctrl 3. Completed review of all outstanding records. standards Effect: Patients at risk of disease progression. Consequences system. lost to follow up patients. Ctrl 2. All patients in Urology have had their initial review. are for poor patient care, poor patient experience, adverse 3. Bank staff employed to review all outstanding patient Ctrl 2. Tests of new system not identified any patients lot to impact on the reputation of the Trust and may leave the Trust records, this is being monitored by our service improvement follow-up. open to litigation. manager. Ctrl 4. Scheduled performance, progress and KPI reports 4. Trust Board report. provided to Finance, Performance and Investment Committee and Board.

Foster, Neal Ctrl 4. Agenda's, papers, minutes/notes. All Departments All Ctrl 1-4 IA Report - SDU Governance arrangements. (May Corporate Level Risk Level Corporate 2017), Assurance level satisfactory. Chief Operating OfficerDavenport) (Liz Operating Chief 1266 Corporate Theme 2 : 1. Safe, Quality Care and 15 Cause: Supply and demand imbalance in surgical division 1. Performance reporting and action plans via directorate 8. Saturday list until the end of the year - dependent on number 15 Ctrl 1. Scheduled performance, progress, KPI and action plan Ctrl 1. Enhanced reporting Ctrl 1. The quality safety and user experience impacts of under Failure to achieve key Best Experience across most specialities to meet waiting time, leading to an meetings, RTT/Diagnostic Risk & Assurance Group (meets of theatre and medical staff volunteering. reports provided to Executive Team and Board via Quality Ctrl 1-7 Surgical SDU has submitted a paper to Exec Board performance are not fully measured and reported. performance / quality inability to deliver elective and urgent care access standards. fortnightly with COO and operational leads), governance 9. Insufficient training grades resulting in consultants having to Assurance Committee. seeking funding to do additional list for UGI and Colorectal to standards meetings, DGM meetings, Divisional Board meetings, Senior action down. Ctrl 1,4. Agenda's, papers, minutes/notes reduce 52 weeks waits. (Approved 19/09/2017) Effect: Poor patient experience and quality of care, reputational Business Management Group, Executive Team meeting, 10. Inability to outsource complex patients - outsourcing ceased Ctrl 2,6. Weekly PTL meeting. impact for the community and the Trust, regulator intervention Finance, Performance and Investment Committee and Trust due to funding considerations with the CCG. Ctrl 3. Investment. and commissioners seeking to apply financial penalties. Board. Reports shared with the CCG. 11. Funding considerations not supporting recruitment of Ctrl 3. Additional weekend lists. 2. Waiting list management process consultant surgeons. Ctrl 5. up-to-date timetable Linked to Risks: 3. Operational teams identifying additional capacity on an ad 12. Approved business case for additional consultants. Ctrl 7. up-to-date policies and procedures. DRM ID No 1103 General Surgery (Upper UGI, Achieve RTT hoc basis i.E. Extra lists Ctrl 1-7. IA Report - SDU Governance arrangements. (May within the 18 weeks target. (12) down from (15) 4. Support from other specialties within Surgery taking on some 2017), Assurance level satisfactory. DRM ID No 1104 Urology, Achieve RTT within the 18 weeks of this backlog of work on specific patients i.e. Hernias and Lap Ctrl 1-7. Risk deep dived at Quality Audit Committee meeting

Foster, Neal target. (15) Choles helping to create additional capacity for this group. on 06/11/2017. (New) All Departments All DRM ID No 1295 Ear Nose and Throat, Outpatient & Inpatient 5. Established clinic timetable. Corporate Level Risk Level Corporate RTT (12) down from(15) 6. PTL monitoring and tracking in place. DRM ID No 1311 Failure to meet RTT's in Dermatology. (20) 7. Policies and procedures. DRM ID No 1523 Pain Service. (15) Chief Operating OfficerDavenport) (Liz Operating Chief

1815 Corporate Theme 2 : 1. Safe, Quality Care and 15 Cause: Continued increase in demand on 2ww pathways and 1. Weekly workload review and task allocation with MDTCs and 5. Additional clinical capacity ceased, which has impacted 15 Ctrl 1-2. Managed leave arrangements to ensure minimal None Identified. Ctrl 1. Capacity to manage demand, specifically in diagnostics. Failure to achieve key Best Experience 62 day cancer pathways. escalation of problems. ability to escalate cancer patients. staffing away at one time to maximise staff capacity. Ctrl 1. Escalation policy not working as robustly as needed. performance / quality A. Reduced capacity within Breast radiology to support TA 2. Achievement of CWT targets and up-to-date with patient 6. Inability to recruit to consultant posts (locum and substantive Ctrl 2.4. Daily validation and escalation by CWT manager to Ctrl 3. Extra hours only available whilst vacancies held. standards clinics, causing breaches against breast 14 day and 2ww tracking posts). manage performance. Ctrl 1-3. Controls in place as far as MDTC admin concerned. pathways. 3. MDT Co-ordinator now in post. Ctrl 1-3 The staff are working additional hours where possible Cancer Services have no control over capacity in Breast and B. Reduced flexibility to provide additional capacity within 4. Monitor performance of CWT and report back to Risk and to manage the workload to cover vacancies within the data Dermatology. surgical specialities affecting ability to achieve the 62 day Assurance group fortnightly. team. cancer target. Ctrl 3. MDT Co-ordinator now in post. C. Reduced capacity in Dermatology senior medical team to provide sufficient capacity to maintain 2ww target. Bell, Christine Bell,

Cancer Services Cancer Effect: Risk of Trust not achieving quarterly cancer standards,

Corporate Level Risk Level Corporate specifically 2ww, 14 day breast symptomatic and 62 day targets. Chief Operating OfficerDavenport) (Liz Operating Chief

1998 Corporate Theme 2 : 1. Safe, Quality Care and 25 Cause: Following an inspection by the Human Tissue Authority 1. Working assurance group set up to clear findings reported by None Identified. 15 Ctrl 1. Working assurance group, Minutes and Action Points. None Identified. None Identified. Failure to achieve key Best Experience, 4. Well the Trust has been found to be non-compliant with the Human the HTA. Down Ctrl 2. Progress and Reviews of Risk 1961 and its associated performance / quality Led. Tissue Act 2004 (HTA) requirements. 2. Separate risk record(DRM ID no. 1961) created to manage From Actions and reduction from 16 to 15. standards non-corporate risks to achieve compliance. 20 Ctrl 3. Positive feedback from resent Inspection. Effects: Failure to meet the regulations of the can have major 3. Revisit by HTA Inspectors on 15/08/17, provided positive consequences to the organisation. comments with regards to progress to date. 1. Potential suspension of services provided by the mortuary, i.e. Storage of bodies and performing post mortems which would have a financial and reputational impact on the Trust,

2. Potential incurred fines for the Trust and there is the option of potential imprisonment for the Designated Individual. 3. Submission of outstanding evidence due for submission 31/01/2018 Goldsworthy, Keith Goldsworthy, Laboratory Medicine Laboratory Corporate Level Risk Level Corporate Linked to Risk DRM ID No. 1961 Human Tissue Act 2004 Non- Compliance. for continuity. (15) Delivery Unit (Keith Goldsworthy) (Keith Unit Delivery Women's, Children's, Diagnostics & Therapies Service Service & Therapies Diagnostics Children's, Women's,

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ID Sub-Objective Organisational Description Controls in place Gaps in Control Actual Assurances in Place on Existing Controls Potential Assurances on Existing Controls Gaps in Assurances on Existing Controls Objectives

Rating Rating Senior (Initial) Responsible (Current) Risk Type Risk Risk OwnerRisk Department Officer

1697 Corporate Theme 3 : 1. Safe, Quality Care and 16 Cause: National shortages mainly due to the deficit between 1. Recruitment updates are reported to Board bi-monthly as Ctrl 2. Link between requirement to train additional staff and 16 Ctrl 1-4,6,7,9,11 Scheduled performance, progress, KPI and Ctrl 8. Overtime being offer to current staff to cover shifts Ctrl 5. Guideline can not be implemented if staffing group is not Inability to recruit / retain Best Experience, 2. the numbers required and the number of training places. part of Workforce Report. sufficient capacity to deliver placements for students and other action plan reports provided to Executive Team and Board via where applicable. on E-Roster. staff in sufficient number / Improved Wellbeing 2. Medical Recruitment is being looked at as part of the Trust's trainees. Workforce and Organisational Development Group meetings. quality to maintain service Through Partnership, 3. Effect: Difficulties in delivering on corporate objectives and Recruitment Strategy working groups. Ctrl 5. E-Rostering system not in place for all staffing groups. Ctrl 3,10. Reports cross referenced with entries on Datix Risk provision Valuing Our Workforce, 4. national targets. Increase in temporary workforce usage 3. Performance Report identifies where compliance with Module and report to Executive Team and Board via Risk Falcão, Judy Judy Falcão, Well Led. including agency leading to budget overspends. RTT/ED/STC impacted by workforce shortage. Group meetings.

Human Resources Human 4. Nursing workforce strategy in place including capacity plan Ctrl 4. Plans monitored by the Executive Vacancy Risk Group

Corporate Level Risk Level Corporate Linked to Risks: Linked to Risks: that identifies demand and supply routes (including overseas to manage vacancies and redeployment during the care model DRM ID No 668 Risk of Not Covering the EDS Rota Due to nursing, redesign and vocational career pathways) monitored implication should lead to reduction in the vacancy gap for Staff Shortages) (15) by Workforce and OD group. nursing. DRM ID No 1073 Timely And Effective Access To Neurology 5. E-Rostering system in place for nursing staff. Ctrl 5. E-Rostering guidelines in place and management Service. (20) 6. Restricted use of agency staff. working with HR_OD to ensure effective implementation. DRM ID No 1080 Emergency Services, inability to recruit 7. Use of bank staff wherever possible. Ctrl 11-13. Agenda's, reports and minutes/notes and feedback. experienced Senior (middle grade) doctors (15) 8. Additional support from current staff. DRM ID No 1149 Child Health, Cannot sustain a full middle 9. Risk discussed at Local level with escalation process for grade rota and 6 person rota (9 down from 15) (link to be risks. removed) 10. 15+ being linked to this risk. DRM ID No 1464 Trauma & Orthopaedics, Foot & Ankle 11. Risk discussed at HR SDU meetings. R+R Groups. Consultant. (12 down from 15) (link to be closed) Workforce OD Group, Quality & SDU Performance meeting, DRM ID No 1736 General Medicine, George Earl Ward, Nursing working board group meeting, Risk Group meeting,

Staffing level inadequate. (20) Executive Team meeting, Audit & Assurance meeting and & WPHR Falcão) (Judy DRM ID No 1830 Cancer Services Vacancy for Breast and Trust Board meeting. Colo-rectal Clinical Oncology. (15) 12 STP Workforce Strategy Group reviewing hard to fill DRM ID No 1953 Haematology Consultant Capacity. (15) vacancies. DRM ID No 1955 Lack of Breast Radiologists. (12 down from 13. Plans monitored by the Executive Vacancy Risk Group to 16) (Link to be removed.) manage vacancies and redeployment during the care model DRM ID 2005 Restorative Dental Consultant Vacancy (20) implication should lead to reduction in the vacancy gap for nursing.

75 Corporate Theme 4 : 1. Safe, Quality Care and 16 Cause: Reduction in supply of care homes and care providers 1. There is a robust operational/action plan and procedure in 7. Domiciliary market under Mears but capacity remains 16 Ctrl 1. Scheduled performance, progress and KPI reports Ctrl 1. Receipt of Mears action plan. None Identified Lack of available Care Best Experience due to financial safeguarding/quality concerns. place that manages care home closures. problematic across Torbay and South Devon. provided to Safeguard / Inclusion Group, Executive Team, Ctrl 1, 2. CQC oversight of plan - In addition the CCG have Home / Domiciliary Care 2. CQC inspection reports monitored by Trust Safeguarding 8. External contractor (Mears) rated inadequate and required to Quality Assurance Committee and Board by Chief Nurse. identified some extra capacity with Jenny Turner who is also capacity of the right Effect: Lead and QAIT team. produce action plan. DRM ID No 1695. Ctrl 1. Up-to-date operational/action plan supporting this area of work and market development with specification / quality - Inability to provide assessed care in a timely way, resulting in 3. Financial viability of care homes is being monitored by the 9. Enhanced contract management arrangements. Ctrl 1. Up-to-date procedures. Council commissioners. delayed transfers of care. Need to find alternative care for Adult Social Care (ASC) commissioners. 10. Market development in progress, strategy to be finalised. Ctrl 2. CQC inspection reports. Ctrl 3. Cost based assessment of care home fees being clients of failed domiciliary care or care home providers. 4. Quality is monitored via QAIT team and bi-annual care home 11. Care home fees 2017/18 not yet agreed. DRM ID No 78 Ctrl 3. Agendas, papers, minutes/notes of meetings. undertaken to inform 17/18 18/19 settlement. (Updated) - Any care home closures or whole home safeguarding takes visits. There is a similar team in place in DCC that undertake (12) Ctrl 4. Outputs/reports from QuESST and bi-annual reports of significant operational capacity from health and wellbeing this role in South Devon care homes. care home visits. teams which impacts on patient flow across the whole system. 5. Escalation process in place. Ctrl 5. Up-to-date process for specific escalation of 6. There is a significant amount of work which is safeguarding issues. Note: Risk included at request of Lead Director, Sustainability undertaken by the operational teams to support the quality Ctrl 1,4-5,6. Bi Monthly control report considered at Community of care home and nursing home provision within the community of the services in care homes to prevent care homes services Board by Quality Improvement team. at risk. having to close. (New) Ctrl 1-5. Placed People's Board engagement with CCG. Ctrl 1-6. IA Report - SDU Governance arrangements. (May Linked to Risks: 2017), Assurance level satisfactory. Williams, Catherine Williams, Corporate Level Risk Level Corporate DRM ID No 78 Care Home Fee Challenge. (8 down from 12) Ctrl 6. This form part of the day to day management of the Operations (Head Office) (Head Operations DRM ID No 1223 (CLR) Financial Sustainability Risk Rating. operational team. (New) (20) Ctrl 1-6 Minutes and Reports from the market management

DRM ID No 1695 (CLR) Mears Group Risk (16) group. (New) OfficerDavenport) (Liz Operating Chief DRM ID No 1715 Independent Sector Market.(15)

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ID Sub-Objective Organisational Description Controls in place Gaps in Control Actual Assurances in Place on Existing Controls Potential Assurances on Existing Controls Gaps in Assurances on Existing Controls Objectives

Rating Rating Senior (Initial) Responsible (Current) Risk Type Risk Risk OwnerRisk Department Officer

1695 Corporate Theme 4 : 1. Safe, Quality Care and 20 Cause: Lack of management processes and staff at Mears as 1. Provider of Concern process invoked to hold the provider to 22. KPI's and performance reports remain inadequate from 16 Ctrl 1. 3. 7. 12 Agenda's, papers, minutes/notes. Ctrl 1. CQC follow-up review Ctrl 1-11. Capacity analysis of domiciliary care sector. Lack of available Care Best Experience, 2. evidenced by the Care Quality Commission and Health watch account. Mears. (Was 18) Ctrl 1. CQC report Ctrl 1. Healthwatch follow-up review Ctrl 1 - 21.Trust cannot assure sufficient market capacity Home / Domiciliary Care Improved Wellbeing reports and the care failure in Torbay over the weekend of 25 - 2. Senior Managers time released to lead the operational 23. Staff training in Mears on MCA/DOL's not adequate. (Was Ctrl 1. Healthwatch report Ctrl 1. Release from provider of concern process for dom care in the Torbay Area so remains a risk. (New) capacity of the right Through Partnership 28 August and additional issues during and since the beginning response and action plan. 19) Ctrl 4. 11 Reports logged and notes reported on. Ctrl 2. Receipt of Mears action plan. specification / quality of October. 3. Weekly operational review meeting overseeing delivery of 24. Capacity and Quality within the subcontractor market not Ctrl 5. List of clients Ctrl 2. CQC oversight of plan. action plan by Mears. confirmed. (Was20) Ctrl 5. Up-to-date protocol Ctrl 10. Staff training records Effects - Adequate and sufficient volume of Torbay provision 4. Daily review of the Outstanding package of care list daily 25. Torbay's wider domiciliary care market has limited capacity Ctrl 6. Protocol in place to use other providers other than Ctrl 10. Staff turnover rates within Mears and sub-contractor. that effects: calls with provider to anticipate any issues. and will incur higher cost implications. (Was 21) Mears. Ctrl 8. Letters to clients A. Safety and quality of care delivered to clients compromised 5. Sample of Mears clients contacted by the Trust to see and 26. Other organisational priorities at a time of change impact Ctrl 4. 9. Complaint and incident reports. due to failure to visit/provide double handed care. perform a light touch review. on senior managers time. (Was 22) Ctrl 1-10 IA Report - SDU Governance arrangements. (May B. Delayed discharges across the Acute and Community 6. Off contract protocol in place to procure Domiciliary Care 2017), Assurance level satisfactory. hospitals. from alternative sources. Ctrl 10. Judy Saunders has completed on-site visit with Mears C. Lack of public confidence in the provider and the Trust. 7. Liaison with Devon County Council. to support their recruitment processes. Follow up visit also D. Impact on the residential and nursing home market capacity 8. Working with the Communication Team re media responses planned. as winter pressures start. and letters to clients. Ctrl 11-15,19 Daily monitoring of incidents and escalation of E. Increased level of complaints. 9. Monitor of complaints and incidents. Mears related incidents are managed my CSDU Clinical F. Risk to organisational strategy for the new model of care 10. Mears are incentivising staff and their sub contractors to Governance Lead. David Hickman. (updated) development. promote better retention and take up of work. Ctrl. 14. Breach of contract notice has been issued. 11. Incidents that our staff report relating to care homes and Resulted in fortnightly meetings. (New) Linked to Risks: care providers in the south Devon area are notified by David Ctrl 1 -16 Due to the level of concerns, decision has been DRM ID No 75 (CLR) Viability of Care Homes and Nursing Hickman to DCC made to put the service into a "Whole service Homes. (16 up from 12) 12.Incidents that our staff report relating to care homes in the safeguarding process" under a S42 process. (New) DRM ID No 631 Insufficient Capacity for Domiciliary Care. (8) Torbay Localities (Torquay, Paignton & Brixham) are notified to Ctrl 17 Paper has been reviewed the exec team. Closed TSDFT QAIT Team for investigation and interventions as Ctrl 18 Judy Falcão now leading as part of the "winter big DRM ID No 1398 Mears Contract. (12) Closed required. 7". (New) DRM ID No 1671 Mears Personal Care Delivery Failure 12. Incidents that our staff report relating to Mears in the Ctrl 20. Factual but this remains an area of risk. (New) Concerns Across Torbay & South Devon. (8) Closed Torbay Localities (Torquay, Paignton & Brixham) are notified to Ctrl 21. Mears have sourced another subcontractor in the DRM ID No 1715 Independent Sector Market.(15) New Cathy Williams, Jon Anthony, Nigel Sutton and Emma Bewes. Torbay Market. (New) DRM ID No 1974 Unsourced Packages of Care.(12) (Was 13) 13. Non safeguarding concerns incidents relating to MEARS (or a sub-contractor of MEARS) are notified to MEARS via their secure NHS email address for them to investigate and respond to David Hickman in 14 working days using an agreed template. (Was 14) Machin, Shelly Machin, 14. Incidents relating to MEARS (or a sub-contractor of Corporate Level Risk Level Corporate Personal Care Service Care Personal MEARS) which raise possible Safeguarding concerns incidents are notified to the persons in control 13 and also to the TSDFT safeguarding alert email address in the 1st instance for triage

prior to provider notifications. (Was15) OfficerDavenport) (Liz Operating Chief 15.Breech of contract notice issued to Mears re the care failure over the bank holiday, specifying required improvement actions. (Was 16) 16. Options Appraisal completed and has been sent to the board for consideration. (Was 17) 17. New paper being compiled for Execs to consider. (New) 18. Judy Falcão now leading as part of the "winter big 7". (New) 19. Agincare commissioned for 6 months to provide additional dom care capacity to support rapid response. (New) 20. Mears have increased their capacity resulting in a reduction of the unsourced list. (New) 21. Mears working with other sub-contractors to increase capacity across Torbay and South Devon. (New)

1223 Corporate Theme 5 : 4. Well Led. 25 Cause: Inability to meet total recurrent CIP savings target. 1. Performance reports at Senior Business Management Ctrl 2,4. Schemes do not yet meet target level and additional 20 Ctrl 1. Scheduled Progress and KPI reports provided to Board Ctrl 6-7. PwC as external auditor. Ctrl 1-10. CIP Schemes do not yet fully cover the required Failure to achieve Group, Efficiency Delivery Group, Joint Executive meeting for £5m challenge (New) via Finance, Performance and Investment Committee. Ctrl 1,6-7. NHS Improvement feedback / letters. target and in year cost pressures to be validated. financial plan Effect: Results in a failure to achieve the business plan SWSP, Finance, Performance and Investment Committee, Ctrl 1-2,4-5. Agenda's, papers, minutes/notes from these Ctrl 6-7. Audit South West review of CIP. Ctrl 1-10. SDU asked for forecast run rate reduction plans for objectives for 2017/18. Financial Improvement Scrutiny Committee and Board. meetings. Ctrl 6-7. Future publication of reference costs. £5m. (New) 2. Deep dives on schemes undertaken at Efficiency Delivery Ctrl 1. Approved budgets to Board via Finance, Performance Ctrl 6-7. Future publication of Carter process. Ctrl 1-10.CCG asked for SSP deliver to be improved to plan Linked to Risks: Group and Finance, Performance and Investment Committee. and Investment Committee. Ctrl 1,6-7,9. Performance report demonstrating full delivery. further £1.5m. (New) DRM ID No 75 (CLR) Viability of Care Homes and Nursing 3. Programme office and management function established, Ctrl 3,8. Agreed CIP schemes registered with the Programme Ctrl 6. Progress on CIP delivery plans and progress on further Homes. (16) up from (12) monitoring and reporting delivery of schemes. Office. CIP scheme identification. DRM ID No 1196 (CLR) Supporting the Delivery of the CIP 4. Regular updates provided to the Social Care Programme Ctrl 1. Bi-weekly review of CIP delivery via Efficiency Delivery Plans through HR Workforce Strategies & Support. (12) Board. Group. DRM ID No 1228 Spend On Variable Staffing. (15) 5. Exec-led performance monitoring of SDUs/support Ctrl 3. Programme office exception reporting directorates. Ctrl 3,8. Programme office distributing scheme updates / flash 6. CIP plan established for 2017/18. reports to scheme leads and executive sponsors.

Finance 7. Trust-wide improvement programme for 2017/18 onwards Ctrl 9-10 Executive has considered draft report form Mark with potential savings verified with reference to external Hacket and incorporated agreed actions into the PMO plans. Muskett, Rodney reports. Ctrl 1-10. Board Considered RSA and additional income from Corporate Level Risk Level Corporate 8. Executive sponsors and management leads identified for Torbay Council £4m at last meeting. schemes. Ctrl 1-10 New RSA Signed. 9. Executive Check and Challenge meetings. Ctrl 1-10 Risk deep dived at Finance, Performance and

10. NHS-E and NHS-I monthly review process under the NHS Investment Committee meeting on 19/12/2017 (New) Wagner) (Ann Improvement and Strategy E Capped Expenditure Programme.

1236 Corporate Theme 5 : 4. Well Led. 20 Cause: Increased expenditure on the Independent Sector 1. Performance reporting through Service Delivery Units, 11. Torbay Council consultation responses could result in 16 Ctrl 1.Scheduled progress, performance and KPI reports Ctrl 4. Benchmark rates of expenditure. Ctrl 1. Board report detailing output of client level audit / Failure to achieve (Placed People, Adult Social Care) budgets. Finance, Performance and Investment Committee and Board. increased cost if accepted. provided to Finance, Performance and Investment Committee Ctrl 4. Potential use of a combined Devon County Council fee review. financial plan 2. Placed People Oversight Group. 12. Outcome of Torbay Council judicial review unknown. and Board. model. Ctrl 1-10. SDU asked for forecast run rate reduction plans for Effect: This could lead to un-budgeted overspend and effect 3. Standing Financial Instructions (SFIs) and Scheme of 13. Universal standard use of NHS contract Ctrl 1-2,8. Agenda's, reports, minutes/notes. Ctrl 4. Market strategy. £5m. the Trust's ability to achieve the current business plan Delegation 14. Inability to attract packages of care within agreed fee Ctrl 3. Board approved SFIs and Scheme of Delegation. Ctrl 1-10.CCG asked for SSP deliver to be improved to plan objectives. 4. ICO joined Devon County Council, Torbay Council, structure. Ctrl 4. Agreed process further £1.5m. Plymouth Council, NEW Devon CCG and South Devon and Ctrl 5,7. Up-to-date policies and procedures. Linked to Risk: Torbay CCG 2017/18 fee setting process. Ctrl 6. Agreed care home fee model and care market DRM ID No 1716 Inability to Meet Savings Target on 5. Policies and procedures for care planning and package consultation process. System Savings. (Outpatient Innovations)(16) (New) approval. Ctrl 6. Outcome of judicial review consultation process. Judicial 6. Care home fee model and care market consultation process. review ruled in the Council’s favour. (New) 7. Policies and procedures for outside of fee rate. Ctrl 8. Person now in post and liaising with providers and 8. Joint Role to oversee market development across the teams. system. Ctrl 9. Evidence Recorded in smartsheets with fortnightly Machin, Shelly Machin, 9. We are working on a number of schemes to reduce spend presentations to Mark Hackett. Corporate Level Risk Level Corporate Personal Care Service Care Personal and increase threshold into social care spend-these are Ctrl 10. Committee in place, minutes and agenda of meeting identified on the CIP smart sheet schedule. available. 10. A new Health and Social Care Uplift Committee is in place Ctrl 1-10. Fran Mason has secured on-going nursing Home reporting to Executives, that considers all uplift requests from provision in Torbay. OfficerDavenport) (Liz Operating Chief providers Ctrl 1-10. Risk deep dived at Finance, Performance and Investment Committee meeting on 19/12/2017 (New)

Board Assurance Framework.pdf Page 4 of5 Page 11 of 13 Overall Page 167 of 253 Attachment three 2018-01-15 BAF Report Final.xlsx

ID Sub-Objective Organisational Description Controls in place Gaps in Control Actual Assurances in Place on Existing Controls Potential Assurances on Existing Controls Gaps in Assurances on Existing Controls Objectives

Rating Rating Senior (Initial) Responsible (Current) Risk Type Risk Risk OwnerRisk Department Officer

1239 Corporate Theme 5 : 4. Well Led. 25 Cause: Failure to achieve control total. 1. Annual plan control total. Ctrl 1-2. Sufficient detailed CIP plans to cover, a Risk share 25 Ctrl 1-13 Quarter 1 &2 achieved. Ctrl 1. Approved plan Ctrl 1. Forecast requires further £6.5m of financial Failure to achieve 2. Performance reporting and escalation through Service contract challenge and deliver the control total. Ctrl 1,4-5. NHS Improvement returns (routine and ad hoc) Ctrl 5-6. NHS Improvement segmentation. improvement to achieved Control total. (New) financial plan Effect: Failure to achieve Sustainability and Transformation Delivery Units, Finance, Performance and Investment Ctrl 1-2. Cross referencing gaps in CIP and income. Ctrl 2. Agenda's, papers, minutes/notes. Ctrl 2-4. PwC use of resources assessment (3 Es) Ctrl 1-4. SDU's asked to populate £5m additional actions to (STF) and subsequent impact on financial performance plan. Committee, Financial Improvement Scrutiny Committee and 15. System wide savings plans being developed. Ctrl 2. Self-certifications. Ctrl 2-4. Internal audit reviews (CIP, review of Standing address. Damage to risk rating and reputation with the regulator. Board. 16. SDU asked to work up £5m contingency plan Ctrl 2,4. Detailed monthly cash flow forecasts, monthly closing Financial Instructions / Scheme of Delegation) Ctrl 11. CCG asked to push SSP schemes for full delivery. 3. Core financial controls. (Budget setting, Standing Financial cash balance/budgets and year-end cash balance process. Ctrl 1-13. Partner organisations taking same review to their Instructions / Scheme of Delegation) Ctrl 3. Board approved SFIs and Scheme of Delegation. Up-to- own governance committees. 4. Cash management, cash planning and working capital in date policies and procedures for budget setting. place. Ctrl 5. NHS Improvement correspondence to Trust. 5. Reporting to regulators. Ctrl 7-9. Executive has considered draft report form Mark 6. Engagement with regulators to ensure aspects of the Single Hacket and incorporated agreed actions into the PMO plans. Oversight Framework covered. Ctrl 1-34. Board considered ICO risk share agreement at 1st 7. Assistance from NHS-I with Mark Hackett. July meeting and issued letter to Partners. 7. Building relationships with NHS-I team. Ctrl 1-14. Council Oversee and Scrutiny recommended same 8. NHS-I monthly review process under the NHS E Capped conditions to full council. All Departments All Muskett, Rodney Expenditure Programme. Ctrl 1-13. CCG governing body meeting 18/7/2017. Corporate Level Risk Level Corporate 9. Board considering revised RSA/PBR at next meeting. Ctrl 13. Agreement Signed. 10. Trust Board CCG and Council all approved the New RSA 11. CCG taking RSA to NHS E 12. NHSE approved CCG 2017/18 Plan as part of CEP process OfficerDavenport) (Liz Operating Chief so CCG can now sign 2017/18 contract. 13. New risk share agreement signed with CCG and Council.

1095 Corporate Theme 6: CQC 1. Safe, Quality Care and 20 Cause: Overcrowding due to exit block and capacity issues 1. Intentional rounding and departmental escalation policy in Ctrl 1: Freeing up ward capacity. Late discharged remain a 15 Ctrl 1. These are audited monthly by the departmental Senior Ctrl 3. New pilot on EAU3 where direct medical and surgically None identified. rating 'requires Best Experience throughout the hospital meaning no flow through department. conjunction with hospital escalation plan. Challenging when problem. Sisters and 2 hourly escalation sheets held in department of expected patients are being transferred to reduce overcrowding improvement' and the there are high rates of admission and low rates of discharge i.e. internal actions taken. in dept. inability to deliver Effect: Non-achievement of ED quality standards, delayed Unable to adjust thresholds further to allow a patient to go Ctrl 3: Review required of the support to be provided to the Ctrl 2. Evidence available via internal escalation record sheets. sufficient progress to ambulance handovers. No capacity creates delays to patient home. department by the 104/110 bleep holder to be instigated. (See Ctrl 3. Part of internal escalation plan. Ctrl 10. New SWAST and ED initiative. achieve 'good' or assessment, diagnostics, treatment and represents a clinical 2. Two hourly board rounds during high volume situations; pilot comment about site management team). Ctrl 4. SAFER bundle rolled out on EAU4 in/2016 - ALAMAC 'outstanding' risk to patients. use of overcrowding score to be used in conjunction with Trust no longer in use as replaced by ED dashboard and internal wide actions. escalation tool. Linked to Risk: 3. Early escalation of capacity problems to on-call teams. Ctrl 5,8,9. Agenda's, papers, minutes/notes. DRM ID No 1276 Lack of side rooms in Orthopaedic wards Escalation to Bronze and Silver command in SWAST. Ctrl 6. Up-to-date policies and procedures. (10)(Closed) 4. ED dashboard will support greater understanding of ED Ctrl 8. Up-to-date on call executive rota. pressures Ctrl 1-9. CQC self-assessment. 5. Performance closely monitored through ED governance Ctrl 1-9. IA Report - SDU Governance arrangements. (May process and trust flow board 2017), Assurance level satisfactory. 6. Policies and procedures including clear SOP's Ctrl 1-9. Positive CQC report - August 2017 (see documents) 7. On call executive rota/potential creation of site management Houlihan, Lisa team. Emergency Services Emergency Corporate Level Risk Level Corporate 8. 3 x daily control meetings with real-time information and appropriate management responses. 9. Ward discharge coordinators have daily meetings to review ward discharges. OfficerDavenport) (Liz Operating Chief 10. SWAST and ED initiative with use of 'expected cards' to highlight if patients could be directed elsewhere e.g. AMU/EAU3

1504 Corporate Theme 6: CQC 1. Safe, Quality Care and 15 Cause: 2-3 Occurrence's weekly where vulnerable patients are 1. Situation regularly escalated. (Averaging weekly occurrence) 6. Not enough mental health bed capacity. 15 Ctrl 1. Escalated and control room informed. None Identified. None Identified. rating 'requires Best Experience admitted to the EAU's awaiting Mental Health Beds. 2. Extra staffing can be requested via temporary staffing (as 7. Reduced mental health staffing overnight means long delays Ctrl 2. Bank Staff and Records from temporary staffing. improvement' and the available). for review and support. Ctrl 3. Devon Partnership Trust rota documented and available inability to deliver Effects: 3. Psychiatric liaison team available in hours. 8. Not an appropriate place of safety. on request. sufficient progress to A. Delays in transferring patients to appropriate units due to 4. Manager on call and/or Executive team 9. EAU staff do not have specific mental health training. Ctrl 4-5. Patient Flow Board Meeting Minutes

achieve 'good' or Houlihan, Lisa bed availability. 5. Appropriate discussion in progress with Devon Partnership Ctrl 1-5 IA Report - SDU Governance arrangements. (May 'outstanding' B. Poor patient experience. Trust. 2017), Assurance level satisfactory. Emergency Services Emergency Corporate Level Risk Level Corporate C. Huge strain placed on these wards, often requiring extra Ctrl 1-5. Positive CQC report - August 2017 (see documents) Davenport) staffing to support, adding stress/workload for ward teams. Chief Operating Officer (Liz Operating Chief

Board Assurance Framework.pdf Page 5 of5 Page 12 of 13 Overall Page 168 of 253 Attachment four Board Assurance Framework (BAF) Heatmap Current Risk Rating

Trust Strategic Objectives 2016/18  = Safe, Quality Care and Best Experience  = Improved wellbeing through partnership 18 1 2 4 16  = Valuing our workforce  = Well led

3 6 7 11 5 10 14 17 12 13 15

8 10 9

Risk Title: 1. Corp Theme 1, DRM ID No 1050 “Special Theatres Ventilation.”  2. Corp Theme 1, DRM ID No 1083 “Insufficient Capital Expenditure.”  3. Corp Theme 1, DRM ID No 1159 “Current IT Systems & Infrastructure Will Not Meet Future Demands.”  4. Corp Theme 1, DRM ID No 1231 “Failure To Raise Sufficient Capital”  5. Corp Theme 2, DRM ID No 1070 “Outpatient & Inpatient RTT”  6. Corp Theme 2, DRM ID No 1101 “Medical Retina Demand.”  7. Corp Theme 2, DRM ID No 1110 “Follow Up Appointments Are Followed Up In Agreed Timescales.”  8. Corp Theme 2, DRM ID No 1266 “Poor Patient Experience And Quality Of Care.”  9. Corp Theme 2. DRM ID No 1815 “High Quality Patient Tracking to Avoid any Unnecessary CWT Breaches.” 10.Corp Theme 2. DRM ID No 1998 “Human Tissue Act 2004 Non-Compliance.  11.Corp Theme 3, DRM ID No 1697 “Inability to Attracted Service Critical Staff.”  12.Corp Theme 4, DRM ID No 75 “Reduction in supply of care homes and care providers.”  13.Corp Theme 4, DRM ID No 1695 “Mears Personal Care Delivery, Failure Concerns Across Torbay & South Devon.”  14.Corp Theme 5, DRM ID No 1223 “Financial Sustainability Risk Rating.”  15.Corp Theme 5, DRM ID No 1236 “Increase In Overspends On The Independent Sector.”  16.Corp Theme 5, DRM ID No 1239 “Failure To Secure Fund Monies.”  17.Corp Theme 6, DRM ID No 1095 “Safer Care - No Delays in ED.”  Board18.Corp Assurance Theme Framework.pdf 6, DRM ID No 1504 “Delays to Mental Health Pathways.”  Page 13 of 13 Overall Page 169 of 253 Overall Page 170 of 253

REPORT SUMMARY SHEET

Meeting Date 7th March 2018

Report Title Feedback and Engagement Annual Report

Lead Director Chief Nurse

Corporate Objective Safe, quality care and best experience Well led

Corporate Risk/ Failure to achieve key performance standards Theme

Purpose Information Assurance Decision

X X

Summary of Key Issues for Trust Board Strategic Context An objective of the report is to provide the Board of Directors and our wider stakeholders with assurance that feedback and engagement is being handled effectively and in compliance with regulations.

This report will provide information on the recording of feedback, themes and methods of sharing learning.

Key Issues/Risks National surveys are positive.

Recommendations Accept as assurance.

Summary of ED The increased operational escalation over Q4 and the need to prioritise direct Challenge / care activity increases the risk of complaint responses being outside the set Discussion timeframe.

The staff survey shows that staff are not confident that patient experience is used effectively to improve services. It may be that the improvements made as a result of user feedback are not visible to staff. For this reason the Trust are participating in the Patient Experience Collaborative Project led by Northumbria which focuses on real time feedback to staff on the day so they can be involved in making the improvements direct.

Internal/External Healthwatch, SEAP, CCG, Patient Rep involvement in the groups that monitor Engagement inc. and maintain feedback and engagement. Public, Patient & Governor Involvement Equality & Diversity Nil Implications

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Trust Board Summary Report

Feedback and Engagement Annual Report

1st January 2017 to 31st December 2017 1.0 Introduction:

Torbay & South Devon NHS Foundation Trust (the Trust) strives to be a learning organisation to all those that use its many and varied services in the community it provides for. Our main purpose is to highlight the value of listening to the people who have used these services and to share that learning with all areas of our organisation, work on that feedback and change our practices for the better.

This partnership working builds the culture that allows the organisation to deliver its strategic values of providing safe, high quality health and social care at the right time, in the right place to support the people of Torbay and South Devon to live their lives to the full.

This annual report encompasses the work undertaken across the Trust and delivered through the Service Delivery Units (SDUs) of the organisation. This report focuses on the key areas of work and is by no means representative of all the on- going work that the organisation is or has undertaken.

2.0 Trustwide Groups supporting Feedback and Engagement

2.1 Learning from Complaints Group

This group meets monthly and is a forum for the senior staff responsible for the management of complaints, both at a corporate and at Service Delivery Unit level, to review the effectiveness of complaints handling and the actions taken in response to complaints, to share good practice and to develop a culture of learning in the handling of complaints. The group also includes the local Clinical Commissioning Group (CCG), Support, Empower, Advocate, Promote (SEAP) representative and a member of the Working with Us panel. This dynamic group allows for a truly wide and representative view of how the Trust handles its complaints.

The principle KLoE for the group (R4): How are people’s concerns and complaints listened and responded to and used to improve the quality of care?

The group captures key information from the presentations discussions, and reports that are used at each meeting to satisfy this KLoE. Please see section 3.2 of this report for examples of learning.

Key achievements for 2017 include:

 The development of a Trust-wide investigation pack for complaints – after listening to feedback the group reviewed the process and simplified the process, tested the changes on the Medical Service Delivery unit and rolled out across the Trust.  With the implementation of Datix the second step in its use was to create a suite of dashboards which are now used by the group with the aim of highlighting areas of good practice and areas of concern.  The group has been valuable as a vehicle in the sharing of ideas in relation to the handling of complex complaints.

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2.2 Engagement Group:

Engagement is a process where staff co-design together with patients, service users, family, carers and the wider community to achieve positive outcomes for all parties. It is a meaningful, collaborative process where everyone involved works in partnership and values such as equality and respect are an integral part of the process. The Trust is committed to working with its communities to ensure services meet the needs of local people and believe that ideas and proposals are improved through two-way discussions to help understand perspectives, issues, aspirations and wishes in order to influence thinking and planning of future services.

The Engagement Group within the Trust meets bi-monthly and aims to develop and maintain partnerships with patients, service users and with key stakeholder groups in the wider community in order to inform service development and delivery. The members of the Engagement Group identify local and national areas of good practice and disseminate through the Service Delivery Unit structure.

The Engagement Group monitors the implementation of the Engagement Strategy for the Trust with due regard for the identified Trust priorities and identify the key pieces of Trust work to be monitored through the group. Through the Quality Improvement Group (QIG), contribute to the assurance process for service user involvement against the following CQC Key Lines of Enquiry.

R2 - Do services take account of the needs of different people, including those in vulnerable circumstances?

The Trust uses a number of areas to review this including national surveys, the Quality Assurance Improvement Team, (the team monitors care in the South Devon’s care home).

R3 - Can people access care and treatment in a timely way:

This continues to be monitored via the performance dashboard and in the Performance and Quality Reviews and much work is underway to both improve the performance and monitor the individual risk of people who have a long wait. It has been noted that A/E carefully monitor any patients who remain in the department beyond 12 hours after a decision to admit has been made.

W4 - how are people who use the services, the public and staff engaged and involved? Utilising the national and local surveys we undertake, we also make use of the Working with Us panel, a panel of volunteers who undertake discharge surveys and also the Patient Experience Collaborative who survey current inpatients.

Key Achievements for 2017 include:

 Presentation of the Hospital Carer Evaluation Final report which was very positive. 181 questionnaires completed, 91 on acute wards and 90 on community wards, most carers felt welcomed and involved in the patients care, medications and discharge planning with the free text very praising of the care and compassion given by our staff.

The Carer’s Services have also displayed their work at Torbay Hospital during Carers week.

 Patient Experience Collaborative project which has started with 8 pilot wards within acute and community hospitals surveying patients in real time and providing instant feedback to the areas.

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2.3 Quality Improvement Group (QIG)

This group is jointly chaired by the Medical Director and Chief Nurse, and has standing items on engagement and experience. The QIG dashboard has a section designed around complaints metrics. QIG feeds into the Quality Assurance Committee and ultimately the board.

2017 – Key achievements:

The building, use and continued development of the QIG Dashboard in using and triangulating patient data.

The format of the second part of QIG where clinicians challenge and share patient safety and feedback issues.

3.0 Complaints, Comments and Concerns Overview

Feedback and Engagement team

Our responsibilities for the handling of complaints are defined in Statutory Instrument 2009 No. 309 - The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. http://www.legislation.gov.uk/uksi/2009/309/regulation/4/made

The instrument requires us to:

• deal with complaints efficiently • properly investigate them • be respectful and courteous to complainants • assist with understanding the process • be timely and appropriate with the response • include the outcome and what actions we are taking in our response.

One of the main aims of the Trust’s complaints policy and therefore strategy is to ensure we are a learning organisation and this is demonstrated by:

 Ensuring learning from experiences (complaints, concerns, compliments, comments and Patient Advocacy and Liaison Service enquiries & MP enquiries).  Developing a reflective, supportive and open culture that encourages all staff to report incidents, accidents and near misses on a confidential, non-punitive basis to share learning and best practice.  Monitoring and reviewing learning to ensure it is acted upon and that best practice is used across the Trust.  Ensuring that learning from patient / service user experience is used to influence future arrangements.  Promote a culture that encourages mutual questioning and challenge in a safe psychological space.

The team has developed a number of processes to enable learning from feedback to be given to individuals, areas and boards, and these include:

 Direct feedback to the area/individual of every concern or compliment raised in real time.  CLICC (Complaint, Litigation, Incident, Coroners Case & CAS alert) Report - this is a weekly report to the Executive Team with regard to the areas outline as above. The report also triangulates concerns issues into themes. Public

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 Learning from Complaints Group  Engagement Group  Service Delivery Unit Boards – The Delivery Unit Directors and Associate Directors of Nursing are responsible for disseminating learning from their specific complaints across the organisation.  Local resolution at speciality / area level.  Quality Improvement projects  Quality Improvement Group (QIG) Dashboard available to all staff  Datix Dashboard, the Feedback and Engagement Team provide a monthly report to the Learning from Complaints Group.  Datix Digest, this is a monthly overview of the Trust’s activity as reported on Datix. It has been designed to give all staff an insight in to incidents, feedback and litigation reported in Datix and is shared with individuals and teams.

As a basic premise of any complaint the team always asks the complainant what actions they would like to happen as a result of the complaints process. From our review, complainants most frequently state that they would like:

• an investigation to establish that their concerns are valid (and are taken seriously) • an explanation of why it happened • an assurance that it will not happen again (to them or anyone else) • an acknowledgement that the Trust made a mistake or was wrong • to know what the Trust are going to do about the issues they raise (for example, implement staff training) • specific actions to remedy the mistake.

3.1 Complaints, concerns and compliments data

Table 1: Aggregated Trustwide Number of Contacts by type January to 31st December 2017

Total number of contacts by type 2017 and for Comparison 2016

Type of Enquiry 2017 Grand Total 2016 Grand Total Variance + / - Comment 444 147 ↑ 297 Complaint 330 426 ↓ 96 Compliment 426 371 ↑ 55 Concern 759 343 ↑ 416 MP Concern / Complaint 31 24 ↑ 7 Advice & Information PALS 625 1140 ↓ 515 Grand Total 2615 2451 ↑ 164

Table 1

In 2016 the Trust operated two risk management systems and the team was split between two offices. Datix was introduced and became fully operational in 2017. This has helped to streamline the work of the department and it has also helped in standardising the way the work is ordered and defined. This is evident in the above table. The decrease in the classification of work in the ‘Advice and Information’ section is now largely recorded as a concern. Overall the contact number has increased for 2017 and the following tables offer further granular detail of the work undertake in this year. This is to be welcomed as feedback from our users is vital in helping to change or develop our services. Public

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The following chart, chart 1 highlights the number of formal complaints received by the Trust by month:

Chart 1

The chart shows the variation between months and a decline in number received over the Trust’s busiest period, November/December. This needs to be observed for more data points and any statistical significance. During this period the number of concerns received, did rise and these have all been fed back to the areas.

Table 2 takes the Trustwide data and displays the contacts by the Service Delivery Units (SDUs) within the organisation. The Medical Delivery Unit, as it houses Accident and Emergency and OPD, typically records the most contacts. The distribution within the table below is largely within expected norms and is similar to previous years.

Table 2: Trustwide contacts by type and SDU from January to December 2017

Community Health and Social Social and Health Community Unit Delivery Service Care Service Emergency and Medical Unit Delivery Unit Delivery Service Surgical Diagnostics Children's, Women's, Delivery Service Therapies and Unit Directorate Operations and ofNursing Directorate Practice Professional Facilities and Estates Management (HIS) Services Informatics Health Organisational and Workforce Development and Performance Finance, Group Investment Affairs Corporate Applicable Not Improvement and Strategy Directorate (PMU) Pharmaceuticals Torbay Total Complaint 80 115 79 50 1 0 2 2 0 1 0 0 0 0 330 Concern 126 182 238 160 6 7 19 5 0 3 1 12 0 0 759 Comment 64 92 85 80 7 42 29 14 5 0 4 19 1 2 444 Compliment 102 156 59 99 1 3 1 1 0 0 0 3 0 1 426 Advice/support 31 59 61 38 5 5 10 3 2 1 1 8 0 0 224 Information/signposting 43 52 68 40 7 41 19 38 4 0 5 84 0 0 401 MP Concern/Complaint 12 5 6 71000000000 31 Total 457 661 596 474 28 98 80 63 11 5 11 126 1 3 2615

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Chart 2: Contacts by top 15 location

This Trustwide data splits the contacts into locations. Where a complaint or contact is about a clinic booking, or appointment they are recorded under outpatients, this does not mean all the contacts are about the actual outpatient’s location. The detail of the top two locations themes are represented as overleaf:

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Chart 3: Torbay Outpatients Department

Chart 4: Accident & Emergency Department

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Table 3: as below shows the categories of complaints as recorded on the Datix system

Accessibility transfers discharge, Admission, cancellations delays, Appointment treat to consent Appropriateness, ofStaff Attitude treatment/drugs to access Non-Delivery, Availability, services Commissioning Communication Negligence Competence, Effectiveness Eligibility care ofLife End Handling Information errors prescribing or Prescrition respect dignity, Privacy, care patient Procedures, Security Safety, times waiting delays, Timeliness, Other Total Assessment 2 0 1 2 9 2 0 2 15 5 11 0 0 0 0 0 1 2 1 53 Diagnosis 0 0 0 1 4 2 0 1 16 2 0 1 0 0 0 0 0 2 0 29 Referral 0000000100100000000 2 Appointment 5060500310000000010 21 Transport 1000100000000000000 2 Admission 0000100000000000000 1 Discharge 0605000230000002000 18 Treatment 8 1 3 5 22 12 0 4 52 12 0 0 0 0 1 7 0 2 2 131 Care 6 1 0 5 13 2 2 4 17 2 1 2 1 2 0 3 0 0 1 62 Equipment 0000000010000000000 1 Personal Welfare 1000000000000000000 1 Non-Clinical Support 1000200000000000001 4 Premises 0000100000000000000 1 Record Management 1000000110000000001 4 Total 25 8 10 18 58 18 2 18 106 21 13 3 1 2 1 12 1 7 6 330

Chart 5, as above, shows a graphic representation of this data in a pie chart. Unsurprisingly care and treatment are highlighted as the largest areas of contact we receive.

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Of the complaints received by the Trust during 2017, the following outcomes have been recorded:

 56% of the complaints were not upheld  28% were partly upheld  12% were upheld  2% of cases were withdrawn  2% we received no consent to continue the complaint.

3.2 Themes and learning from Complaints

Each complaint is categorised from the service user’s point of view into what were we providing and what was it about our delivery that was unsatisfactory. Where more than one issue is raised, each issue will be recorded separately. Treatment, care and assessment are the top three provisions that people complain about, which was the same in 2016. However, there has been a shift in the themes of delivery. Most notably, complaints about the appropriateness of care has been superseded from the top spot by complaints about competence and negligence. This has been fed back to the SDUs for comment and feedback and will be looked at during 2018.

There has also been an increase in the complaints about attitude of staff, which was not one of the top three provisions complained about in 2016. This could be indicative of the increased pressure that services have been under in 2017 and again will for the focus of 2018. It is envisaged that the real time patient surveys and Patient Experience Collaborative will bring any of these issue instantly to the manager’s awareness. One area, the Corporate Feedback and Engagement Team have been particularly active in this year has been in raising the profile of the Feedback and Engagement Team’s role. This has helped with ensuring that the enquirer’s desired outcomes are identified at an early stage. To that end the resulting Trust responses have always included specific and measurable time bound actions. Some examples of these changes and learning that have occurred during the year include:

 Vascular Practitioners will not wait for a “one stop” duplex scan in cases of critical ischaemia – patients will now be offered the earliest possible appointment, typically within 1 week as a result from feedback the Trust received (COM 22282).

 A 16 year old patient was asked to sign a consent form for nail surgery which led to the parents expressing concern that his son did not have capacity to consent. An anonymised case study was reviewed by the whole of the Department of Podiatry and Foot Health to raise awareness in relation to issues of consent and to ensure that there is effective communication to patients and their families (COM 20020).

 A Social Services client who was on the waiting list to be assessed for Direct Payments for many months without a review when his needs had changed and when the Trust had been informed of these changes) led to the introduction of a communication pathway between the Review Team and the Social Work Team to ensure that there is a regular review of cases on the waiting list and that individuals are kept informed when waiting over 28 days for a care manager (COM 20935). There was also extra training completed for staff managing the triage process.

 The Trust failed to discuss the risk of chronic pain associated with the surgery. The Trust as a result has now changed the consent form used for hernia repairs to ensure that relevant risks are discussed and documented in the consent process in the future (COM 14005).

 During surgery a tourniquet failed to function adequately. All tourniquets now include the Medical Electronics assessment and a note book so that on every use it can be documented that they have been adequately checked (COM 19375).

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 The Pain Team recognises that the patient’s suggestion regarding the provision of the website address would be beneficial for some patients therefore the Pain Team now inform patients of the website address in appointment letter before consultation with the Pain Clinic.

 Radiology provided an apology for not listening to a relative of patient who has dementia. This has been highlighted to the team involved, noting the specific requirement to be properly aware of a patient’s condition and to listen to the advice of their relatives. As a result of this, the Manager has asked the Lead to ensure that all of his team access the Trust’s training packages around Dementia Awareness with the aim of improving the care that they provide.

 Patient with dementia and other co-morbidities was listed for hip surgery – became unwell and patient subsequently passed away. Consultant involved will take more care to consider whether patients with such presentations should undergo surgery and a pathway was put in place which ensures that patients with dementia who are listed for any operation are referred to the high risk anaesthetic clinic. The purpose of this clinic is to assess an individual's specific risks of any elective surgery (not specific to the operation proposed) and to come to a shared decision as to whether surgery is the right option. This pathway is relatively new and has been highlighted to all clinicians listing patients for surgery and reiterate the importance of referring patients with dementia, who are considering surgery, to this clinic.

4. Cases Referred to the Local Government and Parliamentary and Health Service Ombudsman:

When the Trust has investigated and responded to a complaint, the complainant may refer the case to an Ombudsman who will establish if the Trust has acted appropriately in dealing with the complaint, and may issue recommendations. We answer to the Parliamentary and Health Service Ombudsman (PHSO), for healthcare and the Local Government Ombudsman (LGO), for adult social care.

During 2017, the Trust were approached about 15 cases. Of these cases, 1 was upheld, 1 was partly upheld, 2 were not upheld, 4 were not investigated and 7 are still being investigated by the Ombudsman. This is a reduction in cases being referred to the Ombudsman, there were 20 cases referred in 2016.

The case that was upheld (COM 11718) related to a financial assessment completed by the Trust. The outcome was that the Trust should have gone back to the complainants after they provided contradictory information about gifts to family, before it made a deprivation decision. Therefore the Trust gave the family the opportunity to provide further information about financial gifts to family and its decision was reviewed. The Trust also took too long to make decisions and had poor communication for which it has apologised. The case that was partly upheld (COM 20809) related to fault on the part of the Trust as carers (in a placement commissioned by the Trust) should not have given a client a dose of morphine which exceeded the prescribed dose. The provider has a medication policy which states that errors must be reported to a line manager without delay, which did happen. The carer also called 111 which arranged for paramedics to visit the client. The paramedic crew examined the patient and offered reassurance that the excess dose was minor and unlikely to have a significant impact. Other than observing the client, the paramedics did not provide any treatment. The records also show the provider was open about what had happened. The Head of Care completed an Incident Reporting Form and spoke to the member of staff about the incident and stressed the need to check doses carefully. The Head of Care also telephoned the Practice (the day after the incident) and told them what had happened. The Practice already knew as they had received a report from the Out-of-Hours service. The Ombudsman concluded that there is no evidence this exceed dose caused the client any harm or an injustice.

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5. Online Feedback

The majority of comments about Trust services received online and via social media are positive. The Feedback and Engagement Team respond promptly to posts on NHS Choices, Care Opinion and Healthwatch’s Rate and Review online site. The Communications Team currently respond as required to posts on other social media site such as Facebook, Twitter and Spotted Torquay and signpost to the Feedback and Engagement Team where appropriate. The general themes from social media are encouraging with most patients and relatives expressing their gratitude for the care and treatment they have received.

6. Friends and Family Test

The NHS Friends and Family Test (FFT) helps service providers and commissioners understand whether their patients are happy with the service provided, or where improvements are needed. It is a quick and anonymous way to give your views after receiving care or treatment across the NHS. It asks people if they would recommend the services they have used and offers a range of responses. When combined with supplementary follow-up questions, the FFT provides a mechanism to highlight both good and poor patient experience. The results are not statistically comparable against other organisations because of the various data collection methods. However, FFT continues to provide a broad measure of patient experience that can be used alongside other data to inform service improvement and patient choice.

Table 4 - Trust Friends and Family Test Satisfaction Scores by Service area for Calendar Year 2017

Area Overall Satisfaction Emergency Services 97%

Inpatient Services 98%

Maternity Services 96%

Community Services 98%

Outpatient Services 96%

Overall, the Trust’s Friends and Family results remain consistently high, with an average of over 96% of patient and clients reporting that they would be either “extremely likely” or “likely” to recommend the service they received to a family member or friend. The results are encouraging but more work is required to publicise this data and the actions taken as a result of feedback received via the Friends and Family tool.

“You are always welcoming, friendly and efficient, give good treatment and helpful advice if needed. The waiting area is roomy and comfortable, television and magazines provided. The reception staff are always pleasant”

“Helpful hints in coping with ankle & caring with mobility problem, a great help & OT a wonderful listener which is so important”

“Interaction with children and professional attitude towards parents. Very informative when required didn’t have to wait long to be seen”.

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“Supply better healthier food. Avoid swamping cooked food with gravy even steak & kidney pie which by its nature has its own comes with another copious quantity of this noxious artificial substance which also seeps into the vegetables Xmas dinner inedible”.

“Speed up the process and communicate better with the clients representatives in the early stages. Once the Community Care Worker was appointed the wheels moved more efficiently - getting to that stage was very frustrating - which is not good when the carer is in a vulnerable emotional state. We were at one time even told that the file had been marker "no further action"!! If we had not chased, no action would have been taken”.

7. Surveys

7.1 National Surveys:

Despite the pressures of the last year the national surveys were positive in the feedback they recorded

In 2017 the Trust undertook and received feedback on the following CQC national surveys, Inpatient survey - Children and Young People’s Inpatient and Day Case Survey, Maternity and Emergency Services

The feedback for each of the surveys was very positive and this has been fed back to the areas and via the Engagement Group. Where actions where needed this have been led by the SDU in creating and managing an action plan.

The following is a sample of the overall responses from each survey in terms of our position against benchmark

Emergency Department Survey –

Chart 6

Report Summary:

• With a mailing of 1250 questionnaires and a total of 441 returned completed, the Trust had a response rate of 36%. • Overall positive survey • The survey questions received an average score of 75% which is higher than in 2014.

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• 31 questions showed no significant change in score since 2014. No questions showed a statistically significant worsening of score since 2014. Four questions showed statistically significant improvement. • The Trust scored in the top 20% of trusts nationally on 7 questions and in the bottom 20% of trusts on 5 questions.

Comments received:

• This hospital provide excellent service. All staff from whatever department/grade were helpful, courteous and friendly, as well as being competent. The hospital areas I saw were all very clean and gave the impression of tidiness and good management. A credit to the NHS. • All nurses/doctors who dealt with me were pleasant, helpful and very good at their jobs. If there was a 'Trip Advisor' for hospitals, I would rate it 5 stars, excellent

Children’s & Young Peoples Inpatient and Day Case Survey:

Chart 7

Report summary

 Circa a response rate of 32%  3 questions better than last survey  35 questions no change  2 worse than last time  Overall positive survey

Maternity Survey

Chart 8

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Report summary: • 300 surveys were posted and there was a 40.5% response rate. • The average Mean Rating Score, across all questions, was 84% which is higher than in 2015. • The Trust scored in the top 20% of Trusts on 31 questions and the bottom 20% of Trusts on 1 question. • 19 questions showed at least 5% improvement on the 2015 score, and 3 questions showed a 5% or more worsening of score. The remaining questions showed less than 5% in change in score since 2015.

Comments

My stay at Torbay Hospital along with the birth of my daughter was fantastic. I loved the fact that we were offered a natural C-section because it was magical! The fact my husband could stay the night with me was really beneficial. He was able to lift our baby and help me which saved having to ask a nurse.

SCBU and all maternity wards give so much help and support and are brilliant. All maternity wards should not be closed down-they go beyond importance. I will never forget the excellent care my baby and I received. The staff deserve more than a medal. Though my baby was early and is thankfully doing well, he hasn't put me off having a sibling for him. I am very lucky in having the staff we had.

Overall my experience of birth is quite scary but the staff at Torbay Hospital made me feel as if I was the only lady they had to look after.

8 Local surveys

The Working With Us Panel support the Trust’s work to involve patients, carers and members of the public in decision making relating to the design, planning, delivery and improvement of healthcare provided at Torbay Hospital. The Panel aims to represent the patient view on a variety of forums as requested, predominantly by visiting inpatient wards at Torbay Hospital and asking identified patients on the day of discharge a range of questions about their care and treatment. Any feedback received is given directly to the ward.

Table 5 Real Time Patient Experience – January to 31st December 2017

The team have been very active in every quarter with the specific numbers displayed in the table below:

Table 5 2016/17 2017/18 2017/18 2017/18 Quarter Q4 Q1 Q2 Q3 Total Number of Surveys Undertaken 82 132 83 124 421

The following tables (Tables 6 – 9) are examples of the questions asked and the responses received by the RTPE volunteers. The majority of the responses are positive which is very encouraging for the Trust and are fed back to the areas in real time

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Table 6

Were you involved as much as you wanted to be in decisions about your 2016/17 2017/18 2017/18 2017/18 care and treatment? Q4 Q1 Q2 Q3 Total Yes definitely 71 118 75 108 372 Yes to some extent 7 10 7 13 37 No 3 1 0 2 6 Total 81 129 82 123 415 Yes definitely 88% 91% 91% 88% 90% Yes to some extent 9% 8% 9% 11% 9% No 4% 1% 0% 2% 1%

Table 7

Did you find someone on the hospital 2016/17 2017/18 2017/18 2017/18 staff to talk to about your worries and fears Q4 Q1 Q2 Q3 Total Yes 38 70 48 61 217 No 4 4 1 7 16 I had no worries or fears 39 56 34 52 181 Total 81 130 83 120 414 Yes 47% 54% 58% 51% 52% No 5% 3% 1% 6% 4% I had no worries or fears 48% 43% 41% 43% 44%

Table 8

Have you had confidence and trust in 2016/17 2017/18 2017/18 2017/18 the doctors treating you? Q4 Q1 Q2 Q3 Total Yes definitely 74 124 79 115 392 Yes to some extent 6 4 3 7 20 No 1 3 0 2 6 Total 81 131 82 124 418 Yes definitely 91% 95% 96% 93% 94% Yes to some extent 7% 3% 4% 6% 5% No 1% 2% 0% 2% 1%

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Table 9

Did the hospital staff do everything 2016/17 2017/18 2017/18 2017/18 they could to help control your pain? Q4 Q1 Q2 Q3 Total Yes definitely 63 100 65 90 318 Yes to some extent 6 15 4 11 36 No 0 1 0 0 1 I have not had any pain 12 13 13 20 58 Total 81 129 82 121 413 Yes definitely 78% 78% 79% 74% 77% Yes to some extent 7% 12% 5% 9% 9% No 0% 1% 0% 0% 0% I have not had any pain 15% 10% 16% 17% 14%

Table 10

Overall, how would you rate the care 2016/17 2017/18 2017/18 2017/18 that you received? Q4 Q1 Q2 Q3 Total Excellent 56 100 64 95 315 Very Good 21 23 16 22 82 Good 4 6 1 4 15 Fair 0 1 0 0 1 Poor 0 0 0 1 1 Total 81 130 81 122 414 Excellent 69% 77% 79% 78% 76% Very Good 26% 18% 20% 18% 20% Good 5% 5% 1% 3% 4% Fair 0% 1% 0% 0% 0% Poor 0% 0% 0% 1% 0%

The final table, table 10 highlights the overall experience score relating to the current episode of care. Here as in the other 4 tables the responses are very encouraging and overwhelming either very good or excellent.

The Trust, via Clinical Effectiveness, also undertake a number of local surveys throughout the year designed to gain user feedback and improve services.

8.1 Patient Experience Collaborative

From 2017 and into 2018, the Patient Experience Collaborative, a new national project, has established an innovative way of measuring patient experience within the Trust. We have signed up 8 pilot wards (3 community hospitals wards and 5 wards at Torbay Hospital) in the organisation which are having patient experience measured in real time (i.e. with when people are inpatients with us) and we the feedback is given directly to the wards in real time too (i.e. the afternoon of the day the morning surveys took place). The Ward Managers also receive scores about the overall care on the ward and these are broken down into sub-scores for each part of the care experience. In this initiative the patient is still present on the ward

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The survey used was developed by the Picker Institute who are an international organisation dedicated to improving patient experience. The survey is the most widely validated survey in the world, to accurately measure patient experience for inpatients. We have the British version and are working with 12 other Trusts to establish this survey as the norm in each organisation for measuring inpatient experience. The survey we are doing has the potential to have real benefits for staff and patients, as demonstrated in Northumbria Care NHS Foundation Trust who lead in the UK on this sort of measurement.

In November and December 2017 a baseline survey was completed and shared with the wards. From January 2018 onwards, two visits per month are being completed on the 8 project wards. This is fed back to the ward coordinator on the day for immediate feedback to all staff - including the doctors, Allied Health Professionals and pharmacists. The idea is that we focus on what makes for a good experience for patients and staff. The data which is collected is rich in terms of numbers- the scores we get for all the aspects of patient experience and the stories (comments) about what it is like to be a patient here. It is the comments which are so rich and support what we do.

8.2 Healthwatch:

Healthwatch Devon and Healthwatch Torbay are independent health and social care champions, who listen to what people like about services and what could be improved and help them to find the information they need. Healthwatch build a network of partnerships to reach out into the communities to get a broader range of views and escalate concerns. They encourage services to make positive changes and to involve people in decisions that affect them. Healthwatch aim to gather, publicise and escalate views about people's experience of health and social care services in Devon and Torbay, in order to inform and improve the access to, and experience of, health and social care.

Healthwatch Torbay’s reports include:

 Healthwatch Torbay Quarterly Report which is produced throughout the year.

 Healthwatch Torbay Annual Report 2016-17- Annual Report for 2016/17, showing all of the statutory activities they undertake and activity they have achieved.

Healthwatch activity

TRIO project

The ICO and the Adult Social Care Zones in Paignton and Brixham have been working with Healthwatch Torbay, to undertake a pilot to involve a service user in the health and wellbeing hub meetings. A suitable patient representative has been appointed to work with the hubs to co-design the role of the service user within the meetings together with a role description. This project has now moved from the planning stage to the pilot stage.

Paignton Health and Wellbeing Hub visit

The ICO has asked Healthwatch Torbay (HWT) to do an evaluation by asking those who use the centre the question: What is right and what is missing?

Healthwatch Torbay propose is to describe the current base-line by working with focus groups of patients and similarly a focus group of practitioners. The Paignton League of Friends will be included in the deliberation.

Healthwatch Torbay has set up a reference group with Terms of Reference to include expert advice on operational issues and to receive progress reports from HWT on findings. HWT has set up an internal

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project group including a lead Trustee and has agreed to start engagement activity at Paignton Health and Wellbeing Centre week commencing 19th Feb 2018 for a 3 week period.

Evaluation of Carers Strategy – During December 17 – January 18, Healthwatch Torbay worked in partnership with Torbay Carers Service to undertake an independent survey and review of local Carers as part of improving and monitoring the Torbay Carers Strategy for 2018 – 2021. Final report pending release end February 2018.

A small project to explore how patients on one of the Healthcare of Older People wards felt able to express concerns or worries in the way their care was delivered. The project also evaluated the impact of the ‘Take a Quarter’ training provided in the Trust.

9. Service Delivery Unit (SDU) Improvement priorities 2018:

As care within the organisation is organised and delivered via the main Service Delivery Units please see below for some of the key action areas for 2018 based on past feedback comments and projected future need:

9.1 Medical SDU

 Focusing on staff attitude and communication  Safe Nursing  Sustainability of the Medical Take  Review the use of ED assessment space

9.2 Surgical SDU

 Continue the focus on providing more face to face meeting with anyone who raises a concern as this has proved very beneficial during 2017, in providing resolution and closure  Medicines management – to provide more timely and written information to patients when changes to meds have been made  Continue with the success of the real time patient engagement in providing instant feedback to the ward managers who have then made rapid changes  Focusing on staff attitude and communication  A key focus will be on providing relevant and timely information regarding waiting times

9.3 Women’s, Children’s, Diagnostic’s and Therapies

 Improved facilities for Maternity  Add more

9.4 Community SDU

 Voluntary partnership board development (engagement with the voluntary organisations who provide front line support and assistance to patients and service users in their own homes, bringing together the various voluntary groups so that their involvement can be developed and other opportunities explored to work in partnership)

 Development of the health and wellbeing centres in our localities with stakeholder engagement  Carers strategy  Consultation on the Teignmouth rehabilitation beds

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10. Key achievements of 2017

 Excellent feedback from clinical induction  Continued and embedded use of patient stories and feedback at the Trust’s Board  Integral involvement of the Chief Executive and/or Chief Nurse in the complaints handling process  The Feedback and Engagement team are now located in one office  Co-location has allowed for standardisation of work  PALs and Complaints are handled by the whole team now  Two Pack approach to complaints handling  QIG Dashboard metrics  Complaints Dashboard metrics  Continued auditing of complaint responses via mail shot

• Take a Quarter training completed with the participants as below: The newly revised training has proved a popular and engaging methodology for training staff in feedback. Circa 200 staff have been trained including many junior doctors.

The team also train on average 15 – 30 participants on a monthly basis at Clinical induction too

• New Trustwide Risk Management System A key tool in supporting the feedback and engagement process is the introduction of the Datix system. In addition to recording, managing and reporting feedback it is also used across the Trust for incident reporting, risks and requests for information. Feedback is recorded on the Datix system and the Trust maintains a record of the type of contact received the subject matter and outcome (for complaints), the lessons learned and follow-up actions taken. The system also provides dashboards for wards and areas to use and uploads to the Department of Health to satisfy the K041 reporting requirements. Prior two systems were in operation and since the introduction all definitions and entering of data is now standardised.

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11. Looking forward

The Trust has a number of objectives for 2018 for example:

Objective Who By When How we will meet this objective Raising the profile of complaints within the Feedback and July 2018 Attending team meetings ICO Engagement Team and presenting at a range of forums. Reducing the length of time it takes to All ADNS/DGM for December Investigators to attend respond to a complaint from 6 weeks to 5 each SDU 2018 complaint training to enable weeks with 50% less extension them to complete effective and efficient investigations Increasing the numbers of complaint All ADNS/DGM for July 2018 Datix reports to be supplied cases that have an action plan in place by each SDU regularly and any 50% outstanding action plans to be sought from the Feedback and Engagement Team Sharing learning further using both the Feedback and July 2018 Learning pages updated on intranet and the public website Engagement Team both ICON and the public website with new cases added monthly Review and re-design the Datix fields to Feedback and July 2018 Data integrity report to be improve the speed and quality of data Engagement provided monthly by Datix entry Team, Datix Administrator Administrator Further review the quality assurance Quality and July 2018 Regular audits of completed procedures within the complaints process Experience Lead to ensure quality. Introduce further monitoring and audit of All ADNS/DGM for May 2018 Reports to be submitted to how we have changed our practices in each SDU the Learning from response to patient feedback. Our Complaints Group on a recommendation is that this level of monthly basis auditing should be built into our processes and be monitored routinely. Formal review of the Patient Experience Patient Experience August Project to be rolled out Project Collaborative 2018 following the completion of Group the pilot Process mapping all the Experience Engagement April 2018 Workplan to be produced activity Group Refocusing the Engagement group Engagement April 2018 Re-consider Terms of Group Reference and priorities for 2018 Introduce Always events into the Patient Safety July 2018 Using patient engagement, organisation Lead create a series of always events of what the patients always what us to achieve

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In the 2018/19 Quality account the following areas have been selected for specific project work:

Experience • Priority 4: NHS Quicker: Increase the use of NHS Quicker App across Torbay & South Devon by both the local population and visitors (>20% increase from the baseline) • Priority 5: HOPE programme: HOPE is an evidence based and validated 2 ½ hour a week 6 week long, group program combining the delivery of peer support, self-management education and health coaching. The model has been shown to work best when it is co-facilitated by someone from the health and social care ‘workforce’ and someone with lived-experience (patient). HOPE is an intervention that fits perfectly with our ICO model of care and could help us as a system achieve the triple aim of healthcare:

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Appendix One

Surveys and Questionnaires - Projects Ref No Project Title Classification Community Allied Health Professionals 0257 Nutritional needs of Intermediate Care Service Evaluation Patients 0272 Nutrition and Hydration in Torbay Care Service Evaluation Homes Healthy Lifestyles 0254 Healthy Lifesyles Assessment Patient/Carer Survey Medical services Allied Health Professionals 0262 Oncology patient satisfaction Service Evaluation Cancer Services 0250 Living with cancer day V2 Patient/Carer Survey Gastroenterology 0261 Coeliac Group Sessions - Patient Service Evaluation Evaluation of General Medicine 0252 Endoscopy Unit Patient Satisfaction survey Patient/Carer Survey Pharmacy 0253 Pharmacy Satisfaction Survey Patient/Carer Survey Organisation wide Organisation wide 0264 Bereavement Service Survey Patient/Carer Survey Professional Practice 0246 Physician Associates - Retrospective Staff Survey registration 0265 Equality, Diversity and Human Rights- How Staff Survey we perform against the Equality Delivery System Surgical services Breast Services 0248 Breast care - Change in symptom support Service Evaluation 0266 Breast Care- Family History Patient/Carer Survey Public

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General Surgery 0258 Nurse Led Flexible Cystoscopy Clinic for Patient/Carer Survey Bladder Cancer Surveillance Head & Neck 26 February 2018 Page 1 of 2 Ref No Project Title Classification 0243 Maxillary obturator prosthesis following Service Evaluation hemi maxillectomy surgery for oral or sinonasal cancer. 0259 Creation of an e-learning package for Staff Survey management of mandible trauma Trauma & Orthopaedics 0249 Outreach nurse led followup for hip and Service Evaluation knee arthroplasty at 6 weeks- home visit 0268 DNACPR (do not attempt cardiopulmonary Service Evaluation resuscitation) orders in patient with a fractured neck of femur who lack capacity Trustwide Corporate 0263 Trust Members Survey 2017 Patient/Carer Survey Trustwide 0251 User Satisfaction with the Complaints Service Evaluation Process 0256 Quality Improvement Questionnaires for Staff Survey Junior Doctors - Pre and Post QI Projects 0269 Exception reporting for junior doctors Staff Survey Women's, children's and diagnostics

0247 Satisfaction survey- British Association for Service Evaluation sexual health HIV BASHH Allied Health Professionals 0271 Omelette and Sandwich satisfaction in Patient/Carer Survey Torbay Hospital Obs & Gynae 0245 User survey - Antenatal and newborn Service Evaluation screening 0260 Patient experience with endometrial Service Evaluation sampling

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Pathology 0270 Pathology Users Satisfaction Questionnaire Service Evaluation Sexual Health 0244 HIV Patient satisfaction survey Service Evaluation

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Report of Finance, Performance and Investment Committee Chair to TSDFT Board of Directors

27 February 2018 Meeting date:

Report by + date: Robin Sutton, 28 February 2018

This report is for: Information☒ Decision ☐ (please select one box) Link to the Trust’s strategic 1: Safe, quality care and best experience ☒ objectives: (please select one or 2: Improved wellbeing through partnership ☒ more boxes as appropriate) 3: Valuing our workforce ☒ 4: Well led ☒ Public or Private Public ☒ or Private ☐ (please select one box)

Key issue(s) to highlight to the Board (Month 10):

1. For assurance the Committee reviewed the Month 10 financial performance. Overall financial position: The financial position against NHS I Control Total for the 10 months to 31 January 2018 is a surplus of £0.52m against a planned surplus of £0.57m. In the month of January a surplus of £1.31m has been achieved, which is £0.56m behind plan. (After the income reduction of Q3 ED STF, 75% of MARS accrued and a £200K hit on provisions) Pay expenditure: Total pay costs are underspent against plan to Month 10 by £0.64m (after the MARS accrual). Cumulative Savings Delivery: The Trust has delivered £33.5m against our year to date savings profiled target of £32m (including income Generation target); resulting in a £1.5m over-delivery year to date. System Savings Plan Year End Forecast Out-turn Delivery: To achieve a 2017/18 surplus and achieve the Control Total excluding STF, the Trust needs to deliver £40.74m cost reduction target, and a further income generation target of £1.33m (Total £42.1m). At the end of Month 10, the Trust has identified savings potential of £42.0m resulting in a £0.1m current-year shortfall. It is important to recognise that this scale of current-year forecast delivery represents a significant improvement on the achievements of previous years. Any slippage in delivery would however put the plan and £2.04m STF funding at risk, affecting liquidity and, in turn capital investment plans. The forecast recurrent delivery Full Year Effect (FYE) against the 2017/18 projects is £30.1m. In addition, we believe there is a potential further £1.5m to £3.0m of FYE mitigation, which we are scoping with a view to add before the end of the financial year. Use of Resources Risk Rating: NHS I no longer publish a planned risk rating for Trusts, due to changes they have made to the risk rating calculation. However, at Month 10, the Trust had an actual use of resources risk rating of 2 (subject to confirmation by NHS I). The Agency risk rating of 1is a material improvement to the planned rating of 2. Capital Spend: A significant underspend against the revised approved budget exists at 31 January 2018. A further £1m of capital expenditure slippage was reported to NHS I Scheme during January 2018. Scheme leads have been asked for assurance that the full year revised spend forecast of £9.6m will be delivered.

2. For assurance, the Committee reviewed the Month 9 Performance Standards. 4 hour ED standard: In January the Trust achieved 83.82% of patients discharged or admitted within 4 hours of arrival at accident and emergency departments. This is a fall on last month 88.34% and is below the agreed Month 10 Operational Plan trajectory of 98.9% and below the 95% national standard. Performance to 20 February shows 79.62% of patients being discharged from ED and MIU within 4 hours in February. RTT (target 92% / trajectory 89.3%): RTT performance has improved in January to 82.51% waiting less than 18 weeks from 82.2% in December. People waiting over 52 weeks: The number of people experiencing very long waits is starting to 2018 02 27_FPI_Cttee_Report_to_Board.pdf Page 1 of 2 OverallPage 1Page of 2 197 of 253

reduce in line with plans with 29 people reported as waiting over 52 weeks at the end of January against the target of 34. The trajectory remains to achieve no more than 16 people waiting over 52 weeks by the end of February and zero at the end of March. The March delivery of zero is at risk due to the current operational pressures which are limiting the number of elective inpatient admissions. In January higher numbers of elective inpatient operations requiring beds have been stood down with this continuing into February whilst the urgent care pressures remain in the system. Teams are monitoring on a daily basis and implementing additional lists where possible to mitigate for this loss in capacity to deliver the March position of zero waiting over 52 weeks. 62 day cancer standard: 85.6% (as at 20th February 2018) against the 85% national target, this is an improvement on last month (82.4%). The standard in Q4 NHS I assessment is predicted to be met against the target 85%. Diagnostics: The diagnostics standard is not met and increased to 5.38% over 6 weeks outside of the agreed tolerance of 4%. The greatest number of long waiting patients over 6 weeks are for routine MRI with an increase in Echocardiography waits the greatest change in the January reported performance. Dementia screening: The Dementia find standard is not met in January with 52.1% reported (last month 65.5%). A drop in reported performance was forecast with the transition to the “Nerve Centre” clinical information tool which is being rolled out; a definitive timeline for this work is still awaited.

3. The NHSI monthly self-certification form for Month 10 was approved by the Committee subject to the circulation of the accompanying financial narrative.

4. For assurance, a monthly Deep Dive was undertaken by the Committee into the Trust’s performance as measured by the Carter Model Hospital. Adverse indicators were reviewed and discussed for assurance.

5. No business cases were submitted to the Committee for consideration.

6. The Torbay Pharmaceuticals financial report for January 2018 was reviewed by the Committee for assurance.

7. Updates to the Finance Risk Register was provided for information and the BAF risk numbers 1231 (Capital Resources) and 1223 (Financial Sustainability) were briefly reviewed and discussed.

8. Future deep dives are planned for Capital (March 2018), Care Model (April 2018) and CIP (May 2018).

9. The Committee discussed the positive progress in plans to recover the 2017/18 financial position together with the associated implications of such actions.

10. EDG and SBMG meetings for February 2018 were postponed.

Key Decision(s)/Recommendations Made:

Name: Robin Sutton (Committee Chair)

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Report of Quality Assurance Committee Chair to TSDFT Board of Directors

Meeting dates: 24th January 2018

Report by + date: Jacqui Lyttle, 19th February 2018

This report is for: Information☒ Decision ☐

Link to the Trust’s strategic 1: Safe, quality care and best experience ☒ objectives: (please select one or 2: Improved wellbeing through partnership ☐ more boxes as appropriate) 3: Valuing our workforce ☐ 4: Well led ☒ Public or Private Public ☒ or Private ☐+ Freedom of Information (please select one box) Act exemption [insert exemption if private box used]

Key issue(s) to highlight to the Board:

QIG ways of working and QAC assurance The committee reviewed the new way of working in relation to the QIG. There was consensus that the new working framework has led to continued improvement in cross organisation and SDU discussion of risks, patient safety, and quality. The deep dives and discussions of appropriate topics and the clear and appropriate assurance or identification of risks being reported to QAC was working well. The committee felt that the current process gave good assurance that issues are being dealt with at the appropriate level within the trust.

Integrated safeguarding The committee received a very comprehensive report from the chief nurse which demonstrated a good level of assurance of both the processes in place, multi-agency and organisations working and the escalation and de-escalation of risks to the QAC and board. Key Decision(s) Made:

Annual plan The committee reviewed and agreed its annual plan, which includes programmed deep dives and direct reporting by service leads for the provision of additional suitable assurance.

Significant adverse events (SAE) The committee agreed that whilst detailed SAE discussion, challenge and review was appropriate at sub QAC level, to ensure full assurance of process and organisational learning that they would receive an annual report. The committee also agreed that the report would be used to inform future annual work plans

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The operations manager presented a detailed report on the trusts performance position. Whilst the committee received assurance that all ‘at risk’ KPI’s i.e. A&E, RTT, 52-week waiters, 62-day cancer and follow up past their clinical recall date had detailed recovery plans in place, they sought additional assurance that patient safety and clinical quality was not being compromised in relation to 52-week waiters and 62-day cancer targets.

Mortuary service The mortuary manager presented an excellent report to the committee on the extensive work undertaken in the past 12 months. The committee received good levels of assurance on the service and its management and that the issues highlighted by the HTA had been actioned. Once the final stage actions had been completed the committee were happy to agree to a reduction in the risk score, with appropriate BAF refresh

28-day readmissions The committee received a very comprehensive presentation from the operations manager of 28-day readmissions which identified the trust to be an outlier within the SW (3rd out of 17). This was particularly marked regarding short lengths of stay. Whilst it appeared that the introduction of new ambulatory care services and the continued implementation of the new care model and associated changes to activity/coding were the main contributing factor for this change in trend. The committee sought further assurance that patient’s clinical needs had been fully assessed on discharge and that readmissions were not as a failure of a duty of care by the trust.

Risks from the Board Assurance Framework: - deep dive review: Risk 1070 – Achievement of 4-hour standard Following review the committee agreed that the score was still appropriate, but the narrative did not reflect all the actions undertaken. The committee requested that the gaps in assurance be reviewed and the BAF updated accordingly. Risk 1095 – Safer care, no delays in ED Following review the committee members felt whilst the score accurately reflected the current position the narrative needed to be changes to reflect the current organisational and system context, i.e., new care model implementation, closure of acute beds and winter planning and escalation. The committee were content that following this refinement of the risk that the BAF could be updated. Recommendation(s): 1. To note this report and its key actions and decisions

Name: Jacqui Lyttle - Committee Chair

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REPORT SUMMARY SHEET

Meeting Date 7 March 2018

Report Title Report of the Interim Chief Operating Officer

Lead Director Interim Chief Operating Officer

Corporate Objective  Safe, quality care and best experience

 Improved wellbeing through partnership

 Valuing our workforce

 Well led

Corporate Risk/  Available capital resources are insufficient to fund high risk/high priority Theme infrastructure/equipment requirements/IT Infrastructure and IT systems

 Failure to achieve key performance standards

 Inability to recruit/retain staff in sufficient number/quality to maintain service provision

 Lack of available Care Home/Domiciliary Care capacity of the right specification/ quality.

 Failure to achieve financial plan

Purpose Information Assurance Decision

 

Summary of Key Issues for Trust Board Strategic Context The report provides the Board of Directors with an update on operational work programmes managed by the Chief Operating Officer.

Key Issues/Risks Key points of note:

The operational response detailed in the Trusts Winter Plan continues to be led by the Winter Team on a day-to-day basis due to the level of operational escalation. January and February have seen the following levels of escalation and 4 hour performance.

Status January to 20th Feb OPEL 1 0 0 OPEL 2 2 2 OPEL 3 23 16 OPEL 4 6 2 4 hour % 83.8% 79.5%

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Report of the Interim Chief Operating Officer.pdf Page 1 of 7 Overall Page 201 of 253 This level of escalation has put significant strain on teams and individuals across the Trust. The impact is on training, development reviews, support to Quality and Performance and Check and Challenge meetings and operational planning capacity. The executive recognise the impact this is having and are seeking to identify ways of supporting individuals and teams at this time.

Levels of flu have continued to be high and norovirus has also impacted on the ability to keep patients moving smoothly across acute, community and care homes. These issues have also impacted heavily on staff. The Trust has had a number of wards closed at various times and individual bays and beds have been closed to admission throughout this period.

These issues have resulted in delays with some patients being medical fit for discharge due in part to being in closed areas and limited access to some of our care homes struggling to cope with infection.

Early indications are that the Trust as experienced a high level of acuity in our elderly population particularly 85+ and often several 95+ presentations.

In response:

 All available escalation capacity has been opened, however this places a significant pressure on clinical cover.  The Winter Team leadership has managed the control process on an almost constant basis.  Elective inpatient workload has continued to be capped whilst maximising use of day surgery.  Infection control issues are manged proactively on an hour by hour basis to maximise opportunity to open capacity safely in line with the Infection Control Team direction. This includes escalated use of the deep cleaning team.  Staffing has been a challenge and the Trust has continued to support safe staffing through escalated measures to cover ward areas as safely as possible.

The operational risks highlighted include:

 Resilience of staff and services through the winter period when the service is under significant pressure  Delivery of NHSI Single Oversight Framework performance standards including 4 hour wait, RTT – 52 week, Cancer 62 day and diagnostic 6 week waits  Care home and domiciliary care capacity to support care at home  Clinical recruitment challenges affecting capacity in specialities including ED, Dermatology, Neurology, Histopathology and Endoscopy  Impact of extended hours for the medical take on RTT compliance in some specialities  Delays to follow up - high levels in Ophthalmology, Rheumatology and Cardiology.  Emergency Duty Service resilience  Delays in mental health pathways (adult and paediatric)

Recommendations To consider the assurance provided in the report and to provide further challenge on the risk mitigation in place

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Report of the Interim Chief Operating Officer.pdf Page 2 of 7 Overall Page 202 of 253 Summary of ED The Executive Team have considered: Challenge/Discussion  Effectiveness of winter plan and actions required to improve service resilience  The impact of prolonged pressure on staff wellbeing and morale and have asked that protected time is given to staff to discuss how they can be supported  The impact of estate on service resilience during period of pressure with a particular focus on side room capacity  On-going focus on management of 52 week waits  Internal/External The changes to care model have been subject to a period of formal consultation Engagement inc. with the public. No other issues identified. Public, Patient & Governor Involvement Equality & Diversity All changes are subject to quality and equality impact assessments. No specific Implications issues identified.

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MAIN REPORT

Report to Board of Directors

Date 7th March 2018

Lead Director Interim Chief Operating Officer

Report Title Report of the Interim Chief Operating Officer

1 Purpose

To provide the Board of Directors with an update on operational work programmes

2 Provenance

The report is informed by the following:

 Minutes and action log from the Care Model Delivery Group  Care Model Delivery Group Risk Register  Minutes and action log from Senior Business Management Team  Minutes and action notes from the A&E Delivery Board  Adult Social Care Programme Board Minutes  Market Management Development Group Minutes  Feedback from Service Delivery Units  Feedback from the Winter Team Lead

3 Winter Plan February has continued to be very challenging for the Trust and the Region with:

 High levels clinical acuity with impact on 85 and 95 + year olds  Challenge to recovery from the cumulative impact of low levels of discharges due to high acuity  Infection control issues with both Flu and norovirus requiring laboratory screening, clinical management and side-room isolation, impacting heavily on patient flow.  Surges in ambulance demand.  High levels of pressure on ITUs across the Network.  Increased trauma activity.  Staff sickness.

The operational response detailed in the Trusts Winter Plan continues to be led by the Winter Team on a day-to-day basis due to the level of operational escalation. January and February have seen the following levels of escalation and 4 hour performance.

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Levels of flu have continued to be high and norovirus has also impacted on the ability to keep patients moving smoothly across acute, community and care homes. These issues have also impacted heavily on staff. The Trust has had a number of wards closed at various times and individual bays and beds have been closed to admission throughout this period.

These issues have resulted in delays with some patients being medical fit for discharge due in part to being in closed areas and limited access to some of our care homes struggling to cope with infection.

Actions taken have included:

 The Winter Team leadership has managed the control process on an almost constant basis

 Additional bed capacity created by opening Warrington Ward led by the Associate Director of Nursing with Multi- disciplinary team support support.

 Cancellation of meetings to release clinical staff.

 Elective inpatient workload has continued to be capped whilst maximising use of day surgery.

 Mandatory training postponed to release clinical staff.

 Public messaging sent out via the CCG

 Increased support from nursing and medical staff to support ward bases

 Review of all acute & community patients to expedite discharge

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Report of the Interim Chief Operating Officer.pdf Page 5 of 7 Overall Page 205 of 253  Director of Infection Prevention & Control with Head of Operations leading outbreak management.

 Daily review of long stay patients: acute & community.

 Minors patients signposted to community MIU to reduce ED pressures.

 Streaming of suitable patients to the onsite GP service.

 Full Radiology support for Newton Abbot MIU

 Extra capacity from support staff, ie pharmacy, portering and cleaning

 Additional weekend control team leadership.

The Trust continues to work closely with its partners in SW Ambulance Service (SWAST), Devon Docs and primary care to optimise safe and effective care for emergency patients.

Work continues on the seven key winter priorities:

 Rapid Response and domiciliary care;  Single point of referral;  Intermediate care and integration of nursing  Ambulatory care pathways;  Technology to support alternatives to hospital;  Winter team leadership;  Communication and information;

All teams have worked exceptionally hard during this period under the leadership of the Winter Team. Individuals and Teams have committed themselves over and above their contract hours and on many occasions individuals have provided support outside their normal roles to provide resilience and safety.

4 Operational Planning for 2018/19

Operational Service Delivery Units have developed the outline business plans for 2018/19 and have presented the key aspects of these to the Board seminar last month. The teams continue to progress further detail on the plans, including the savings and key investment requirements. This includes reviewing the impact of the savings schemes in 2017/18 and will be set out in the context f the move to a new operational model and delivery structure in the coming weeks.

5 Operational update

52-week waits – In line with predictions the number of people waiting over 52 weeks for treatment increased to 42 in December. The Trust remains committed to reducing this number to zero by the 31st March and set the following trajectory:

December 40 (UGI 31; Urology 8; other 1) January 34 (UGI 26; Urology 8; other 0) February 16 (UGI 12; Urology 4; other 0 March 0

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Report of the Interim Chief Operating Officer.pdf Page 6 of 7 Overall Page 206 of 253 Teams are implementing plans in line with the agreements reached with the Executive Team. In January 29 patients waited over 52 weeks which was better than planned (34). February, however is forecast to not to deliver on the trajectory of 16. The number over 52 weeks is anticipated to remain at a similar level or just over the January number waiting. Although every effort has been made to avoid cancelation of long wait patients over the winter period, this has not always proved possible and some impact over the winter pressures has been experienced.

Breaches of the 52 week position are now isolated almost entirely to Urology and Upper GI. These teams have reviewed in detail the capacity they have available and the number of patients who need treating before the end of March to avoid any 52 week waiters. The forecast is that further progress will be made during March. The forecast is currently that there will be less than 10 patients waiting over 52 weeks at the end of March and further review is being carried out to move closer to delivery of the commitment to avoid any patients waiting over 52 weeks.

Financial plans- The bi- monthly check and challenge meetings continue, chaired by the Director of Finance and the Chief Operating Officer. Due to the Trusts OPEL status and impact on operational teams these meetings have been held with Business Advisors and Planning team and have focused on SDU financial planning for 2018/19.

Cancer 62 day Standard – The main pathways where the Trust is challenged in delivery of its 62 day pathways and where there are regularly high numbers of patients waiting over 62 days Lung, Upper GI, Lower GI as well as Dermatology and Urology. In response to these challenges the Cancer Team has;

 Coordinated the implementation of the new Prostate pathway in Urology. This started at the end of January and it is therefore anticipated that breaches of the standard in this pathway will reduce from March / April.  In addition the team also has a plan to implement the Optimal Lung Cancer Pathway, which will reduce the time to treatment for these patients.

6 Summary of Operational risks and issues

Risk registers are maintained by all services and projects with risks reviewed through the monthly quality and performance meetings with deep dives at the Risk Committee on a scheduled basis. The operational risks highlighted include:

 Resilience of staff and services through the winter period when the service is under significant pressure  Delivery of NHSI Single Oversight Framework performance standards including 4-hour wait, RTT – 52 week, Cancer 62 day and diagnostic 6 week waits.  Care home and domiciliary care capacity to support care at home  Clinical recruitment challenges affecting capacity in specialities including ED, Dermatology, Neurology, Histopathology and Endoscopy  Impact of extended hours for the medical take on RTT compliance in some specialities  Delays to follow up - high levels in Ophthalmology, Rheumatology and Cardiology.  Emergency Duty Service resilience  Delays in mental health pathways (adult and paediatric)

7 Recommendations

The Board is asked to review the report and consider the assurance provided then provide advice on any further actions to enhance the risk mitigation described in this paper.

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REPORT SUMMARY SHEET

Meeting Date 7 March 2018

Report Title Chief Nurse Portfolio Report - Antenatal and Newborn Screening

Lead Director Chief Nurse

Corporate Objective Safe, quality care and best experience Well led

Corporate Risk/ Failure to achieve key performance / quality standards. Theme

Purpose Information Assurance Decision

 

Summary of Key Issues for Trust Board Strategic Context The Antenatal and Newborn Screening Programme is part of the National Screening programme, which is monitored by Public Health England. There are 6 elements that fall within this programme and have a requirement to be quality assured : 1. Sickle Cell and Thalassemia Screening 2. Infectious Diseases in Pregnancy Screening 3. Fetal Anomaly Screening 4. Newborn and Infant Physical Examination (NIPE) 5. Newborn Bloodspot screening 6. Newborn Hearing Screening Every year a comprehensive annual report is submitted to Public Health England. In addition the programme is subject to a Quality Assurance (QA) visit, where the services are assessed against the National Standards. Both reports evidence a significant amount of work that has been completed by the team to ensure implementation of the screening standards. A number of areas of good practice have been highlighted. The annual report highlights the challenges of having sufficient resource and capacity to maintain and monitor the standards, along with the lack of a robust IT system. The first Antenatal and Newborn Screening QA visit took place in November. This was a very positive visit, with the team being commended and opportunities for sharing good practice identified. 29 recommendations were made. There were no immediate concerns identified. An action plan has been developed to be implemented over the next 12 months.

It has been identified, as in the annual report, that ensuring sufficient resource and capacity, along with a robust IT system is key to achieving these.

Key Issues/Risks Insufficient resource to fully meet recommendations and data / evidence requirements.

Recommendations The Board is recommended to review the document and review the evidence presented. Public

Antenatal and Newborn Screening.pdf Page 1 of 5 Overall Page 209 of 253 Summary of ED Executives noted the content and the recommendations. These will progress Challenge/Discussion through internal governance systems.

Internal/External National Screening Committee Engagement inc. Public Health England Public, Patient & Governor Involvement

Equality & Diversity None Implications

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MAIN REPORT

Report to Trust Board

Date 7th March 2018

Lead Director Chief Nurse Report Title Antenatal and Newborn Screening

1.0 Background: The Antenatal and Newborn Screening Programme is part of the National Screening programme, which is monitored by Public Health England. There are 6 elements that fall within this programme and have a requirement to be quality assured : 7. Sickle Cell and Thalassemia Screening 8. Infectious Diseases in Pregnancy Screening 9. Fetal Anomaly Screening 10. Newborn and Infant Physical Examination (NIPE) 11. Newborn Bloodspot screening 12. Newborn Hearing Screening Elements 1-5 are overseen by the Antenatal Newborn Screening Co-ordinator Midwife, whilst the Newborn Hearing Screening is co-ordinated by Newborn Hearing Screening Programme Local Manager. They are supported by colleagues from maternity, child health, audiology and labs.

Every year a comprehensive annual report is submitted to Public Health England. In addition the programme is subject to a Quality Assurance (QA) visit, where the services are assessed against the National Standards.

2.0 Annual report: The annual report for financial year 2016 / 17 was completed by the Antenatal and Newborn Screening Co- ordinator and submitted on 31 October 2017. This identifies areas of achievement, development and concern. The team were commended on the content and quality of the report submitted by the Public Health England Commissioners. 2.1 Achievements: Significant improvement in meeting standard the standards for newborn blood spot sampling. This has led to a reduction in the number of unnecessary repeats of blood samples taken from newborn babies. 2.2 Developments: Plan to develop an audit schedule to consider quality standards Need to identify an improved ITR solution to collecting data for the KPI’s associated with the screening programme.

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Completion of Standard Operating Procedures for all programmes (excluding newborn hearing which are already in place) 2.3 Issues: The lack of a robust IT system means that data is often being manually collected. This has an effect on the resource and capacity with the service.

There is also the challenge of keeping pace with the increasing volume of work required to evidence meeting the standards. The current screening co-ordinator is 0.6wte, which is significantly lower than other Trusts within the South West and insufficient administrative support for the programme. The report has been reviewed by the service team and actions to address capacity are underway.

3.0 Screening Quality Assurance Visit: The Trust received it inaugural QA visit on 7 November 2017. It was identified that screening services are delivered by a team who are motivated and have good communication links across all disciplines. It was also noted that the team was aware of gaps in the service and had a commitment to address these areas and drive improvements in the screening programme. There were no immediate concerns identified, however the QA team identified three high priority findings:  there were no standard operating procedures to support the processes undertaken by the screening team to ensure resilience within the team in the absence of key individuals  the required training has not been completed by sonographers performing scans for first trimester trisomy screening  women accepting screening for sickle cell and thalassemia do not have results available by 10 weeks gestation

A 6 month timeframe was provided to meet these findings. In total there were 29 recommendations, with 6-12 month timescales applied to achieving these. The QA team also identified a number of areas of good practice that they felt we should share with other organisations. These included network meetings: trust business continuity plan encompasses all aspects of screening programmes; Child Health Information Service has access to newborn screening IT systems; laboratory standard operating procedures contain hyperlinks to national handbooks, standards and guidance; newborn blood spot results for sickle cell screening are recorded on the Trust laboratory system; audiology department has attained accreditation with improving quality in physiological services.

3.1 Actions: A screening action plan has been developed and fortnightly assurance meetings set up to ensure progress against actions. It has been highlighted that 3 of the recommendations are likely to be difficult to achieve. These are: a. Implement and monitor a plan to meet the acceptable level for the key performance indicator for ST2 – women having antenatal sickle cell and thalassemia screening with a screening result available by 10 weeks gestation b. Ensure counselling of women and couples at risk of sickle cell and thalassemia is performed by appropriately trained staff c. Ensure an agreed capital replacement programme is in place for the re-provision of automated auditory brainstem response (AABR) equipment used within the newborn hearing screening service

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Antenatal and Newborn Screening.pdf Page 4 of 5 Overall Page 212 of 253 Recommendation a: The standard recommends that all women should be screened for sickle cell and thalassemia by 10 weeks of pregnancy. This standard has been in place for a number of years. Within the South West, there is very low prevalence of these conditions and it had previously been agreed that a risk assessment could be completed and only those women who have risk factors would be screened before 10 weeks of pregnancy. All other women would be screened at 12 weeks when they attended for their scan appointment. This means that the woman would only require one lot of blood samples rather than having blood drawn on two separate occasions. Compliance of this is monitored. We are currently exploring options to see how we can modify our pathway to fulfil the recommendations, however this will require a complete reconfiguration of how we provide the first midwifery appointments, requiring additional appointment times. Recommendation b: The recommended training is currently only provided in London, with a significant cost attached. We have two staff members trained, one obstetrician and one midwife. The current screening co-ordinator is not trained to that level, however has been undertaking the role for a number of years and is very experienced in counselling for women and their families. She is due to retire shortly the team plan to review this once the current post-holder retires. . Recommendation c: The surgical SDU have been approached regarding gaining the capital monies required for the replacement programme, however the audiology department have been advised that there is no capital monies to complete this action. The QA report highlighted that resource within the screening team should be reviewed. The recommendations and adherence to and maintenance of the National Screening Committee standards will require additional resource. In addition there is a requirement to provide data against KPIs. These require data to be pulled from a number of different IT systems and manually collated. Therefore improved IT capability would support the team significantly in relation to their capacity.

4.0 Summary: The 6 programmes within the Antenatal and Newborn Screening Programme take a significant amount of resource to implement, maintain and monitor. The attached papers provide evidence of the amount of work that is undertaken to ensure appropriate, safe and timely services are provided to women and their families. The team should be commended on what has been achieved with the current limited resources. All standards have been implemented, with the majority meeting the Key Performance Indicators. In particular, the team has worked hard to reduce the number of unnecessary repeat blood samples on newborn babies. The QA visit highlighted a number of areas of good practice, however also provided a number of recommendations. An action plan has been developed, along with a fortnightly assurance meeting. It is recognised that the current resource for the monitoring and co-ordination of the standards is not sufficient, whilst the introduction of a more robust IT system would support the data collection in a more timely and efficient way. These issues are key to achieving the action plan.

5.0 Next steps: The following recommendations will be taken through the SDU and the Senior Business Management Team Meeting for discussion and action. :  Additional resource to antenatal and newborn screening co-ordinator role.  Capital replacement programme for AABR equipment  Prioritisation of improved IT provision within maternity.

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Board Report Summary

Meeting Date 7th March 2018

Report Title Trust End of Life Annual Report

Lead Director Chief Nurse

Corporate Objective Safe, quality care and best experience Well led

Corporate Risk/ Failure to achieve key performance standards Theme Care Quality Commission requirement notice sets out significant concerns regarding safe quality care and best experience

Purpose Information Assurance Decision

 

Summary of Key Issues for Committee Strategic Context The CQC inspection in February 2016 identified a number of concerns resulting in a rating of requires improvement for the acute and community End of Life (EoL) services. Of concern was the lack of a coherent Trust End of Life strategy setting out the next steps to an integrated end of life care service. Whist the EoL group had a work plan to deliver this the CQC recommended that the Trust develop an organisational strategy.

In response to the CQC recommendation to develop an integrated strategy, the End of Life Strategic Board was established in April 2016 to develop a system level strategy involving the CCG, the Trust and other partners. This resulted in the publication of the South Devon and Torbay End Of Life Strategy which was approved by the CCG led System Delivery Board in October 2016. The vision, values and priorities set out in this document reflect the six national ambitions for end of life care and informed the development of the Trust End of Life Strategy ratified by the Trust EoL group in February 2017, the Quality Improvement Group in March 2017 and the Board in April 2017. The End of Life Group have continued to deliver the priorities identified in the strategy through the work plan:

 Integrate Torbay Hospital Specialist Palliative Care Team and the community Palliative and EoL team.  Develop the new structure for EoL care within the Locality Health & Wellbeing hubs  Develop an education strategy for EoL care training within the Trust in line with Strategic Board priorities. o Train 25% of all staff in year 1 in Dying Matters Awareness  Develop a plan to improve recognition of patients likely to be in the last year of life o Develop a plan to increase the numbers of patients entered on to the EPaCCs system  Develop a plan to support staff working in care homes to deliver high

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Trust End of Life Report.pdf Page 1 of 13 Overall Page 215 of 253 quality EoL care o Identify service gaps such as lack of 7 day working and develop action plan to address  The Trust EoL group oversee Trust performance on EoL care.  Monitor EoL quality standards and patient experience through regular audit. o Improve documentation of end of life care delivery and individualised care plans including TEPS

A number of work plan objectives have been achieved but some have been a challenge and are recognised as a risk. Documentation has emerged as a specific issue with the implementation of the new clinical risk document and Nerve centre creating some confusion regarding completion of individual care plans. This will be reflected in the EoL risk register and urgent actions to address are in progress.

Whilst the draft education strategy is now complete, the development was delayed due to vacancies in the team. This has delayed the development of the EoL education essential standards and the review of recording and reporting compliance. This will be reflected on the risk register and the new documentation pack implementation plan advanced.

In addition, the CQC 2016 report highlighted areas for improvement:

o Mental capacity assessment during Do Not Resuscitate (DNR) discussions  The need for an EoL risk register  Improved competency assessment for controlled drug checking for syringe drivers o Accurate record keeping

Although progress has been made in these areas and early audits showed improvement, there is still work to do to ensure improved practice is embedded. Recent evidence shows a need to revisit documentation in response to the introduction of the clinical risk document and Nerve centre.

The 2018/19 work plan will carry forward those actions not completed / embedded and focus on issues raised through patient and staff feedback.

Key Issues/Risks The recent move toward paper light and electronic patient records may be contributing to confusion regarding where and how to record some information. A new EoL document pack has been developed and piloted on Turner ward, Cheetham Hill and Allerton wards. This is now being rolled out with anticipated Trust adoption in Q1.

Education records are held at department level, this increases the risk of inaccuracy in compliance data. From April 1st training will be held on ESR. The EoL training strategy clearly sets out training for each staff group and how this will be achieved.

Reduced capacity in the EoL and the Chief Nurse team has led to a slower rate of improvement in some areas than expected. The recent appointment to the EoL education lead role and the imminent senior management review will strengthen the required operational management capacity to respond to emerging risks.

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Trust End of Life Report.pdf Page 2 of 13 Overall Page 216 of 253 Recommendations The Board is recommended to review the document and review the evidence presented.

Summary of ED Executives recognised the progress on developing a collaborative strategy with Challenge/Discussion the STP, CCG and partners. They agreed the need to consider how the Trust remains sighted on the risks associated with the move form paper documentation to electronic and this will be discussed at the next Risk Group. The need to centralise training records were also agreed.

Internal/External The STP End of Life Steering Group has multi-disciplinary representation from Engagement inc. the CCGs, the Acute Trusts, Local Hospice and Devon Partnership Trust and Public, Patient & independent providers. Governor The South Locality Strategic Board has representation from local partners Involvement including SWAST, DPT, Rowcroft, CCG, Council. The Trust EoL Group has a NED member. The strategy and work plan have been informed by patient experience, EoL patient stories and by the Dignity in Death survey report.

Equality & Diversity Ensuring the safety of those at end of life, their families and carers. Implications

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Trust End of Life Report.pdf Page 3 of 13 Overall Page 217 of 253 End of Life Annual Report

1.0 End of Life Annual Report 2017:

EoL care is provided across the organisation in acute and the community hospitals, in patients own homes, in nursing and residential homes and in Rowcroft hospice. EoL care is therefore provided by a range of clinical and social care teams, supported by the specialist team at Rowcroft Hospice, specialist community Palliative care team and the hospital palliative care team. There is a good history of close working relationships between these teams and one which will be fostered as the Trust undertakes further work to restructure care provision to better reflect the care model.

1.1 Framework / structure of End of Life:

1.1.1 STP EoL Steering Group:

Since the April 2017 EoL strategy report the Trust have advised and contributed to the development of the STP EoL Steering Group. This group has representation from the four acute Trusts, partners and stakeholders. The STP group meets quarterly and over the last year has produced an STP strategy and work plan. For EoL, the STP has now established a North, East, West and South locality structure. The STP have used the template established in Torbay in 2016 to inform the framework and priorities of the STP group. The work plan is set out in six key priorities:

1. Early intervention 2. Care is co-ordinated by your health and social care team 3. Rapid access to 24/7 nursing and medical support to manage symptoms 4. People caring for you are confident, competent and compassionate 5. Access to personal care at home 6. Information and support for your family & significant others

In total there are 32 actions that map to the locality and Trust action plans.

1.1.2 EoL South Locality Strategic Board:

The EoL South Locality Strategic Board was formed in 2016 and adopted the strategic aim of - “We want to be the care community in which patients, partners and staff would wish to be cared for at the end of their life”.

This supports the national overarching vision: “I can make the last stage of my life as good as possible because everyone works together confidently, honestly and consistently to help me and the people who are important to me, including my carer(s).”

The Trust End of Life Group have adopted this aim to ensure priorities, objectives and work plans are aligned.

The following objectives, adopted from the six national ambitions for end of life care are intended to drive the local system to deliver our triple aim of: better outcomes, better experiences and better use of resources.

 Locality EoLC ‘offer’ designed and a delivery mechanism for each of the five health and wellbeing hubs agreed

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Trust End of Life Report.pdf Page 4 of 13 Overall Page 218 of 253  Promoting recognition of people at the end of life [defined as anticipated to be in the last 12 months of life] to identify what matters to the person and their family  Maximise and effectively use all available resources for service provision of End of Life care across the whole health and care community  Provision of education and training to the workforce to deliver high quality end of life care to build a commonality of understanding of why end of life care is important in our system

In total there are 26 actions that map to the STP and Trust action plans. Over this year a priority for the group has been the collation and examination of data across the South Devon and Torbay footprint. This has required collaboration with Public Health England and with Torbay and Devon Councils. Good progress has been made against some actions but others such as EPaCCS require an STP level solution.

The Trust End of Life Group have used the above priorities and plans to develop an organisational work plan. This is in addition to the actions in response to the specific issues raised by the CQC. The ‘must do and should do’ actions are managed and monitored through the CQC Assure Group.

The Locality Board has a single sub-committee that is responsible for delivery of the work plan objectives. This multi-agency group has focussed on development of the EoL education strategy and on developing the EoL offer for the Health and Wellbeing hubs.

1.1.3 Trust EoL Group:

The Trust End of Life Group is comprised of consultant medical, nursing, chaplaincy and bereavement staff groups. In addition to reporting progress and issues externally to the EoL STP and locality Boards, the group reports internally to the Quality Improvement Group, and to the Trust Board through the Quality Assurance Committee.

The Chief Nurse holds the Executive Lead and is the strategic lead for EoL, there is also a named Non-Executive Director. EoLC is included in the Deputy Chief Nurse’s portfolio.

The EoL clinical leadership for the Trust rests with the Consultant in Palliative Care, and the Matron / Lead Cancer Nurse. A priority for 2018 is to review the clinical and operational leadership structure to ensure there is the right skill, capacity and resilience to deliver the integrated palliative care and End of Life service.

The Trust EoL Group devised an annual work plan which is described in detail in the following section. The workplan is aligned to the work of the EoL STP and Locality Boards. Importantly it also takes account of the Care Quality Commission inspection findings from February 2016 which assessed EoL as Requires Improvement.

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Trust End of Life Report.pdf Page 5 of 13 Overall Page 219 of 253 1.1.4 The Trust EoLC work plan and update on progress for 2017/18 below.

Objective Driver Action Owner Update 01 Integrate Torbay Hospital Trust Review current team Deputy Skills and Specialist Palliative Care Integration structure, function, Director competencies of Team and the Palliative plan skills, competence Nursing, team reviewed, and end of life community and map to service CB single team in place team. need 02 Develop the new Trust Care Collaborate with Deputy Service spec agreed, structure for EoL care Model plans Locality / Hub leads Director need to embed within the Locality Health to clarify local need Nursing, & Wellbeing hubs CB 03a Develop an education EoL Strategic Review existing EoL CNS, Draft Education strategy for EoL care Board priority strategies from PK Strategy in approval training within the Trust in partner process line with Strategic Board organisations. priorities. Undertake gap analysis. Identify Include Dying Matters priorities. Work with awareness training for all Horizon team on staff delivery model.

03b Train 25% of all staff in Enabler to Set the expected EoL CNS 100+ staff trained. year 1 in Dying Matters above trajectory and This will roll into Awareness coordinate delivery of 2018 plan the training 04a Develop a plan to EoL Strategic Scope existing Exec lead STP have identified a improve recognition of Board mechanisms and & Clinical tool and are working patients likely to be in the priorities identify the tool that Lead toward last year of life will be used across implementation the system 04b Develop a plan to EoL strategic Link in with Acute, EoL CNS, This has been increase the numbers of Board priority Community, Primary PK superseded by the patients entered on to the Care and STP plan EPaCCs system Independent sectors 05 Develop a plan to support Trust Care Link in with Horizon Deputy PVI sector can now staff working in care Model priority Centre team to Director access all Hive / homes to deliver high develop the EoL Nursing Hibleo education quality EoL care module of the care free. Now monitoring home staff training uptake offer 06 Identify service gaps such 5YFV plan Scope existing EoL & Team redesign as lack of 7 day working position and develop Palliative delayed BC. This will and develop action plan a business case to care roll in to 2018 plan. to address address. Consultant 07 The Trust EoL group Trust priority Develop a dashboard Chief EoL dashboard oversee Trustwide of end of life care Nurse, JV created. Complaints performance on EoL care. indicators with & incidents regular reporting and monitored discussion at Trust end of life group. 08 Monitor EoL quality Trust priority Develop an annual EoL CNS, Audit program in standards and patient audit programme and PK place and reported experience through undertake audits of regular audit. end of life care in acute trust and community setting

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Trust End of Life Report.pdf Page 6 of 13 Overall Page 220 of 253 09 Improve documentation of National care Review existing Deputy Further work to do end of life care delivery of the dying documentation. Director here and a risk and individualised care audit results Scope best practice Nursing, identified with care plans including TEPS & Trust documents from CB plan completion priority other Trusts. Link with Resus Group regarding TEPS to align delivery plans

1.1.5 Achievements of the EoL Group:

In addition to tthe work plan, the EoL group have led a number of activities to raise the profile of EoL care in the Trust:

. The EoL Strategy has been launched with signposting to the strategy communicated on the Trust website and computer screens. . An EoL care Hibleo video has been produced to communicate the strategy. . The Trust Chaplain has produced a Spirituality Hibleo video in increase awareness about the importance of discussing and documenting spirituality. . The first hospital based Dying Matters event hosted in Q2 was successful with staff, patients and the public engaging with the team to discuss death and dying issues such as how to arrange a funeral, make a will or discuss the end with loved ones. . Following a redesign of the palliative and EoL team, an education lead has been appointed. . The Development of the Ambassador role in collaboration with Rowcroft Hospice is gaining momentum, the system now has 35 EoL champions, . Staff involvement in developing new EoL care documentation. . The Chief Nurse contacted NHSI to request a peer review of the service, the findings will be available in Q1. . 3 Board presentations about EoL care . In collaboration with Rowcroft Hospice – Advance Care Planning research . In collaboration with Rowcroft Hospice – successful bid for Heart Failure End of Life research . Presentation of strategy to Clinical Management Group . Update of palliative & end of life home page on ICON & public website

1.1.6 The 2018/19 priorities and work plan:

The 2018/19 Trust EoL priorities are informed by:

. STP Strategic Board / Locality EoL Strategic Board priorities . Incomplete achievement of the 17/18 work plan . Dignity in Death – peoples experience of EoL care in Devon . Nice guidance / quality standards . Patient / carer experience . Staff survey . Delivering high quality end of life care for people who have a LD . Trust audits . CQC 2016 report and 2018 draft feedback . The six National Ambitions for Palliative and EoL care 1. Each person is seen as an individual 2. Each person has fair access to care 3. Maximising comfort and wellbeing 4. Care is co-ordinated 5. All staff are prepared to care

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Trust End of Life Report.pdf Page 7 of 13 Overall Page 221 of 253 6. Each community is prepared to help

. The five Gold Standards Framework (GSF): 1. Right patient — Identification of patients nearing end of life. 2. Right care — Assessing their needs, clinical and personal. 3. Right place — Planning coordinated cross boundary care. 4. Right time — Planning care at home in the final days. 5. Every time — Embedding consistent good practice and identifying areas to improve further.

Objectives 18/19 Driver Action Owner By when 01 Train 25% of all staff in STP priority 1 Key priority of the new Clinical Nurse Q3 year 1 in Dying Matters Locality Board education lead. Implement Specialist Awareness priority brief intervention approach. PK Ambition 3 GSF 2 02 Develop a plan to STP priority 2 The STP are working on a new STP lead TBC increase the numbers of Ambition 2 STP level system L C-B patients entered on to the GSF 1 & 3 EPaCCs system 03 Identify service gaps STP priority 2 Submit business case Professional Q1 such as lack of 7 day 5YFV plan lead SB working and develop Ambition 6 action plan to address GSF 5 04 Improve monitoring of STP priority 4 Review the EoL dashboard Deputy Director Q3 Trust performance on CQC indicators and SDU Nursing EoL care. Ambition 3 monitoring, inc vital pak/ blue CB GSF 5 b’fly, Swiftplus 05 Improve documentation STP priority 1 Developing the documentation DDN Q1 of individualised care CQC bundle –blue butterfly plans Ambition 1 GSF 2 & 4 06 Improve documentation Trust priority EoL awareness events Senior Chaplain Q2 of spirituality CQC Monitor Hiblio hits SM Ambition 1 Launch new documents GSF 2 Sample audits 07 Improve documentation STP priority 1 Extend TEP Audit activity DDN Q3 of TEPS. Current Trust CQC Increase training average 90% ST spot Ambition 1 GSF 2 Explore Nerve centre record audit 08 Improve recognition of STP priority 1 Work with STP Dr JS Q2 patients likely to be in the Ambition 3 Develop Nerve centre flag last days of life GSF 1 Increase use of Gold star 09 Implement Education STP priority 4 Setting up essential training CNS Q3 Strategy Ambition 3 / 5 profiles on the HIVE and GSF 5 developing reporting for achievement in education 10 EoL Gold Standard Trust EoL group Trust work plan informed by STP lead TBC Framework (GSF) GSF 1 - 5 GSF. STP to lead system wide S C-B accreditation GSF process 11 Improving and using STP priority 5 Review CCG experience DDN Q1 feedback from service Ambition 1 survey results. Contribute to users / families. GSF 5 locality action plan Staff survey 12 Obtaining feedback from STP priority 4 Commission EoL internal Chief Nurse Q2 staff providing EoL (e.g. Ambition 5 audit. postcards) GSF 5 Staff survey

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Trust End of Life Report.pdf Page 8 of 13 Overall Page 222 of 253 13 Explore incidence of STP priority 4 Identify incidence & causes. DDN Q2 delayed transfer / Ambition 2 Develop actions to address discharge GSF 5 14 Review the structure and Trust priority Review team structure to Exec Lead Q2 function of the leadership Ambition 4 ensure competent, resilient CN GSF 4 and resourced to deliver an integrated Palliative and EoL service

2.0 The Team:

Chief Nurse – Executive / Strategic Lead Consultant in Specialist Palliative and EoL Care – Clinical Lead Deputy Director of Nursing – EoL Portfolio lead Matron Cancer Services – Service Lead

The CQC report (2016) suggested that the EoL leadership structure was unclear and to address this the structure and function has been reviewed. The former Care Trust EoL lead left the Trust in April 2017 which provided the opportunity to bring the acute and community teams together under a single leadership and management function. The reconfiguration allowed the creation of a new role to strengthen education and training which was appointed in January 2018.

The team has integrated roles and functions to deliver a single Palliative and EoL service. The Consultant led Specialist Palliative and EoL Care Team consist of Doctors, Clinical Nurse Specialists, an EoL tutor and a team secretaries. The service now comes under the professional practice leadership of the Matron for cancer services. The team is a consultative service and has no specialist palliative or EoL care beds. The team currently works 9-5 Monday to Saturday for face-to-face consultations. The changes facilitate the delivery of a cohesive service by a single team that supports staff working in the community hospitals, community nursing teams and care homes. The 2018/19 work plan will strengthen and evaluate this approach to ensure consistent cover across the Trust and will review clinical and team capacity and resilience to provide an integrated service into the future..

A chaplaincy team is based in Torbay hospital to support patients, families and staff. Support to the community hospitals is provided by a combination of visits from the chaplaincy team and from local clergy. The bereavement officers at Torbay Hospital provide signposting help and support to bereaved families. In community hospitals and community nursing teams there is a bereavement standard that the families of persons under the care of the Trust are telephoned / and or visited. All are given a bereavement pack.

Trust staff interface with a large number of other staff in the wider health community in order to provide co-ordinated care for patients in the last year of their life e.g. GP’s, Devon Doctors, Care homes, Marie Curie, social services, and national and local voluntary agencies.

Out of hours Specialist Palliative Care support and advice to Trust staff is provided via a 24 / 7 advice line at Rowcroft Hospice, our independent local hospice. Nursing and medical advice is available. Rowcroft provides its services through community inpatient beds, a community multidisciplinary specialist palliative care service, a 24/7 ‘Hospice at Home’ service, a bereavement service and the 24/7 advice line. The hospital palliative care team and Rowcroft are integrated through the role of the Clinical Director, consultant workforce and through shared electronic records.

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Trust End of Life Report.pdf Page 9 of 13 Overall Page 223 of 253 3.0 Education and Training:

Both the Specialist Palliative Care and EoL Team in partnership with Rowcroft Hospice provide a range of education on provision of good end of life care to ICO staff:  Ward based end of life education  Breaking bad news training  Syringe pump training  Work-based placements with hospital palliative care team  Regular teaching sessions for junior doctors, medical students, pharmacists etc.  Care home education via a dedicated care home facilitator  Lay carer education programme  Level 3 accredited City & Guilds certificate in End of Life  Advanced care planning training  Verification of Expected Death (VOED) training  SNR training to act as the second signatory /checker for syringe pumps.  Symptom management  Communication skills  Individualised Care planning at EOL  Spiritual care  Enhancing Palliative Care Skills course.

939 staff have attended training at Rowcroft Hospice 63 staff have received EoL updates for the Trust team. 22 staff have undertaken verification of death training in 2017 60 staff have completed syringe driver training

The EoL Education and Training Strategy set out three tiers of training to deliver the 6 ambitions. Staff groups have been reviewed and allocated to each Tier.

Tier 1 Training ICO Trust wide induction Dying matters awareness training Dying matters awareness week focus ICO, community teams, Primary care Tier 2 training EOL care awareness training . Recognising and understanding the needs of the patient and their family in end of life . Understanding principles of the Conversation Project, to support communication, advance care planning, holistic assessment and care planning . Understanding the principles of coordinated, patient centred discharge planning in end of life care . Understanding the needs of the dying patient and the principles of providing compassionate, patient centred care in the last days/hours of life . Understanding principles of compassionate care after death for the deceased patient and their family  EOL “Ambassadors Network”  Syringe pump training  Communication skills training  Verification of expected death (VOED)  Enhancing palliative care skills course (Rowcroft Hospice)

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Trust End of Life Report.pdf Page 10 of 13 Overall Page 224 of 253 Tier 3 training Advanced communications skills Complex symptom control Modes of training delivery . New starters training as part of Induction, provided by ICO EOL education team . Face to face sessions provided by the specialist EOL Education team & SPCT ward/community/classroom based. . eLearning modules via the HIVE . information videos on the Hiblio

Recording and reporting arrangements . All training will be recorded on ESR . All staff portfolio on ESR will be update in the 1st quarter of 2018/19 to reflect EOL TIER education required . All previous recorded training can be included in compliance reports . Compliance reporting is required for monitoring by Trust EoLC group to enable reporting to CQC, The EOL Board, NICE, National EOL audit, local teams/SDU/localities

Methods of delivery have been identified and a work plan to deliver has been developed.

At present EoL training records are held at department level. As part of the training strategy these records will be brought to the central HIVE / ESR system to ensure an accurate record of compliance is maintained.

4.0 Feedback:

Complaints:

The Trust have received 19 complaints relating to end of life between April 2017 and January 2018. These relate to a range of issues including: access to treatment, care, attitude of staff, procedures, diagnosis and transport. These are investigated following the Trust complaints process and actions taken in response to findings.

Incidents:

A specific category for EoL has now been created on Datix and we are now able to identify themes. In 2017 there were 50 incidents where the primary causal factor of the incident was End of Life issues. Most were no harm, near miss or low harm, there was 1 moderate harm. Incidents occurred across the Trust with most common issues shown in the table overleaf.

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Complaints and incidents are reviewed monthly by the EoL group who discuss individual cases and facilitated the presentation of one complaint to the Board by the family.

The CCG undertook a survey in 2017 to explore the experience of EoL in Devon. They received 155 responses from across Devon.

Some clear themes for areas of improvement have emerged from the survey and the responses received, largely, these can be broken down into the following themes:  Communication  Funding  Compassion  Training  Variation in care  Expectation setting  Staffing  Time pressures

The report found evidence of hugely positive experiences of end-of-life care within Devon, such as how staff treat patients and their loved ones, relatives and carers and their dedication and compassion shown in most cases.

Ten recommendations which have informed the Trust EoL Group 2018/19 work plan.

5.0 Risk Register:

There are currently three risks on the risk register: . The experience of bereaved people through the death certificate process . CQC identified concerns . Fragmentation and incomplete documentation

These are monitored through the Trust EoL group and through the Trust Risk Group.

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Trust End of Life Report.pdf Page 12 of 13 Overall Page 226 of 253

6.0 Monitoring:

Over the last year, the EoL group have developed and refined the EoL dashboard which provides information on a number of performance measures including, complaints, incidents and gold star compliance. This will be refined over the coming year.

The EoL work plan will be monitored though the Trust EoL Group reporting internally to the Trust Quality Improvement Group, the Trust Quality Assurance Group and the Board and externally to the EoL Locality Strategic Board and STP Steering Group.

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Board Report Summary

Meeting Date 7th March 2018

Report Title Chief Nurse Portfolio Report – Safe Staffing 6 month update

Lead Director Chief Nurse

Corporate Objective Safe, quality care and best experience Well led

Corporate Risk/ Failure to achieve key performance standards Theme

Purpose Information Assurance Decision

 

Summary of Key Issues for Trust Board Strategic Context Significant streams of work continue under the Nursing Workforce Programme to ensure safety, quality and experience are delivered whilst driving forward efficiency.

The key focus over the past 6 months has been to ensure the programme is aligned to the Trust’s Corporate Objectives, National Quality Board (NQB) Chief Nursing Officer (CNO) right staff in the right place at the right time, CQC and Lord Carter driving forward productivity and efficiency whilst maintaining safety and quality.

The three key focus areas have been:

 To monitor & review safer staffing levels  Recruitment, career & workforce plans  Allocate E rostering system

The report details the streams of work above along with key messages from each section

Key Issues/Risks Key Issues/Risks:

Increasing patient acuity and dependency associated with Winter activity, Flu and Norovirus require a responsive and flexible approach. This is time intensive for senior nursing staff. Allocate will provide daily and shift by shift staffing and safety information that will allow this to be done centrally.

Retirement of experienced workforce over the following 5 years. Whilst a number will not retire and others will retire and return, there is a national and local bulge of retirement expected. The Workforce and OD Committee have been planning for this over the last 2 years.

Public Safe Staffing 6 Month Update.pdf Page 1 of 15 Overall Page 229 of 253 The Associate Directors of Nursing have highlighted that the necessary focus on the daily operational response to escalation means that other areas of their role are neglected. This manifests through reduced appraisals and training, delays in the incident and complaint process, their engagement in QI projects, their response to information requests and their actions from the QIG or from the Quality and performance meetings.

Recommendations The Board is recommended to review the document and review the evidence presented.

Summary of ED Executives noted the Unify data which was discussed at the NHSI use of Challenge/Discussion resources meeting in February. Reasons for staffing above establishment are understood but there is a need to monitor these monthly at QIG in addition to the Unify data. It is anticipated that the daily monitoring of staffing levels enabled by the new Allocate e-roster system will allow increased surveillance and prompt action to address.

Executives are aware of the nursing vacancies and the work to keep vacancies below 10%. There is variation between departments and this is to be expected, they requested a briefing on those areas with a vacancy factor over 10%.

The Carter nursing workforce data was discussed and the latest national report shows that this Trust is the third most cost effective nursing workforce in the dataset. Executives discussed the need to ensure that nursing is not too lean and that we continue to deliver safe staffing. Allocate will provide more accurate information on daily staffing levels and will be part of the 2018/19 nursing establishment review to maintain safe staffing standards.

Executives recognise that commitment of the senior nurses in daily operational management and in escalation is significant and appreciate this creates a challenge in balancing daily operational requirements with the broader remit of their role. This challenge applies to other senior leaders who have also raised this issue. Executives agreed to hold a number of open sessions to discuss the challenges faced by senior leaders. It is anticipated that the Senior Management restructure will create the necessary capacity and resilience as we move into the new organisational form.

Internal/External SDU Senior leadership teams Engagement inc. Quality Improvement Group Public, Patient & Governor Involvement Equality & Diversity None Implications

Public Safe Staffing 6 Month Update.pdf Page 2 of 15 Overall Page 230 of 253 Safe Staffing Report

1.0 Safe Staffing Report:

The purpose of this briefing is to provide information and assurance regarding the Nursing and Midwifery Safer Staffing levels over the previous month. On a monthly basis the number of planned nursing hours (based upon the agreed baseline safe daily staffing numbers for each ward) and actual nursing hours (the total number of nursing hours used each day) for each inpatient ward area is submitted to the national dataset. The model hospital dashboard has now been updated to show the national median data which is summarised below from September 2016 to January 2018.

1.1 Carter Data:

The Table below shows that whilst the Trust is over its planned total (RN + HCA) staffing levels in several areas and above the national Carter Median of 7.76 overall, the trust is still below the national CHPPD range of 4.74 for RN’s ( TSDFT 3.91) and above the national 2.91 for HCA’s ( TSDFT 3.84).

TSDFT TSDFT National Median January 2018 September 2016 September 2016 Total CHPPD 7.75 7.84 7.76 RN/ RM CHPPD 3.91 3.73 4.74 HCA / MCA CHPPD 3.84 4.11 2.91

Public Safe Staffing 6 Month Update.pdf Page 3 of 15 Overall Page 231 of 253 Planned vs Actual CHPPD RN / RM January 2018 5.0 Planned RN / RM CHPPD 4.5 4.0 Actual Mean 3.5 Monthly RN / RM 3.0 CHPPD 2.5 2.0 1.5 1.0 0.5 0.0

Planned vs Actual CHPPD Planned HCA / MCA CHPPD 6.0 HCA / MCA January 2018 Actual Mean 5.0 Monthly HCA / MCA CHPPD 4.0

3.0

2.0

1.0

0.0

The graphs above and the UNIFY table below show that all clinical areas during January that were above the total planned RN & HCA numbers. This was due to the hospital being in escalation with 93.55% of the month being in OPEL 3 & 4.

There have been a number of escalation beds open including Warrington ward. The arrangements to ensure continuity of leadership is that substantive staff are deployed to this ward and backfilled with bank registered nurses and HCA as required to maintain safe staffing on their own wards.

The overall dependency of the patients within the hospital has been high with a large number of patients requiring specialing as shown particularly in Cromie, Dunlop & Forrest where there is a high percentage of additional care staff working on Night shifts. Also there have been CAHMS patients on Louisa Carey & ED as shown below with the average fill rate of care staff for Louisa Carey being 271.3% and the actual fill rate of RN & HCA in ED being 117.5 % & 119% (appendix 1). One patient required 3:1 care for 4 days 24 hours per day along with additional support needed because of the OPEL status.

Public Safe Staffing 6 Month Update.pdf Page 4 of 15 Overall Page 232 of 253 1.2 UNIFY Report January 2018:

This information is published monthly and was initially reported to the Board but the Carter information is now used more routinely to describe staffing levels and areas of risk.

Jan-18 Day Shift Night Shift Registered midwives/nurses Care Staff Registered midwives/nurses Care Staff

Ward name Planned Actual Average Planned Actual Average Planned Actual Average Planned Actual Average Hours Hours Fill (% ) Hours Hours Fill (% ) Hours Hours Fill (% ) Hours Hours Fill (% )

Ainslie 1380 1311 95% 1553 1601 103% 1035 863 83% 1035 1231 119%

Allerton 2235 1884 84% 1035 1695 164% 1035 1058 102% 1035 1143 110%

Cheetham Hill 1380 1281 93% 1553 2539 164% 690 725 105% 1035 1915 185%

Coronary care 1380 1932 140% 0 158 1035 1036 100% 0 0

Cromie 1380 1452 105% 1035 1366 132% 1035 1047 101% 690 1113 161%

Dunlop 1035 1085 105% 1208 1357 112% 690 713 103% 690 1162 168%

EAU3 1725 1774 103% 1380 1564 113% 1380 1369 99% 1035 1633 158%

EAU4 1380 1834 133% 1380 1357 98% 1380 1518 110% 1035 1138 110%

Ella Rowcroft 989 922 93% 1288 1286 100% 943 909 96% 690 736 107%

Forrest 1380 1492 108% 1035 1517 147% 1035 1058 102% 690 1161 168%

George Earle 1380 1348 98% 1380 2084 151% 690 725 105% 1380 1592 115%

ICU 2760 2708 98% 0 0 2760 2726 99% 0 0

Louisa Cary 1380 1935 140% 690 1872 271% 1035 1392 134% 690 840 122%

John MacPherson 690 917 133% 690 684 99% 690 902 131% 345 380 110%

Midgley 1725 1653 96% 1208 1377 114% 1035 1035 100% 690 1038 150%

SCBU 1035 963 93% 0 275 1035 758 73% 0 333

Simpson 1380 1322 96% 1553 1856 120% 690 734 106% 1035 1402 135%

Turner 1380 1186 86% 1380 1510 109% 690 720 104% 1035 1127 109%

Warrington 1035 658 64% 1035 919 89% 1035 601 58% 690 934 135%

1035 Night Shift Registered midwives/nurses Day Shift Registered midwives/nurses Care Staff Community Hospital Planned Actual Average Planned Actual Average Planned Actual Average Planned Actual Average Hours Hours Fill (% ) Hours Hours Fill (% ) Hours Hours Fill (% ) Hours Hours Fill (% )

Brixham 630 868 138% 840 1463 174% 360 744 207% 360 720 200%

Dawlish 651 833 128% 1302 1162 89% 372 696 187% 682 451 66%

N.A Teign Ward 868 1309 151% 1519 1911 126% 682 693 102% 682 968 142%

N.A Templar Ward 1302 1288 99% 1953 1960 100% 682 693 102% 1116 1176 105% Totnes 868 875 101% 1365 1197 88% 372 744 200% 682 473 69%

Public Safe Staffing 6 Month Update.pdf Page 5 of 15 Overall Page 233 of 253 1.3 Organisational Alert Status

An organisational Opel status is published and shared with our partner organisations on a daily basis which provides an indicator of the operational pressures experienced within the system. This is summarized within this report, as it provides a good proxy indicator of the wider organisational pressures and climate the wards are working within, and which may impact on our staffing decisions. The alert status for the organisation for the month of January 2018 is summarised in the table below.

TSDFT Alert Status No Days in Month % days in Month Opel 1 0 0% Opel 2 2 6.45% Opel 3 23 74% Opel 4 6 19.55%

1.4 Medical Services Delivery Unit and Emergency Department:

The table overleaf details the daily planned, actual and % fill rates for nurse staffing in the Emergency Department.

The total fill rate for January 2018 was 117.5% (17.5% above plan) for RN and 119% for HCA. This is because of the new RN’s in the department and still in their supernumerary period. There are a number of new bank HCA’s undergoing observation shifts and for specialing patients. The department was in OPEL 3 for 23 days and OPEL 4 for 6 days which required additional nursing support.

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1.5 Maternity Services:

We are still awaiting the final report from birth rate plus however form the audit that was undertaken in September, the initial results show the trust currently has the correct number of clinical and non-clinical midwives and Band 3 Maternity Support Workers to effectively and safely run the maternity service.

Maternity services are actively recruiting to vacant posts and are proactively managing sickness in conjunction with HR. There has been a significant amount of planned surgery for our staff group, whilst levels of stress are also high. We are working with the organisational development team to look into this.

Public Safe Staffing 6 Month Update.pdf Page 7 of 15 Overall Page 235 of 253 1.6 Further Nursing Workforce Programme Updates:

Recruitment & Retention:

There are currently 103.9 WTE vacancies across all clinical areas of the Trust including community Nursing and specialist areas which has remained stable over the past 12 months between 100 & 120 WTE. The Trust RN vacancy factor stands at 8.3% which is marginally higher than the last quarter with turnover being 10.68% however is being closely monitored and feeds into the Trust workforce plan.

 Community Services VF 10.31%  Medical Services VF 7.37%  Surgical Services VF 7.94  Women’s, Children & Diagnostics VF 3.69%

There is variation within department which are reviewed at the Nursing Workforce and Program Board (NWPB) and the Workforce and OD Committee to ensure appropriate recruitment activities are developed. We compare favourably with other Southwest providers.

Trust N&M LTR Yeovil District F 18.98%

Royal Bournemouth & Christ F 13.18%

North Bristol 13.16%

Taunton & Somerset F 12.54%

Royal Devon & Exeter F 12.37%

Dorset County F 12.15%

Royal Cornwall 12.04%

North Devon 12.03%

Royal United Bath 11.59%

Poole F 11.53%

Devon Partners 11.25%

Torbay & South Devon F 10.68%

Plymouth Hosp 10.57%

Gloucestershire Hosp F 9.37%

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The Trust age profile is shown below with a significant number of Registered nurses eligible to retire over the next 5 years. This is also national challenge and the Trust’s workforce plan includes its projections over the coming years.

The table below shows the number of nurses aged between 55 & 60 due to retire over the next 5 years and the age profile of our registered nurse workforce.

Retirements 12 Staff Group 3 Months 6 Months 9 Months 5 Years Due Months N&M 99 110 119 130 135 300 Registered

The workforce challenge is recognised by the Trust both now and over the coming 5 years and is proactively refreshing its workforce plan to ensure it is fit for purpose and meets the projected demand over the coming years. This will include international recruitment which fits in line with Health Education England’s workforce strategy and a review paper will be presented in due course to the Executive team with cost benefits and recommendations for a future campaign.

Other workforce streams include return to nursing:  Nurse Associate  Registered Nurse Apprenticeship programme including growing our own workforce from level 2 through to level 6 and RN apprenticeships.  Trainee Assistant Practitioners

The Trust recruitment & retention campaigns continue with a new trust recruitment steering group in place to review marketing and values based recruitment. We have targeted our Second & third year student nurses and invite them to monthly drop in sessions to discuss career opportunities and working in Torbay. The recent recruitment open day was a success with 19 students being offered a placement when qualified on the rotational program.

Further open days are planned and monthly drop in sessions will continue.

Public Safe Staffing 6 Month Update.pdf Page 9 of 15 Overall Page 237 of 253 We have the beginnings of a Fifth Cohort from the Philippines and are now waiting for a few more nurses to join the group in order for us to be able to bring them over to the UK. Cohort 3 has recently sat their OSCE and has passed and we are awaiting the results of cohort 4. So far we have a 100% success rate for our nurses.

The NMC have also recently launched the acceptance of a further English Language Test called the OET (Occupational English Test) alongside the IELTS. This is following months of discussion and consultation with regards the challenges faced by Trusts with international nurses struggling to reach level 7 in writing. This is a welcomed decision and the NMC will be further reviewing IELTS during the next 6-12 months. The Trust will be supporting those nurses that wish to transfer to OET.

E rostering:

The Allocate ‘Big Bang’ approach is underway and on target to meet the go live date of 16th April 2018. The project board is established and initial data workbook gatherings have been completed and initial roster templates are being built for the 4 early adopter wards. These wards are Cromie, Simpson, EAU 4 & Brixham Hospital.

ESR GO element is almost complete together with Payroll and the Safe care module is due to kick off at the end of February. This is timely and will be an opportunity to review establishments in line with the CNO recommendations to undertake these every two years. The bank & temporary staffing training is also underway and the general consensus of the system so far has been positive.

The new roster policy guidelines have been updated and are due to be ratified together with an Ask Allocate webpage has been created to inform staff of progress, post FAQ’s together with a generic rostering email address for rostering questions as the project progresses. A KPI’s and benefits realisation plan will be commencing in due course. Quality & Safety

There is a robust quality and safety monitoring process in place to ensure patient care is not compromised in any way. Patient incidents are monitored monthly by the senior nursing teams and reported through the monthly Quality Improvement Group (QIG) as a dashboard. In addition, each clinical area completes the monthly Questt tool which triggers actions as highlighted in the escalation procedure. The Deputy Director of Nursing & Professional Practice & standards ensures contact is made for any area triggering an amber score and ensures appropriate action is taken place.

A weekly huddle takes place with the Chief Nurse, Associate Directors & Deputy Directors of Nursing to discuss staffing, safety & quality issues and concerns. These are closely monitored in terms of acuity of patients, safe staffing levels and any use of agency/temporary staff. In addition staffing levels and ward status is discussed three times a day at the control meetings with the Matron of the week, Senior Nurses and on call manager. The Questt Dashboard is displayed in the tables below for the Acute & Community Hospitals inpatient areas:

The report is now including non-bed based nursing and therapies so as to give a broad overview of staffing trigger points. In January 2018 the dashboard identified 15 teams’ triggered amber and 1 triggered red shown in the tables below:

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Ricky Grant Day Unit: Trigger due to staff sickness, maternity leave and vacancy rate

Teign Ward: Trigger - Teign Ward Newton Abbot Community Hospital As last month, due to vacancies, sickness and unusual demand on service (investigations etc.), Your World Agency Support (3 RGN’s), four staff off long term sick all being managed with HR, with two possibly returning this month.

Coastal Community Nursing: Trigger - Coastal Community Nursing due to vacancy rate, short and long term sickness, appraisals not being completed due to service demands and shortages.

OOH Nursing: Trigger: due to vacancy rate, short and long term sickness, vacancies slow to recruit into. Limited Temporary Staffing support.

Social Care HDAT Torbay & S. Devon & Newton Abbot: Trigger: This was due to the complexity of patients and demand and escalation status of the Trust. All routine work was ceased and the focus shifted towards discharge planning.

Three care homes remain closed due to safeguarding processes and therefore a lack of capacity and investigations are on-going. This together with vacancies, leave and staff sickness has contributed to the trigger.

Physiotherapy/Occupational Therapy: Trigger: This was due to the OPEL status of the trust and resources being redirected as required including additional support on Warrington ward.

Public Safe Staffing 6 Month Update.pdf Page 12 of 15 Overall Page 240 of 253 Podiatry This has triggered because of maternity leave, annual leave and long term sickness.

Staffing Incidents and Red Flags

Staffing Incidents and red flags are monitored monthly by the Associate Director of Nursing Workforce which are reported to the Quality Improvement group monthly. These are monitored alongside the Trust Quality Dashboard in relation to Falls, Medication errors, Pressure Ulcers & CHPPD.

Staffing Incidents January 2018

There were 26 incidents during January with 13 related to staffing. 2 were recorded as a near miss due to redeployment of staff however appropriately escalated and risk assessed. 2 incidents recorded patients were found to have grade 2 pressure ulcers, 2 were related to medication errors and others were due to communication, notes missing and a patient fall. No harm came to any of the patients however one moderate harm incident involved a member of staff unable to take her break and was feeling stressed working on a newly opened escalation ward with minimal ward stock and equipment. Senior nursing support was given and the ward appropriately stocked.

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Public Safe Staffing 6 Month Update.pdf Page 14 of 15 Overall Page 242 of 253 Appendix 1 – Care Hours Per Patient Day for Acute and Community Setting Wards

Key Explanatory notes

RN = Registered Nurse / Registered Children’s Nurse RM = Registered Midwife HCA = Healthcare Assistant MCA = Maternity

Care Assistant Red cells indicate the mean monthly Care Hours per Patient Day (CHPPD) were below that planned and agreed as the budgeted safe staffing level for the ward. Measures to ensure safety are managed on a daily basis by the ward manager and matron.

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REPORT SUMMARY SHEET

Meeting Date 7 March 2018

Report Title Getting it Right First Time (GIRFT) status report

Lead Director Medical Director

Corporate Objective  Safe, quality care and best experience  Well led

Corporate Risk/  Failure to achieve key performance / quality standards. Theme  Failure to achieve financial plan.

Purpose Information Assurance Decision

 

Summary of Key Issues for Trust Board Strategic Context Getting It Right First Time (GIRFT) is a national initiative aiming to drive out unwarranted variation with benefits for patients in terms of quality and safety and financial benefits for the NHS through employment of most cost-effective pathways and equipment. Impressive savings have been reported in some systems though the scale will depend on baseline performance.

TSDFT has engaged with all appropriate GIRFT specialty reviews so far undertaken. An internal governance system for reporting outcomes and action plans has been defined and a shared reporting system across the Devon STP has been agreed.

Key Issues/Risks Outcomes from the reviews completed so far are largely positive and are supportive of high quality care with top quartile markers of cost-effectiveness. There are areas of potential improvement in all reviews and action plans are in place or in development. Potential value has been identified from some reviews in the development of common pathways across the STP or in peer to peer review of volume activity alongside the GIRFT outcomes.

The GIRFT initiative has been associated with significant benefits for patients and/or substantial savings in some Trusts through change of process to move to top quartile performance. On the basis of the reviews completed to date, there may be some improvement in care and experience of care for patients but there is no expectation of substantial savings. This situation may change with future reviews.

There is the possibility of savings through standardisation of procurement and this process will be led at STP level in order to achieve benefits of scale. Sharing of experience through peer to peer challenge may bring benefits to the STP as a whole.

Recommendations The Trust Board is asked to consider the risks and assurance provided within this report and to agree any further action required.

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GIRFT.pdf Page 1 of 9 Overall Page 245 of 253 Summary of ED The Executive team supports the involvement of clinical and operational teams Challenge/Discussion in the GIRFT programme as a process likely to lead to improvement in quality and patient experience.

Internal/External The National GIRFT programme includes public involvement in design and Engagement inc. review of national outcomes. Public, Patient & Governor Involvement

Equality & Diversity Implications None

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MAIN REPORT

Report to Trust Board

Date 7 March 2018

Lead Director Medical Director Report Title Getting it Right First Time (GIRFT) status report

1. Purpose

The aim of this paper is to provide an update for the Board in relation to the Trust’s engagement with the Getting It Right First Time (GIRFT) initiative and to provide early indications of the potential benefits to patient and to the organisation.

2. Provenance

 Presentations to Sustainability and Transformation Programme (STP) Clinical cabinet by: o GIRFT lead for Plymouth Hospitals’ Trust o Warwick Heale, System Delivery Director, Devon STP o Eiri Jones, Regional GIRFT Hub Director  Local speciality GIRFT reports  National GIRFT report for General Surgery  Planned Care Lead’s membership of Operational Delivery Group for the STP

3. Introduction

Getting It Right First Time (GIRFT) is a national initiative aiming to drive out unwarranted variation with benefits for patients in terms of quality and safety and financial benefits for the NHS through employment of most cost-effective pathways and equipment. Impressive savings have been reported in some systems though the scale will depend on baseline performance.

The GIRFT draws on nationally reported Trust data covering a number of quality indicators for each Trust. A report is sent to the local team and the national team attend to discuss the findings. The two main components are the provision of a benchmarking information package, produced by the GIRFT team, and peer-to-peer discussions between national clinical leaders and Trust clinicians and managers.

Reviews commenced in Orthopaedics and then were focussed initially on surgical specialties. The scope of reviews has now been broadened to include more than 30 specialties across all clinical areas over the next 2-3 years.

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GIRFT.pdf Page 3 of 9 Overall Page 247 of 253 At Trust level the recommendations found in each speciality are collated into a single implementation plan. Trust data is uploaded to the Model Hospital portal, which will be the gateway for accessing GIRFT information for all providers and commissioners.

After at least forty Trust reviews have been completed, the clinical lead oversees the creation of a national GIRFT report into their speciality. The report presents the original data, GIRFT’s findings, examples of best practice and an action plan of proposed changes and improvements.

4. Governance

4.1 STP arrangements

A standard approach has been agreed through the STP Clinical Cabinet. When all four hospitals within the STP have had their speciality GIRFT meetings there will be a meeting of clinical and operational leads to agree optimum pathway improvements. The STP has started to collate all the GIRFT reports from each of the four hospitals, to support these arrangements.

The Clinical Cabinet have discussed the strategy for managing the process including the clinical leadership for each speciality. The clinical cabinet has asked Warwick Heale to write a generic job description that will apply to all the speciality GIRFT leads within the STP.

The national GIRFT team has established a system-wide hub, based in Exeter, led by Eiri Jones the Regional GIRFT Hub Director. There will be seven implementation managers in post that will be locality based, there are currently two managers in place and half the team will be in post by March. Three clinical ambassadors will also be in post and may be able to support with a level of external clinical challenge.

4.2 Local Arrangements

The Medical Director (MD) is the Clinical & Executive lead and the Planned Care Lead (PCL) is the management lead reporting to the MD. Each of the Service Development Units (SDU) supported by the PCL, where appropriate, is responsible for ensuring the implementation of the local and any STP GIRFT pathway recommendations. Assurance is via the monthly Quality and Performance meetings as a standing Agenda item to check the status of the speciality action plans.

4.3 Proposed change

It is proposed that following each speciality GIRFT meeting that the Clinical Director/Clinical Lead supported by the operational manager and business advisor, will present five selected metrics from their GIRFT report to the Medical Director to focus on for a targeted level of improvement over a six month period. (proposed tracker appendix 1)

 The metrics need to be SMART in their selection  Benefits proportionate with scale of improvement/service change sought  The Clinical Director/Lead will be issued with a tracker, cross referenced with activity, where available, to identify benefits

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5. Methodology for Reporting Benefits

The table below describes the standardised approach to reporting that has been adopted by the Devon STP.

Tracker Comments Column Cost Savings Costs are removed from existing budgets as a direct result of improvement. The following are examples: • Reduction in non-pay prosthesis/implant, Med Surgical & drug costs as a result of change. • Reduction in clinical time need to be removed from Job Plans. • Removal of theatre slots from inpatient and day case provision as the services move from inpatient to day case and some procedures move to an outpatient base. Staffing and overheads costs can be removed. . Reduction of Trust overheads through a reduced use of estate

Cost When services have made changes, such as increasing intervals of follow Avoidance up, this will enable backlogs to be reduced and indeed eliminated over time and avoid weekend or extra sessions having to be paid at premium rate. Alternatively there will be greater capacity to respond to an increase in referrals without additional resource. Cost Pressure Improvement in the metric may result in other costs being incurred through use of new technology costs required to improve metric performance, e.g. Urology increasing day case rates and reducing LOS by introducing green light laser (non-pay costs associated with use of laser). This is an ‘invest to save’ initiative.

Opportunity Releasing time/resources as a result of efficiencies being achieved Gain through: • Additional activity or Productivity (Cases per theatre list/ Outpatient attendances per clinic) • Change of setting delivery (Inpatient to Day Case, Day Case to Outpatients): potential release of theatre time/sessions Public

GIRFT.pdf Page 5 of 9 Overall Page 249 of 253 • Reduced number of cancellations by volume and percentage (improved experience for the patient and reduction in re-working) • Releasing time to secure additional income, or reduce RTT backlog

Releasing Total bed days that could be released principally from Length of Stay- Bed Days based metrics – supporting an improvement in patient flow for emergency admissions or avoiding the cost of opening escalation bed capacity.

Income: Improvement in the metric results in creation of new income opportunities; Opportunity • private practice through released resources

Patient Improved performance will result in patient benefits in a pathway or Improvement experience with the service, including reduction of variation of access and Access reduction in cancellations.

6. Status of GIRFT reports

Whilst the content of the meetings between the national and our local teams have been consistent, the feedback post meeting has been variable. Specialities have either received a feedback report and action plan or relied on the local team to pick up on issues and put together their own action plan.

Currently only the following surgical specialities have had a review, however the intention is to include all specialities over time:

6.1 Adult Orthopaedic Surgery This was the first speciality to have a GIRFT report and our first meeting was in 2016. Following this the STP established six-monthly GIRFT meetings attended by the Clinical Directors and operational managers from each of the four hospitals as well as CCG representatives. One of the early recommendations was that the majority of hip prostheses should be cemented and TSDFT is now meeting this target. Linked to the GIRFt reviews is the establishment of Oxford Hip and Knee scoring thresholds for hip and knee arthroplasty with effect from 15 January 2018. There is also a review of shoulders and foot & ankle surgery by the Devon CCG technical team working led by the STP planned care clinical lead who is an Orthopaedic surgeon from Derriford. There is an STP wide meeting with shoulder surgeons from the four Trusts to discuss potential pathway changes and agree a common pathway for each condition during March. The pathway changes will be discussed and agreed with Implementation plans being developed during quarter one of 2018/18.

6.2 Ear, Nose and Throat The GIRFT report has been received with the first meeting arranged for 26 June between the national and local team.

6.3 General Surgery The national report has been published with five main themes, data and performance measurement, Procurement, Choice, commissioning and care pathways, surgical performance and efficiency and emergency provision. As a result Ian Currie, Deputy MD for TSDFT and the planned care lead have reviewed the recommended pre-operative assessment pathway with pre-assessment lead Anaesthetists and we are assured we meet the requirements. Our procurement of specific items has been reviewed and we compare favourably with the lowest price per unit across the range. There has been agreement at Clinical Cabinet that the GIRFT reviews should form the basis of further procurement standardisation (which has resulted in significant savings nationally).

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GIRFT.pdf Page 6 of 9 Overall Page 250 of 253 6.4 Obstetrics and Gynaecology

The national team visited the Trust on 8 November to discuss the report, overall it was a favourable report with nine actions the local team are addressing. The STP technical team are reviewing both the GIRFT and CCG activity volume information to determine whether there would be a benefit for an STP wide Gynaecology GIRFT group.

6.5 Ophthalmology

The national team visited the Trust on 19 October 2017. The report was very positive with few recommendations for change; to continue to optimise the cataract pathway and review coding of the complex cataracts, to develop the multi-disciplinary team in particular roles in emergency eye service, to review follow up appointments for strabismus (coding of attendances) and to review the finding that within the vitreoretinal service the number of patients attending between 6-12 months is higher than average.

This was followed by an STP wide Ophthalmology meeting, when it was agreed to review the three highest volume pathways; wet age related macular degeneration (WAMD), glaucoma and cataract. There is a follow up meeting being arranged after the publication of NICE guidance in January 2018 for the management of WAMD. The objective is that all four hospitals will follow the same, agreed pathway for these three conditions and their management. The first STP meeting to discuss the pathways will take place in March 2018.

6.6 Oral and Maxillofacial Surgery

The national team visited in July 2017. The main points discussed include the finding that average numbers of procedures were higher than benchmark. This was attributed to x-rays which the department do themselves and count as a procedure. Paediatric extractions were an outlier however all community service extractions are treated under oral surgery.

There are a low number of emergencies recorded, however the department believe this is due to running daily emergency clinics which were not included in the data analysis.

There were a few actions agreed as follows: (1) to review hospital cancellations for children. This work is ongoing, and no outcome to date. (2) Reference costs for outpatients – review being undertaken with finance support. (3) Osteotomy return between 2014-15 Length of Stay looked high. Though numbers of procedures is small, enquiries have been made over purchase of equipment currently used in Exeter and Derriford for cooling the jaw to reduce welling and length of stay. This has disposable costs of circa £25 per patient.

6.7 Urology

The national team visited the Trust on 20 June 2017 to discuss the report. There were 11 issues/areas to be addressed which the team are working through, such as consideration of being a five day unit as part of closer networking with Exeter, develop on call service, readmission rates for resection of bladder tumours. Length of time between referral and cystectomy is one of the longest in the country. In addition there were a number of notable areas of good practice; new to follow up ratio for outpatients, including telephone follow up for prostate cancer patients, one of shortest lengths of stay for patients undergoing resection of bladder tumours, good day surgery rate.

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GIRFT.pdf Page 7 of 9 Overall Page 251 of 253 6.8 Vascular Surgery

The report acknowledged the joint working between TSDFT and RD&E. The recommendations and actions had an Exeter focus and our vascular surgeons continue to be involved with those.

These specialities conclude the surgical specialities to be reviewed locally.

6.9 Future GIRFT specialities

Paediatric Services – the GIRFT report is being prepared, however we have not been offered any dates yet.

Emergency Medicine – we have been approached by the national project manager the following information which will be submitted, as requested by 1 March 2018:

The main areas include:

 ED Infrastructure (beds, cubicles, IT, Clinical Decision Units)  Finance – Direct costs of the department;  Workforce – Skill mix, workforce metrics and temporary staffing;  Process – links to the function which support urgent and emergency care

The intention is that the national team will visit with the local team later in 2018.

Medical Specialities – the national team for each speciality are currently being recruited and visits are anticipated for Q3/Q4 2018/19.

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GIRFT.pdf Page 8 of 9 Overall Page 252 of 253 Summary Details Date: Speciality/Directorate: Date of GIRFT Visit: Speciality CD/clinical lead: Operational Manager: Finance Business Advisor: Medical Director Approval: Check in Date Date for Completion

Action GIRFT Page Data Source Year Metric in Scope Baseline Position: Improvement Scale of Improvement Activity in Scope (Use % of Total Timescale for Action Plan Required Clinical/Patient benefits that Cost Cost Cost Opportunity Releasing Income Comments on Financials Delivered? Ref Eg Rank, RAG, Position Target? required? latest data available Service Line delivering (Next could be realised from Savings Avoidance Pressure Gain bed days Opportunity Performance (NB Must be and refer to data Activity 6 months) Improvement sought? (£) (£) (£) Against National SMART) source) Mean #REF! #REF! #REF! #REF! #REF! #REF! Cost Cost Cost Opportunity Releasing Income Savings Avoidance Pressure Gain bed days Opportunity (£) (£) (£)

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