AGENDA
Meeting Board of Directors Time of meeting 09:30-12:30 Date of meeting Tuesday, 02 February 2016 Meeting Room Dulwich Room, Hambleden Wing Site King’s College Hospital, Denmark Hill
Members: Lord Kerslake (BK) Trust Chair Christopher Stooke (CS) Non-Executive Director Faith Boardman (FB) Non-Executive Director Sue Slipman (SS) Non-Executive Director, Vice Chair Prof. Ghulam Mufti (GM1) Non-Executive Director Prof. Jonathan Cohen (JC) Non-Executive Director Dr Alix Pryde (AP) Non-Executive Director Erik Nordkamp (EN) Non-Executive Director Nick Moberly (NM) Chief Executive Officer Dawn Brodrick (DB) Director of Workforce Development Colin Gentile (CG) Chief Financial Officer Alan Goldsman (AG) Acting Director of Strategic Development Steve Leivers (SL) – Non-voting Director Director of Transformation and Turnaround Ahmad Toumadj (AT) – Non-voting Director Interim Director of Capital, Estates and Facilities Jeremy Tozer (JT) Interim Chief Operating Officer Dr. Geraldine Walters (GW) Director of Nursing & Midwifery Attendees: Tamara Cowan (TC) Board Secretary (Minutes) Sally Lingard (SL) Associate Director of Communications Fiona Clark (FC) Public Governor Paul Donohoe (PD) Deputy Medical Director Anne Duffy (AD) Divisional Head of Nursing Apologies: Trudi Kemp (TK) – Non-voting Director Director of Strategy Prof. Julia Wendon (JW) Medical Director Judith Seddon (JS) Acting Director of Corporate Affairs Circulation List: Board of Directors & Attendees
Encl. Lead Time
1. S TANDING ITEMS Chair 09:30 1.1. Apologies 1.2. Declarations of Interest 1.3. Chair’s Action 1.4. Minutes of Previous Meeting – 15/12/2015 FA Enc. 1.4 1.5. Matters Arising FE Enc. 1.5 2. FOR REPORT 2.1. Patient Story FR Presentation A Duffy 09:35 2.2. Chief Executive’s Report FR Enc. 2.2 N Moberly 10:00 2.3. Improving Quality of Care for Patients 2.3.1. Quarterly Patient Outcomes Report FR Enc. 2.3.1 G Walters 10:15 2.3.2. Adults Safeguarding Report (Annual) FR Enc. 2.3.2 G Walters 10:30 2.3.3. Children Safeguarding Report (Annual) FR Enc. 2.3.3 G Walters 10:45 2.3.4. Trust Quality Priorities 2016/17 FE Enc. 2.3.4 G Walters 11:00 2.4. Deliver the Financial Plan 2.4.1. Finance Report (Month 09) FA Enc. 2.4.1 C Gentile 11:30 2.5. Move to Operational Sustainability 2.5.1. Performance Report (Month 09) FA Enc. 2.5.1 J Tozer 11:15 2.5.2. Monthly Nurse Staffing Levels Report FA Enc. 2.5.2 G Walters 11:45 2.6. Board Working & Governance Arrangements 2.6.1. Board Committee Updates 12:00 2.6.1.1. Quality & Governance FI Verbal G Mufti 2.6.1.2. Finance & Performance FI Verbal C Stooke 2.6.1.3. Education & Workforce Development FI Verbal F Boardman 2.6.1.4. Audit FI Verbal A Pryde 2.6.2. Council of Governors Report FI Verbal F Clark 12:20 3. FOR INFORMATION Chair 12:25 3.1. Monitor Quarterly Submission FI Enc. 3.1 3.2. Chair & Non-Executive Directors’ Activity Report FI Enc. 3.2 3.3. Confirmed Board Committee Minutes 3.3.1. Finance & Performance Committee – FI Enc. 3.3.1 24 November & 15 December 2015 4. ANY OTHER BUSINESS Chair 12:30 5. DATE OF NEXT MEETING Tuesday, 01 March 2016, 09:30 in the Boardroom, Trust Headquarters, PRUH.
Key: FE: For Endorsement; FA: For Approval; FR: For Report; FI: For Information Enc. 1.4 Subject to Chair’s Approval
King’s College Hospital NHS Foundation Trust Board of Directors - PUBLIC Minutes of the meeting of the Board of Directors held at 09:30 on Tuesday, 15 December 2015 in the Dulwich Room, Hambledon Wing, King's College Hospital, Denmark Hill site
Members: Lord Kerslake (BK) Trust Chair Sue Slipman (SS) Non-Executive Director, Vice Chair Chris Stooke (CS) Non-Executive Director Faith Boardman (FB) Non-Executive Director Prof. Ghulam Mufti (GM1) Non-Executive Director Prof. Jon Cohen Non-Executive Director Dr Alix Pryde (AP) Non-Executive Director Nick Moberly (NM) Acting Chief Executive Officer Dawn Brodrick (DB) Director of Workforce Development Judith Seddon (JS) Acting Director of Corporate Affairs Ahmad Toumadj (AT) – Non-voting Director Interim Director of Capital, Estates & Facilities Jeremy Tozer (JT) Interim Chief Operating Officer Geraldine Walters (GW) Director of Nursing & Midwifery Julia Wendon (JW1) Medical Director
In attendance: Tamara Cowan (TC) Board Secretary (Minutes) Simon Dixon (SD) Sally Lingard (SL) Associate Director of Communications David Dawson (DD) Deputy Director of Strategy Lynne Watkins (LW) Joint Head of Nursing Trauma, Emergency and Urgent Care Tom Duffy Patient Governor Tim Bradley Public Governor Fiona Clark Public Governor Victoria Silvester Public Governor Andy Simmons Southwark Council Arju Dooraree Astellas Ltd Brigid Quinn Allscripts
Apologies: Alan Goldsman (AG) Interim Chief Financial Officer Trudi Kemp (TK) – Non-voting Director Director of Strategic Development Steve Leivers (SL1) – Non-voting Director Director of Transformation & Turnaround
Item Subject Action
15/124 Apologies
Apologies for absence were noted.
1 Enc. 1.4 Subject to Chair’s Approval
Item Subject Action
15/125 Declarations of Interest
There were no declarations of interest reported.
15/126 Chair’s Action
There were no Chair’s actions to report.
15/127 Minutes of Previous Meeting
The minutes of the meeting held on 24 November 2015 was approved as a correct record subject to reflect that Tim Bradley, Public Governor was in attendance.
15/128 Matters Arising/Action Tracking
The action tracker was noted and there were no matters arising since the last meeting raised for discussion.
15/129 Patient Story
The Board received a presentation which included the recorded comments from patients using the emergency services.
The following key points were reported: • Decision for mental health patient to be admitted is about identifying a bed;
• From DTA to bed is longer mental health patients staying longer;
• Patients over the age of 75 are presenting with more co-morbidities which result in more time in hospital;
• The Trust has good working relationships with psychiatric liaison teams which are based on the shop floor;
• The positive stories from patient feedback of the emergency department include reduced waits, helpful staff and great care. Whilst negative feedback include slow service and nurse behaviours;
• The Trust has invested in three extra cubicles and a distraction unit;
• The service is under pressure especially at weekends when people have no alternatives but to come to A&E; and
• If the Trust had the resources and capacity, the 4-hour target would be attainable.
2 Enc. 1.4 Subject to Chair’s Approval
Item Subject Action
The Board raised the following key points in discussion: • Whilst there are many interesting initiatives going on in the emergency department but the Trust has to ensure that frontline administration and reception staff are trained properly to deal with patients and services users in a professional manner and with the correct attitudes.
It is accepted that there is ongoing training the key point that this staff group is the first contact and set the tone of the rest of the patient journey and experience in most cases.
Communication is key to how the Trust manages its patients.
• The Trust is responding to the diverse patient group needs;
• The challenges in the ED derive from the sheer volume of patients attending the hospital make the Trust one of the top 10 A&E facility on the country;
• The issue with mental health patients goes beyond the Trust and require system-wide changes and additional capacity. However whilst it is a national problem the Trust has a role to play in starting the conversations and seeking a solution and should therefore engage with South London & Maudsley (SLaM) to progress discussions.
There had previously been discussions about expanding the capacity to host mental health patients with SLaM but these did not reach fruition;
• It is evident that in comparison to a few years ago, A&E has gotten considerably busier and the environment has changed.
This makes staff rostering more important hence the Trust regularly reviews staffing and activity which are then mapped back to job plans and the service subject to regular reviews and audit.
It is further apparent that people need to be educated on the proper use of the A&E service. Whilst there has been a GP in the department for the past 20 years there may be scope to engage with GP and commissioner colleagues to support the service;
• The Trust should ensure that it looks at other organisations, such as Leicester, for any opportunities to learn how to improve our clinical and logistical challenges.
The Trust is unique in that in addition to its emergency work it also has a thriving tertiary service;
• This service will form part of the transformation programme;
• The biggest challenges for the A&E department include the acuity and the complexity of the patients attending the ED. More and more patients require multidisciplinary care.
3 Enc. 1.4 Subject to Chair’s Approval
Item Subject Action
The Trust also needs to look at getting 24/7 GP services in the ED along with getting more beds which in part will be accomplished when the acute care hub opens in January 2016; and
• The Trust is having conversations with local commissioners to work on demand management. Internal work will be conducted on capacity and flow to work on ward processes.
15/130 Chief Executive's Report
The Board received and noted the report from the chief executive officer (CEO).
15/131 IMPROVING QUALITY OF CARE FOR PATIENTS
15/131.1 Quarterly Patient Safety Report
The Board received the quarterly patient safety report.
The following key points were reported: • There has been one never event since the last report to the Board;
• There were three maternal death in the past three months which is now subject to robust internal and external reviews;
• There are still never events incidents which are now in non-traditional surgical areas. The Trust has increased training for junior doctors and new appointments on the use of the surgical site checklists and introduced secret shopper initiatives to improve the use of the checklist and promote correct procedures;
• The Trust’s monitoring of deteriorating patients has been improved by the use of electronic systems to enter patient data at their bed side which supports pathway escalation;
• Falls are down and the Trust is running ‘falls awareness days’ whilst there has been a small increase in the severe cases of pressure ulcers;
• The Trust is required to access all patients for hospital acquired thrombosis which is decreasing across both sites;
The Board raised the following key points in discussion: • In ophthalmology changes made to improve the service include appointing a Clinical Director for the service who is driving cohesive behaviours and standardisation across the department in addition to cohorting all the patients on one site;
• There are also plans to rationalise delivery of ophthalmology services; and
• The iMobile service has robust data on deteriorating patients but the Trust needs to improve how it communicates and use this information.
4 Enc. 1.4 Subject to Chair’s Approval Item Subject Action
The Board agreed that Quality & Governance Committee (QGC) would conduct deep dives into ophthalmology services, deteriorating patients and QGC iMobile services.
15/131.2 Nursing Revalidation Report
The Board received the monthly nurse staffing report supported by a verbal update from GW.
The following key points were reported: • Register Nurse (RN) levels was at 100% on most wards but some wards were working with half the required numbers of staff;
• Healthcare assistants (HCAs) on nights equalled more than 100% and were being used to cover shortfalls in RNs. In some cases HCA cover related to foreign nurses who were waiting for their pin number before they are fully registered;
• In July/August there were more HCA being used but this is now reduced;
• Red shifts are where the Trust does not have enough staff to cover a shift and this occurred mainly in medicine and general surgery.
• Red shifts at the PRUH are as a result of high number of vacancies in band 5 RNs; and
The opening of Twinning to create capacity to support the elective and emergency activity is the driver for the red shift at the Denmark Hill site. This issue will be alleviated with the opening of the acute care hub (ACH) where most of the patients will be decanted.
The Board agreed that an update on band 5 nurse vacancies would be presented to the Board. DB/GW
The Board also agreed that the monthly nursing report should be recast to clearly flag where the main issues are and provide some tracking data. GW
15/132 MOVING TO OPERATIONAL SUSTAINABILITY
15/132.1 Finance Report (M8)
The Board received and discussed the month 8 finance report.
The following key points were reported and noted: • At month 8 the year to date is a deficit position of £63.9m which is circa £1m away from year-end forecast deficit of £65m;
• Income looks positive because of £10m and winter pressure additional funding received from commissioners;
• The run rate was £5.8m against a target of £3.1m;
5 Enc. 1.4 Subject to Chair’s Approval
Item Subject Action
• Drivers for the current position include cost of PwC support, non-achievement of CIPs pay cost creeping up and whilst staff numbers are going up the agency spend is not reducing;
• Lots of action has been focus on CIPs;
• The financial restructuring is underway but the benefits will not materialise until end of the year;
• There has been adverse movement on CIPs in December; and
• Based on the current position the Trust is unlikely to attain its target in the next three months.
The following key points were raised in discussion by the Board: • This is not a good result and the management is not comfortable with this position therefore focus is being given to delivering CIPs over the next three months.
A number of schemes are now in the pipeline to cover the gap and the Trust is putting in further restrictions on finances and expenditure. Other plans include capacity management and demand reconfiguration;
• It is evident that despite processes in place people are finding it deliver CIPs;
• It is further apparent that the Trust has not cracked cultures issues about delivery of CIPs and local accountability;
• The Trust is now very much focused on not exceeding the forecasted £65m deficit at year end;
• Based on the current performance the Trust is due to run out of cash come February and this issue has been raised with Monitor;
• Safety of patients remain critical deciding factor however where feasible tighter controls will be put in place for Medical staff. The WAP/VAP processes have also been streamed lined to reduce recruitment;
• This has not been a good month for the Trust and every opportunity should be taken to follow through and implement all green saving schemes, reconfigure finances and reconfigure capacity and demand structures;
• The Trust also needs to, with some urgency, resolve the issue of cash with Monitor;
• The Trust should also focus on getting the low hanging fruit in divisions but going forward similar targets should be set. It is important to understand the accountability and repercussions for the individual divisions. There is evidence that the divisional leads are focused and have made delivering targets a priority however more work needs to be done on escalation processes.
6 Enc. 1.4 Subject to Chair’s Approval Item Subject Action
15/132.2 Performance Report (M8)
The Board received and discussed the month 8 performance report.
The following key points were reported and noted: • All cancer targets are being met however colorectal and urology targets at the Denmark Hill (DH) site are at risk. With commissioner colleagues the Trust needs to do more on the referral systems;
• Referral to treatment (RTT) validation is on track and the Trust is down to 40 week. The validated data will result in increasing the backlog.
84 patients waiting 52 weeks were subject to a clinical review. 56 patients were added totalling 127 patients on the backlog pathway. The Trust can confirm there was no harm done to any of the 56 patients.
The reason for the additional 56 patients relate to process error but now the Trust has combined PTL this should not occur again;
• The Trust’s emergency department (ED) figure is up in the quarter at the PRUH site which compares preferably against the same period last year. Whilst it is not at 95% but it is in a much better place. Quarter 4 will be crucial point and proposed the high impact changes will be presented to the Board;
• On the DH site ED performance has dipped compared to last year during the same period which relates to issue with flow through the department and processes; and
• The ‘Pulling Together Week’ which runs from 10-17 December is hoped to reap good results for the DH ED.
The following key points were raised in discussion: • The performance on cancer is encouraging but the Trust has to have a clear communication strategy for the 52 waiters. 70% of these waiters have been given appointments and will be seen in the short-run;
• A full root cause analysis has been undertaken on each of these patients;
• Once the validation is completed, the backlog of 40 week waiters will increase to circa 400 patients. These patients are predominately in ophthalmology and orthopaedics;
• Other performance themes include dental services, patients requiring carers, complexity of patient cases and the concentration of patients using the hospital services that require community support; and
• It would be useful for the NEDs to have a crib sheet of the key factors impacting on the performance of the Trust so they can share these in conversations with community partners.
7 Enc. 1.4 Subject to Chair’s Approval
Item Subject Action
15/133 UPDATES FROM BOARD COMMITTEE AND COUNCIL
15/133.1 Council of Governors Activities
The Board noted the following update on Council of Governors activities from Tom Duffy, Patient Governor and Chair of Governor Patient Experience & Safety Sub-committee: • The Council is dismayed by the current financial challenges and losses facing the Trust and urge the Trust to grapple with the system to ensure the hospital flourishes.
• The results of the PwC governance review highlighted the important of good governance and the important role that governors play in addition the need for increased transparency.
15/133.2 Council & Board Governance Arrangements
The Board noted and received the PwC Governance Review and the Board Governance Arrangements, which were discussed and agreed at the private board and council of governors meeting.
The documents were placed in this session for full transparency.
15/134 FOR INFORMATION
15/134.1 Chair's and Non-Executive Director's (NEDs) Activity Report
The Board noted the report on the Chair and NED's activity.
15/134.2 Confirmed Board Committee Minutes
The Board noted and received the confirmed minutes of the Finance & Performance Committee held on 27 October 2015.
15/135 ANY OTHER BUSINESS
There were no matters of any other business raised for discussion.
15/136 DATE OF NEXT MEETING
Tuesday, 02 February 2016, 09:30 at the Demark Hill site
8
Enc. 1.5 BOARD OF DIRECTORS (PUBLIC MEETING) ACTION TRACKER
Date Item Action Who Due Update COMPLETED 15/12/2016 15/131.1 Quarterly Patient Safety Report – The Board agreed that QGC This action now programmed into the Quality & Governance Committee (QGC) would conduct QGC workplan deep dives into ophthalmology services, deteriorating patients and iMobile services. DUE 27/10/2015 15/104.3 Monthly Nursing Staff Levels Report – It was agreed that GW/DB 02/02/2016 the Trust should also look at what other organisations are doing on retention of nurses.
15/12/2015 15/131.2 Monthly Nursing Staff Levels Report – The Board DB 02/02/2016 DB will provide a verbal agreed that a report on nurse and HCA vacancies would be update under agenda item provided to the Board. 2.3.2
The Board also agreed that the monthly nursing report Revised report under should be recast to clearly flag where the main issues are agenda item 2.3.2 and provide some tracking data. GW
27/10/2015 15/104.3 Monthly Nursing Staff Levels Report – It was agreed that GW/DB 02/02/2016 See agenda item 2.3.2 the Trust should also look at what other organisations are doing on retention of nurses.
NOT DUE 24/11/2015 15/116 Patient Story - It was agreed that data on appointment AW 01/03/2016 cancellations would be circulated to the Board.
24/11/2015 15/118.2 Quarterly Patient Experience Report – It was agreed that NM/JS 01/03/2016 Proposals for Complaints the current complaints performance was not acceptable process was presented at and accordingly NM would progress this as a matter and QGC on 14 January and report back to the Board in the new year. will come to Board in
March.
Action Status as at: 02/02/2016 1
Date Item Action Who Due Update 24/11/2015 15/118.3 Doctors Revalidation Report - It was agreed that the JW1 01/03/2016 Trust would discuss the feasibility aligning the appraisal system with KCL.
27/10/2015 15/102 Patient Story – It was agreed that the Board would receive MS/GW 05/04/2016 an update in 6 months on the actions taken.
2
Enc. 2.1 Nora’s Story
Board of Directors, Tuesday 2nd February 2016, Anne Duffy, Divisional Head of Nursing and Lead Cancer Nurse Enc. 2.1
Nora • Born in 1951 diagnosed with breast cancer at the age of 56. Nora is a nurse who has worked in the NHS for over 40 years in various roles including as a Director of Nursing. She is currently an Operational Manager in London
• She has an active life in and out of work with family and a lot of friends who are very supportive.
• In the 8 years since her diagnosis she has only taken 56 days off sick due to her cancer Enc. 2.1
Her story
• Diagnosed in May 2007 with breast cancer, Nora underwent a radical mastectomy as her first treatment with node clearance • Following surgery, Nora underwent further investigations and work up prior to starting planned chemotherapy • Had 3 x FEC and then transferred to GSTT for Taxol • This plan changed when it was found the Nora already had metastatic disease in her spine • New plan was for 6 FEC, Taxol to be held in reserve and started on Pamidronate in August then Herceptin in October. Changed from Pamidronate to Ibandronite after 8 treatments • Underwent 3 weeks of radiotherapy (15 sessions) Enc. 2.1 Palliative care?
Just after Nora was given her diagnosis in 2007, her GP suggested a palliative care referral
“I was taken aback, I wasn’t thinking of anything like that, I still have a lot to offer.” Enc. 2.1
Did we give Nora enough choice?
After so much Nora declined a PICC as Nora wanted a portacath treatment and trying all she did not want as it was less of an infection places to cannulate something inserted risk and suited her lifestyle venous access had into her that would be The oncologist agreed and become so difficult Nora an infection risk this was inserted at GSTT was offered a PICC Enc. 2.1 Nora’s treatment continues – 2010 to 2013 • Treatment continued with Herceptin then there was a blip with Nora’s heart. Nora continued Herceptin although an Echo was required prior to each dose, she had a CT 6 monthly and had a visit to cardiology • New medications introduced Letrozole, beta blocker and Ramipril as Herceptin had caused heart damage and Nora had more radiotherapy to thorax and neck • In September 2013 Herceptin was stopped due to heart damage. Nora was reviewed by cardiologist and started on Bisoprolol • Scans were done every 3 months and a bone scan 6 monthly. One day she saw the registrar who said that she no longer needed the scans. Nora checked with her Consultant who said that she should still have scans. For a number of reasons, the scan was delayed and wasn’t repeated until about 4 ½ months later. When she eventually had the scan on 26th February 2015 it showed more disease in the ribs • She was prescribed Everolimus and this required specialist commissioning which was granted in March 2015. She also had to discuss the drug with pharmacy as it’s a potent medication with a lot of side effects. • Nora also changed from Letrozole to Exemestane. Enc. 2.1
Nora admitted as an emergency
Routine GP appointment lead to an emergency admission to the PRUH as her creatinine was sky high Enc. 2.1
Inpatient experience - PRUH
• Nora was the youngest patient on the medical ward with dementia patients. Fortunately Nora had a side room
• A nurse wanted to give Nora the wrong drug and was insistent - Nora in the end had to read the chart for the nurse who then conceded that Nora was right
• Came off all drugs whilst an inpatient for 2 ½ to 3 days and then went back on Exemestane and a reduced dose of Ramipril
• Seen by Acute Oncology Services
• Nora was not happy when palliative care arrived but Nora found it more acceptable when they said they were covering for the breast nurse and they did liaise with GSTT consultants to get the right treatment plan for her
Enc. 2.1 What Nora felt about her experience • I know people well at the PRUH medical, nursing and radiology everyone recognises me and they are supportive and caring. • Continuity of medical staff exemplary. I have seen the same 2 consultants all the time they know me and my condition and all the history. They can discuss my concerns with me and remember everything about me without the medical notes. • Always welcomed • The staff have great clinical skills • I saw a collapsed patient and a nurse was dealing with the patient she was so reassuring never stopped talking to the patient whilst directing nurses to get the things she needed • When the chips are down they are good • Acute Oncology Nurse is excellent she can put the jigsaw together and when she thought there was a problem with me being confused an appointment was made for me to see the doctor I obviously wasn’t confused • Nurse D is lovely • People look out for me • Staff work under a lot of stress and strain as they are always constantly observed due to the layout of the unit, not just by patients but also the people that escort them
Enc. 2.1 Nora saw changes in the Chartwell Unit from 2011 • Nora was concerned about staffing at this time and wrote to the Director of Nursing expressing her concerns about the increased activity and the demands on the staff. She said she felt like it was an accident waiting to happen
• Staff look battle weary
• I have seen upset staff that needed some nurturing
• The unit is much busier
• Nora has observed wrong information being given out to patients over the phone
• Don’t need people contradicting previous advice as you lose confidence Enc. 2.1 Nora raised some important questions for us • Are we a team? • Do we have strong leadership to motivate our staff and have a happy working environment • Is the environment a fit place to care for our patients • Do we really provide holistic care, do we really engage with patients, do we know our patients hopes and fears? Enc. 2.1 Nora shared some thoughts about how we could do things better • The waiting environment for chemo patients could we improve it? • How can we better support patients when they have heightened anxiety when having chemo even though we are busy? • The door sign “The wig lady” - could we think of a better name? • How can we improve the leadership and team building? • As a team should we meet weekly for just an hour where the team can reflect on the week, what was good what have we learned, were there any near misses (this will not only help with team building but linking it to the code of practice will help with your revalidation) • Could there be more access to the breast care nurses? • Could long term patients have a regular review with the nurses at least annually? Enc. 2.1
What’s happened as a result? We had an away day with the Chartwell team to discuss Nora’s story because hers is a real experience of our care and we need to listen to what she has to say. As a result of her story and other feedback:
• The Chartwell Chemotherapy Unit at the PRUH has been refurbished • There are new operational policies in place to unify practice • There are now team meetings as suggested by Nora • Nora’s story has changed the attitude of the leadership in the Unit • An additional Band 7 nurse is joining the team • Sharing Nora’s story has been a very positive experience Enc. 2.1 Refurbed Chemo Unit Enc. 2.1
“Thank you to you all for keeping me here.”
Enc. 2.2
Report To: Board of Directors
Date of Meeting: 02 February 2016
By: Nick Moberly, Chief Executive Officer
Presented By: Nick Moberly, Chief Executive Officer
Subject: Chief Executive’s Board Report
Introduction
Since the last meeting of the Board key areas of focus for the Trust has included: • Maintaining operational stability over the winter period; • Delivering our 2015/16 financial targets; • Developing our financial and savings plans for 2016/17; • Articulating the Trust’s strategy; • Considering options for refining our operational structures; • Starting to design a major multi-year clinical transformation programme, to launch in Q4, to drive quality and achieve a step change in our productivity; • Working with KHP colleagues to mobilise detailed work on the “Institutes” programme; and • Starting work on the master plan for the long term development and renewal of the Denmark Hill campus.
Although the last 12 months have been challenging ones for the Trust, a huge amount has been achieved in turning around performance, and we can look to the future with some confidence and optimism. The text of my latest staff briefing note, which gives a view of our journey towards sustainable excellence, is attached as an annex for information.
Improving The Quality Of Care For Our Patients
The Trust continues to work hard to deliver safe and effective care for our patients. Overall we are performing satisfactorily against most indicators, although our infection control performance is currently behind plan with 67 C Difficile cases recorded YTD (13 more than YTD plan).
Although we continue to receive very positive feedback from the great majority of our patients, our overall performance does not stand out when compared to other trusts nationally. Patient experience will therefore continue to be an important area of focus going forward.
1. Delivering The Financial Plan
We continue to work hard on delivering our £86m savings target for the year and a full update on the current financial position is provided under agenda item 2.4.1.
We are keenly aware of the need not to exceed our £65m deficit forecast at year-end and accordingly we continue to implement tight controls on expenditure whilst exploring further options to close the savings gap.
1 of 4 Enc. 2.2
We are also working hard to finalise our plans for the coming year. One important new development this month has been the offer from NHS Improvement of transitional financial support in FY 16/17, subject to a variety of conditions and commitments. The Board will need to respond formally to this offer by 8 February.
Moving To Operational Sustainability
Managing the increased winter pressures have been extremely challenging in both the Lambeth/Southwark and Bromley health care systems. Our overall performance against the 4-hour target worsened further from 88.8% reported in November to 87.47% in December, and we have continued to experience operational pressures in January.
The RTT Improvement team have now validated all incomplete pathways down to 30 weeks. We plan to have validated all 18+ week wait pathways by the middle of March, ahead of returning to national reporting of our month-end March position in April 2016. Root cause analysis (RCA) meetings continue into January to review the RCAs for pathways who breached 52+ weeks in our November position. A Trust-wide RTT training programme has been launched at the end of November for staff users of PiMS to attend general RTT training sessions.
Performance against the 6-week diagnostic waiting time standard has worsened considerably at the end of December with 630 patients waiting over 6 weeks, compared to 130 at the end of November. The main test modalities with increased breaches are non- obstetric ultrasound and MRI. An action plan is being produced which will be reviewed at a new weekly access board meeting which will assess all elective waiting time target performance.
On a positive note, all cancer waiting time targets are being achieved at a Trust-level for Q3, including the 62-day first treatment target of 85% which is currently at 86.4%. The Q3 position is close to being finalised and we expect all targets to achieve subject to final pathway validation.
Investment In Organisational Development And Leadership
The high-level priority areas for organisation development for the next 3 years, in line with the Trust’s emerging vision and strategy, have been discussed this month in a variety of fora including the EWDC.
One of the key OD priorities identified is the need to redesign the organisation's operating model and the structures needed to deliver this. KE has devoted considerable time to this topic during January, and an Organisation Design steering group has been set up to provide input into the redesign work as the project develops.
National Policy Developments, King’s Strategy, And KHP
National Planning Requirements 2016/17 NHS Improvement has published technical guidance for annual planning as part of the move towards joint/ aligned planning, and a unified process.
Providers are required to submit a draft Annual Operational Plan by February 8 2016 and final submission by April 11 2016. The Strategy Department will co-ordinate inputs from finance, contracts, quality, workforce and estates (all using the content in FRP2 as a baseline) and drafts will be submitted to the Board for review at relevant points.
There is also a requirement for a 5-year Sustainability and Transformation Plan. These must cover all CCG and NHS England commissioned activity and integration with local authority services. The most compelling STPs will secure additional funding from April 2017. Local health and care systems will submit proposals on scope and footprint by 29 January 2016.
2 of 4 Enc. 2.2
Given the work already undertaken through Our Healthier South East London, including both the strategy and local productivity work, and the existing governance structures that bind the programme, the six boroughs of South East London and the providers located within it will form the SE London footprint and the preparation of the documentation will be done by the Our Healthier South East London body – with input from all providers – including KCH. Final submission will be end of June 2016. The Board will receive regular updates through the process.
Strategy Framework
Good progress has been made in developing a new Trust corporate strategy framework, and a final version of this is being submitted to the Board this month for review and approval.
King’s Health Partners Institutes Strategy documents for both the Cardiovascular and Haematology Institutes were successfully presented to the KHP Joint Boards in December 2015. Project groups, involving KCH finance, estates and strategy inputs, are now preparing more detail about financial and estates options. In early February 2017 the project brief and scope will be finalised for the delivery of the Strategic Outline Cases.
An external review of the Liver academic portfolio is underway, and work on considering and evaluating options for Child Health will be kicked off in Q4.
Board Working
The Trust is pleased to welcome non-executive director Erik Nordkamp and executive director, Colin Gentile to the Trust this month.
Erik brings a wealth of commercial experience to the role. His record of accomplishment in business and organisational transformation speaks for itself, and helps to strengthen the King’s Board at a critical time for the Trust.
Colin takes on the role as Chief Financial Officer. He has a strong track record of helping NHS Trusts generate savings and improve their financial performance, whilst also helping to protect standards of patient care and frontline services.
We are also pleased to announce the appointment of Jane Farrell who joins us as Chief Operating Officer in April. Jane will join King’s in April from Western Sussex Hospitals NHS Foundation Trust (WSHFT), where she is currently Deputy Chief Executive and Chief Operating Officer.
Developing Relationships with our Stakeholders
As we enter the New Year stakeholder engagement remains of great importance and working with our partners on transformation and sustainability plans is a major priority.
Meetings with key stakeholders have already taken place including new leadership from NHS Improvement and the local constituency MP for Dulwich and West Norwood.
Plans to extend the face to face meetings programme to capture a wider audience from the national policy landscape are being worked through.
Due to planned industrial action in December, plans for the Bromley stakeholder event were put on hold. Development work for briefing Bromley stakeholders on areas of priority for the Trust and specific local issues is currently underway.
3 of 4 Enc. 2.2
Media Highlights and Visits
New and events can be found on the Trust’s website: https://www.kch.nhs.uk/news
Some noteworthy media coverage and events include:
Medium Summary
BBC Radio 4 King’s was featured in a BBC Radio 4 programme called Volunteer Nation, which was presented by Andy Haldane, Chief Economist at the Bank of England, and looked at the impact of volunteers and unpaid workers on the economy.
Petula Storey, Head of Volunteering, was interviewed about the role of the King’s Volunteers scheme within the Trust and the positive impact it has on patient experience. Rosie Willis, one of our Volunteers on Toni & Guy ward at Denmark Hill, also spoke about how four years of volunteering at King’s has given her more confidence.
The programme is available to listen to on demand on the BBC website. The Daily Mail There was coverage in the Daily Mail featuring a King’s patient, six- year-old Jakub Steczikiewicz, who was allowed home in time for Christmas.
Jakub was born with a severe form of Hirschsprung’s disease and had previously spent every Christmas Day in hospital.
Jakub has recently had a second set of organ transplants at King’s, and was lucky enough to be able recover at home over Christmas.
Dr Jonathan Hind, Consultant Paediatric Hepatologist at King’s, is quoted saying: “For a child to have one multi-organ transplant is difficult, but to have two is amazing. The fact that he’s still alive and recovering at home is as much a credit to him and his family as to our team.” The Guardian Following the industrial action on Tuesday, 12 January, there was coverage in The Guardian about what effect the decision to strike had on NHS Trusts.
King’s was highlighted as one of the Trusts experiencing disruption, with the junior doctors’ action meaning 485 patients were affected. South London Press King’s was mentioned in an article about nursing shortages in London. The original data was from a Freedom of Information investigation by the Royal College of Nursing in July last year, and included most Trusts in London.
We provided a statement and up-to-date figures to the South London Press, explaining that we have recruited more permanent nursing staff at our hospitals, and reduced the amount we spend on agency staff.
The article referenced the fact that in July 2015, we had a 16 per cent vacancy rate (653 empty posts) but this has since dropped to 13.6 per cent (as of November 2015).
4 of 4 King’s College Hospital (Denmark Hill)
Princess Royal University Hospital
Orpington Hospital
Beckenham Beacon
Queen Mary’s Hospital The Chief Executive’s Issue 24 - January 2016 Nick Moberly’s monthly update for our staff at Denmark Hill, the PRUH, Orpington, Queen Mary’s and Beckenham Beacon Brief A new year brings a fresh start for Join us for King’s. Over the next few months we the Director will see a great deal of activity to Roadshows prepare for the future. in February Despite all the challenges, great to hear the progress has been made over the last latest news 12 months to turn around the Trust’s See page three performance. (continued) 1 Three achievements are particularly noteworthy: l The excellent work that has been done to control our financial position. Substantial savings have already been made during the course of the year. Going into the final quarter of 2015/16, a key requirement is to ensure that we end the year with a deficit of no more than £65m, in line with our plan. Although further work is still needed, I am confident that we are on track to achieve this goal, provided we all keep our focus for the remaining months of the financial year. l The good work that is underway focussing on improving our operational performance. Much has been done throughout the year at the PRUH and Denmark Hill to improve emergency performance. At Denmark Hill, we successfully launched the Acute Care Hub in Matthew Whiting Ward in the first week of January, which provides an assessment area for medical and surgical patients admitted through the Emergency Department (ED). It is helping us to speed up the pre-admission process, and in some cases eliminates the need for admission altogether. In terms of performance, we are now meeting all our cancer wait targets, our ED four-hour performance is much better than it was this time last year, and we are making great progress in ensuring our Referral to Treatment (RTT) figures are accurate. This is the time between a patient’s referral to a non-emergency service and a clock stop event (for example, treatment, start of active monitoring etc). The RTT waits are still high, but we feel much more confident that the data is accurate. l The good progress that has been made in rebuilding the Trust’s leadership team. Following my own appointment, we have successfully appointed a new Medical Director (Jules Wendon), a new Chief Financial Officer (Colin Gentile), and a new Chief Operating Officer (Jane Farrell). We have been fortunate to attract three outstanding new Non-Executive Directors – Jon Cohen, Erik Nordkamp and Alix Pryde. As we move into 2016/17, we will need to continue the current financial discipline and focus on operational performance, but we will increasingly be looking to change the way we work. Over time, this will help us improve the quality and productivity of our services and move us towards a position of consistent and sustainable excellence. Three specific areas are worth highlighting: l Strategy. To make progress, it is extremely important that the Trust has a clear and exciting strategic direction, which we can all understand and buy into. Over the last couple of months, the Board has done a considerable amount of work to set this out, and we will be sharing and discussing this widely across the organisation in the near future. l Organisation structure. To help us deliver our strategy, it is important that the operational structures and processes in the Trust are well thought through and fit for purpose. Having spoken to many people across the organisation since my arrival, it is clear that the current arrangements need some streamlining, and we should be in a position to share our thinking and ask for your input on this important topic, before the end of March. l Transformation. An important part of establishing a sustainable future for King’s will be the transformation of our services, to ensure we are delivering the right services to the right people as consistently and efficiently as possible. We are hoping to launch our Transformation Programme in April this year, but we will be calling on you to help us in the design stages from late February onwards. Looking further ahead, we are also beginning to work on a number of important topics which will contribute to the long-term sustainability of the organisation. l Strategic service development. We are already working with local partners to develop a much more integrated way of working, with the aim of supporting and sustaining people in the community, and reducing the need for them to come to hospital. We are also thinking carefully about how best to organise our services across all of our sites, to improve access for our patients and the scale we need to achieve outstanding levels of quality and productivity. As part of King’s Health Partners, we are working out how to further develop our specialist services, with some exciting plans starting to emerge for Haematology, Cardiovascular, Neurosciences, and Liver/Diabetes. l Estates renewal. Part of the future strategy includes the development of some ambitious plans for the Denmark Hill site – examining ways in which we can finance some much needed expansion and redevelopment to ensure our physical environment matches our clinical and quality aspirations. This is a long-term plan, but we are hoping we can share some early thoughts with you over the coming months. Welcome to 2016 – after a challenging year, this is going to be an exciting time for all of us at King’s as we see the Trust getting in shape for what I am confident will be an outstanding future.
Nick Moberly Chief Executive 2 New Chief Operating Officer Jane Farrell to join in April This month we have announced the appointment of a new Chief Operating Officer. Jane Farrell will join the Trust in April from Western Sussex Hospitals NHS Foundation Trust (WSHFT), where she is currently Deputy Chief Executive and Chief Operating Officer. She will bring to the Trust a wealth of senior management experience. Before the formation of WSHFT in 2009, Jane served as Director of Operations and Deputy Chief Executive at Royal West Sussex NHS Trust, and Chief Operating Officer at Ealing Hospital NHS Trust. Jane is also a qualified nurse who ultimately specialised in both paediatrics and critical care, and held several professional leadership roles before moving full time into NHS management. She said: “I am delighted to be joining the team at King’s – it’s fantastic to be joining a Trust with such a long and illustrious history, at such a pivotal time. I look forward to working with clinical and managerial colleagues in meeting the challenges and opportunities ahead.” Jez Tozer will continue in his role as Interim Chief Operating Officer until Jane arrives in April.
Join us at next month’s Director Roadshows Throughout February, we will be holding our next series of Director Roadshows. All staff are welcome to come along so please join us to find out the latest news from across the Trust. If you work at Denmark Hill or the PRUH, you will have an opportunity to meet our new Chief Executive, Nick Moberly. Nick has been at King’s for almost 100 days, so it’s a good time to come along and to ask him your question about King’s. At all the Director Roadshows, we will be telling you about the important developments happening across the Trust, including our thinking around our future direction, the appointment of new senior colleagues, and the latest on our finances. The dates and times for the Director Roadshows are below, along with the names of who will be presenting. l The PRUH, Thursday 4 February, 3pm to 4pm, lecture room one, Education Centre – Nick Moberly, Chief Executive l Queen Mary’s Sidcup, Friday 5 February, 12pm to 1pm, Hockenden Room, Third Floor, Block B – Dr Paul Donohoe, Deputy Medical Director with responsibility for our Bromley and Bexley sites l Denmark Hill, Wednesday 10 February, 4.30pm to 5.30pm, Boardroom – Nick Moberly l Denmark Hill, Friday 12 February, 10am to 11am, Boardroom – Nick Moberly l Orpington Hospital, Wednesday 24 February, 2.30pm to 3.30pm, ground floor meeting room –Dr Paul Donohoe and Debbie Pook, Managing Director of Operations for our Bromley and Bexley sites l Beckenham Beacon, Friday 26 February, 12pm to 1pm, Muirhead Room, first floor Sally– Lingard, Associate Director of Communications and Marketing. We have organised two Denmark Hill roadshows at different times, so that if you are not able to come to the first one, you can come to the second. If you can’t come to your nearest Roadshow but would like to ask a question, you can email it to [email protected], and she will ask your question for you. 3 Denmark Hill marks a year as a smoke-free hospital Last January, our Denmark Hill site went smoke-free, with patients and members of the public no longer allowed to smoke in the hospital grounds. The PRUH went smoke-free last October. It’s still early days but this change has helped to make the hospital a cleaner, healthier and safer environment for everyone who comes here. But there is more to our smoke-free policy than this: equally important is the work we are doing to support patients and staff who want to quit. For example, we are one of the first hospitals in London to trial routine carbon monoxide tests for patients admitted to an acute medical ward (pictured above). This test records the amount of carbon monoxide in a patient’s exhaled breath. Carbon monoxide is one of the toxic gases inhaled by smokers from cigarettes. By showing patients the extent of damage that carbon monoxide could be causing, we hope that the test will be an important motivational tool to encourage patients to be smoke-free during their admission, and after they go home. As part of a pilot, patients on RD Lawrence Ward, and shortly on Annie Zunz Ward, at Denmark Hill are able to know their CO level. Arran Woodhouse, our Tobacco Liaison Specialist, said: “We admit around 6,500 patients a year with smoking-related conditions. So it is important that we give our patients who smoke the appropriate treatment and professional support they need to help them quit their habit for good. “We also support our own staff who want to, or are trying to go smoke free. Staff can attend a specialist clinic run by our partners at SLAM. Please contact the clinic on 0203 228 3848 or email [email protected]” Have your flu jab and win a John Lewis voucher It may be the new year, but there’s still time to have your flu vaccination to protect yourself and your patients. Everyone who has the flu vaccination will be entered into a prize draw to win one of four John Lewis vouchers worth £50 each. The winners will be drawn from a hat at the end of the vaccination campaign in early March. So for your chance to win, make sure you have your jab. As healthcare professionals, we have a duty of care to protect all our patients, many of whom are frail and vulnerable, or Caption: Paul Donohoe, Deputy Medical Director, has his have long-term complex health conditions. For them, the flu vaccination at the PRUH virus can have a serious, and sometimes fatal, impact. Even if you don’t work directly with patients, flu can pass from person-to-person very quickly and an outbreak can have a serious impact on staffing on wards and in clinics. Trained vaccinators will be doing more walk rounds at Denmark Hill and the PRUH, which is a fast and easy way to have your jab. You can also arrange for a vaccinator to come along to your ward, clinic or office to vaccinate you and your colleagues at a time that suits you best. To arrange for a vaccinator to come to your work area, please call Ross Whyte (for Denmark Hill) on 32269 or Jackie Young (for Bromley and Bexley sites) on 65014. For more information, please go to Kwiki and search for ‘Flu vaccinations’. 4 Service moves at Denmark Hill and the PRUH
The past few months have seen a number of service location moves and the launch of new facilities at both Denmark Hill and the PRUH. It’s important that you know what these changes are so that you can contact the right location and direct patients. Here is a summary:
The PRUH l Clinics previously based in Fracture Clinic, orthopaedics and neurology have moved to outpatients C and Orpington. The space left behind is in the process of being adapted into a new home for an expanded Ambulatory Day Unit, which was previously based on Farnborough ward.
Ambulatory care services assess and treat patients who do need to come into hospital, but who do not need to be admitted as inpatients or stay overnight. Most referrals come from GPs, although around 25 percent come to the PRUH Ambulatory Unit through the Emergency Department (ED) l Acute Medical Unit 1, on Level One of the North Wing, is now the PRUH’s Acute Care Hub. It is different to the Ambulatory Unit, in that it provides a space where patients who have been admitted (usually through the ED) can be assessed further and receive specialist care before being either discharged, transferred to a ward or taken to theatre.
Denmark Hill l We will shortly be moving some women’s and maternity services into the newly built Fetal Medicine Research Institute (FMRI), which is located on Windsor Walk, immediately next to Denmark Hill station. l From the week beginning 26 January, the following services will be provided out of the FMRI; the Harris Birthright Centre, hypertension clinic and the Maternity Assessment Unit. These services are currently located in the Golden Jubilee Wing. l Other King’s services – including the King’s Hewitt Fertility Centre (currently based in Unit 6, KCH Business Park) – will move to Windsor Walk in Spring 2016. l Matthew Whiting Ward, on the fi rst fl oor of Cheyne Wing, is now Denmark Hill’s Acute Care Hub. Contact details remain as they are on Kingsweb.
Spotlight on... Mini Joseph Where do you work? I am the nurse in charge of the Cardiothoracic and Vascular Theatres at Denmark Hill, working as a Clinical Co-ordinator.
What does your job involve? I am a trained theatre nurse and it is my responsibility to make sure that every patient who goes into theatre is safe and receives the best care possible. I work very closely with the theatre team and I act as the role model for my colleagues. I make sure that staff are well trained, fully competent and accountable. And I also keep my own knowledge and skills up-to-date by doing regular training.
What has been your proudest moment in work? It is very challenging job, but at the end of the day we respect and value each other. I am proudest of working with a great Cardiothoracic and Vascular Team who are always aiming higher.
What is the most rewarding part of working for King’s? Team work, and the quality of the care provided by the team. Last year, I was also named as the Perioperative Practitioner of Year by the Association for Perioperative Practice. It’s brilliant to be recognised in this kind of way, but I think that the award is a refl ection of the dedication and caring attitude of the whole team. 5 Stroke services score straight A’s for the first time in national audit Stroke services commended for their commitment to specialist care and rehabilitation
For the first time, our stroke services have scored a top ‘A’ rating in this year’s Sentinel Stroke National Audit Programme (SSNAP). This means that our stroke services are now rated among the best in the country.
Our stroke services consist of two specialist hyper acute stroke units (HASUs) and two step-down stroke units focused on rehabilitation, based at Denmark Hill and the PRUH. The HASUs were ranked second and third respectively when compared with the 10 other units in England. The two stroke units were ranked second and fourth respectively against the nine other stroke units in London.
The SSNAP audit asks hospitals for data about each stroke patient they treat across the six month period after admission. The audit looks at how we measure against a set of indicators for both stroke units and HASUs.
Both our HASUs reached the highest standard across a number of indicators, including time to admission; door to thrombolysis time (when patients receive clot-busting medication), and time taken for a patient to be seen by stroke care specialists.
Our stroke units were measured on their performance for patient rehabilitation, therapy and excellent care planning.
Maria Fitzpatrick, Nurse Consultant in Stroke Management, said: “Our stroke teams look after around 180 patients a month, providing life-saving care as soon as they come through the door and throughout their stay until they are ready to move on.
“For us to achieve an A rating across the board is fantastic, and is testament to the skill and dedication of all our staff in stroke services. There is a very good care pathway in place for patients who come to us having had a stroke, with a focus on recovery and rehabilitation.
“But we’re not resting on our laurels: caring for stroke patients, we can learn something valuable every day, and we’re always striving to improve our care for patients.”
The SSNAP has been developed by the Royal College of Physicians, to provide a strong evidence base for stroke services across the country which can be used to improve services. To achieve an A grade, a stroke service needs to score over 80 per cent across all indicators.
You can find out more about SSNAP at www.strokeaudit.org
PRUH 2015 Denmark Hill
Number of strokes at the PRUH 813 Number of strokes at the PRUH 821
Number of patients who have received clot-busting drugs 103 Number of patients who have received clot-busting drugs 142
6 In Focus... Managing neurodegenerative conditions and Parkinson’s disease at King’s Thanks to new clinical research and the development of practical tools at King’s to help people manage their condition, our services for patients with neurodegenerative diseases have improved immeasurably in recent years.
This month, we meet some members of the neurodegenerative team based at Denmark Hill, including our Parkinson’s international centre of excellence, to fi nd out how they are making a difference to patients with a range of complex needs. “The prognosis for patients with dementia and neurodegenerative conditions, including Parkinson’s disease, has improved considerably in recent years”, says K Ray Chaudhuri, Professor of Movement Disorders at the Trust.
Neuro-degenerative conditions affect neurons in the brain, and parts of the body such as the gut, causing a range of illnesses such as Parkinson’s, Alzheimer’s and Huntington’s disease. Indeed, the Government has recently highlighted dementias and neurodegeneration (DeNDRoN) as a priority area for research within the NHS.
King’s sees over 1000 patients every year with neurodegenerative conditions. As well as treating patients, we have offered hundreds the opportunity to take part in research programmes.
“Living with diseases like Parkinson’s can be extremely challenging”, says Professor Chaudhuri. “Even when we have established treatment programmes and drug regimes for patients, many need extra support to stop them becoming socially isolated, and to live as full a life as possible – and the research we are leading is helping us to do this.”
Thanks to the combined efforts of staff and patients at King’s, research and clinical teams have developed new initiatives and practical tools to help people manage their condition. They include: l An app for smart-phones which Parkinson’s patients can use, via a prompting mechanism, to help increase the loudness of their voice. Low volume speech is a common symptom of Parkinson’s disease, and a key cause of social isolation for patients with the condition. l Development of the King’s Parkinson’s Pain Scale, which is the world’s fi rst pain scale for patients with the condition. Pain management is a key unmet need in Parkinson’s, and the pain scale is already being used in national and international research studies. l The creation of a new Parkinson’s expert patient group (‘Community for Research Involvement and Support for People with Parkinson’s – CRISP’), which helps patients, their carers and clinicians contribute to developing real life research projects that take the patient’s perspective into account.
Parkinson’s is just one of the priority research areas the team is focussing on – there are also major studies at King’s looking at dementia, as well as motor-neurone disease, and the impact this has on people and their carers, as well as palliative care strategies to help manage the disease.
Professor Chaudhuri concludes: “The work we are doing is helping to make a real difference to patients with neurodegenerative conditions. The progress we are making is a credit to the staff at King’s, but also the patients we see, who are willing to help us explore new and innovative treatments for them.” Photo caption: Professor Chaudhuri (far left) plus staff and patient members of the CRISP expert patient group.
If you have a story that you would like to be considered for the CE Brief, please contact Joanna Nurse, Head of Internal Communications, on extension 34682 or email [email protected]
Enc. 2.3.1
Report to: Board of Directors
Date of meeting: 2 February 2016
Subject: Patient Outcomes Report, 2015-16 Quarter 3
Author(s): Claire Palmer, Head of Patient Outcomes
Presented by: Geraldine Walters, Chair – Patient Outcomes Committee
Sponsor: Geraldine Walters, Executive Director of Nursing & Midwifery Jules Wendon, Executive Medical Director
History: Previously considered Quality & Governance Committee - 14/01/2016 Status: For information
1. Summary of Report
Patient outcomes are defined as ‘the results people care about most when seeking treatment, including longer life, symptom relief, quicker recovery and the ability to live normal, productive lives.’ Ensuring good performance in relation patient outcomes is a key Trust strategic objective.
This report outlines KCH’s performance in relation to the patient outcomes indicators defined by the Trust’s Patient Outcomes Committee and reported in: o External data, including: CQC reports, national clinical audits, national registries and the Consultant Outcomes Programme. o Internal data, including: that analysed for mortality monitoring, Trust Patient Outcomes Quality Priorities, Local Incentive Schemes (previously CQUINs), NICE implementation, clinical governance.
2. Action required
The Quality and Governance Committee is asked to approve the Quarter 3 performance against the indicators provided.
3. Key implications
Legal: Delivering good patient outcomes reduces risk of litigation. Financial: • Contractual requirement to participate in the National Clinical Audit & Patient Outcomes Programme (approx. 30 workstreams) and the four Patient Reported Outcomes Measures (PROMs). Participation costs KCH approximately £27,000 pa. • Commissioning increasingly outcomes-based. • Commissioners require compliance with NICE guidance. • Best Practice Tariffs associated with performance in an increasing number of national clinical audits. • Cost implications in relation to implementation of NICE guidance – NICE recommendations take into account cost-effectiveness across the system but can incur costs for acute care. Assurance: • Assurance provided for: Trust Board, CQC, Monitor, commissioners. • Assurance provided by: external data including CQC Intelligent Monitoring Report and Outliers Programme, national clinical audit programme, Hospital Episode Statistics provided through Healthcare Evaluation Data (HED); internal data including investigation reports, Trust governance reporting processes. Clinical: Patient outcomes and clinical quality indicators reviewed and improvement actions monitored.
Equality & Patient outcomes can vary amongst different population groups. Analysis according to Diversity: demographic characteristics such as gender, age, ethnicity and levels of deprivation will, therefore, often be undertaken. Performance: Performance provided for Summary Hospital-level Mortality Index (SHMI), other outcomes indicators as available, national clinical audits.
Strategy: • Key strategic objective: improved patient outcomes. • Updates provided for Trust Quality Priorities related to patient outcomes. Workforce: None in this report.
Estates: None in this report. Reputation: Risk and opportunity – results contribute to CQC rating and often are publically available e.g. Consultant Outcomes Programme and national audit results.
Other: None in this report.
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4. Key messages of this report
Overall Indicators rated green (positive analysis): 22 performance: Indictors rated yellow (neutral analysis): 22 Indicators rated red (negative analysis): 2 Red National Hip Fracture Database (NHFD) Annual Report (published September 2015) – poor indicators: results in high profile national clinical audit. Data collection period: 1/1/14 – 31/12/14
Performance against achieving all 9 criteria of best practice for every patient was below national average at both sites: Denmark Hill (DH) performance against all 9 best practice standards improved from 14% in 2013 to 35% in 2014. Princess Royal University Hospital (PRUH) performance reduced slightly from 41% in 2013 to 38% in 2014. National average performance for 2014 was 63%.
Actions to improve further are incorporated into the Hip Fracture Forum action plan and the Hip Fracture Steering Group action plan, with progress reported quarterly to the Patient Outcomes Committee.
The latest data shows that both sites have been exceeding national average performance since August 2015 – see figures 1 & 2 below (slightly larger versions provided in Appendix 1). Achievement of all 9 best practice criteria for every patient is represented by the purple shaded area; national average is represented by the blue dotted line.
Figure 1: Denmark Hill performance against best practice criteria, Apr 2012 - Oct 2015
Source: NHFD online, 7/1/16
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Figure 2: PRUH performance against best practice criteria, Apr 2012 - Oct 2015
Source: NHFD online, 7/1/16
Improving care of patients with hip fracture is a Trust Quality Priority and will continue to be closely monitored by the Patient Outcomes Committee.
Green The Trust continues to perform above expected against all mortality indicators, including: indicators: Trust-level Summary Hospital-level Mortality Indicator (SHMI) SHMI – Denmark Hill and PRUH sites SHMI – weekend admissions.
Above-average performance was achieved in national clinical audits in the following areas: Paediatric diabetes at PRUH Urology (nephrectomy and prostatectomy) at DH Percutaneous coronary interventions (PCIs) at DH Stroke at both sites Inpatient falls at both sites Major trauma survival at both sites.
Above-target performance was achieved in the Local Incentive Schemes for: Alcohol and smoking targets at PRUH Dementia at both sites.
Quality governance targets were met on both sites for: Mortality monitoring National clinical audits and confidential enquiries NICE.
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Updates on 1. Mortality after hip fracture, PRUH site areas identified for improvement: Significant actions taken to improve the care pathway for patients with hip fracture appear to be leading to improved outcomes. The Summary Hospital-level Mortality Indicator (SHMI) for fractured neck of femur at PRUH for 12-months to August 2015 is 83 (95% CI, 58 to 116; total number of discharges = 423).
Figure 3: Summary Hospital-level Mortality Indicator (SHMI) for fractured neck of femur at PRUH, 12-months to Aug-15
Source: HED, 7/1/16
2. National Emergency Laparotomy Audit (NELA)
Due to be reported to Patient Outcomes Committee 20/1/16.
5
5. Performance against key patient outcomes indicators
Key:
Overall positive analysis Overall neutral analysis Overall negative analysis Improved since last Quarter Same as last Quarter Deteriorated since last Quarter
No arrow indicates no comparative data available.
5.1 Trust quality priorities
Indicator Data source Positive analysis Neutral analysis Negative analysis RAG
Hip fracture – National Hip Significant performance Fracture improvement achieved against 9 criteria Database – at Denmark Hill: of best practice online data to • Since August Oct-15 2015: 69%
Target = 60%
• 2014/15: 36% • 2013/14: 26% • 2012/13: 4%.
Improvement in Summary Hospital-level Mortality Indicator (SHMI) at PRUH – now within expected range.
Preventable ill Local Incentive Alcohol and Smoking Commissioning health Scheme (LIS) screening and brief targets not met in monitoring intervention for PRUH some ward areas achieved commissioning at DH. Issues are targets of 90% for being addressed existing wards (with the and the majority exception of AMU were achieved by which achieved 88%) December. and 60% for new wards.
5.2 CQC Intelligent Monitoring Report (IMR) patient outcomes indicators at risk
No new IMR since May 2015.
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5.3 Performance against Trust internal mortality indicators
Indicator Data source Positive analysis Neutral analysis Negative RAG analysis Summary Hospital- Internal – HED SHMI remains below level Mortality expected at 88.68 Indicator (SHMI) (95% CI, 85.6 to 91.9) 12-mo to Aug-15. SHMI Denmark Hill Internal – HED SHMI remains below expected at 86.17 (95% CI, 81.7 to 90.8) 12-mo to Aug-15. SHMI PRUH Internal – HED SHMI remains below expected at 90.95 (95% CI, 86.6 to 95.4) 12-mo to Aug-15. SHMI – weekend Internal – HED SHMI remains below admissions expected at 90.16 (95% CI 83.9 to 96.7) 12-mo to Aug-15. Mortality Internal – Specialty areas with monitoring – Mortality mortality monitoring quality governance Monitoring in place and reported Committee to MMC: DH – 95%; (MMC) PRUH – 93%.
5.4 Performance in national clinical audits
Indicator Data source Positive analysis Neutral analysis Negative RAG analysis DH PRUH
Paediatric PICANet, Nov- The standardised Intensive Care 15 mortality ratio at DH Audit Network is one of the lowest (PICANet) nationally and the lowest compared to all London peer trusts.
National Paediatric Royal College PRUH performed DH and PRUH DH performed Diabetes Audit of Paediatrics better than national within NICE better than (NPDA) Report and Child average for 6/7 target range. national 2013 - 14: Part Health process criteria. average for One, Care (RCPCH), Sep- 3/7 process Processes and 15 criteria. No Outcomes patients received all process criteria.
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Indicator Data source Positive analysis Neutral analysis Negative RAG analysis DH PRUH
UK Inflammatory Royal College Small numbers Bowel Disease of Physicians, nationally. (IBD) Audit: Sep-15 Actions already National Clinical taken at DH and Audit of Biological PRUH Therapies demonstrate - adult improved data capture across sites. IBD Audit: Royal College DH demonstrated National Clinical of Physicians, compliance with Audit of Biological Sep-15 NICE Technology Therapies Appraisal 187. – paediatric
Annual Report on NHS Blood and DH has the highest 1 DH within Liver Transplant, year risk-adjusted expected range Transplantation – Sep-15 survival rate for survival. adult nationally for super- urgent transplants. Annual Report on DH within Liver expected range Transplantation – for survival. paediatric
Audit of Patient NHS Blood and KCH performed Blood Transplant, in line with or Management in Oct-15 above the Adults undergoing national Elective, average for Scheduled Surgery 8/11 key indicators. Surgical Outcomes British DH is below the Audit - Association of national average for Nephrectomy Urological the risk-adjusted Surgeons, Sep- complication, 15 transfusion and mortality rates.
Surgical Outcomes British DH achieved a 0% Audit - Radical Association of transfusion and Prostatectomy Urological complication rate. Surgeons, Sep- 15 Surgical Outcomes British KCH not Audit - Stress Association of identified as an Urinary Urological outlier. Small Incontinence Surgeons, Sep- patient 15 numbers.
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Indicator Data source Positive analysis Neutral analysis Negative RAG analysis DH PRUH
National Hip British NHFD online data Hip Fracture is a Published Fracture Database Orthopaedic shows that both sites Trust Quality report, based (NHFD) Annual Association, have performed Priority, on 2014 data, Report 2015 – British above the national focusing on shows both published report Geriatric average from August improving the sites below (based on Jan – Society, Royal 2015. achievement of national Dec 2014 data). College of all 9 best average Surgeons practice criteria. against many (RCS), Age UK, criteria. National Osteoporosis At the PRUH Society, Falls the rates for and Fracture patients Alliance, Sep- sustaining a 15 hip fracture as an in-patient and the 30 day mortality rate are above the NHFD average. National Joint National Joint KCH within Registry Registry expected range Centre, Sep-15 for 90-day mortality Orpington following hip and knee replacement and for hip and knee revision rate.
Congenital Heart British KCH not Disease Congenital identified as a Cardiac mortality Association, outlier. Jul-15
Adult Cardiac Society for DH not Surgery Cardiothoracic identified as a Surgery in mortality Great Britain & outlier. Ireland (SCTS), Sep-15
Heart Failure British Society DH performed for Heart better than the Failure and national National average for Institute for 12/13 criteria.
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Indicator Data source Positive analysis Neutral analysis Negative RAG analysis DH PRUH
Cardiovascular DH performed Outcomes below the Research, Oct- national 15 average for the proportion of patients located in non- cardiology beds. A pathway is in place at KCH, however, that ensures cardiologists’ input – no quality of care issue. Percutaneous British DH above expected DH within Coronary Cardiovascular range for freedom expected range Intervention (PCI) Intervention from in-hospital for 30-day post- Audit Society (BCIS), major adverse PCI survival. Oct-15 cardiac and cerebrovascular events. Sentinel Stroke Royal College PRUH HASU National Audit of Physicians, achieved the 2nd Programme - Sep-15 highest score Hyper Acute compared to Stroke Unit (HASU) national peers; DH data HASU 3rd highest.
Adherence to British Society DH achieved 100% The recording British Society for for Clinical for 10/11 criteria. of hand Clinical Neuro- temperature Neurophysiology physiology requires (BSCN) and (BSCN) and improvement, Association of Association of consistent Neurophysiological Neurophysiolo with the Scientists (ANS) gical Scientists national Standards for (ANS), Nov-15 picture. Ulnar Neuropathy at Elbow (UNE) testing
National Vascular Vascular DH not Registry Society of identified as a Great Britain & mortality Ireland outlier. (VSGBI), Sep- 15
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Indicator Data source Positive analysis Neutral analysis Negative RAG analysis DH PRUH
National Audit of British KCH has the lowest Below national Inpatient Falls Orthopaedic rate of falls per 1,000 average Association, occupied bed days against a British (OBDs) in London, number of Geriatric and the 3rd lowest process Society, Royal rate nationally. measures. College of Actions Surgeons, Age KCH has the 3rd already UK, National lowest rate of falls planned across Osteoporosis leading to moderate/ sites to Society, Falls & severe harm or improve Fracture death per 1,000 practice. Alliance, Oct- OBDs in London. 15
UK Cystic Fibrosis Cystic Fibrosis The number of Registry 2014 Trust patients with Annual Data chronic Report: Strength in pseudomonas Numbers aeruginosa at KCH is below the national average; and KCH has the second highest proportion of patients using preventative inhaled medication DNase.
National Cardiac Intensive Care KCH survival is Arrest Audit National Audit within expected (NCAA) & Research range. Centre (ICNARC), Sep-15
The Trauma Audit TARN, Jul-15 More trauma & Research patients admitted to Network (TARN) - KCH are surviving online survival compared to the data number expected based on the severity of their injury.
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Indicator Data source Positive analysis Neutral analysis Negative RAG analysis DH PRUH
Clinical Report II TARN, Aug-15 South East London, DH survival is Core Measures for Kent and Medway within expected all patients: BOAST (SELKM) Trauma range. 4 eligible fractures, Network is the best Open limb performing network fractures, Severe in comparison to all pelvic fractures other Trauma Networks nationally. TARN - Major TARN, Aug-15 DH performed Trauma Dashboard better than previous for 5/10 process criteria. National clinical Internal, to Participation – 100% Action plans in audit and Dec-15 place – DH 79%; confidential Results – 100% PRUH 89% enquiries – quality governance Reviewed at Trust- level – 100%
5.5 Performance in Local Incentive Schemes – patient outcomes
Indicator Data source Positive analysis Neutral analysis Negative analysis RAG
Dementia Internal – 96% appropriate targets Local Incentive patients screened and Scheme fully assessed for monitoring dementia exceeds (Oct and Nov target on both sites. data only) Smoking and (As 5.1) alcohol
5.6 Implementation of mandatory NICE guidance
Indicator Data source Positive analysis Neutral analysis Negative analysis RAG
NICE – Internal – 100% mandatory Evidence- guidance fully Based Practice implemented Committee
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Appendix 1: National Hip Fracture Database – KCH results
Figures 1 and 2 below, display KCH performance against the 9 best practice criteria from April 2012.
The purple shaded area represents the proportion of care that meets all 9 best practice criteria for every patient. The blue dotted line is the national average.
The most recent period shows both hospitals performing above national average.
Figure 4: Denmark Hill performance against best practice criteria, Apr 2012 - Oct 2015
Source: NHFD, 7/1/16
Figure 5: PRUH performance against best practice criteria, Apr 2012 - Oct 2015
Source: NHFD, 7/1/16
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Table 1 shows KCH performance against each of the 9 best practice criteria for 2014 (NB: In the Table ‘King’s College Hospital’ refers to Denmark Hill only).
Table 1: National Hip Fracture Database results published 2015, based on 2014 data
Source: Royal College of Physicians: National Hip Fracture Database (NHFD) Annual Report, September 2015
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Appendix 2: NICE Performance Report
All NICE guidance implementation actions completed: DH – 79% (last quarter – 79%) PRUH – 75% (last quarter – 74%)
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Enc. 2.3.2
Report to: Board of Directors
Date of meeting: 2 February 2016
Subject: Safeguarding Adults Annual Report 2014 -2015
Author(s): Ann Hamlet – Head of Safeguarding Adults
Presented by: Ann Hamlet – Head of Safeguarding Adults
History: Bi-annual report presented at 14 January 2016 Quality and Governance Committee Status: Information
1. Summary of Report
This was made to the Quality & Governance Committee on performance over the last financial year, and provides assurance about the systems and process being used within the trust to identify and care for adults at risk. Data provided is for the year 2014 - 2015 with the exception of the DoLS referral data which is available from Quarter 2. Some additional information for 2015 -2016 has been included. The next bi-annual report will be presented in September 2016
2. Action required
The Board is asked to note content and recommendations.
3. Key implications
Safeguarding Adults is now on a statutory requirement under the Legal: Care Act 2014 There are no cost implications as recommendations to be Financial: delivered within existing resources This will be monitored via the Safeguarding Adults, Learning Assurance: Disabilities and Mental Capacity Act Group This work is relevant for all clinical and non-clinical staff Clinical: Safeguarding Adults work goes across all areas, and Equality & Diversity: Discriminatory abuse is discrimination on the grounds of race, faith or religion, age, disability, gender, sexual orientation and political views. Compliance is monitored via the Safeguarding Adults, Learning Performance: Disabilities and Mental Capacity Act Group Safeguarding Adults is now on a statutory requirement under the Strategy: Care Act 2014 Relevant to all staff Workforce:
Estates:
Reputation:
Other:(please specify)
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Enc. 2.3.2
Safeguarding Adults Annual Report 2014 -2015
Purpose of the Report
This is a report to the Committee on performance over the last financial year, and provides assurance about the systems and process being used within the trust to identify and care for adults at risk. Data provided will be for the year 2014 - 2015 with the exception of the DoLS referral data which is available from Quarter 2. Some additional information for 2015 -2016 has been included.
Key Points
The focus of this report is on activity, training and Deprivation of Liberty Safeguards. There have been changes in both these areas during the year.
This paper provides the committee with an update on:
1. Deprivation of Liberty Safeguards (DoLS) 2. Referral data 3. Training compliance 4. Coroners Cases/ Internal management Reviews/Serious Case Reviews/Domestic Homicide Reviews 5. Other developments 6. Conclusion
1. Deprivation of Liberty Safeguards applications (DoLS)
Case Law
Cheshire West 2014 was one of the most significant pieces of case law since the introduction of the DoLS legislation. Up to this point it was generally accepted that in order for DoLS to be considered (in an acute setting) the person would need to be seeking to leave and would be prevented from doing so. Following this ruling the ‘acid test’ was introduced which is in two parts, and both need to be met in order for DoLS to be considered, in addition to the existing criteria.
(1) Is the person subject to continuous supervision and control? (all three aspects are necessary e.g. 1:1 supervision; a wander-guard)
AND
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Enc. 2.3.2
(2) Is the person free to leave? (The person may not be saying this or acting on it but the issue is about how staff would react if the person did try to leave).
This change means that there are considerably more patients for whom DoLS would need to be considered. Internally there has been a significant increase in the number of applications and this is replicated across the country.
As of Quarter 2 this year the Safeguarding Adults team took over the co-ordination of all DoLS applications. As this was a change in process it has taken time for this to be embedded. One omission that had been identified is the requirement to notify CQC of completed applications. Contact with CQC on 5/2/15 confirmed that they would like notification for the historical cases and this has been done by the Safeguarding Adults team.
The clinical teams are responsible for identifying patients that may require a DoLS application and the Safeguarding Adults team will provide support in reviewing and signing off the application.
Data on the number of applications has only been collected since July 2014 but there has been an increase in the number of applications in each quarter which is as expected.
Quarter No applications 2 10 3 16 4 22
There has been significant learning both for the safeguarding team and the Trust in terms of making sure that the applications contain the right information and are completed in a consistent way. This table shows the position at the end of quarter 4.
Quarter Active Suspended Rejected Cancelled 2 0 7 3 0 3 0 9 5 2 4 1 14 3 4 Active = all ongoing active DoLS Suspended = DoLS where the person has been discharged/ improves etc Rejected = DoLS not granted Cancelled = DoLS where process started but stopped as patient improved or discharged so process not completed
Inconsistency in applications in terms of quality and detail, and the internal checks put in place within the team may have contributed to the numbers that were rejected. Guidance was produced by the team and is available on Kwiki and includes a blank form with helpful hints. This was developed with input from the legal team and reflects the learning from those rejected applications.
Reasons for rejected applications include the patient being discharged before the assessment process was completed. This highlights one of the challenges when deciding whether an application is required, and the challenges for clinicians when
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Enc. 2.3.2 balancing the use of least restrictive measures and meeting the legal obligation to maintain a patients’ Human Rights.
A standard authorisation application is sent to the Local Authority alongside an urgent authorisation application that allows King’s College Hospital NHS Foundation Trust (KCH) to deprive a patient of their liberty for up to 7 days. The local authority should normally complete their assessments within these 7 days. DoLS should not be used for ‘short term’ care but there is a lack of clarity about what this means. Assessments are by external assessors and include a “Best Interest Assessor” completing a Mental Capacity Assessment (MCA) and a Section 12 Doctor who will confirm that they meet the criteria for DoLS.
A requirement of the DoLS process is that the person ‘’is suffering from a mental disorder (i.e. an impairment of, or disturbance in, the functioning of the mind or brain)’’ and that they are ‘‘lacking capacity for the decision to be accommodated in the hospital.’’ Where applications have been rejected this has been on the basis that the external assessors felt that the person had capacity or that the Mental Health Act should apply. In these cases our assessments did not support this view. Within the DoLS legislation, there is no formal process to appeal these decisions and this is managed through ongoing supportive discussion with the relevant supervisory body.
DoLS going forward
It was announced that following the judicial review the review of DoLS has been accelerated, and the draft report and draft Bill will be published at the end of 2016, rather than 2017 as previously thought.
King’s contributed to the consultation, which started at the beginning of 2015 – 2016, and proposes a number of changes to the process.
2. Referral data
Referral data was previously recorded internally on an access database developed and supported within the team. This was identified as a risk as there was no support and relied on a single team member. It was agreed a new database would be developed which could be supported by the Business Intelligence Unit. This was completed and was rolled out in 2015 -2016.
Referral data shows that core activity for the team remains stable. Data entry has been a challenge and this has resulted in gaps in recording. This did improve over the year.
There has been a small increase each quarter on the number of safeguarding cases and a corresponding decrease in the number of adults at risk which is encouraging and indicates that staff are more confident in identifying concerns appropriately. The split between adult at risk, safeguarding and learning disabilities remains the same.
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Enc. 2.3.2
Safeguarding Adults Referrals
Adult at risk liaison LD liaison Safeguarding Grand Total Quarter 1 DMH 189 84 75 348 PRUH 15 11 49 75 Other 1 12 9 22 Not Known 80 30 29 139 Total 285 137 162 584 Quarter 2 DMH 259 75 105 439 PRUH 30 23 58 111 Other 4 23 8 35 Not Known 1 0 2 3 Total 294 121 173 588 Quarter 3 DMH 251 95 131 477 PRUH 24 25 42 91 Other 5 21 9 35 Not Known 1 0 1 2 Total 281 141 183 605 Quarter 4 DMH 316 113 155 584 PRUH 33 22 35 90 Other 7 21 7 35 Not Known 4 1 5 Total 360 157 197 714
There are significantly more referrals from the Denmark Hill (DMH) site than the other sites. While the bed base is larger at DMH there is a significant difference in referral data. This trend continued into 2015 - 2016.
The majority of referrals from all sites are from TEAM. At DMH80% of all alerts are from the Emergency Department. 55% of all the alerts raised by ED are adults at risk and do not go on to be safeguarding, with the remainder equally split between safeguarding and learning disabilities. In general, of the total number of alerts, 54% are adults at risk.
Local data is provided at the Safeguarding Adults, Learning Disabilities and Mental Capacity Act Group.
3. Training compliance
There has been much work over the year to try and improve compliance. The previous Safeguarding Adults Training Strategy did not cover the full scope of the safeguarding adult’s agenda, with safeguarding adults and MCA training delivered as separate sessions. In 2013 -2014 the team did not have capacity to deliver the
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Enc. 2.3.2 training and an external provider was used to deliver Level 2 training. A cycle of training was not established and the team provided training when requested so the on-going compliance issue was not being addressed.
The Safeguarding Adults Training Strategy was reviewed and approved in July 2014 to include both Safeguarding Adults and Mental Capacity Act. The updated training programme was introduced in October 2014 includes 5 levels of training.
Compliance is set at 80% and reported as Level 1 and Levels 2-5 are reported together. At the beginning of the financial year Safeguarding Adult Training was reported against Level 1 & Level 2. Data from Quarter 1 and most of Quarter 2 is against Level 1 & 2 data and Quarters 3 & 4 includes Levels 1 – 5. For ease of reading they are listed in the tables as Level 1 and Levels 2 – 5.
Table 1 – Staff who have received safeguarding adults training Level 1 and 2-5.
Level 1 (%) Level 2 -5 (%) Quarter 1 89 53 Quarter 2 89 66 Quarter 3 91 48 Quarter 4 91 57
This is a breakdown by quarter by site.
Level 1 (%) Level 2 -5 (%) Level 1 (%) Level 2 -5 (%) DMH DMH PRUH PRUH Quarter 1 92% 60% 80% 19% Quarter 2 89% 66% This is data for both sites as not available by site Quarter 3 85% 50% 48% 36% Quarter 4 91% 60% 89% 48%
There are a number of factors that have meant that overall compliance has not been achieved. Staff turnover has contributed and there has been an increase in overall staff numbers (690 more in Quarter 3 from Quarter 2). The change in medical staff can also have an impact as even when the overall staff number has not changed the staff themselves may have.
More detailed analysis has suggested that some staff may be attending training while still in date so not affecting overall compliance. In order to address the compliance issue a targeted email was sent to Divisional Managers by the Deputy Director Nursing on 05/03/2015 listing their staff who are non-compliant. While this has had some effect there is further work to do.
The Safeguarding Adults team have delivered a significant amount of training this financial year, 184 sessions to 3655 staff. See table below.
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Enc. 2.3.2
DMH PRUH Trust wide Q 1 No. of Training Sessions 9 13 22 No. of Staff Trained 270 168 438 Q 2 No. of Training Sessions 25 14 39 No. of Staff Trained 561 328 889 Q 3 No. of Training Sessions 39 30 69 No. of Staff Trained 775 351 1126 No. of Staff DNA 137 37 174 No. of Staff Walk-in 64 71 135 Q 4 No. of Training Sessions 30 24 54 No. of Staff DNA 91 60 151 No. of Staff Walk-in 30 62 92 No. of Staff Trained 602 600 1202 Total No. of Staff DNA 325 Total No. Walk-ins 227 Total no. of Training Sessions 184 Total no. of Staff Training 3655
From this it is clear that the team are providing enough sessions and the number of staff attending training increased each month. Actions to increase compliance will include
Further support from the Executive Team in communicating compliance levels to Divisional Managers for action Consider other options such as e-learning packages to improve compliance at level 2 – 5.
4. Coroners Cases/ Internal Management Reviews (IMR) /Serious Case Reviews (SCR) /Domestic Homicide Reviews (DHR)
It is a requirement to advise the Coroner of all deaths of people subject to a DoLS authorisation, as this is seen as being in ‘state detention’.
The Coroner is notified via the Bereavement Office of any deaths while under DoLS. However one patient was admitted from a nursing home into DMH, they had under a standard DoLS authorisation while at the nursing home, who failed to notify the Trust to this fact. The patient unfortunately died during their admission following an acute event. In this case the nursing home should have suspended the DoLS, but this did not occur. Had it occurred it would have allowed the Trust to consider if a DoLS was required...
Coroners case – In December 2013 an adult with a learning disability died following self- extubation. This was raised as a safeguarding allegation of neglect. There was also an internal SI investigation. The safeguarding case was substantiated on the basis that preventative measures had been identified but not implemented. This case has been referred to the Coroner but no date has been provided of when the case will be heard. The Learning Disabilities Co-ordinator has provided a
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Enc. 2.3.2 statement and they and others will be called as witnesses. The legal department are co-ordinating the preparation of staff.
This case has already been to the High Court for Judicial Review on 24/06/2014. There are a specific set of circumstances when a Coroner will hear a case with a jury present, one of these being when a person is being held in ‘state detention’, e.g. under a DoLS.
In this case the argument put forward was that even though no DoLS was issued, the patient had been deprived of their liberty during their time in ICU, which meant that the patient was in “state detention” for the purposes of the Coroners and Justice Act 2009 (“CJA”). The CJA stipulates that an inquest must be held with a Jury if the Coroner suspects that the deceased died while in custody or otherwise in state detention and that either the death was violent or unnatural or the cause of death was unknown.
The 36 page Judgment has just been handed down by the Court the judicial review failed and the patient was found not to be in ‘state detention’.
There has now been an appeal lodged so this is ongoing but is significant as it does potentially provide more clarity around DoLS and ITU.
IMR/SCR –
1. In April 2014 an IMR was provided for a case dating from 2013-2014. This was a Child SCR, but the children were not known to the Trust and so the Safeguarding Adult’s Team provided an IMR in relation to the Mother who was known to the Trust. This was submitted in April 2014 and the Trust was not represented at any panel meetings. 2. In October 2014 an IMR was provided in relation to a person who had committed suicide in April 2014, who had been seen by the Neurology service in 2012. The Trust was not represented at any panel meetings. 3. In November 2014 the team were asked to contribute to a Safeguarding Adults Review for a patient treated in 2012. This was an in-patient at a Mental Health Trust under Section 3 MHA and transferred to DMH with DKA (raised blood sugars). He spent 2 days in the Trust as an inpatient and was transferred back after commencing on insulin. Following his discharge from the Mental Health Trust, the patient was not followed up in relation to his diabetes and was later found dead.
An IMR and chronology has been provided and the Head of Safeguarding Adults attends panel meetings. All partners have provided their reports and these are being pulled together into a single report.
DHR – There have been no new DHR in the year. The review that started in December 2013 was completed. The executive summary is yet to be published.
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Enc. 2.3.2
5. Other points for the committee to note
1. A Nurse Specialist for Safeguarding Adults was recruited and commenced in the Trust at the end of April 2015
2. The Learning Disability post became vacant at the end of the financial year, but has been recruited to and will commence in the Trust in February 2016
3. The Safeguarding Adults, Mental Capacity Act and Learning Disabilities Group was re-established. Terms of reference reviewed and amended to ensure representation from each of the Divisions who are expected to provide updates regrading training compliance and any ongoing safeguarding cases where Kings are alleged to have cased harm.
4. The CQC visit at the beginning of 2015-2016 highlighted the need for improved compliance in safeguarding adults training and increased knowledge for staff in Mental Capacity Act and DoLS. The action plan is monitored through the CQC Steering Group.
Actions include identifying a Mental Capacity Act Lead at DMH and PRUH (completed). The training strategy and delivery are being reviewed in addition to actions stated under Training compliance.
6. Conclusion
Progress has been made in relation to training compliance. Data collection has improved and the team hold more referral data to allow identification of trends (e.g where alerts are made/ where DoLS applications are from).. There has been a significant increase in the number of DoLS applications made during the year and this trend has continued into 2015 -2016. More work is underway and planned as described above.
The Safeguarding Group was re-established and this will be key in ensuring training compliance and embedding of the Mental Capacity Act and DoLS. Overall there has been progress in key areas and a plan in place to continue these changes into the next financial year.
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Enc. 2.3.3
Report to: Board of Directors
Date of meeting: 02 February 2016
Subject: Annual report 1st October 2014 – 30th September 2015
Author: Rosalinda James Head of Nursing Safeguarding Children
Sponsor: Dr Geraldine Walter Director of Nursing & Midwifery
History: Reported to the Quality & Governance Committee – 14 January
Status: For Report
1. Summary of Report
To provide assurance that the Trust has safeguarding systems in place which are actively protecting children by reporting on: • actions raised in the previous annual report • safeguarding activity in the Trust • section 11 compliance • safeguarding training • the progress of Internal Management Reviews/Serious Case Reviews/Case Reviews • allegations against staff and safeguarding complaints • local /national safeguarding issues and the Trust’s response
2. Action required
The Board is asked to note the safeguarding activity carried out in the Trust and consider the actions from the annual report.
3. Key implications
Legal: This report includes information on the Serious Crime Act (2015)
Financial: This report requests additional resources for safeguarding support in maternity Assurance: This report identifies safeguarding activity in the Trust to protect children Clinical: Key issues that require action are highlighted This report has been subjected to an equality impact assessment. Equality & Diversity: Actions in this report are not believed to disadvantage any groups of patients or staff. Performance: Staff training in safeguarding children is being monitored Strategy: Risks highlighted by this report are recorded on the Trusts Risk Register Workforce: This report requests an additional member of the safeguarding team to support maternity Estates: There are no direct estates implications Reputation: Wired (statutory and mandatory training record system) cannot be
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relied on to provide accurate information on safeguarding children training Other:(please None specify)
Safeguarding Children Annual Report 1st October 2014 - 30th September 2015
King's College Hospital NHS Foundation Trust provides services from three acute hospital locations: Denmark Hill, the Princess Royal Bromley and Orpington Hospital and provides community services from sites in Dulwich, Sidcup, Beckenham, Camberwell and Lewisham. 10,500 Trust staff provide services to approximately 1,000,000 adults and children who live in Southwark, Lambeth and Bromley. Tertiary specialist services at Denmark Hill serve patients regionally and nationally and Denmark Hill is also a designated trauma centre for patients across the south east.
Denmark Hill has approximately 1006 beds which include 96 major critical care beds, 91maternity beds, 123 paediatric beds and cots. The Princess Royal University Hospital has 523 acute beds, 22 critical care beds, 30 maternity beds, a birthing centre and 24 paediatric beds and cots. There are 63 beds at Orpington.24 hour Emergency Department services for adults and children are provided at Denmark Hill and the Princess Royal University Hospital (PRUH).
At Denmark Hill the Trust’s local client group is ethnically and culturally diverse, with high levels of social deprivation. Lambeth ranks as 29th out of 326 local authorities for deprivation and Southwark ranks as 41st. In Lambeth there are 21,00 children aged 0-4 and 67,400 under 19 year olds. 85.8% of school children are black or from a minority ethnic group and 29% of under 16 year olds live in poverty. In Southwark there are 21,800 children aged 0-4 and 67,600 children under 19. 79% of children are from an ethnic minority and 28.6% of children under 16 live in poverty. Our non-local cohort of patients has additional vulnerabilities due to chronic illness, severe injury or trauma, whether accidental or non- accidental.
At the Princess Royal the local client group is less socially deprived and culturally diverse, Bromley ranks as 203rd out of 326 local authorities for deprivation. There are 21,100 0-4 year olds, 77,000 under 19 year olds, 31.8% of school children are from an ethnic minority, 16.2% of children under 16 live in poverty (Public Health England, 2015).
1. Scope of this report
This report relates to the period from 1st October 2014 to 30th September 2015 and addresses the King’s College Hospital NHS Foundation Trust’s (‘the Trust’) responsibilities towards safeguarding the welfare of children and young people from pre-birth to 18 years of age. For the purposes of this report the term ‘child’ or ‘children’ will be used to denote any child or young person under the age of 18 years.
2. Statutory Framework/Section 11 reporting The Children’s Act 1989/2004 provides the statutory basis for services for children and young people. The Trust is required, under Section 11 of the Children Act, to ensure that it has robust arrangements in place to safeguard and promote the welfare of children and young people. This report details how the Trust discharges its responsibilities under Section 11 and in accordance with guidance contained in Working Together (2015)1 and the London Child Protection Procedures2.
1 Department of Health (2015), Working Together to Safeguard Children 2 London Safeguarding Children Board 4rd Ed (2014), London Child Protection Procedures
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3. Governance Framework
3.1 Executive Leadership and Strategic Management The Trust’s Board of Directors is accountable for and committed to ensuring the safeguarding of children and young people in their care. The Executive Director of Nursing and Midwifery has Board level responsibility for safeguarding children. The Safeguarding Children’s Team (SCT) acts on her behalf to ensure that the Board is assured that all necessary measures are taken to safeguard children. Safeguarding children is incorporated within the Board Assurance Framework. The Trust Board receives an annual report from the safeguarding children team. The Trust’s accountability for and commitment to safeguarding children is stated on the Trust website. Roles and responsibilities of all staff are detailed in the Safeguarding Children and Young People policy which was updated in 2014 and this is highlighted on Trust induction for all new nursing and midwifery staff and child health medical staff.
3.2 Safeguarding Children Team (SCT) The Trust has a Safeguarding Children Team, comprising a Named Doctor at the Denmark Hill (DH) site and a Named Doctor at the Princess Royal site (PRUH). A Head of Nursing/Named Nurse Safeguarding Children across all sites, a Named Midwife at DH and a safeguarding midwife at the PRUH. There is 1 Senior Clinical Nurse Specialist and 2 clinical nurse specialists at DH, 2 part-time Senior Clinical Nurse Specialists (1WTE) at the PRUH. The Named Nurse is supported by a PA who also serves as the SCT administrator at DH and a part-time administrator supports the safeguarding staff at the PRUH. The Named Nurse reports to the Deputy Director of Nursing as part of the Executive Nursing and Practice Development Team, the work at DH is also supported by the Assistant Director of Nursing. The centralisation of the team reflects its Trust-wide remit and responsibility. The roles and responsibilities of the Named Professionals are outlined in Working Together (2015) and the Trust’s Safeguarding Children and Young People Policy (2014).
3.3 Reporting Structure The Trust has a Safeguarding Children Committee which meets 4 times a year and is chaired by the Deputy Director of Nursing. The Committee, brings together the Trust’s clinical leads and Named professionals with colleagues from partner agencies. This Committee reports through the Trust’s Quality and Governance Committee. The SCT reports to the Quality and Governance Committee to enable detailed consideration of key issues and recommendations and ensure that Trust-wide issues are acted upon and embedded across the organisation. The Executive Lead for Safeguarding Children, Deputy Director of Nursing, the Assistant Director of Nursing and the Named Nurse represent the Trust on the membership of the Lambeth, Southwark and Bromley Local Safeguarding Children Boards (LSCB).
3.4 Safeguarding Children Steering Groups The Named Nurse chairs the Safeguarding Steering Groups comprising colleagues from across Child Health and Maternity, the Emergency Department (ED) and other key clinical services. This group meets quarterly at DH and the PRUH.
Figure 1 – Safeguarding Children Reporting Structure
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4. Regulatory Framework
4.1 The Trust was inspected by the Care Quality Commission (CQC) in April 2015.
Denmark Hill CQC Safeguarding Report At Denmark Hill the inspection found that in services for children, patients were safeguarded from the risk of abuse. Staff were well versed in the Trusts local safeguarding policies and could describe national best practice. A safeguarding policy was readily available to staff. Staff said they were well supported by the safeguarding team. 88% of nurses and 60% of doctors and paediatric dentists were trained to level 3.
In ED it was noted that verbal consent was sought from parents to undertake background checks but this was not documented. However, the Trust informed the inspectors that the paper flow chart was no longer in use in ED, as safeguarding questions and verbal consent were mandatory fields on the computer system, for all children. 83% of nurses and 63% of medical staff working in trauma, emergency and acute medicine had received training at level 2. 83% of nurses and only 20 % of senior medical staff (ST4 and above) had undertaken safeguarding training at level 3, therefore the Intercollegiate Standard ‘all children and young people must have access to a paediatrician with child protection experience and skills (level 3 training)’ had not been met. The Inspectors observed GP’s operating from a cubicle in the children’s area brought in adult patients’ in-between paediatric patients, they felt this compromised safety.
In Maternity 90% of midwives and 80% of medical staff were trained at level 2. 83% of midwives and 68% of medical staff were trained at level 3. Staff in NICU were able to describe arrangements for safeguarding, there was a close working relationship with the Named Midwife and nursing and medical staff.
The Trust reported to the Inspectors that WIRED, the Trust’s statutory and mandatory training record, was not up to date.
CQC Should Improve Recommendations Safeguarding flowcharts should be completed. Improve the number of senior medical staff trained in safeguarding children at level 3 to meet the ‘Intercollegiate Standards for Children and Young People in Emergency Settings’. Review the practice of undertaking adult consultations in the children’s ED. Improve attendance at mandatory training.
The Trust’s Should Improve Actions Paper flow charts are no longer in use and they have been superceeded by mandatory fields on Symphony, the ED IT system. The Head of Nursing ED will ensure flow charts are removed from the paper record. The consulting room used by GP’s in ED was a dual consulting room with one door from the children’s area and one from the adult area. At times of overcapacity/overcrowding in the adult area, the GP’s had been instructed that as long as they escorted their adult patient to and from the room and did not leave them unattended, they could see adult patients there. GP’s were notified that this practice should cease.
The paediatric clinical lead in the ED trains medical staff to level 2. Training records were reviewed to make sure they are accurate and to ensure that staff that who required training were identified. A bulletin containing details of level 3 e-learning was sent out to ED medical staff. Staff have been notified that they are required to complete level 3 training by the end of the year.
The Trust’s report to the Inspectors that WIRED was not up to date was reviewed at the Safeguarding Children Committee in September 2015. The statutory and mandatory training manager reported that PGME and WIRED staff had been working to update On-Line Management System records, if staff records are not up to date WIRED would be inaccurate. An example was given of 528 medical staff who joined the Trust rotation in July and had received level 2 safeguarding training, had not been put on WIRED. The difficulties
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with obtaining an accurate picture of safeguarding children training will be reported to the Clinical Quality Review Group.
4.2 Princess Royal CQC Safeguarding Report Staff are aware of their safeguarding responsibilities, they understand procedures and how to report concerns. The ED has a flagging system in place. The section on safeguarding children at the PRUH does not reflect current practice. Corrections were sent to the CQC but they did not accept the changes as they were provided by a member of the SCT at the PRUH. The Board should be assured that the Trust is compliant with safeguarding standards. To ensure that the safeguarding nurses at the PRUH are able to support safeguarding activity to a high standard they are currently working under the guidance of the Named Nurse at DH. A member of the DH team is supporting staff at the PRUH.
76% of nurses and 18% of medical staff in trauma, emergency and acute medicine had received training in safeguarding children at level 2. 33% of staff on the children’s ward and 70% in SCBU had obtained level 3 training.
In maternity managers and staff showed an understanding of what was important to promote women’s safety and protect unborn and new babies. Midwives knew the name of the safeguarding midwife. 90% of clinical staff has attended level 3 training. Arrangements were in placed to provide supervision quarterly. Staff identified the lack of perinatal mental services as a concern.
CQC Should Improve Recommendations The Trust should continue to improve attendance at mandatory training.
Trust’s Should Improve Actions ED senior medical staff were asked to review training records and ensure that safeguarding training had been accurately recorded. The Named doctor was asked to review training records for medical staff. Since inspection all the nurses that require training have been given a training date. Additional training sessions for level 2 were arranged in October and November, a bulletin with details of E –learning was sent out.
4.3 Section 11 Report Section 11 of the Children Act 2004, places duties on the Trust to ensure their functions and any services contracted out to others, are discharged having regard to the need to safeguard and promote the welfare of children. In order to fulfil its statutory function under regulation 5 of the local safeguarding children board’s regulations 2006, an LSCB should, assess whether LSCB Partners are fulfilling their statutory safeguarding obligations. Under this regulation the Trust was asked to submit a Section 11 report to a ‘challenge panel’ of the Southwark safeguarding children board in February 2015. Questions were asked about children aged 16-18 years who were cared for an adult wards. The panel was informed that the safeguarding children team supports the safeguarding needs of children up to 18, even if they are cared for on adult wards and units. The panel also asked for the Trust’s response to Kate Lampard’s report for the Secretary of State for health in matters relating to Jimmy Savile to be made available to them. So the Trust’s action plan has been included in the report. The Section 11 report included 12 actions, 5 of which were audits which were added to the annual workplan.11 of these actions were completed by August 2015. An audit of early help interventions was not carried out in June due to demands on the safeguarding team. This audit has been added to the work plan of 2015-16. The action plan was also reported to the Lambeth Clinical Commissioning Group Safeguarding and Looked After Children Working Group. The Trust provided an update on the 2014 Section 11 report to the Bromley Safeguarding Board in May 2015 and as reporting is bi-annual the Trust will submit another report to the Bromley board in February 2016.
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5. Safer Recruitment
The Trust adheres to the mandatory Employment Check Standards issued by NHS Employers and Government legislation which supports safeguarding. DBS disclosures are obtained for all relevant groups that work with children and/or vulnerable adults as defined by the Safeguarding Vulnerable Groups Act. Contractors are required to provide assurance that workers receive induction training and annual update training relevant to the normal duties the worker is expected to perform and in line with King’s policies and procedures. Clinical agency staff are provided, by their agency, with induction information which includes reference to the roles and competencies for healthcare staff as determined by the Intercollegiate Document (2014). Safeguarding responsibilities/profiles are also included within the paediatric job profiles. The Trust is compliant with the standards/procedures required by the local authorities, local safeguarding children boards and the London Child Protection Procedures which are consistent with those outlined by NHS Employers. Under these procedures, the Trust is required to identify and act on allegations against members of staff which have implications for safeguarding children. Where such concerns arise, staff are asked to identify this to their manager, the appropriate HR manager and the Named Nurse. The Named Nurse will report the concern to the Local Authority Designated Officer (LADO), who will advise on the safeguarding aspects of the case. In the period of this report there have been 3 cases referred to LADO, 1 at the PRUH, and 2 at DH. Managing Safeguarding Allegations Against Staff Policy and Procedure (NHS England) was updated in June 2015.
6. Policy Framework
The Trust works primarily to the London Child Protection Procedures. These are supplemented by local procedures, from Lambeth, Southwark and Bromley social care, in specific areas of practice such as parental mental health, substance misuse, learning disability and domestic violence, child sexual abuse. The Trust Safeguarding Children and Young People Policy was revised in 2014 to ensure it reflects guidance in Working Together, NICE guidelines3 and learning from Serious Case Reviews. The Safeguarding Children and Young People Policy also incorporates the safeguarding supervision policy, to ensure that staff are adequately supported and lessons are learnt from complex cases. All safeguarding procedures are available to staff via the Trust intranet which gives details of how to contact the SCT and provides links to key documents: Working Together, Children Act, 2004, policies and guidelines, referral forms, information on training and on child death reporting.
7. Partnership The Trust has close working relationships with Lambeth, Southwark and Bromley Local Safeguarding Children Boards (LSCB) and is represented by the Director of Nursing at executive board meetings of Southwark and Lambeth. The Deputy Director of Nursing attends the Bromley board and the Named Nurse the Southwark and Lambeth boards. The Trust is represented by the Named Nurse on relevant sub-committees of the boards. The Lambeth social care was inspected in February 2015, by Ofsted, the overall judgement was that children’s services were inadequate which is a deterioration since the inspection in May 2012, where it was found to be outstanding. The safeguarding board was also found to be inadequate. Throughout 2014, the board had not carried out its statutory functions, this was recognised and new structures, membership and operational groups were established but it was too early at the time of the inspection to identify the impact. It was noted that since the last inspection the LSCB has overseen 3 SCR’s and reviews absorb a significant amount of resources and time from partners. Learning had been widely distributed across partner agencies and staff from partner agencies were able to articulate this learning and apply it to their work. The SCR sub-committee has also appropriately considered serious incidents and whether to instigate multi-agency reviews. Action plans had been developed and monitored and reported to the board. However, multiagency audits had not been completed as planned.
3 NICE (2009) When to suspect child maltreatment.
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Health partners were noted to be actively engaged with the work of the LSCB and they were routinely represented on the board and relevant sub-groups. The Child Death Overview panel had carried out its functions appropriately. A new health subgroup was formed in January 2015.
Some of the immediate priorities for the board are to re-establish a multi-agency audit plan, re-establish a safeguarding data set, ensure engagement of all the board partners and deliver an effective multi-agency training programme. A Lambeth ‘shadow board’ has been set up to ensure that the improvement plan is driving forward improvements to ensure children in Lambeth are safeguarded. The Director of Nursing and Midwifery is a member of the shadow board. The Lambeth Safeguarding Children Board annual report 2014-2015 will be presented to the Trust’s Safeguarding Children Committee in December.
8 SCT Operations 2014-2015
8.1 The role of the SCT is to: • Promote staff awareness of safeguarding issues through training and acting as an expert resource • Ensure policies, procedures and guidelines are in place and disseminated to staff • Support staff to manage complex cases • Support staff to contribute to strategy meetings and child protection conferences • Liaise closely with other professionals for safeguarding and other partner agencies including the police and social care, in accordance with the guidance contained in ‘Working Together’ (2013) • Work with the Local Safeguarding Children’s Boards (LSCB) to monitor and improve local safeguarding practice • Audit Trust safeguarding practices and participate in LSCB audit programmes. • Advise and provide assurance to the Trust in regard to the discharge of its responsibilities according to Section 11 of the Children’s Act and to appraise the Trust of pertinent new local, national and statutory guidance as appropriate • Conduct Individual Management Reviews for Serious Case Reviews (SCR) in which the Trust is asked to participate and lead on the implementation of learning from SCR’s.
8. 2 Identifying Children and Young People at Risk • The SCT conduct a ward round Monday – Friday in Child Health areas at DH and at the PRUH, the team can also be contacted by staff by phone or pager. This clinical contact provides an opportunity to talk with individual staff and it provides an opportunity for teaching and sharing guidance. • Out-of-hours staff are supported at DH by a Paediatric Nurse Practitioner and the Paediatric Consultant on call and at the PRUH by the Paediatric Consultant on call • At DH the SCT conducts a weekly meeting to review cases with staff and provide guidance and attends a weekly child review meeting in the ED at DH and the PRUH. The SCT at DH also attends safeguarding case review meetings; twice a month with each of the 3 Havens, monthly with the sexual health team and the paediatric diabetes and respiratory teams • The Named Midwife provides advice and support to maternity staff in the maternity unit at DH and to staff in the community midwifery teams. A weekly safeguarding meeting is held to discuss vulnerable women and is chaired by the Named Midwife at DH. The meeting has multi-agency attendance, including representatives from Lambeth and Southwark Social Care, mental health services and primary care. Women are discussed at or close to the 28th week of pregnancy, plans and actions are recorded detailing which professional is responsible for the required actions • At PRUH the safeguarding midwife maintains a presence in the maternity unit on 3.5 days. Since February 2015, a maternity safeguarding meeting has been held fortnightly
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• The Named Midwife and safeguarding midwife maintain records of babies born at the Trust who are subject to child protection and child in need plans, this information is shared with the ED department. The Named Midwife and safeguarding midwife receive feedback from the ED Child Review Meeting and women are checked against the midwifery electronic record and an ‘alert’ may be added. Where women have been sent from ED to the Early Pregnancy Unit (EPU) for a scan, the Named Midwife will liaise with the EPU to establish outcome and ensure appropriate liaison • Safeguarding supervision is provided to community midwives, case-loading teams and antenatal clinic midwives.
9 Safeguarding Activity
There were 1,150 referrals to the Safeguarding Children Team in 2014 – 2015 that required a safeguarding intervention.
Table 1 No of referrals to SCT
No referrals to SCT 2014 - 2015 2013 - 2014 Oct – Sept Oct – Sept Total 1,150 1,078 DH 785 825 PRUH 365 253
Table 2 DH by boroughs
Borough of 2014 - 2015 2013 - 2014
residence
Lambeth 169 180
Southwark 238 170 Lewisham 62 58 Bromley 47 29 Croydon 37 43 Greenwich 26 28 Other boroughs 206 317 Total 785 825
Table 3 DH by referral reasons
Referral reasons 2014 - 2015 Neglect 72 Stabbing 51 Overdose 39 RTA 36 CP plan 34 DNA 29 Domestic abuse 29 Fall from height 28 Traumatic injury 28 Parental mental health 26 Mental health 24 TOP 22 Physical assault 21 Self-harm 21 Physical abuse 19 CIN plan 18 Sexual abuse 18 Parental ill-health 16
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Sexual health 15 Child Sexual Exploitation 14 LAC 14 Sexual assault 14 Burn 13 Parenting issue /Poor parenting 15 Dental neglect 10 Emotional abuse 10 NAI 10 Non-compliance 10 Parental non-compliance 10 Complex health needs 9 NAHI 9 Dog bite 6 Fabricated illness 6 Parental alcohol misuse 6 Complex social needs 5 Head injury 5 Parental substance misuse 5 Substance misuse 5 Suicidal ideation 5 Delay in presentation 4 Ingestion 4 Rape 4 Cyber bullying 3 Historic sexual abuse 3 Shooting 3 Missing child 2 Near drowning 2 Other 2 Physical injury 2 Referral for early help 2 Sexualised behaviour 2 Suffocation 2 Young carer 2 Alcohol misuse 1 Bruises 1 Eating disorder 1 Failure to thrive 1 FGM 1 FGM risk 1 Gang assault 1 Historic forced marriage /trafficking 1 Homelessness 1 Honour based violence 1 House fire 1 Injection 1 No recourse 1 Parental overdose 1 Parental self-harm 1 Pregnancy 1 Private fostering 1 Section 47 1 Separated family 1 Shaken baby 1 Witch craft/spirit possession 1 Total 785
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Table 4 PRUH by boroughs
Borough of residence 2014 - 2015 2013 -2014 Bromley 260 73 Croydon 31 29 Lewisham 13 9
Greenwich 18 8
Other boroughs 43 21 Total 365 140
Table 5 PRUH by referral reasons
Referral reasons 2014 - 2015 DNA 38 Neglect 37 Overdose 27 Mental ill-health 23 Parental mental health 18 Physical abuse 15 CP plan 14 Traumatic injury 14 Substance misuse 13 Self-harm 10 Sexual abuse 10 LAC 9 Sexual health 9 Complex health needs 8 Parental substance misuse 8 Vulnerable parent 8 Complex social needs 7 CIN plan 6 Parental poor compliance 5 Parenting issues/Poor parenting 5 Child Sexual Exploitation 4 Delayed presentation 4 Domestic abuse 4 Domestic Violence 4 Head injury 4 Other 4 Parental overdose 4 Physical injury 4 Alcohol misuse 3 Anger management/aggressive 3 behaviour Burn 3 Non compliance 3 Parental ill-health 3 Physical assault 3 Pregnancy 3 RTA 3 Bruises 2 Emotional abuse 2 Fabricated illness 2 Fell from height 2 ICO 2 NAI 2 Poor supervision 2
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Section 47 2 ADHD/Autistic spectrum 1 Dog bite 1 Failure to thrive 1 Historical sexual abuse 1 Homeless/inadequate housing 1 Poor physical health 1 Private fostering 1 Witch craft/spirit possession 1 Young carer 1 Total 365
Table 6 No. of children reviewed at Paediatric Safeguarding Review Meetings at Denmark Hill
2014 - 2015 Emergency 2982 Department Havens 438 Sexual Health 141 Respiratory 25 Diabetes 28
Table 7 No. of children reviewed at Paediatric Safeguarding Review Meetings at PRUH
2014 - 2015 (April – Sept 2015 ) Emergency Department 575
9.2 Midwifery There were 5,348 births at Denmark Hill; 138 babies were placed on a pre-birth CP or CIN plan. There were 4,687 births at the PRUH ; 43 babies were placed in CP or CIN plan.
Table 8 Midwifery DH
2014 - 2015 2013 - 2014 Total number of registerable 5,348 5,270 births Number of unbooked women 17 22 presenting birth Number of women discussed 346 415 at Maternity Safeguarding Meeting Number of CP plan 87 89 Number of CIN plan 51 47 Number of ICO 24 38 Police Protection Order 8 4
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Table 9 Midwifery PRUH 2014 - 2015 2013 - 2014 Oct 14 – April 14 – Sept 15 Sept 14, not from Oct 2013 Total number of registerable 4,687 2,335 births
Number of unbooked women 4 2
presenting birth
Number of women discussed 318 248
at Maternity Safeguarding
Meeting
Number of CP plan & CIN plan 43 19
Number of ICO 1 4
Table 10 Total no. of babies and children reviewed by the Trust at Safeguarding Review Meetings Total number of babies 4,853 and children reviewed by the Trust at safeguarding review meetings Emergency Department 2982 (DH) Havens 4 38 Sexual Health 141 Respiratory 25 Diabetes 28 Emergency Department 575 (PRUH) Number of women 346 discussed at Maternity Safeguarding Meeting (DH) Number of women 318 discussed at Maternity Safeguarding Meeting (PRUH)
9.1 Actions raised in the annual report 2013-2014 The 2014 annual report recorded that safeguarding in maternity had been added to the Trust’s risk register. This was due to the high level of demand for advice and support at DH and that the safeguarding midwife at the PRUH was part-time and also held responsibility for pregnant women with mental ill-health. At the time of this report demand for support and advice at DH remains the same. A job description has been formulated for an 0.6 WTE specialist midwife for mental ill-health at the PRUH. It is essential that this aspect of the safeguarding midwife’s role is designated to a specialist midwife, to increase capacity in advising on safeguarding matters and to allow development of a specialist mental health role.
10. Training
10.1 In January 2015, the Trust achieved a compliance rate of 80% in safeguarding children training. 129 face to face training sessions were provided at levels 2 and 3. However, at the time of this report WIRED reported a compliance rate just above compliance at level 3 and below compliance at level 1 and 2.
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Table 11 Percentage of staff who received safeguarding children training DH
Level Sept 2015 Sept 2014 Level1 72.3% 91.4% Level 2 77.0% 71.0% Level 3 80.0% 82 .0%
Table 12 Percentage of staff who received safeguarding children training PRUH
Level Sept 2015 Sept 2014 Level1 83.8 % 75.1% Level 2 77.8 % 34.0% Level 3 83.3 % 63.6%
10.2 Staff were also advised about safeguarding children matters through a Safeguarding Children E-bulletin. The following bulletins were sent out in this reporting period: • ‘Protecting patients from abuse’, the conviction of Dr Myles Bradbury • ‘Neglect’: Serious Case Review Child I (Lambeth), Practice Review Child S (Southwark), Safeguarding Board multi-agency audit on neglect cases (Bromley) • ‘Serious Crime Act, 2015’ • ‘Female Genital Mutilation’ mandatory reporting.
An on-line training link for female genital mutilation and child sexual exploitation was also sent out.
10.3 Midwives were provided with training on female genital mutilation at their annual update. Staff in Sexual Health, the Havens and the young persons midwifery group attended additional training on child sexual exploitation. Several staff attended training by Barnardo’s provided by the Lambeth Safeguarding Children’s Board and training by BASHH.
10.4 FGM ‘champions’ were recruited in the Havens, the Emergency Department and Sexual Health, who were provided with additional training. A female genital mutilation and child sexual exploitation a study day has been planned for senior maternity staff in October 2015.
11. Service Development in the Trust
11.1 Maternity Traditionally midwifery care has been provided by the antenatal clinic, geographically based community midwifery teams and case-loading teams. The aim of the review is to support increased access to the service, ensure women with medical and social needs are supported and improve continuity of care. In September, 4 new community teams and 4 new case loading teams were formed. A new post of specialist midwife for migrant women was also created and the high risk midwifery medical team enlarged.
11.2 The Havens The Havens safeguarding meetings at Camberwell, Paddington and Whitechapel reviewed 438 children , the young person’s advocate has worked to ensure that under 14’s are appropriately followed –up and supported in their boroughs of residence.
In March 2015, the paediatric medical lead, the review lead and a clinical lead for the Haven, examined the pathway for the support of children in London following sexual assault, on behalf of NHS England (London). 200 stakeholders involved in the care of sexually abused children were interviewed for the Haven review. Each year approximately 400 children attend the Havens for a forensic medical examination. However, recently published studies have suggested that the number of children assaulted in London is likely to be in the region of 12,540, with only a quarter of assaults being reported to the police by young people or their families (NSPCC, 2014). The Havens do not provide after - care for children and are dependent on commissioned services in the London boroughs to support vulnerable children.
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The review identified inequity in services provided for children by the boroughs. The review recommended that there should be development of services for children in London and suggested 3 options: • A ‘children’s house’ model where children receive a forensic examination and follow- up care including psychological support in one place, London would need at least 3 centres. • Development of paediatric services in the Havens along with 2-4 other ‘hubs’ in London. • Individual services commissioned across London to support children.
In November 2015, children who attend the Camberwell Haven will be seen in a designated paediatric area which is separate from the adult service. There will also be an increase in senior paediatric medical support to children, with two posts being created, a 0.6 WTE registrar and 0.5 paediatric consultant. Children will continue to be supported by the children’s advocate but psychological support will be increased with a new psychological support service provided by the South London and Maudsley Mental Health Trust.
12. Audit During this reporting period the SCT has regularly evaluated interventions undertaken to safeguard children, to provide assurance that the Trust is making a positive difference to children’s lives. 11 audits were carried out and the Trust participated in 3 multi-agency audits.
12.1Neglect audit (DH) The audit sought reassurance that when a neglected child attended the Trust they were identified promptly, their neglect was addressed and information was shared with agencies. Findings 53 children who attended the Trust in October 2014, were identified by the audit. 45 had come to physical harm and 8 had not had their basic health needs met. 52 children were identified at the primary examination in ED and the safeguarding team informed and neglect issues were addressed. 1 child was identified by the ED review meeting. Information sharing protocols were followed in all 53 cases. This provides assurance that the Trust is identifying children at risk of neglect and staff are complying with information sharing protocols.
12.2 Domestic violence audit (DH) In response to finding 1 in the Serious Case Review Child H (Lambeth) where a child died from physical injuries and domestic violence had been a feature in the family, a domestic violence audit was carried out. Findings The audit was completed between January – March 2015 and included 20 adults who were parents who reported domestic abuse. Domestic violence was also a feature for 9 children who presented for care. 2 children reported current domestic abuse, 1 was injured during domestic abuse and 6 children had experienced domestic abuse in the family home at some time. All the families were provided with information about domestic violence advocacy services, discharge plans were recorded and information sent to social care agencies. 19 cases with a domestic violence component were reviewed also at the midwifery safeguarding meeting.19 women were provided with information about domestic violence support agencies and 19 referrals were made to social care. This provides assurance that domestic violence protocols are being followed by staff.
12.3 Adherence to ‘Was Not Brought’ (DNA) policy audit (DH) Non-attendance at health appointments is often a feature in child abuse and neglect. The Trust DNA policy has been in place since 2011.The audit was complicated by multiple record-keeping systems in 11 specialities and in particular use of ‘outcome’ recording. It was noted that the diabetes and respiratory teams concerned about DNA’s, met regularly with the safeguarding team to discuss patients.
Findings After the first DNA 16% of parents were written to.
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8% were telephoned. Where there had been more than 1 DNA, 50 % of parents were written to and 25% were telephoned. Actions Following this audit, a DNA policy and procedure promotion month was held in July. Every consultant was written to by the Named doctor and a poster with the ‘Was Not Brought’ pathway was displayed in each clinic room.
12.4 Young persons midwifery group notes audit (DH) This audit was carried out in response to the Trusts recommendations in a Homicide Review in 2013. 10 sets of notes from October 2014- May 2015 were audited. There were 5 audit questions seeking documentary evidence that the young person was asked about the baby’s father and who was present during a pregnancy and delivery. Findings There was 100% adherence to 4 of the documentary recommendations. But only 2 sets of notes included information about postnatal visits. But 3 mothers were cared for by other Trusts in the post-natal period, 4 sets of notes did not have postnatal documents filed, 1 baby was cared for in SCBU so home visits were not undertaken. Actions Feedback was provided to the young persons group, audit outcomes will be included in midwives mandatory training in 2016. Record keeping was raised at the maternity risk management meeting.
12.5 Young persons midwifery group notes audit (PRUH) This audit was carried out in response to the Trusts recommendations in a Homicide Review in 2013. There were 6 audit questions seeking documentary evidence that the young person was asked about the baby’s father and who was present during a pregnancy and delivery. Findings All young people were asked about the father at booking,8 had information about who accompanied the young person to clinic,7 had records about who was present during antenatal visits,6 sets of notes had information about who was present at the deliver, only 1 set had information about postnatal visits. However, 1 mother was cared for by another Trust in the postnatal period, 1 set of notes was incomplete, 2 mothers had not yet delivered. Actions Feedback was provided to the young persons group, audit outcomes will be included in midwives mandatory training in 2016. Record keeping was raised at the maternity risk management meeting.
12.6 Confidence to safeguard children after level 2 training audit ( PRUH) Staff confidence and competence following level 2 safeguarding training was audited to ensure that training is equipping staff to carry out their safeguarding responsibilities. 60 evaluation forms completed at the end of a training session were randomly selected. Participants completed questions to assess confidence in 7 safeguarding domains. The majority of staff reported feeling ‘confident’ or ‘fairly confident’ to safeguard children at the end of the training.
12.7 Confidence to safeguard following safeguarding training level 2 (DH) Staff confidence to safeguard children after training was audited to ensure staff remained confident to safeguard children following training. 10 staff completed a questionnaire 3 months after completing training. There were 7 audit questions about understanding child maltreatment, policies and procedures, sharing information, seeking advice and listening to children. 9 out of10 staff reported they were confident or fairly confident to safeguard children.1 staff member consistently scored ‘some confidence’. He was contacted to understand more about his response. He reported that he had not used his training and therefore did not know if he would be confident when he came across a safeguarding issue.
12.8 Confidence to safeguard following safeguarding training level 3 (DH & PRUH) Staff confidence to safeguard children 3 months after undertaking level 3 training was audited, to ensure that training is equipping staff to safeguard children.16 staff returned a questionnaire. There were 7 audit questions about understanding child maltreatment,
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policies and procedures, sharing information, seeking advice and listening to children and acting on concerns.16 out of 16 staff reported that 3 months following their training they felt confident or fairly confident to recognise child maltreatment and neglect and safeguarding children.
12.9 Young persons experiences of being safeguarded by the Trust (DH) Young people admitted to the Trust between January and March 2015 were asked to participate in an audit to understand their experiences of being safeguarded by the Trust. 7 young people returned a completed questionnaire.1 had come to physical harm following the ‘spiking of a drink’, 3 had been stabbed, 2 physically assaulted, 1 sustained a traumatic injury after falling off a moving vehicle. All of the young people reported that they found being spoken to by a member of the safeguarding team helpful because: it provided support/ someone listened /made them feel safe. 5 were aware of safety measures being taken on the ward to keep them safe.5 were aware they were given advice about their safety after discharge. 6 were aware that their admission was discussed with social care and 4 understood why. 4 also met a youth worker (Redthread), 2 met with a member of CAMHS liaison. This audit provided assurance that safeguarding interventions are viewed in a positive light by young people.
12.10 Safeguarding children: How are we doing? (DH) A questionnaire was formulated to ascertain parental experiences where their young child has been safeguarded by the Trust. Only 4 questionnaires were returned by parents, therefore this audit will be continued in 2016.
12.11 Audit of children under 1 attending the ED following a physical injury (DH) Following Serious Case Review Child I (Lambeth, 2014), The Trust recommended that children under 1, with a child protection plan, who present to ED with a physical injury, should be reviewed by the safeguarding children team. The audit reviewed 32 under 1’s who attended ED in May 2015. 1 child was on a child protection plan and they were referred to the safeguarding children team.
12.12 Neglect multi-agency audit (PRUH) Neglect has been a key theme for the Bromley safeguarding children board and in 2011; neglect was a feature in a Serious Case Review (Child D and B). A multi-agency audit of neglected children was completed in March 2015. The audit found that neglect cases require robust management to prevent drift. Too many children continue in a cycle of improvement and then decline, as children have been stepped down from child protection too quickly. Where there are complex developments or medical needs there can delay progressing cases. Further challenge of parents and professionals must take place. Actions These key findings were included in safeguarding training and sent out via an E-bulletin to staff.
12.13 CSE multi-agency audit (PRUH) An audit of 18 children referred to the MASE panel was carried out in January 2015. Children had been seen at the PRUH. The PRUH appropriately referred these cases to children’s social services. The audit recommended that Bromley’s CSE strategy is reviewed annually. Children with learning difficulties and autism were found to be more vulnerable to exploitation. Actions Key findings were included in safeguarding training.
12.14 Domestic abuse audit (PRUH) An audit of 10 cases, where children had been subject to a Child Protection Plan and domestic abuse was a contributory factor. 2 cases were subject to a Child In Need (CIN) plans, 1 of had recently been stepped down to CIN from CP and 1 had been transferred from another borough .The cases sampled were mixed in terms of multi-
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agency involvement, ages of children, disability and ethnicities. The Trust was able to contribute to 1 case as the mother received maternity care at the PRUH.
Findings The LSCB should consider how:
• child protection plans should reference how the child/young person will be involved in the plan and how their wishes and feelings will be communicated to the multi-agency network.
• child protection plans should reflect the work and contribution of all agencies who do direct work with children e.g. schools. • that strategy meetings are multi agency (with CSC, police and health as a minimum) and an agreed record which is distributed to all parties • agencies are aware of the escalation process and how to use it to raise concerns to senior managers.
• information sharing protocols ensure that information about domestic abuse and domestic violence in families is shared with all agencies. Actions Audit findings will be reported to the Steering group at the PRUH and sent out to staff via an e-bulletin.
13. Serious Case Reviews/IMR’s
13.1 Homicide Review (Southwark, 2013). Actions required: Audit of young person’s midwives documentation was completed at DH and PRUH and presented to the Safeguarding Children Committee in September 2015.
13.2 SCR Child I (Lambeth). Actions required: Monitoring of midwives attendance at supervision. Review of midwives providing written information to health visitors where there has been slow neonatal weight gain. Audit of under 1’s presenting with a physical injury who are on child protection plan, a second audit will be carried out at the end of 2015, due to low numbers of children presenting in the initial audit period.
13.3 IMR Child KL (Lambeth). Actions required: IMR completed waiting to be discussed at the Lambeth Serious Case Review panel.
13.4 Child J (Lambeth). Actions required: Chronology submitted.
13.5 SCR (Sutton) Serious Case Review published March 2015. There were no actions for the Trust.
13.6 Case Review Child G (Lambeth). Action required: a root cause analysis was completed and submitted to the SCR panel.
13.7 Child JR (Hillingdon).Action required: Chronology submitted.
14. Child Deaths
14.1 59 child deaths were reported to the Safeguarding Children Team between 1st October 2014 to 31st September 2015.
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Table 13 Number of deaths of a child or young person Child death Number of child death Number of child death incidents incidents 2015 2014 Expected 38 43 Unexpected 21 20
Table 14 Number of deaths by borough Boroughs Number of child death Number of child death incidents incidents 2015 2014 Southwark 12 12 Lambeth 11 12 Lewisham 8 4 Bromley 5 5 Other non-local boroughs 23 30 Total 59 63
14.2 Unexpected deaths/serious incidents 1. Maternal and neonatal death, the baby was born by emergency caesarean section after mother died from sudden arrhythmogenic death syndrome, intensive neonatal care was provided to the baby but the baby died aged 3 days. 2. The High Court was asked to make a ruling for withdrawal of care for a child in SCBU– care was withdrawn. 3. Unexpected death of a 5 year old after a sickle cell crisis (SUI highlighted the importance of listening to parents concerns.) 4. Unexpected death of a baby after induction of labour. The mother had health and social issues, the baby had been issued with a pre-birth child protection plan.
5. Unexpected death of a child who had previously undergone neurosurgery. The child was on a child protection plan at the time of his death. The child was referred to the coronor. The Trust is carrying out an investigation in the care provided.
14.3 Southwark and Lambeth Child Death Overview Panel 2014/2015 • The panel reviews all deaths of children who resided in Southwark and Lambeth. Since April 2008 there have been an average of 67 child death cases each year. The main aim of the panel is to identify if modifiable factors were present which could in the future be prevented. • 31 cases were reviewed this year, 17 were neonates and 14 children. 24 were under 1, 17 under 28 days old. • There was a reduction in the number of children reviewed this year due to administrative challenges (not within the Trust). • Modifiable themes that were identified: sudden unexplained death in infancy, domestic abuse, youth violence and safety in the home.
Recommendations • ensuring staff are trained in providing preventative advice, • encouraging a culture of respectful challenge to assumptions of a child’s safety, • implementation of a public health approach to reducing youth violence (where prevention efforts need to be focused) , • ensuring safety equipment and literature on home safety is available to vulnerable families in Southwark and Lambeth.
More detailed information about the work of the Southwark and Lambeth CDOP can be found in the Southwark and Lambeth CDOP annual report which will be published in November 2015.
14.4 Bromley Child Death Overview Panel 2014/2015
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• The panel reviews all deaths of children who reside in Bromley. Since April 2008 there have been on average 17 child death cases each year. • 17 cases were reviewed by CDOP this year • 7 babies died in the first month of life mostly due to prematurity. There was 1 sudden unexpected death in infancy • There were 10 unexpected deaths (7 were neonates) and 4 expected deaths. Recommendations • Siblings of children who die from congenital heart disease should have a cardiology review • There is a continuing need for health education on safe sleeping and smoking when vulnerable babies are discharge from hospital into the community • The PRUH bereavement midwife to attend the CDOP panel • Training on substance misuse should be provided for agencies • BSCB leaflet ‘When a child dies’ should be updated.
Detailed information about the work of the Bromley CDOP will be available in the Bromley CDOP annual report which will be published in December 2015.
15. Report from the Safeguarding Children Committee
15.1 The Committee During this reporting period the Safeguarding Children Committee received reports on the Trust’s participation in SCR’s and IMR’s /Case Reviews. The Committee monitored the safeguarding children training plan and received progress reports on the Trust’s response to child sexual exploitation and the support and training provided to staff to identify children at risk. The Committee received progress reports on the development of joint guidance by the Southwark and Lambeth boards on female genital mutilation to which the Named Nurse and Named Midwife contributed and which is due to be ratified by the safeguarding children boards in November 2015. 12 audits were also presented to the Committee.
15.2 Child Protection Information Sharing project (CP-IS) The Committee received regular updates on the Trust’s progress with implementation of the CP-IS. The Trust will be ‘going live’ in November 2015 when an electronic alert will appear on the screen in ED when a child on child protection plan or is child looked after by the local authority, attends and their local social care have subscribed to the CP-IS information sharing process. To show national progress of the CP-IS project, a map has been developed to give clear indication of where local authority or NHS unscheduled care partners have adopted CP-IS. The map identifies: • NHS unscheduled care sites in England that are using CP-IS (and those that have committed to using CP-IS soon) to view Child Protection Plans and Looked After Child information. • Every local authority in England and their status in sharing Child Protection Plans and Looked After Child information using CP-IS. • By 2018 80 % of NHS Urgent care facilities should be integrated with CP-IS.
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15.3 Performance dashboards The Committee was informed that in 2013, the health partners of the Southwark Safeguarding Children Board had been asked by the Chair to contribute health data to a performance dashboard. The dashboard would include safeguarding activity, thresholds, and quality and outcome measures for all the boards’ partners. Work was commenced by the health partners to find data that would inform the board, but the work was held up. The current Chair of the Southwark board asked the health partners to recommence this work. Health partners were supported by the interim Designated Nurse Southwark to formulate a dataset, this was then finalised by the newly appointed Designated Nurse Southwark.
Providing data has been a considerable challenge for the SCT where data collecting systems other than the Trusts own governance reporting, have not been in place. Further work will be carried out in the next reporting period to address this difficulty.
The Bromley board has acknowledged the work by the health partners in Southwark and they have accepted the same data for the Bromley board. The interim Chair of the Lambeth board has not chosen to adopt the same dataset for their health partners, however, the dashboard that is under development makes few demands on health partners from the acute Trusts.Should this change, health partners will again request that the Southwark dataset is accepted.
Quarterly Safeguarding Performance Data for Children from NHS Health Organisations to the SSCB
2015/16 Target Q1 Q2 Q3 Q4 Comments April-June July -Sept Oct - Dec Jan - March 1.Leadership and Workforce Number of incidents of allegations against staff working with children Number of those allegations reported to the Designated Officer for the Local Authority (Working Together2015) % Staff vacancies within:- Paediatrics Special Care Baby Unit Maternity % Staff sickness within:- Paediatrics Maternity Special Care Baby Unit 2.Training - % Eligible Staff up to date with the following levels Level 1 Level 2 Level 3 Level 4
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2015/16 Target Q1 Q2 Q3 Q4 Comments April-June July -Sept Oct - Dec Jan - March 3.Safeguarding Supervision - Number of staff requiring Safeguarding Supervision % of staff up to date with Safeguarding Supervision Paediatrics
Maternity
5.Safer Recruitment Practices % of managers (who interview staff) trained in safer recruitment % of staff with up to date with Disclosure and Barring Service checks 6. Vulnerable Groups Please add other additional information that is relevant to this section Number of children missing appointments Number of Children missing appointments referred to the safeguarding team No. of late bookers to maternity > 20 weeks No. of children under 16 attending the sexual health clinic Number of Serious Incidences (SI) involving children Number of active Serious Case Reviews (SCR)/ Individual Management Reviews (IMR) FGM notifications –pregnant women No. of children presenting to the Emergency Dep.
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2015/16 Target Q1 Q2 Q3 Q4 Comments April-June July -Sept Oct - Dec Jan - March with:- Suicide Self-harm Suicidal thoughts Overdose Other Mental Health issues Substance /Alcohol Misuse Stabbings Shootings
16. Report from the Steering Groups During the period of this annual report the steering groups at DH and the PRUH reviewed progress against the training plan and reviewed the impact of the safeguarding e-bulletins to ensure that these are meeting staff information/training needs. Multi-agency threshold guidance was reviewed and at the PRUH the positive outcomes from the changes to the maternity safeguarding meeting were reported. Multi-agency audits were reported. Trust actions to ensure children at risk of female mutilation and child sexual exploitation were reviewed. At DH Lambeth’s Ofsted inspection findings were considered and findings from the Southwark /Lambeth CDOP panel. Findings from the Bromley CDOP will be considered at the PRUH Steering group in 2016.
17. National and Local Guidance
17.1 Serious Crime Act (2015) The Serious Crime Act received Royal Assent on 3 March 2015. Part 5 of the Act makes a number of changes to protecting children from abuse, protecting girls from female genital mutilation (FGM) and strengthening the protection afforded to victims of domestic abuse. For a summary of the Act see appendix 3.
How will the amendments to the 1933 Act affect our safeguarding work? In regards to psychological harm staff will be required to consider more fully the psychological evidence of harm when writing reports following physically abusive acts on children.
In 2013-2014 the Trust cared for 3 children following concerns about suffocation. In each case consideration was given to the possible influence of non-prescribed medication.
The Act adds the weight to the advice and guidance already provided to health professionals about our duty to identify and protect girls at risk of FGM. The Trusts safeguarding policy and procedures includes guidance on information sharing. The annual report (October, 2014) included the steps the Trust had taken to educate and support staff to identify FGM. Training provided in level 2 and 3 safeguarding children training was refreshed and in January 2015, FGM was added to midwives annual mandatory training. In ED staff have received FGM training in level 2 and 3 safeguarding training and both adult and paediatric ‘FGM champions’ have been identified who have received additional training on high risk cultural and ethnic groups , high risk presentations and making sensitive enquiry. Where FGM is identified in NHS patients it is mandatory to record this in the patient’s medical record along with any discussions or actions taken. Since September 2014, the Trust has provided a monthly report to the Department of Health on the number of patients who have disclosed that they are survivors of FGM.
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17.2 New Guidance The DfE published the following in March 2015 ‘Working Together to Safeguard Children’. Key changes include clarification of the processes for managing allegations against professionals, the notification of serious incidents to Ofsted and consideration of cases for Serious Case Reviews. ‘Information Sharing: Advice for practitioners providing safeguarding services to children, young people, parents and carers.’ ‘What to do if you are worried a child is being abused: Advice for practitioners”.
DfH published ‘Female Genital Mutilation Risk and Safeguarding: guidance for professionals’ March 2015.This information has been sent out to staff by E-bulletin/ the safeguarding KWIKI page has been updated and it has been added to safeguarding training.
NHS England refreshed ‘Safeguarding Vulnerable People in the NHS’ in July 2015 and Managing Safeguarding Allegations Against Staff Policy and Procedure in June 2015.
Refreshed LSCB guidance “The Child’s Journey in Bromley- Partnership Threshold Guidance” (June 2015). “Southwark Threshold Document” (2015).
17.3 Complaints There was 1 safeguarding complaint during this reporting period. The complaint was made by a parent, 15 months after their child was sent to ED in an ambulance by the G.P. The child sustained a head injury and was admitted to one of the paediatric wards. The child’s parent felt the Trust’s safeguarding investigation into the injury and delay in seeking medical attention, took precedent over the medical intervention. This was not upheld by the Trust.
18. Recommendations This report provides assurance that the Trust is discharging its responsibilities under Section 11 requirements. However, our continued performance depends on Trust staff receiving safeguarding training that enables them to identify and protect children at risk of harm and an accurate record of that training is available. The WIRED system is not currently recording training to the level of accuracy that is required.
The Head of Nursing Safeguarding Children will continue to address the performance management issues in the SCT at the PRUH, to ensure the team is able to support safeguarding activity to a high standard.
Safeguarding in maternity remains on the Trust at risk register. The role of specialist midwife for mental ill-health at the PRUH must be developed.
Should there be any further development of services by the Trust in 2016, provision of safeguarding advice and support to that service must be considered, as the team has no capacity to engage in more activity.
The Trust is committed to supporting the Lambeth Safeguarding Board action plan to ensure that improvements are implemented as quickly as possible.
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Enc. 2.3.4
King’s Quality Account Review of current Quality Priorities and Developing Priorities for 2016 / 2017
January 2016 Enc. 2.3.4
PartialPartial PATIENT OUTCOMES OnOn targettarget Not on target achievementachievement Quality Priorities 2015/2016
Patient Outcomes – Working to reduce preventable ill-health - Objectives Status
• Develop KCH and PRUH as ‘health promoting hospitals’, continuing the culture change that started in 2014/15 to make health promotion mainstream. • Increase the number of staff trained to support patients in reducing smoking /harmful alcohol use; • Increase provision of advice and brief interventions relating to • smoking and harmful alcohol use; • Increase referrals into smoking cessation and alcohol services; • Work with the providers of hospital food, both on the wards and in our cafes, to promote and deliver healthier food; • Review ways in which we can increase promotion of exercise to • improve health; • Continue work to implement NICE public health guidance. Patient Outcomes – Improving outcomes following hip fracture - Objectives Status
• Increase the proportion of patients getting the surgery they need to repair their hips in under 36 hours. • Ensure that all patients receive the physiotherapy they need. • Ensure effective shared care between orthopaedics and geriatrics. Increase the proportion of patients who have a geriatric assessment within 72 hours. • Ensure all patients are tested for delirium before and after surgery. • Ensure all patients have a falls assessment and a bone health review. • Increase the proportion of our patients who have an admission anaesthetic review prior to surgery, to ensure that our patients are in the best health for surgery. • Our work in 2015-16 will focus on the care pathway for hip fracture patients on both of our acute 1 hospital sites, Denmark Hill and the PRUH. Enc. 2.3.4 Patient Outcomes – Working to reduce preventable ill- health: What have we achieved?
Alcohol and smoking screening have been rolled out to 16 wards at DH (3 more during Q4) and 10 wards at PRUH ( 2 more during Q4)
Brief intervention is given to all patients that smoke, and those who score higher than 3 on the FAST audit tool for alcohol.
Staff on all wards are working towards completing alcohol and smoking training to support screening and brief intervention. Senior clinical and nursing leads also completing this training.
Both sites now smoke free, and patients are offered Nicotine Replacement Therapy during their stay.
CO monitoring launched on RD Lawrence ward and being extended into Annie Zunz ward in Q4.
Increased referrals for smoking during the last quarter.
Medirest and ISS are reviewing their food provision and launching some excellent initiatives across both sites for both patients and staff.
The Department of Health’s Prevention, Obesity and Diabetes team visited some TEAM wards and are working with the Head of Nursing for Trauma, Emergency & Medicine and her team to take 2forward obesity screening and related health promotion further. • Enc. 2.3.4 Patient Outcomes – Working to reduce preventable ill- health: What’s missing and what’s next?
• Further roll out to the rest of the wards at DH and PRUH sites.
• Expand screening into Paediatric clinics (asthma in particular) within the 16/17 CQUIN at DH and further develop the screening within Maternity.
• Further staff training and medical engagement to support the nursing staff who are currently completing the screening.
• CO monitoring expansion following launch on RD Lawrence Ward and Annie Zunz Ward.
• Further work in continuing the smoking referrals and reviewing the data to show how many actually quit.
• Reviewing the Alcohol pathways across both sites for those patients who require additional brief intervention.
• Continue to work with Medirest, ISS and the Dietetics department to continue to improve the availability of healthy food and ensure that a well balanced diet is offered.
• Physical activity – draw up plans for delivery of brief advice around physical activity for patients and staff as part of the CQUIN for 16/17.
3 Enc. 2.3.4 Patient Outcomes – Improving outcomes following hip fracture: What have we achieved?
• King’s Denmark Hill (DH) is still challenged to get all patients the surgery they need within 36 hours. At Princess Royal University Hospital (PRUH) site, however, most patients receive surgery within 36 hours.
1. Most patients receive the physiotherapy they need and are mobilised out of bed the day after surgery, although this still requires improvement.
2. Most patients, on both KCH sites, receive a geriatric assessment within 72 hours.
3. Most patients, on both KCH sites, are tested for delirium before surgery.
4. With very few exceptions, all patients, on both KCH sites, have a falls assessment and bone health review.
5. The entire care pathway, as represented by achieving the 9 best practice criteria defined by NICE, has improved on both KCH sites.
4 Enc. 2.3.4 Patient Outcomes – Improving outcomes following hip fracture: What’s missing and what’s next?
• Continue to embed the improved care pathway and ensure that results are maintained.
• Reduce time to surgery, particularly on the KCH Denmark Hill site.
5 Enc. 2.3.4 Appendix 1: Hip fracture
• KCH Denmark Hill, results in the National Hip Fracture Database (as at 15/1/16).
6 Enc. 2.3.4
• KCH PRUH, results in the National Hip Fracture Database (as at 15/1/16).
7 Enc. 2.3.4
PartialPartial OnOn target target Not on target PATIENT SAFETY 2013/14 achievementachievement
Patient Safety – Surgical Safety Culture - Objectives Status
• To develop and implement a strategy to ensure the Overall – partial achievement Surgical Safety Checklist (SSC) is integrated into the working practices of all theatre/interventional teams
• Measured through the following outcomes:
o Zero Surgical Never Events 2014/15 = 8 2015/16 = 6 (to date)
o 100% compliance with completion of safer surgical 2014/15 = 100% 2015/16 = 97% (one list in checklist Endoscopy did not have SSC)
o >75% compliance with quality of checks performed 2014/15 = 41% 2015/16 = 61%
The 2015/16 culture survey (done o 20% improvement in Surgical Safety Culture rating Jul 15) differed from the 2014/15 one so results not comparable. Plan is to re-do 15/16 culture survey in Feb 16 & compare 8 Enc. 2.3.4 Patient Safety – Safer Surgery Culture – What have we achieved
• Policy – Safer Surgery Policy updated in line with NatSSIPs requirements – Surgical Count Policy – Site Marking Policy
• Safer Surgery Improvement Group – Monthly review/presentation of incidents – MDT forum for discussion – Helping to standardise practice across range of interventional areas.
• Annual Observational Audit – Showing significant improvement in process measures – Showing improvement in quality measures but still some work to do.
• Guidewire Working Group – Standardisation of CVC equipment and checklist included in pack
• Anonymous Survey – Giving staff a chance to escalate issues not being addressed. Followed up at SSIG. • Increased training and awareness
• Support and develop local variation of SSC – Increases ownership and engagement in checklist 9 Enc. 2.3.4 Patient Safety – Safer Surgery Culture – what’s missing and what’s next?
• Specific slot on new doctors induction & e-learning [Starting Feb 2016]
• Checklist completion data to be published [Underway] − By Theatre & Day of Week & Monthly review by Consultant
• Add ‘Team Brief’ and ‘Debrief’ as a specific time slot on Galaxy to ensure that time is available to perform it & performance can be tracked [April 2016 – in line with Galaxy upgrade project]
• Changes to standardise EPR op note [Spring 2016]
• Combined surgical safety consultant development morning annually (including theatre staff, a human factors component & feedback on Never Events etc.)
• Two ‘Centres of Excellence’ (Cardiac & Neuro) are developing their LOCSSIPs to share good practice. Four areas which have had recent problems (Ophthalmology, Dental, Maternity & Endoscopy) have been prioritised to develop their LocSSIPs
• Audit of implementation of new invasive device insertion sticker and process (2 person contemporaneous check) across all areas (including non-ICU areas) where seldinger technique used [to be tracked via SSIG]
10 Enc. 2.3.4
PartialPartial OnOn targettarget Not on target Quality Priorities 2013/14 achievementachievement
Patient Safety – Medication Safety - Objectives Status
• To improve safety in relation to the prescription and 10-fold dosing errors 2015 administration of medications by stage of the medicines process 8 6 Administration • Measured through the following outcomes: 4
2 Dispensing 0 o Reduction in incidents involving 10-fold errors Prescribing July Nov May Sept June April
March August January October February
December o Reduction in incidents involving administration 2014/15 = 59 incidents of drugs to patients with known allergies 2015/16 = 46 incidents (projected)
o Increase in % of nursing staff passing the drug TBC calculation competency assessment at 100%
o Reduction in the number of medication errors 2014/15 = 79 incidents 2015/16 (projected) = 72 incidents involving the wrong patient
11 Enc. 2.3.4 Patient Safety – Medication Safety – What have we achieved Reduction in incidents involving 10-fold error • “Rule of One” vial promoted in paediatrics in June 2015 • SureMed medication safety alert issued in paediatrics re the risk of tenfold errors in babies under 1 kg • Dose verification chart in development
Reduction in incidents involving administration of drugs to patients with known allergies • Allergy Working Group established – focus of work includes: access to allergy information between primary and secondary care; configuration of allergy fields within the new EPR; update of allergy clinic referral pathway documentation in EPR; structured audit of allergy documentation • Note added to ED CAS card reminding clinicians to check EPMA for drug allergy status
Reduction in the number of medication errors involving the wrong patient • Positive patient identification campaign launched (posters, newsletters, training etc)
Increase in % of nursing staff passing the drug calculation competency assessment at 100% • 6 additional questions added to the Drug calculation competency test 12
Enc. 2.3.4 Patient Safety – Medication Safety - what’s missing and what’s next?
• Reduction in incidents involving 10-fold errors – Dose verification chart in paediatrics to be developed
• Reduction in incidents involving administration of drugs to patients with known allergies – Ongoing work of the Allergy Working Group which will include improving access to drug allergy information between primary and secondary care – DH discharge letters to be amended to include allergy status (part of new EPR upgrade)
• Reduction in the number of medication errors involving the wrong patient – Rollout of patient wristband printers for Minors and UCC in the ED – Re-launch of positive patient ID campaign
• Medication omissions has emerged as a key concern – An analysis of KCH medication errors in 14/15 noted the most commonly reported error related to omissions (18%) – Of 45 errors that were associated with significant harm, 13 were due to omitted medicines
13 Enc. 2.3.4
PartialPartial OnOn targettarget Not on target PATIENT EXPERIENCE achievementachievement
Patient Experience – Improve the experience of cancer patients - Objectives Status
• Ensure that all the core MDT members (doctors and CNSs) are trained in national advanced communication skills training • Ensure that all patients are seen by the CNS/support worker at diagnosis • Increase the number of holistic needs assessments undertaken within 31 days of diagnosis and within 6 weeks of completion of treatment • Ensure all patients receive a FU call from the CNS teams within 48 hours of diagnosis, and within 24 hours of discharge from hospital following treatment • Ensure that the CNS teams to review in-patients at least once during their in-patient stay in order to provide further information and support • Ensure patients and GPs are provided with an end of treatment summary / care plan • Establish health and well-being events for patients (for example HOPE courses) • Undertake specialist training for nurses and HCAs on the in-patient wards • Work with Macmillan to develop the band 4 support worker role in each MDT – an innovative role aimed at helping patients to navigate through their pathways and to provide ‘one to one support’ • Introduce designated nurse led pre-assessment clinics for patients commencing chemotherapy treatment • Continue with the rolling annual internal peer review of each MDT – holding teams to account for progress being made against their patient experience action plans • Develop a designated cancer information hub in the PRUH Chartwell unit and work with Macmillan to ensure that information pods are available in key areas throughout the PRUH • Establish a Trust cancer patient experience steering group Develop KPIs for the CNS teams which aid to hold the teams to account for quality improvements
14 Enc. 2.3.4 Patient Experience – Improve the experience of cancer patients - what have we achieved
• 4 advanced communication courses have taken place over the past two years at a cost of £4,500 per course enabling 40 staff to be trained, a mix of professionals, consultants, Clinical Nurse Specialists and Allied Health Professionals. • The London Cancer Alliance data for 2014 showed that 84% of King’s patients had a nurse contact at diagnosis ranking KCH 7th out of 157 trusts • Peer review meetings have been held with the specialist teams and patient experience continues to be a key element to these meetings • 100% of patients receive a designated nurse led chemotherapy pre- assessment/ new patient talk. Work is currently taking place around ensuring a quality standardised information session takes place across both chemo units.
15
Enc. 2.3.4 Patient Experience – Improve the experience of cancer patients - what have we achieved
• 2 x breast specific Health and Well Being (HWB) sessions have taken place in 2015 approximately 30 patients attended. 1 x generic HWB 2015 with 14 patient’s attending mainly colorectal, a few haematology and 1HPBThere is a plan for 6 events next year, 2 breast, 2 generic DH and 2 generic PRUH. • 3 information stands funded by Macmillan for PRUH to be in place in early 2016 • Chemotherapy unit of the PRUH has been refurbished and opened in December funded by the Chartwell Charity • Successful pilot of a benefits advisor funded by Macmillan for a year for solid tumours at DH and PRUH
16
Enc. 2.3.4 Patient Experience – improve cancer patient experience – what’s missing and what’s next?
• Most specialities are offering patients a HNA at diagnosis. However, there is a need achieve compliance amongst all services. Currently, HNA data for the London Cancer Alliance is collected manually and ideally should move to electronic collection • Trust Cancer Steering Group not established - did identify a group of patients for a User group which had an initial meeting but it was not sustainable within current resource • Phone calls made by the Clinical Nurse Specialists following diagnosis or post inpatient stay will be part of the new KPI’s .
17 Enc. 2.3.4 Patient Experience – improve cancer patient experience – what’s missing and what’s next?
• Successful pilot of a benefits advisor funded by Macmillan for a year for solid tumours at DH and PRUH ran out at the end of 2015, not successful in securing additional funding and exploring an alternative model. • Telephone helpline was initiated in 2014 for cancer patients and has been reliant on funding by the charity and now needs substantive funding. • Need to improve the number of end of treatment summaries and end of treatment care plan (also part of the new KPI’s ). • Awaiting results of the 2015 National Cancer Patient Experience Survey – fieldwork currently underway
18 Enc. 2.3.4
PartialPartial OnOn targettarget Not on target Quality Priorities 2013/14 achievementachievement
Patient Experience – Improving experience and co-ordination of discharge - Objectives Status
Denmark HIll Optimise Integrated Care: a) Southwark and Lambeth Integrated Care (SLIC): Achieve integrated working in the hospital environment building better communications between all parties (internal & external) to facilitate safer patient discharge. b) SLIC: Increase and embed Care home interface meetings- group including hospital and care home managers to enable effective admission and discharge communications. c) Continue to increase usage and profile of Homeless team. d) Increased usage of @Home service across all specialties.
Improve safety and experience for our patients a) Improve timeliness and quality of information around medications for patients and carers. b) Commit to Care ward accreditation system discharge indicators to be green across the organisation. c) Telephone follow up calls to embedded and routine in all appropriate in patient wards areas (50% in first 6/12 up to 85% by year end). d) Ensure all in patient wards have individual actions plans to improve discharge, share good practice and innovative ideas. e) Ensure all patients who have received care from a therapist has a detailed discharge summary sent to GP. PRUH Increase the number of discharges before 11:00 Ensure a robust referral system to external agencies, Bromley Health and Medihome
Implement criteria led discharge throughout medicine and surgery Commit to Care ward accreditation system discharge indicators to be green across the organisation Telephone follow up calls to embedded and routine in all appropriate in patient wards areas(50% in first 6/12 up to 85% by year end) 19 Enc. 2.3.4 Patient Experience – Improve patient information and co-ordination of discharge – what have we achieved
Denmark Hill Optimise integrated Care • Integrated Hospital Discharge Team – learning from the Donne Ward pilot now informing future working arrangements for all parties involved in safe and timely discharge planning across our wards. We are also working with partners to simplify assessment paperwork associated with complex discharges. • We have signed off and are rolling out the Best Practice Discharge Policy – as developed by all partners across Lambeth, Southwark and Bromley.
DH - Improve safety and experience for our patients • Both sites are consistently above benchmark of 75% for patient involvement in discharge as part of How Are We Doing survey. DH range 81-85% PRUH range 79-83% • Telephone calls were not chosen by wards to take forward but other innovations are evident for example one ward building and piloting a ‘bus stop’ that stops doctors starting their ward rounds without the nurse in charge being present to improve communication and discharge planning • C2C now partially rolled out across the Denmark Hill site and where required wards have individual action plans around discharge. • Robust pilot completed of a care bundle for patients being discharged to care homes from wards and ED currently being evaluated. • Patient feedback re information around medications is now being collected. Question - Have you received enough information about your medication during your stay? 92% in December 2016, steady rise over 6 months form 55%
Enc. 2.3.4 Patient Experience – Improve patient information and co-ordination of discharge – what have we achieved
PRUH No report available
21 Enc. 2.3.4 Patient Experience – Improve patient information and co- ordination of discharge – what’s missing and what’s next?
• Denmark Hill We are planning to collocate all key staff (social care and health) involved in the planning and coordination of complex discharge arrangements for our patients. We will be exploring how we capture and track the details of this coordination and how we communicate between partners to minimise risk and improve the experience for patients and carers.
Discharge is anticipated to be the subject of both a national and a local CQUIN for 2016/17.
22 Enc. 2.3.4 Longlist for suggested priorities for 2016
• OUTCOMES • Improving outcomes for patients with sepsis • Improving outcomes for patients undergoing emergency abdominal surgery • Improving outcomes for patients following planned major surgery
• SAFETY • Never Events –“improve safety in invasive procedures”). • Sepsis (improvement of its recognition, management and escalation) • Reduce Medication Omissions
• EXPERIENCE • Improving staff health and wellbeing to improve patient experience • Improving outpatient experience • Improving accessible information for disabled people
23 Enc. 2.4.1
Finance Report
Month 9 (December) 2015/16
Public Board 2nd February 2016 Enc. 2.4.1
Report to: Public Board Date of meeting: 2nd February 2016 Subject: Finance Committee Report – Month 9 (December 2015) Author(s): Simon Dixon, Nicola Hoeksema Presented by: Colin Gentile, Chief Financial Officer Sponsor: Colin Gentile, Chief Financial Officer History: First submission to Finance and Performance Committee Status: Decision/Discussion/Information
1. Purpose . The Finance Reports includes information on the Trust’s financial performance and position which support the in-year submissions to Monitor on a quarterly basis. . This report covers the Income & Expenditure position, Cost Improvement Programme, Capital and Working Capital Plans.
2. Action required . The Board is asked to approve the Finance Report
Page 2 Enc. 2.4.1
3. Key implications
Legal: Reporting to Monitor and Commercial Bank
Trust reports financial performance and position against published plan and notifies the Financial: committee of financial risks, cost pressures and action plans to mitigate any material variance from financial targets. The summary and appendices provide assurance that the Trust is meeting Financial targets Assurance: (internal and those set by Monitor) and is compliant with its terms of authorisation.
Clinical: There is no direct impact on clinical issues
Equality & Diversity: There is no direct impact on E&D
Financial Performance against annual plan, budgets, CIPs and Monitor Risk Ratings and Performance: Limits.
Strategy: Performance against the Trust’s Annual Plan including Risk Ratings
There are implications for workforce recruitment in respect to service developments and Workforce: vacancies.
There are implication on the Trust’s estates strategy. Estates:
Finance Committee Report is provided to Monitor and Commercial Bankers as additional Reputation: information to support the quarterly Monitor Return.
Other:(please specify) None.
Page 3 Enc. 2.4.1 Key Messages
1. The Trust is £71.9m overspent at month 9 against a year end plan of £65m deficit.
2. Given the level and rate of deficit, the Trust has put in place a mitigation plan to manage the position back to £65m by the close of the financial year. The plan has strong focus from the executive team.
3. For the mitigation to be effective the Trust needs to deliver to the planned profile for months 10 to 12, with particular emphasis on CIP delivery and continued cost containment. The Trust will also need to manage the risk of fines/penalties and data challenges from NHSE specialist commissioners. We are meeting with NHSE with the aim to resolve this prior to the completion of month 10.
4. The cash flow is being managed to not exceed the current approved working capital facility of £98.9m. This is underpinned by tight management of accounts payable, with an additional focus to recover NHS Commissioner contract over- performance debts as year end approaches. The mitigation plan should also deliver cash benefits to enable the Trust to stay within the approved working capital facility.
Page 4 Enc. 2.4.1 2015/2016 Forecast
M9 YTD Forecast Forecast Actual M10 M11 M12 Outturn Ambulatory Services and Local Networks (5,501) 455 193 116 (4,737) Critical Care Theatre & Diagnostic Serv (6,330) (686) (944) (83) (8,043) Liver, Renal and Surgery (27,027) (2,360) (2,362) (2,407) (34,155) Networked Services (24,596) (711) (2,617) 389 (27,536) Trauma, Emergency and Medicine (37,141) (4,006) (4,205) (4,027) (49,379) Womens and Children (19,652) (1,946) (1,949) (2,060) (25,607) CLINICAL DIVISIONS TOTAL (120,246) (9,253) (11,884) (8,073) (149,456) Commercial Services 1,710 190 190 190 2,280 Corporate Services (622) (6) (1) 62 (567) EN / PDT 411 (22) (22) 369 736 Facilities (Estates) 673 (73) (76) (76) 447 Finance 138 (41) (41) 109 165 Procurement 629 89 89 89 895 Information 302 (21) (84) (72) 126 Human Resources (569) 31 34 34 (470) Operations Directorate (3,497) (170) (213) (301) (4,182) Private Finance Initiative (1,108) (123) (123) (123) (1,477) R&D (152) (8) (8) (8) (176) Strategic Development 103 (63) (63) (63) (85) Medical Director (47) (5) (5) (5) (62) Turnaround and Transformation (2,772) (287) (287) (287) (3,634) CORPORATE DEPARTMENTS TOTAL (4,802) (510) (610) (83) (6,005) Clinical Contract Income 7,529 334 334 158 8,355 Education & Training Income 4,637 367 363 367 5,734 PFI Support 8,325 925 925 925 11,100 Bridging/Integration Support 10,425 1,158 1,158 1,158 13,900 Misc Other Operating Income 9,750 348 347 348 10,793 TRUST INCOME TOTAL 40,666 3,132 3,128 2,956 49,882 Contract Services 2,458 273 273 273 3,277 Private Patients and Overseas Visitors 5,764 645 645 641 7,695 Capital charges and reserves 121 124 123 (161) 207 Surplus/(Deficit) (76,039) (5,589) (8,325) (4,447) (94,400)
Impairment (4,125) (458) (458) (458) (5,500)
Operating Surplus/(Deficit) (71,914) (5,131) (7,867) (3,988) (88,900)
Mitigations 23,900
Operating Surplus/(Deficit) after mitigations (65,000) Page 5 Enc. 2.4.1 CIPs / I&E Run Rate Cumulative (Revised)
TheNet Operatingtable above Deficit is an Plan unconsolidated (turquoise line)expenditure based on analysis, CIP phasing excluding as at Trust month subsidiaries 7. . Page 6 Enc. 2.4.1 CIPs / I&E Run Rate by Month (Revised)
TheNet Operatingtable above Deficit is an Plan unconsolidated (turquoise line) expenditure based on analysis, CIP phasing excluding as at Trust month subsidiaries 7. . Page 7 Enc. 2.4.1 Trust-wide Income & Expenditure By Type
Annual Last Month In Month Budget YTD Budget YTD Actual YTD Variance Variance Movement Subjective Summary Staff Type £'000 £'000 £'000 £'000 £'000 £'000 Income Commissioner Patient Activity Income 768,957 577,603 604,403 26,800 13,592 13,208 Commissioner Off-tariff Drugs Income 85,536 61,577 65,503 3,926 4,162 (236) Other Income 173,383 125,363 122,608 (2,755) 9,834 (12,589) Income Total 1,027,876 764,543 792,514 27,971 27,588 383 Pay Nursing Staff Agency (3,336) (2,812) (11,024) (8,212) (7,542) (670) Bank (2,776) (2,044) (19,478) (17,434) (15,520) (1,914) substantive (242,385) (181,691) (154,963) 26,727 23,886 2,841 Medical Staff Agency (1,870) (1,757) (11,592) (9,835) (9,019) (816) Bank (1,042) (794) (3,133) (2,339) (2,022) (317) substantive (196,526) (147,556) (136,489) 11,067 9,458 1,609 A&C Staff/Senior Managers Agency (4,036) (2,991) (9,282) (6,291) (5,824) (467) Bank (548) (411) (2,306) (1,895) (1,764) (131) substantive (95,918) (71,526) (63,918) 7,608 6,513 1,095 PAMS/Scientific/Professional Agency (801) (484) (5,572) (5,089) (4,679) (410) Bank (80) (55) (1,590) (1,535) (1,351) (184) substantive (79,490) (59,257) (52,926) 6,330 5,492 839 Pay Total (628,808) (471,377) (472,273) (896) (2,372) 1,476 Non-Pay Drugs (29,416) (24,716) (32,772) (8,056) (6,862) (1,195) Off-tariff Drugs Expenditure (85,536) (61,577) (65,503) (3,926) (3,675) (251) Clinical Supplies (87,937) (66,341) (72,492) (6,151) (5,279) (872) Non-Clinical Supplies (54,528) (41,275) (42,950) (1,674) (1,360) (315) Sub Contracted Healthcare - NHS bodies (52,782) (38,746) (40,670) (1,924) (1,606) (318) Services Provided by non-NHS bodies (22,911) (17,232) (21,467) (4,235) (4,248) 13 Private Finance Initiative (50,500) (40,385) (42,117) (1,732) (1,706) (26) Misc. Other Operating Exependiture (9,437) (20,576) (21,461) (885) 908 (1,794) Non-Pay Total (393,047) (310,848) (339,431) (28,583) (23,826) (4,757) Financing Loan/PFI Interest & PDC Dividends (38,887) (28,934) (28,648) 286 195 91 Depreciation and Impairment (29,042) (21,781) (22,158) (377) (337) (40) Lease Charges (8,596) (6,447) (6,043) 404 327 77 Financing Total (76,524) (57,162) (56,849) 313 185 128 Surplus / (Deficit) (70,503) (74,844) (76,039) (1,196) 1,574 (2,770) Impairment Expense (5,500) (4,125) (4,125) 0 0 0 Operating Surplus / (Deficit) (65,003) (70,719) (71,914) (1,196) 1,574 (2,770)
Refer to Appendix A for Annual Budget Control Totals. Page 8 Enc. 2.4.1 I&E Run Rate
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Cummulative Subjective Summary Staff Type 2015/16 2015/16 2015/16 2015/16 2015/16 2015/16 2015/16 2015/16 2015/16 YTD 2015/16 Income Commissioner Patient Activity Income 64,871 63,407 62,771 69,867 64,310 67,174 72,385 68,005 66,909 599,699 Commissioner Off-tariff Drugs Income 8,016 7,336 8,187 7,568 7,610 7,137 7,748 8,113 8,492 70,207 Other Income 12,810 14,763 15,490 13,690 12,341 14,034 12,705 15,236 11,537 122,608 Income Total 85,697 85,506 86,448 91,125 84,262 88,345 92,838 91,354 86,938 792,514 Pay A&C Staff/Senior Managers Agency (1,347) (1,532) (1,200) (831) (1,060) (972) (960) (600) (781) (9,282) Bank (324) (282) (313) (298) (246) (286) (224) (168) (165) (2,306) substantive (7,180) (7,140) (6,983) (7,252) (6,908) (7,002) (7,170) (7,314) (6,970) (63,918) Medical Staff Agency (1,402) (1,407) (1,463) (1,404) (1,178) (1,117) (1,385) (1,391) (844) (11,592) Bank (494) (274) (343) (356) (447) (291) (206) (322) (400) (3,133) substantive (14,953) (15,294) (15,216) (14,799) (14,840) (15,340) (15,335) (15,363) (15,347) (136,489) Nursing Staff Agency (2,926) (1,590) (1,065) (1,097) (1,057) (943) (761) (743) (842) (11,024) Bank (2,354) (2,143) (2,087) (2,037) (2,235) (2,095) (2,223) (2,150) (2,153) (19,478) substantive (17,155) (17,505) (17,562) (17,074) (17,005) (17,065) (17,029) (17,375) (17,195) (154,963) PAMS/Scientific/ProfessionalAgency (927) (752) (686) (734) (588) (495) (429) (502) (459) (5,572) Bank (201) (168) (176) (194) (157) (180) (157) (166) (192) (1,590) substantive (5,773) (5,800) (5,955) (5,933) (5,822) (5,929) (6,003) (5,920) (5,791) (52,926) Pay Total (55,036) (53,886) (53,049) (52,009) (51,542) (51,715) (51,882) (52,014) (51,139) (472,273) Non-Pay Drugs (2,260) (2,721) (1,829) (4,176) (3,553) (3,242) (4,180) (3,602) (2,505) (28,068) Off-tariff Drugs Expenditure (8,016) (7,336) (8,187) (7,568) (7,610) (7,137) (7,748) (8,113) (8,492) (70,207) Clinical Supplies (7,819) (8,273) (8,493) (8,668) (7,623) (7,159) (8,148) (8,219) (8,089) (72,492) Non-Clinical Supplies (4,510) (5,041) (4,104) (5,304) (4,100) (5,031) (4,626) (5,442) (4,792) (42,950) Sub Contracted Healthcare - NHS bodies (4,498) (4,189) (4,458) (4,551) (4,233) (4,959) (4,770) (4,433) (4,580) (40,670) Services Provided by non-NHS bodies (2,413) (2,926) (1,622) (2,697) (2,703) (2,510) (2,739) (1,976) (1,880) (21,467) Private Finance Initiative (4,676) (4,642) (4,763) (4,691) (4,652) (4,642) (4,512) (5,026) (4,513) (42,117) Misc. Other Operating Exependiture (3,595) (2,405) (2,582) (1,169) (2,334) (2,326) (1,890) (2,073) (3,087) (21,461) Non-Pay Total (37,787) (37,532) (36,037) (38,823) (36,808) (37,006) (38,613) (38,886) (37,938) (339,431) Financing Loan/PFI Interest & PDC Dividends (2,893) (3,266) (3,127) (2,974) (3,221) (3,170) (3,297) (3,513) (3,188) (28,648) Depreciation and Impairment (2,441) (2,450) (2,501) (2,409) (2,520) (2,445) (2,388) (2,543) (2,460) (22,158) Lease Charges (619) (613) (845) (602) (751) (656) (706) (611) (639) (6,043) Financing Total (5,954) (6,329) (6,473) (5,985) (6,491) (6,272) (6,391) (6,667) (6,287) (56,849) Surplus / (Deficit) (13,080) (12,241) (9,112) (5,692) (10,579) (6,648) (4,049) (6,213) (8,426) (76,039) Impairment Expense (458) (458) (458) (458) (458) (458) (458) (458) (458) (4,126) Operating Surplus / (Deficit) (12,622) (11,782) (8,653) (5,233) (10,121) (6,190) (3,590) (5,754) (7,968) (71,914) • Misc. Other Operating Expenditure includes PWC restructuring consultancy costs, leasing charges and provision for bad debts. • Please note in month 4 the bad debt provision for Overseas Patients (Non-reciprocal) was reduced due to the new re-imbursement arrangements with CCGs for non-recovery of payments. Page 9 Enc. 2.4.1 I&E Run Rate in relation to CIPS
Actual Plan Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Total £m £m £m £m £m £m £m £m £m £m £m £m I&E Actual and Plan Income 85.7 85.5 86.4 91.1 84.3 88.3 92.8 91.4 86.9 85.0 83.0 84.1 1,044.6 Pay * (55.0) (53.9) (53.0) (52.0) (51.5) (51.7) (51.9) (52.0) (51.1) (51.8) (51.7) (50.7) (626.4) Nonpay * (37.8) (37.5) (36.1) (38.8) (36.8) (37.1) (38.6) (38.9) (37.9) (34.0) (32.7) (32.3) (438.6) Financing (5.9) (6.4) (6.4) (6.0) (6.5) (6.2) (6.4) (6.7) (6.3) (6.4) (6.4) (6.5) (75.9) Unmet CIP ("Amber", In Pipeline & Balance to find) 6.6 5.2 7.1 18.9 Net Deficit (13.1) (12.2) (9.1) (5.7) (10.5) (6.7) (4.1) (6.2) (8.4) (0.5) (2.6) 1.7 (77.4) Impairment 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5 5.5 Net Operating Deficit Actual/Forecast (12.6) (11.8) (8.7) (5.2) (10.1) (6.2) (3.6) (5.8) (8.0) Net Operating Deficit Plan (as at month 7) (12.6) (9.7) (8.5) (4.0) (10.1) (5.2) (2.6) (3.1) (4.8) 0.6 0.5 (5.5) (65.0)
CIP Actual & Forecast CIPs identified ("Green") - Actual budget reductions 3.3 1.5 1.2 4.6 3.7 5.1 9.6 8.8 5.4 5.7 5.7 6.6 61.2 CIPs identified ("Green") - Actual budget CIP phasing as per PMO 6.0 2.6 2.9 4.1 4.3 4.6 5.1 6.3 5.7 6.1 6.0 7.5 61.2 CIP in pipeline 2.1 0.7 0.8 3.6 CIP CCG Support 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 2.4 10.0 CIP Identified Control Total 6.7 3.3 3.6 4.8 5.0 5.3 5.8 7.0 6.4 8.9 7.4 10.7 74.8 CIP balance to find 3.8 3.8 3.8 11.5 Total CIPs (Revised phasing as at month 8) 6.7 3.3 3.6 4.8 5.0 5.3 5.8 7.0 6.4 12.7 11.2 14.6 86.3
Total CIPs (By Category) CIP - Revenue Generation 1.0 1.0 1.0 1.3 1.2 1.2 1.4 1.6 1.9 3.1 2.3 5.5 22.7 CIP - PAY 1.3 1.2 1.2 1.6 1.7 2.4 2.5 3.0 2.2 3.9 4.0 4.1 29.0 CIP - Non-Pay 4.4 1.2 1.3 1.9 2.0 1.7 2.0 2.3 2.3 5.7 4.9 5.1 34.6 Total 6.7 3.3 3.6 4.8 5.0 5.3 5.8 7.0 6.4 12.6 11.3 14.7 86.3
Cash Benefit of CIP and Revenue Generation Schemes Based on I&E CIP achievement of 100% (£86m) CIP - Revenue Generation - - - - 1.0 1.0 1.0 1.3 1.2 1.2 1.4 1.6 9.8 CIP - PAY - 1.3 1.2 1.2 1.6 1.7 2.4 2.5 3.0 2.2 3.9 4.0 25.0 CIP - Non-Pay - - 4.4 1.2 1.3 1.9 2.0 1.7 2.0 2.3 2.3 5.7 24.7 Total - 1.3 5.6 2.4 3.9 4.6 5.5 5.5 6.2 5.7 7.5 11.4 59.5
Cash Per Annual Cash Flow Forecast (as at 31 December 2015) Revolving Working Capital Facility drawndown to date - (15.6) (15.5) (10.2) (16.5) (14.3) (6.4) (4.7) (10.4) (93.6) Revolving Working Capital Facility Repayment ------93.6 93.6 93.6 280.8 Revolving Working Capital Facility Drawdown ------(93.6) (93.6) (93.6) (280.8) Forecast cash drawdown requirement included in month end balance - (15.6) (15.5) (10.2) (16.5) (14.3) (6.4) (4.7) (10.4) - - - (93.6) Cash benefit of CIP and Revenue Generation Schemes Assumptions: . The forecast cash benefit is based on an I&E CIP achievement of 100% (£86m). . Pay CIP – cash benefits will be realised one month after implementation of the scheme. . Non-pay CIP – cash benefits will be realised 2-3 months after implementation of the scheme due to the current average creditor payment days being approximately 70 days. . Revenue Generation – cash benefit will be realised approximately 4 months after implementation due to over-performance freeze date, data validation and debt recovery process. Page 10 Enc. 2.4.1 Agency Run Rate
Refer to Appendix B : Bank & Agency Analysis for further detail. Page 11 Enc. 2.4.1 Activity Volume
Notes: (1) Activity extracted from Contract Monitoring data. (2) FCE Inpatient data is by episode end date (not on patient discharge) (3) No case mix waiting applied.
Page 12 Enc. 2.4.1 NHS Contract Income (M8 Flex)
Contract Fines/Penalties/ Block Plan - M8 Actual - M8 Total Actual - M8 Variance - M8 Mapping COMMISSIONER_CODE_NAME MRET Adjustment Block NHS BROMLEY CCG 104,906,667 111,589,251 -994,454 -3,796,797 106,798,000 1,891,333 NHS SOUTHWARK CCG 56,601,333 56,425,726 -661,298 836,906 56,601,333 0 NHS LAMBETH CCG 47,574,000 47,117,011 -597,397 1,054,386 47,574,000 0 NHS LEWISHAM CCG 22,300,000 20,740,533 -262,032 1,821,499 22,300,000 0 NHS BEXLEY CCG 16,131,571 15,671,150 -97,861 558,282 16,131,571 0 NHS GREENWICH CCG 13,116,450 13,708,198 -50,938 -540,811 13,116,450 0 NHS DARTFORD, GRAVESHAM AND SWANLEY CCG 7,620,710 7,761,641 -140,931 7,620,710 0 NHS WEST KENT CCG 6,558,278 6,419,454 138,824 6,558,278 0 NHS MEDWAY CCG 2,316,119 2,159,189 156,931 2,316,119 0 NHS WANDSWORTH CCG 1,764,565 1,748,524 -13,468 29,510 1,764,565 0 NHS CANTERBURY AND COASTAL CCG 1,281,636 1,791,900 -510,263 1,281,636 0 NHS SOUTH KENT COAST CCG 1,269,216 1,367,622 -98,406 1,269,216 0 NHS ASHFORD CCG 911,926 763,002 148,924 911,926 0 NHS THANET CCG 834,121 1,207,869 -373,748 834,121 0 NHS MERTON CCG 805,384 631,875 -3,056 176,565 805,384 0 NHS SWALE CCG 751,150 1,011,310 -260,161 751,150 0 NHS CENTRAL LONDON (WESTMINSTER) CCG 643,024 774,005 -130,981 643,024 0 NHS EAST SURREY CCG 580,694 726,224 -4,270 -141,259 580,694 0 NHS WEST LONDON CCG 504,686 427,320 77,366 504,686 0 NHS EALING CCG 466,766 306,104 160,662 466,766 0 NHS SURREY DOWNS CCG 453,293 513,701 -3,708 -56,701 453,293 0 NHS HAMMERSMITH AND FULHAM CCG 359,212 281,911 -1,092 78,393 359,212 0 NHS KINGSTON CCG 305,817 274,612 31,204 305,817 0 NHS HOUNSLOW CCG 279,045 376,831 -97,785 279,045 0 NHS RICHMOND CCG 263,301 210,311 -578 53,567 263,301 0 NHS BRENT CCG 227,037 229,588 -2,551 227,037 0 NHS HILLINGDON CCG 183,043 186,377 -3,334 183,043 0 NHS HARROW CCG 154,006 164,489 -10,482 154,006 0 Block Total 289,163,051 294,585,729 -2,690,152 -841,192 291,054,384 1,891,333 C&V NHSE - Specialised 201,298,018 211,536,010 -1,800,000 209,736,010 8,437,992 NHSE - Dental 15,949,415 16,745,378 16,745,378 795,964 NHSE - Screening 3,552,704 3,465,096 3,465,096 -87,608 NHS CROYDON CCG 12,789,733 13,375,991 -126,134 13,249,857 460,124 KENT AND MEDWAY AREA TEAM 595,979 699,343 699,343 103,364 NHS HERTS VALLEYS CCG 407,495 471,580 471,580 64,086 NHS SUTTON CCG 406,912 297,895 -5,546 292,349 -114,563 SURREY AND SUSSEX AREA TEAM 300,592 297,682 297,682 -2,910 NHS BASILDON AND BRENTWOOD CCG 265,648 224,808 224,808 -40,840 HCW - Healthcare Commission for Wales 245,051 265,067 265,067 20,016 NHS MID ESSEX CCG 206,200 158,345 158,345 -47,856 NHS NORTH EAST ESSEX CCG 151,081 211,095 211,095 60,013 NHS SURREY HEATH CCG 144,958 55,684 55,684 -89,274 NHS THURROCK CCG 131,704 166,585 166,585 34,881 NHS WEST ESSEX CCG 118,813 119,271 119,271 459 ESSEX AREA TEAM 110,514 77,584 77,584 -32,930 NHS CASTLE POINT AND ROCHFORD CCG 75,208 133,363 133,363 58,155 NHS SOUTHEND CCG 63,785 113,140 113,140 49,355 NHS SOUTH NORFOLK CCG 52,743 60,030 60,030 7,287 EAST ANGLIA AREA TEAM 32,032 40,695 40,695 8,662 C&V Total 236,898,585 248,514,643 -1,931,680 0 246,582,964 9,684,379 KCH 11,131,182 8,870,208 8,870,208 -2,260,975 NCA 22,597,708 25,910,335 0 0 25,910,335 3,312,628 Grand Total 559,790,526 577,880,915 -4,621,832 -841,192 572,417,891 12,627,365 1. Based on Contract Monitoring Data. 2. Reconciliation to Commissioner Income Month 9 Cumulative Variance £28.4m (£14.5m + CCG support £14.9m + Cancer Drugs (CDF) and (IFRs) billed outside of contract £1.8m + other £0.5m – prior year fines £2.3m) 3. NHSE Fines, Penalties and Claim Allowance as at Q2 £1.8m are excluded from above (Re Financial Support/RTT Backlog Investment) Page 13 Enc. 2.4.1 Cash and Borrowing
* Planned Cash in Hand (£11m) and Drawdown (£98.9m) (Source: Annual Cash Flow submitted to Monitor end July).
Refer to Appendix C : Cash Borrowing Requirement for further detail Page 14 Enc. 2.4.1 Statement of Financial Position
STATEMENT OF FINANCIAL POSITION AS AT 31 Mar 15 30 Apr 15 31 May 2015 30 Jun 2015 30 Jul 2015 30 Aug 2015 30 Sep 2015 31 Oct 2015 30 Nov 2015 31 Dec 2015 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 NON-CURRENT ASSETS Intangible Assets 3,495 3,419 3,298 3,205 3,086 3,052 2,993 2,952 2,914 2,808 Property, Plant & Equipment 365,305 359,848 362,910 364,114 365,149 366,519 366,441 367,069 368,019 367,637 On-Balance Sheet PFI 247,392 246,458 246,267 245,827 245,201 244,658 244,127 243,583 242,987 242,411 Investments in associates (and joined controlled operations) 4,386 4,761 5,111 5,462 5,812 6,112 6,462 6,462 6,462 6,462 Trade and Other Receivables, Non- Current 7,272 7,272 7,272 7,272 7,272 7,272 7,272 7,272 7,272 7,272 Total Non-Current Assets 627,850 621,758 624,858 625,880 626,520 627,613 627,295 627,338 627,654 626,590 CURRENT ASSETS Inventories 17,090 4,573 16,470 18,857 16,961 16,199 18,225 17,989 18,054 19,597 Trade Receivables 66,797 67,020 82,699 111,038 75,208 66,117 62,241 59,505 73,137 75,078 Other Receivables 14,236 17,246 11,259 14,053 13,801 11,699 14,657 14,378 15,481 15,512 Impairment of Receivables (18,321) (17,891) (18,575) (18,716) (18,321) (10,837) (10,847) (11,259) (11,306) (11,376) Other Financial Assets 27,924 23,572 22,155 (7,114) 28,833 36,616 36,309 43,070 39,972 32,737 Prepayments 7,581 4,800 6,204 5,600 5,870 7,007 11,150 6,592 6,262 6,813 Cash & Cash Equivalents 43,445 34,324 28,579 24,128 31,741 30,987 19,408 28,922 13,105 26,787 Total Current Assets 158,752 133,644 148,791 147,846 154,093 157,788 151,143 159,197 154,705 165,148 CURRENT LIABILITIES Interest-Bearing Borrowings (4,074) (4,074) (19,641) (33,241) (43,461) (59,973) (74,232) (80,583) (86,461) (93,770) Deferred Income (10,189) (4,955) (4,592) (4,677) (4,153) (4,333) (2,994) (3,589) (1,837) (4,320) Provisions (1,239) (1,252) (1,152) (1,102) (1,046) (981) (929) (878) (826) (767) Current Taxes Payable (11,217) (11,636) (11,748) (11,536) (11,354) (11,007) (11,291) (11,350) (11,393) (11,312) Trade Payables (51,335) (51,309) (50,257) (46,164) (57,124) (53,295) (44,622) (52,547) (52,400) (48,452) Other Payables (10,012) (10,386) (10,327) (10,316) (8,429) (10,128) (10,210) (10,221) (8,386) (11,085) Other Financial Liabilities (95,258) (81,592) (97,973) (97,844) (90,406) (91,341) (86,465) (83,721) (83,622) (93,025) Total Current Liabilities (183,324) (165,203) (195,691) (204,880) (215,973) (231,058) (230,743) (242,889) (244,925) (262,731) Total Assets less Current Liabilities 603,278 590,199 577,958 568,846 564,640 554,343 547,695 543,646 537,434 529,007 NON-CURRENT LIABILITIES Interest-Bearing Borrowings (67,462) (67,462) (67,462) (67,462) (67,462) (67,462) (67,462) (67,462) (67,462) (67,462) Provision (6,295) (6,295) (6,295) (6,295) (6,295) (6,295) (6,295) (6,295) (6,295) (6,295) Other Financial Liabilities (155,109) (155,109) (155,109) (155,109) (155,109) (155,109) (155,109) (155,109) (155,109) (155,109) Total Non-Current Liablilities (228,866) (228,866) (228,866) (228,866) (228,866) (228,866) (228,866) (228,866) (228,866) (228,866) Total Assets Employed 374,414 361,336 349,093 339,980 335,774 325,477 318,829 314,780 308,568 300,141 Financed By (taxpayers' equity): Public Dividend Capital (231,316) (231,316) (231,316) (231,316) (232,800) (233,083) (233,083) (233,083) (233,083) (233,083) Revaluation Reserve (165,237) (165,237) (165,237) (165,237) (165,237) (165,237) (165,237) (165,237) (165,237) (165,237) Income & Expenditure Reserve 22,139 35,218 47,460 56,573 62,263 72,843 79,491 83,540 89,752 98,179 Total Taxpayers' Equity (374,414) (361,336) (349,093) (339,980) (335,774) (325,477) (318,829) (314,780) (308,568) (300,141)
Page 15 Enc. 2.4.1 Working Capital Summary
Trade Debtors . As at the end of Month 9, outstanding trade debtors totalled £73.016m. Significant balances were as follows:
Organisation Debt Type £000 Comments
Private Patients and Overseas Visitors Private Patients and Overseas Visitors 14,256
SLA & Other (e.g. Transaction support; Drugs invoices £4.67m, SLHT Bridging support £2.083, Over- NHS England 9,637 Winter Pressure funding) performance £3m Notification of final position communicated to CCGs for CCGs CCGs Overperformance 2013/14 & 2014/15 831 agreement CCGs NCAs 1,307 2013/14 NCA invoices £609k, 2014/15 NCA invoices £698k CCGs CCGs - 2015/16 NCAs 5,917 2015/16 NCA invoices Health Education England Various 13,540 Q4 invoice raised early Guy's and St Thomas' NHS Foundation Trust Various 1,084 Working with FT to clear down debt on both sides Lewisham and Greenwich NHS Trust Various 1,377 Working with Trust to clear down debt on both sides King's College London Various 3,507 Working with KCL to clear down debt on both sides South London and Maudsley NHS FT Various 2,112 Working with FT to clear down debt on both sides Various Pathology 3,400 Viapath invoices outstanding Provider Trusts Various 2,386 Provider to provider invoices Includes Councils (£1.825m), Irish/Scottish/Welsh (£315k) & Other Non NHS Bodies Various 11,373 other various NON-NHS organisations
Trade Creditors . As at Month 9, outstanding trade creditors totalled £40.7m. This total includes the following outstanding amounts: . King’s College London £2.99m . Guy’s & St Thomas’ NHS Foundation Trust £0.168m
FT Borrowing . As at 31 December 2015, the Trust held loans with the Foundation Trust Financing Facility totalling £65.974m and PFI Liabilities of £155.996m. . The Trust has also drawn down £93.581m against the approved Interim Revenue Support Facility of £98.9m.
Page 16
Enc. 2.5.1
Report to: Board of Directors
Date of meeting: 02 February 2016
Subject: Trust Performance Report 2015/16 Month 9
Author(s): Steve Coakley, Acting Assistant Director of Performance & Contracts
Presented by: Jeremy Tozer, Interim Chief Operating Officer
Sponsor: Jeremy Tozer, Interim Chief Operating Officer
History: Finance & Performance Committee, 26 January 2016
Status: For Information
1. Summary of Report
This report provides the details of performance achieved against key national performance and quality indicators, and governance indicators defined in the Monitor Risk Assessment framework for the Q3 position in 2015/16.
2. Action required
The Board is asked to endorse the M9 performance reported against the governance indicators defined in the Monitor Risk Assessment framework for the Q3 position in 2015/16.
3. Key implications
Statutory reporting to Monitor and the DoH. Legal: Trust reports financial performance against published plan. Financial: The summary report provides assurance that the Trust has met the Assurance: performance targets as defined within the Monitor Risk Assessment framework (RAF) for the Q3 position with the exception of the A&E 4-hour target and the c-difficile threshold. There is no direct impact on clinical issues. Clinical: There is no impact on equality & diversity issues. Equality & Diversity: The summary report demonstrates that the Trust has achieved the Performance: performance indicators for the Q3 position as defined in the RAF with the exception of the A&E 4-hour target and the c-difficile threshold. An extension for a further 6 months beyond reporting September 2015 Referral to treatment (RTT) performance returns has been agreed with host commissioners, NHS England and our regulator which now extends to March 2016.
1
Enc. 2.5.1
Performance against the Trust’s annual plan forecasts and key Strategy: objectives. None. Workforce: There is no direct impact on Estates. Estates: Trust’s quarterly and monthly results will be published by Monitor Reputation: and the DoH.
Other:(please specify) N/A
2 of 15 Enc. 2.5.1
Key Messages of this Report Managing the increased winter pressures have been extremely challenging in both the Southwark and Bromley health care systems. Kings Trust performance against the 4- hour target worsened further from 88.8% reported in November to 87.47% in December. Q3 performance was 89.34% compared to 91.18% reported for Q2. RTT incomplete pathways are being validated to 30+ weeks for the end-December position. There were 169 patients waiting 52+ weeks as at the end of December which is 26 above the 143 patients reported in November - 65 patients are on admitted pathways and 104 patients on non-admitted pathways. All cancer targets are being achieved at a Trust level based on the Q3 position although the position has not been fully finalised and submitted to OpenExeter. Whilst the 62-day first treatment target is not being achieved for the DH site, the 85% target is being achieved at Trust level at 86.4%. There has been 1 further MRSA case reported in December, so the Trust has 2 cases YTD following the case that was reported in October 2015. 67 c-difficile cases reported to the end of December which is above the quota of 54 cases, and approaching the annual quota of 72 cases. There were 7 cases reported in December on the DH site, so 48 cases reported YTD which is above the quota of 40 cases. There was 1 case at PRUH so 19 cases reported YTD which is above the quota of 14 cases.
Introduction/Background The performance report for December 2015 includes updates for the Emergency Care 4-hour performance Action plans for PRUH and DH, the Trust-wide RTT programme and HCAI.
Trust Priorities Emergency 4-hour performance at Princess Royal Hospital (PRUH): All types performance worsened further from 89.9% reported in November to 86.1% in December. Type 1 attendance performance also worsened from 83.4% to 76.4%, although this is higher than the type 1 performance of 55.8% reported in December 2014. The number of breaches in Urgent Care Centre (UCC) increased from 35 in November to 75 in December, but breaches due to late handover from the UCC reduced from 134 to 118 which adversely impact on our all types attendance reported performance. There were no breaches of the 12-hour trolley standard on the PRUH site. Emergency 4-hour performance at Denmark Hill (DH): All types performance improved from 87.9% in November to 88.6% in December, and type 1 attendance performance improved from 85.8% to 86.6%. Attendances to the ED remained high in December with over 11,700 patients seen. A ‘Pulling Together’ week was held from Thursday 10 December at the DH site with the primary aim of trying to resolve the various issues that cause inpatient discharge delays. Volunteers from non-clinical teams as well as from local commissioners and NHS England supported the event. It was a positive week with 4-hour performance improving from 84.7% in the 7-days prior to the Pulling Together Week to 93.8% during the week. There were 2 breaches of the 12-hour trolley standard on the DH site during December. Referral to Treatment (RTT) Incomplete pathway performance: The number of 52+ week breach patients increased from 143 patients reported in November to 169 patients reported in December based on the new operational Patient Tracker List (PTL) reports. The number of patients waiting 40-51 weeks increased from 935 at the end of November to 1,198 at the end of December. We committed to validating the number of pathways for patients waiting 30+ weeks by the end of December. Based on tier 1 validation by the central RTT tracker team, there were 571 patients waiting on admitted pathways and 2,142 patients on non-admitted pathways waiting 30-39 weeks.
3 of 15 Enc. 2.5.1
Key Issues Clinical Effectiveness: The number of diagnostic 6-week waiting time breaches increased by 500 cases reported at the end of December to 630, which represents 6.8% of the total number of patients waiting. This is therefore above the national target of 1%. Main breach areas are non-obstetric ultrasound mainly on the DH site which increased by 322 breaches, and MRI which increased by 124 breaches, again mainly on the DH site. An action plan is being produced to reduce the backlog which remains high based on the mid-month position in January. All cancer waiting time targets are being achieved at a Trust level for the Q3 position, and all targets are being achieved at PRUH. The 62-day time to first treatment target is not being achieved at the DH site with 17 breaches for Q3, subject to final validation. There were 3.5 breaches in each of colorectal, urology and HpB pathways. Breach meetings were held earlier in the quarter to review breach cases and to agree action plans. Safety: There has been 1 MRSA case reported in December so 2 cases reported YTD. There were 8 new c-difficile cases reported in December, of which 7 were on the DH site and 1 on the PRUH site. 67 c-difficile cases have therefore been reported to the end of December which is above the quota of 54 cases. There have been 48 cases reported at the DH site which is above the quota of 40 cases, and 19 cases at the PRUH which is above the quota of 14 cases. There was 1 never event in Child Health relating to a retained guidewire following chest drain insertion on the Paediatric ICU. A root cause analysis will be undertaken and taken to the Serious Incident Committee. The number of red shifts reported increased from 98 in November to 149 in December – 70 shifts were reported in TEAM wards/ED, 26 shifts in Surgery wards, 17 shifts in Haematology wards and 15 shifts in Child Health wards. Patient Experience: The HRWD Inpatient survey overall score and all Friends and Family (FFT) scores for Inpatient and Day Case patients continue to achieve their targets. FFT scores for ED patients are below target on both the DH site at 82.0% and the PRUH site at 80.0% compared to their respective targets of 87% and 86%. The number of inpatient cancellations on the day increased from 78 in November to 94 in December – due to an increase in reported cases at PRUH from 35 to 60 cancellations. The number of 28-day cancellations increased from 10 to 14 cases, of which 5 were due to lack of beds. The number of complaints increased from 62 received in November to 82 received in December, with an increase in the number of cases on both acute sites. Of the complaints received, 12 were rated high or severe with 8 at the DH site and 4 at the PRUH. Finance & Operational Efficiency: Financial position - please see the Finance report for further details. The proportion of inpatients discharged at weekends worsened on both sites in December, from 21.4% to 17.4% at PRUH and from 22.6% to 17.7% at DH. Utilisation decreased below the 80% target across all theatres in December, in part impacted by the reduced number of sessions held over the festive period. On the DH site, main theatre utilisation reduced from 83% to 79%, and DSU utilisation reduced from 80% to 73%. On the PRUH site, main theatre utilisation reduced from 77% to 60% and DSU utilisation reduced from 75% to 68%. Staffing: Vacancy rate improved from 9.6% in November to 8.3% in December on the DH site, but worsened from 14.1% to 14.7% for the PRUH sites, with vacancy rates for both sites remaining above the internal 5-8% target. Compliance against mandatory and statutory training and induction courses remained static at 81 for the DH, one point above the target of 80 for December. No data available for PRUH at this stage.
4 of 15 Enc. 2.5.1
Regulatory Performance/Monitor compliance Monitor – Q3 2015/16 position: The Trust has achieved the performance indicators in the Monitor Risk Assessment Framework for the Q3 position with the exception of the c-difficile target and the A&E 4-hour performance target. RTT performance indicators are not being reported, consistent with the extended RTT reporting suspension that has been agreed with local and national commissioners. We currently have a score of 3.0 based on the latest RAF as the RTT completed targets for admitted and non-admitted pathways are no longer included in national submissions to Unify and to Monitor. RTT performance will only therefore be measured on incomplete pathways achieving 92% within 18 weeks. We are planning to submit March 2016 RTT national performance returns to Unify in April 2016. Given the current c-difficile position, this performance indicator is at risk of being breached in early Q4.
5 of 15 Enc. 2.5.1
Trust Performance Scorecard – DH site
6 of 15 Enc. 2.5.1
Trust Performance Scorecard – PRUH sites
7 of 15 Enc. 2.5.1
Trust Emergency Care 4-hour performance
06/12/2015 13/12/2015 20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016 27/03/2016 Week Ending Week
Actual All Types Performance 83.56% 87.54% 85.43% 93.82% 89.02% 86.96% Trajectory PRUH 88% 90% 91% 92% 92% 93% 93% 95% 95% 95% 95% 95% 95% 95% 95% 95% Trajectory DH 88% 89% 90% 88% 88% 89% 89% 90% 91% 91% 91% 91% 92% 92% 92% 92% Trajectory Combined 88% 89% 89% 88% 88% 89% 89% 90% 91% 91% 91% 92% 92% 93% 93% 93% Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% Combined ED Performance and Trajectory 2015-2016 96.00%
94.00%
92.00%
90.00%
88.00%
86.00%
84.00%
82.00%
80.00%
Actual All Types Performance Trajectory PRUH Trajectory DH Trajectory Combined Target
Highlights – December 2015 Trajectories for ED 4-hour recovery plans were agreed with commissioners in December for each of the DH and PRUH sites. The data table and chart above reflect the combined-site Trust trajectory, although performance will be monitored against each of the site trajectories.
Weekly performance improved overall from the 83.6% reported for w/e 6 December 2015 to 92.8% in w/e 27 December 2015, which was above the trajectory. However, performance has since worsened for the first two weeks into January 2016.
The charts below compare monthly and quarterly Trust performance against the 4-hour target. Performance is just over 3% higher in December this year at 87.5% compared to 84.4% in December 2014.
Kings- Monthly All Types Performance KIngs - Quarterly All Types Performance Dec 2013 - Dec 2015 100% 100%
95% 95% 90% 90% 85% 85% 80% 91.84% 80% 89.89% 90.83% 75% 88.94% 88.49% 89.34% 85.82%
70% 75%
70% Qtr 1 Qtr 2 Qtr 3 Qtr 4
Dec 2013 - Nov 2014 Dec 2014 - Nov 2015 2014/15 2015/16
8 of 15 Enc. 2.5.1
Emergency Care 4-hour performance Action Plan Update @PRUH (1/2)
06/12/2015 13/12/2015 20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016 27/03/2016 Week Ending Week Actual All Types 82.63% 88.06% 81.96% 93.91% 87.83% 82.89% Performance Trajectory 88% 90% 91% 92% 92% 93% 93% 95% 95% 95% 95% 95% 95% 95% 95% 95% Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%
96% PRUH ED Performance and Trajectory for 2015 - 2016
94%
92%
90%
88%
86% Actual All Types Performance 84% Trajectory 82% Target 80%
The data table and chart above show the weekly all types 4-hour performance at PRUH from the beginning of December, incorporating the improvement trajectory that has been agreed with commissioners. The trajectory demonstrates a planned achievement of the national 95% target for the end of January which is not going to be achieved based on current performance in January.
Highlights – December 2015
Emergency 4-hour all types attendance performance worsened on the PRUH site from 89.9% in November to 86.1% in December, and performance for type 1 attendances in ED worsened from 91.2% to 89.3%. Attendances increased in ED by 6.7% in Q3 compared to Q2 this year, with all types attendances increasing by 2.1%. Despite the reduction in performance reported in December 2015, it is 10% higher than the 75.9% performance reported in December 2014, as demonstrated in the charts below.
PRUH Monthly All Types Performance PRUH Quarterly All Types Performance Dec 2013 - Dec 2015 100% 100%
95% 95% 90% 90% 85% 85% 80% 91.50% 80% 89.26% 75% 88.54% 87.98% 83.96% 81.04% 70% 75% 79.58%
70% Qtr 1 Qtr 2 Qtr 3 Qtr 4
Dec 2013 - Dec 2014 Dec 2014 - Dec 2015 2014/15 2015/16
9 of 15 Enc. 2.5.1
Emergency Care 4-hour performance Action Plan Update @PRUH (2/2)
Emergency Care Programme (ECP) update
Due to the festive holiday and winter pressures experienced over this period, focus has been on minimising operational issues resulting in progress on the ECP workstreams slowing down. The key focus going forwards will be to carry out a complete review on the Programme Workstreams, and present a revised programme overview at the next ECP Board meeting.
A number of initiatives within the Patient Flow workstream are progressing but at a slow rate. As this workstream is a critical success factor within the ECP programme, an additional resource to deliver these initiatives and re-evaluate the plan has been recruited. There has also been a number of changes to the Programme Team as follows: Paul Findlay has been appointed as the Programme Director for the System-wide Urgent and Emergency Care Programme. Programme Management responsibilities for the Emergency Care Programme at the PRUH have been handed over to Gaurav Puri. Jane Tombleson has joined the Programme Team as Operational Head of Service Improvement and will be focussing her time on the Patient Flow Workstream.
The ECP have arranged a visit for Diane Fuller from the DH Intensive Support Team to walk through and review the progress with regards to the processes that she had recommended for the ED Department in Q4 2014/15. The visit will take place on 19th January 2016 and based on her observations, there will be a set of recommendations produced to inform the ED plan further.
10 of 15 Enc. 2.5.1
Emergency Care 4-hour performance Action Plan Update @DH (1/2)
06/12/2015 13/12/2015 20/12/2015 27/12/2015 03/01/2016 10/01/2016 17/01/2016 24/01/2016 31/01/2016 07/02/2016 14/02/2016 21/02/2016 28/02/2016 06/03/2016 13/03/2016 20/03/2016 27/03/2016 Week Ending Week Actual All Types 84.27% 87.13% 88.12% 93.73% 90.05% 90.23% Performance Trajectory 88% 89% 90% 88% 88% 89% 89% 90% 91% 91% 91% 91% 92% 92% 92% 92% Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%
DH ED Performance and Trajectory 2015-2016 96%
94%
92%
90%
88%
86% Actual All Types Performance 84% Trajectory 82% Target 80%
The data table and chart above show the weekly all types 4-hour performance at DH from the beginning of December, incorporating the improvement trajectory that has been agreed with commissioners. The performance trajectory has been achieved for the last 3 weeks up to the week-ending 10 January 2016.
Highlights – December 2015
Emergency 4-hour all types attendance performance improved on the DH site from 87.9% in November to 88.6% in December, and performance for type 1 attendances in ED improved from 85.8% to 86.6%. Attendances in the ED remained high with over 11,700 attendances in ED during December, similar to activity levels reported in November.
Although performance improved in December 2015, it is 2.4% lower than the 90.9% performance achieved in December 2014.
DH Monthly All Types Performance DH Quarterly All Types Performance Dec 2013 - Dec 2015 100% 100%
95% 95% 90% 90% 85% 85% 80% 94.06% 92.82% 92.99% 92.51% 90.78% 80% 89.41% 90.50% 75%
70% 75%
70% Qtr 1 Qtr 2 Qtr 3 Qtr 4
Dec 2013 - Dec 2014 Dec 2014 - Dec 2015 2014/15 2015/16
11 of 15 Enc. 2.5.1
Emergency Care 4-hour performance Action Plan Update @DH (2/2)
‘Pulling Together’ Week (Thursday 10 December – Wednesday 16 December 2015)
On Thursday 10 December, ‘Pulling Together’ Week was held on the DH site with the primary aim of helping to resolve the various issues that cause discharge delays. Volunteers from non- clinical teams as well as from local commissioners and NHS England supported the event. Real progress was made during the week where volunteer staff helped escalate discharge delays in areas including difficult repatriations, delays with social services and with arranging difficult rehabilitation packages. Our performance against the 4-hour target improved from 84.7% in the seven days preceding Pulling Together Week to 93.8% during Pulling Together Week. The week also highlighted areas for improvement including:
Writing TTA’s the day before discharge and timely completion of discharge summaries Setting an estimated discharge date for all patients on admission Consistent escalation support for clinical teams out-of-hours and at weekends ICT being made aware of issues in clinical areas that should be treated as a priority Training for staff booking transport
Winter Bed Plan
The existing Matthew Whiting ward has been re-configured as the acute care hub (ACH) where the majority of medical and general surgical emergency patients will be admitted. The ACH went operational on Tuesday 5 January 2016 as planned. A number of medical ward changes were implemented from 21 December 2015 in order to facilitate the implementation of the ACH. In January, specialty Gastroenterology beds will be moving to Lister ward, and inpatients under the HIV service will be moved into Oliver ward, which has become a general medical ward as part of these changes.
12 of 15 RTT Update RTT Reporting Suspension update
Monitor and our commissioners agreed to the Trust’s Board request for an extension to the original suspension of national RTT waiting times performance reporting for a further 6-month maximum period. As a result, the Trust intends to report March 2016 performance in April 2016 via the national Unify reporting system. This submission will be based on a PTL that is fully validated to 18 weeks.
Following further discussions with commissioners in January, we have agreed with the commissioners’ request for the Trust to provide shadow-monitoring of the January month-end position in February, and the February month-end position in March.
Validation Update
Incomplete pathways were validated to 40+ weeks for the end-November position which was submitted to commissioners on 17 December 2015 as planned. The end-December position has been validated down to 30+ weeks and shared with commissioners as planned on 20 January 2016. Further details of this position can be found below.
The central RTT validation team will be working towards having all incomplete pathways validated to 18 weeks to support the reporting of the end-February position by 17 March. The plan is to have validated all admitted incomplete pathways to 18 weeks and non-admitted pathways validated to circa 24 weeks by 17 February position.
End-December Incomplete pathway position
There were 169 patients waiting over 52 weeks that we reported to commissioners and Monitor based on the position as at the end of December, of which there were 65 patients waiting on admitted pathways and 104 patients waiting on non-admitted pathways. This constitutes an increase in the number of patients waiting compared to end-November position where we reported 64 patients waiting over 52 weeks on admitted pathways and 79 patients waiting on non-admitted pathways.
The waiting time position for December 2015 compared to November 2015 is summarised below:
Patients waiting end-December 31-39 40-51 52+ (November position in brackets) Incomplete -Admitted 571 269 (227) 65 (64) Incomplete – Non-admitted 2142 929 (708) 104 (79)
52 weeks
Initial root cause analysis (RCA) review meetings were held in December with representatives from the commissioners, and chaired by our Medical Director to review pathways breaching 52 weeks on 31st October 2015 identified in the validation process. The RCAs conducted for these meetings also included an assessment of whether clinical harm had come to the patients as a result of their long wait. These meetings continue in January to review the RCAs of pathways that became 52+ week breaches during November.
RTT Training On 30th November the RTT Improvement Team launched a trust-wide RTT training programme. All staff are required to attend General RTT Training sessions, there are then specific role-focused training sessions in relation to the registration of referrals, outpatients and admissions. The team are also providing bespoke sessions to clinicians and nursing teams on request.
13 of 15 Cancer – Q3 performance Update Enc. 2.5.1
The table below summarises the achievement of all cancer targets at Trust-level for Q3. The 62 day GP referral target of 85% was also achieved at 86.4% although this position has not been fully finalised for the cancer returns submission to OpenExeter.
However, there were 5 patients who were treated in Q3 over 100 days into their 62-day target pathway as follows:
HpB (Liver): DH patient treated on day 170. Despite being a late referral from another Trust, there were a number of delays in the outpatient phase of the pathway on the DH site. This is being investigated further by the service.
Lung: DH patient treated on day 106. The patient was unwell at the beginning of their pathway, and was transferred late to GSST on day 58. Further delays at GSST resulted in the patient not being treated until day 106.
Urology: DH patient treated on day 107. The patient was referred from another Trust and developed chest pain at their first pre-operative assessment and needed a further echo diagnostic test. A specific surgeon needed to treat due to the complexity of the case.
Colorectal: PRUH patient treated on day 112. The patient required several diagnostic tests prior to surgery, and there was a further 10 day delay in arranging an anaesthetic review.
Lung: PRUH patient treated on day 103. The patient was originally referred on an Upper GI pathway and was subsequently referred to a lung pathway on day 29. This was a complex pathway which was not referred to GSST for treatment until day 62.
14 of 15 Healthcare Associated Infection (HCAI) Update Enc. 2.5.1 MRSA (post 48 hour bacteraemia: 2 cases YTD (1 in October 2015 and 1 in December 2015)
C-difficile: 8 new cases reported in December; 67 cases YTD compared to quota of 54 cases.
VRE bacteraemia: 3 new cases at DH only no new cases at PRUH in December; 29 cases compared to target of 15 YTD.
E-Coli bacteraemia: 6 new cases reported in December at DH and 1 new case at PRUH; 84 cases YTD compared to 85 cases reported YTD last year.
C-Difficile (CDI) Action Plan Update:
Reviewing of current practice and integration of policies and practice: Work is on-going to align policies and protocols across sites. This work will be overseen by the HCAI Operations Committee. Policies approved and published: Infection Prevention and Control, Intravascular Catheters, Waste Management and Trust Decontamination. Protocols approved and published: Isolation Precautions, Infectious Death Handling, Management of Gastrointestinal Infection, Respiratory Virus and Atypical Bacterial Infections Treatment and Infection Control, Varicella Zoster Virus (VZV), Transmissible Spongiform Encephalopathy, Blood Cultures, Standard Precautions, Hand Hygiene, Linen and Laundry, Guidelines for Animals on Hospital Premises and Aseptic Non Touch Technique. Protocols under consultation: MRSA, Clostridium difficile, Multiple Resistant Gram Negative, Tuberculosis protocols are under consultation. Protocols outstanding: Control of Outbreaks of Infection, Pandemic Influenza Protocol, Coronavirus including MERS-CoV & SARS-CoV and Streptococci and Enterococci. Centralisation of endoscope reprocessing: A project on-going to plan and develop a central reprocessing facility for endoscopes . The unit at DH site is being used as a template for the PRUH unit. This project is still very much in the planning stages, but should allow for a much higher level of decontamination than is currently the case.
Norovirus and other infections update:
Denmark Hill May Ray ward was closed to admissions on Monday 11th January following confirmed cases of norovirus. Five patients have been confirmed as norovirus positive. Two bays have also been closed on Cotton wards due to Norovirus. One bay has also been closed on Annie Zunz ward due to Influenza A and B. The bay is required to be closed for four days following the isolation of the symptomatic confirmed case.
PRUH Patients with diarrhoea and vomiting admitted to Trust have been appropriately managed. Two cases of Influenza H1N1 were identified in the CCU bay, the confirmed cases were treated and the contacts monitored for signs and symptoms.
15 of 15
Enc. 2.5.2
Monthly Unify Staffing Report (December 2015)
2nd February 2016 Board Meeting Enc. 2.5.2
Board of Directors Report to:
02 February 2016 Date of meeting:
Monthly Unify Staffing Report (December 2015) Subject:
Maria Donbavand Author(s):
Geraldine Walters Presented by:
Geraldine Walters Sponsor:
Monthly Nursing, Midwifery and Care staff numbers to the Board History:
For Information Status: Enc. 2.5.2
Key Implications
Patients have a right to be cared for by appropriately qualified and experienced staff in safe environments. This right is enshrined within the national Health Service (NHS) Constitution, and the Legal: NHS Act 1999 makes explicit the board’s corporate accountability for quality. Nurses’ responsibilities regarding safe staffing are stipulated by the Nursing and Midwifery council (NMC).
Nursing is the largest professional group in the Trust and consumes a large amount of resource. Financial: Cost efficiency is therefore paramount Assurance: This report provides assurance and evidence on nursing workforce.
Clinical: Nursing is a key component in provision of good patient experience and harm free care
Equality & Diversity: There are no issues or implications relating to equality and diversity within this report
Performance: This report highlights achievements against national and local key performance indicators
Strategy: The contents of this report is directly aligned to the Trust Nursing and Midwifery Objectives
Workforce: This report will inform Trust’s Nursing and Midwifery Workforce Strategy.
Estates: There are no implications
Reputation: Poor nursing care would have a deleterious effect on the reputation of the Trust
Other:(please specify) n/a
Enc. 2.5.2
Summary of Report 1/2
This report provides the Board of Directors with information on the details of the actual hours of Nursing, Midwifery and Care Staff time on ward day shifts and night shifts versus planned staffing levels for December 2015.
KEY POINTS • The number of staff required per shift is calculated using an evidence based tool, which is based on the level of sickness of the patients. This is further informed by professional judgement, taking into consideration issues such as ward size and layout, patient dependency, staff experience, incidence of harm and patient satisfaction, and additional tasks that the ward staff might be required to perform. This method is in line with NICE guidance. This gives us the optimum planned number of staff per shift.
• For each of the 77 clinical inpatient areas, the actual number of staff as a percentage of the planned number is recorded. The overall figures are shown below.
Safer Staffing Fill rate - Dec 2015
Day and Night Site % Average fill rate % Average Fill rate RN HCA
Denmark Hill 94% 122%
PRUH 96% 108%
Some variance between planned and actual levels is to be expected. The report explores in detail where there was a variance of greater than 15% between actual fill rates and planned staffing levels.
Across the Trust, the average actual level of registered nursing staff was generally within 15% of the levels planned across all shifts.
At Denmark Hill, there were 29 clinical areas where the actual number of Healthcare assistants was more the 115% above the planned level, and 6 areas where the levels were less than 85% of those planned.
At PRUH, there were 7 clinical areas where the actual number of Healthcare assistants was more the 115% above the planned level, and 8 areas where the levels were less than 85% of those planned. Enc. 2.5.2 Summary of Report 2/2
• Overstaffing • Reasons for apparent “overstaffing” of healthcare assistants is explored in detail in the report. Key reasons are:
o Extra staff required on an ad hoc basis to “special” high risk/vulnerable patients, this number has reduced over the year o Overseas Nurses awaiting their NMC registration are recorded as unregistered, o HCA usage is increased to minimise the impact of reduced RN fill rates o Where the expected staffing level is only one person, an increase of one member of staff on a few occasions generates a large percentage increase.
In summary the actual number of additional healthcare assistants used is less than the percentage would suggest, usage is subject to controls and is decreasing, Specific reasons for additional usage are shown in the report.
• Understaffing • Although there were no areas where the average registered nurse staffing fell below 85% over the month, there were occasional shifts when this was the case. A system of “Red Shift” reporting is in place which allows staff to flag instances when they believe that the shift is inadequately staffed to look after the current cohort of patients. In some cases this is due to having fewer Registered Nurses than planned, or when the number of staff planned is correct but the patients are more acutely sick or dependent than usual. In total there were 133 red shifts declared in December. The majority from Denmark Hill, many associated with the opening of a temporary ward, and from the emergency medical wards where there are high vacancies. In each case local managers assess the situation and make a judgement about whether moving staff from better staffed areas is required to maintain safety.
• ACTION REQUIRED • The Board is asked to note the report. Enc. 2.5.2 Where we are, trends and patterns, Nursing hours: Planned Vs. Actual – Denmark Hill
The summary below is based on 49 in-patient wards across the Denmark Safe Staffing levels - taken from NHS choices - 31.12.2015 Hill site. Hospital % Against Planned (RNs)
St Thomas Hospital 100% RNy Da and Night Shift - The overall Planned versus actual RN nursing Imperial (St Mary's) 97% hours for December 2015 was 6% below plan. This is a decrease of 2% from the previous month, this is within acceptable limits. Kings College Hospital - DH 94%
yHCA Da and Night Shift - The overall Planned versus actual RN nursing hours for December 2015 was 22% above plan.
Planned vs Actual by month - Denmark Hill
190%
175%
160% AVG - RN Day and Night 145% AVG HCA Day and Night
130% Over Under 115%
100%
85%
70% Jan Feb Mar Apr May jun Jul Aug Sept Oct Nov Dec
6 Enc. 2.5.2 Where we are, trends and patterns, Nursing hours: Planned Vs. Actual – Denmark Hill
240% 225% 210% 195% 180% 165% 150% 135% 120% 105% AVG Combined RN 90% 75% AVG Combined HCA 60% 45% Over 30% Under Lion Todd Lister Oliver Donne Cotton Trundle Twining Dawson Lonsdale Liver ICULiver Davidson Mary Ray Mary Fisk Ward Fisk Sam Oram Toni & Guy Waddington Cheere Ward R D Lawrence Guthrie Ward Howard Ward Howard Frank Cooksey Frank Kinnier Wilson David Marsden Coptcoat Ward Coptcoat Recovery Ward V&A HDU Ward Katherine Monk Katherine Murray Falconer Murray Victoria & Albert Marjorie Warren Rays Of Sunshine Of Rays Matthew Whiting Princess Elizabeth ELF Ward & LIBRA Thomas Thomas Cook CCCC Derek Mitchell Unit Kinnier Wilson HDU Christine Brown CCU Paediatric Short Short Stay Paediatric The Friends Stroke Unit Postnatal William Gilliat Coronary Coronary UnitCare (Sam… Frank StansilCritical Care Jack Steinberg Critical Care Frederick Still (Newborn Unit) Enc. 2.5.2 Exception Report – Denmark Hill
HCA Staffing Levels Higher Than Planned Day Shift Review by HON/Matron/Ward where 15% or more of nursing % Average Fill HCA Division Ward Name H C A Actual hours did not meet agreed staffing levels (Highlighted in rate HCA Planned red)
ward operating at amber nursing levels. Additional HCA T EAM Byron 126% 3 4 HCAs were used on 22 Occasions support (day and night shifts) to sdupport high levels of 1:1 care requirements. Daily monitoring & reporting by Matron
Coronary Care Unit Cardiac 130% 1 2 HCAs were used on 8 Occasions HCA increase due to specialling requirements (Sam Oram)
6 HCAs were used instead on 31 Increased use of HCA's is due to specialling and backfilling Neuro David Marsden 177% 3 Occasions RN vacancies when unable to fill RN bank shifts.
Frederick Still Ward operating at safe staffing levels within the planned Children's 200% 0 1 HCA was used on 2 Occasions (Newborn Unit) number.
Liver and Renal Howard Ward 153% 2 3 HCAs were used on 25 Occasions Additional HCAs required for 1:1 specialling. Increased use of HCA's on nights is due to specialling and Neuro Kinnier Wilson HDU 137% 1 2 HCAs were used on 9 Occasions on days specialling plus when unable to fill RN vacancy shifts on the bank with a qualified nurse.
Children's Rays Of Sunshine 170% 1 2 HCAs were used on 18 Occasions Specialling patient with HCA
Cardiac Sam Oram 173% 2 3 HCAs were used on 29 Occasions HCA increase due to specialling requirements Additional staffing is shown to reflect the reduction in the Surgery Twining 122% 1 2 HCAs were used on 9 Occasions actual formalised budget - ward was reopened without full budget. Enc. 2.5.2 Exception Report – Denmark Hill cont…
HCA Staffing Levels Higher Than Planned Night Shift Review by HON/Matron/Ward where 15% or more of nursing % Average Fill HCA Division Ward Name H C A Actual hours did not meet agreed staffing levels (Highlighted in rate HCA Planned red)
ward operating at amber nursing levels. Additional HCA T EAM Byron 132% 3 4 HCAs were used on 22 Occasions support (day and night shifts) to sdupport high levels of 1:1 care requirements. Daily monitoring & reporting by Matron
Staffing levels were adjusted according to activity levels and there were also instances where staff moved to Twinning Surgery Coptcoat Ward 135% 1 2 HCAs were used on 8 Occasions and Lister to support the ward shortage ensuring patient levels were not effected. The usage on the night shift was due to a patient that required specialling.
Coronary Care Unit Cardiac 350% 0 1 HCA was used on 5 Occasions HCA increase due to specialling requirements (Sam Oram)
Increased use of HCA's is due to specialling and backfilling Neuro David Marsden 192% 3 6 HCAs were used on 31 Occasions RN vacancies when unable to fill RN bank shifts.
RN shortage helped by staff movement from 1 ward to another within haematology unit. Increase usage of HCA requested as added support for RN shortage. Ward Haematology Davidson 152% 1 2 HCAs were used on 16 Occasions managers and matron working on the clinical areas to run the ward amber. This all similar with other ward; Derek Mitchell Unit, Waddington ward & Elf & Libra ward. RN shortage helped by staff movement from 1 ward to another within haematology unit. Increase usage of HCA requested as added support for RN shortage. Ward Haematology Derek Mitchell Unit 128% 1 2 HCAs were used on 10 Occasions managers and matron working on the clinical areas to run the ward amber. This all similar with other ward; Derek Mitchell Unit, Waddington ward & Elf & Libra ward. RN shortage helped by staff movement from 1 ward to another within haematology unit. Increase usage of HCA requested as added support for RN shortage. Ward Haematology ELF & LIBRA Ward 147% 1 2 HCAs were used on 11 Occasions managers and matron working on the clinical areas to run the ward amber. This all similar with other ward; Derek Mitchell Unit, Waddington ward & Elf & Libra ward. Liver and Renal Fisk Ward 125% 1 2 HCAs were used on 8 Occasions Additional HCAs required for 1:1 specialling. Enc. 2.5.2 Exception Report – Denmark Hill cont…
HCA Staffing Levels Higher Than Planned
Night Shift Review by HON/Matron/Ward where 15% or more of nursing % Average Fill HCA Division Ward Name H C A Actual hours did not meet agreed staffing levels (Highlighted in rate HCA Planned red)
Liver and Renal Howard Ward 177% 1 2 HCAs were used on 27 Occasions Additional HCAs required for 1:1 specialling.
Staffing levels were adjusted according to activity levels and there were also instances where staff moved to Twinning Surgery Katherine Monk 137% 3 4 HCAs were used on 23 Occasions and Lister to support the ward shortage ensuring patient levels were not effected. The usage on the night shift was due to a patient that required specialling.
Increased use of HCA's is due to specialling and backfilling Neuro Kinnier Wilson 149% 2 3 HCAs were used on 23 Occasions RN vacancies when unable to fill RN bank shifts.
Increased use of HCA's on nights is due to specialling and Neuro Kinnier Wilson HDU 214% 0 1 HCA was used on 11 Occasions on days specialling plus when unable to fill RN vacancy shifts on the bank with a qualified nurse. There was additional HCA support due to a patient requiring Surgery Lister 159% 2 3 HCAs were used on 27 Occasions 1:1 specialling. There was additional HCA support due to a patient requiring Surgery Matthew Whiting 158% 2 3 HCAs were used on 26 Occasions 1:1 specialling. Children's Rays Of Sunshine 123% 0 1 HCA was used on 6 Occasions Specialling patient with HCA
Cardiac Sam Oram 287% 1 3 HCAs were used on 30 Occasions HCA increase due to specialling requirements
Current vacancines on this ward but escalated to Matron and staffing moved around to ensure patient safety not Children's Toni & Guy 325% 0 1 HCA was used on 18 Occasions effected. - Night shift required for additional specialing patients. Additional staffing is shown to reflect the reduction in the Surgery Twining 159% 1 2 HCAs were used on 14 Occasions actual formalised budget - ward was reopened without full budget. Cardiac Victoria & Albert 150% 0 1 HCA was used on 5 Occasions HCA increase due to specialling requirements RN shortage helped by staff movement from 1 ward to another within haematology unit. Increase usage of HCA requested as added support for RN shortage. Ward Haematology Waddington 400% 0 1 HCA was used on 4 Occasions managers and matron working on the clinical areas to run the ward amber. This all similar with other ward; Derek Mitchell Unit, Waddington ward & Elf & Libra ward. Enc. 2.5.2 Exception Report – Denmark Hill cont…
Actual HCA Staffing Levels Lower than Planned
Day Shift Review by HON/Matron/Ward where 15% or more of nursing % Average Fill HCA Division Ward Name H C A Actual hours did not meet agreed staffing levels (Highlighted in rate HCA Planned red) There is currently a HCA vacancy which we have now 1 HCA was used instead on 15 Women's Brunel 72% 2 recruited to but where there was low staffing this reflects Occasions the reduction in activity. Unable to fill Vacancy with temporary shift however Frank Stansil Critical CCTD 81% 1 0 HCAs were used on 6 Occasions escalated to Ward manager to ensure patient safety was not Care effected. 0 HCAs were used on only 5 MTO staff on sick leave, creating reduction in hours but 1 (req for Liver and Renal Liver ICU 62% Occasions out of the 13 Occasions patient safety not effected as escalation to Ward Manager / 13 shifts) that required a HCA Matron.
Night Shift Review by HON/Matron/Ward where 15% or more of nursing % Average Fill HCA Division Ward Name H C A Actual hours did not meet agreed staffing levels (Highlighted in rate HCA Planned red) 0 HCAs were used on only 5 1 (req for 6 Children's Lion 50% Occasions out of the 6 occasions HCA's moved for specialling as acuity allowed shifts) that required a HCA 0 HCAs were used on only 10 MTO staff on sick leave, creating reduction in hours but 1 (req for Liver and Renal Liver ICU 17% Occasions out of the 12 Occasions patient safety not effected as escalation to Ward Manager / 12 shifts) that required a HCA Matron. 0 HCAs were used on only 14 1 (req for Children's Princess Elizabeth 60% Occasions out of the 22 Occasions HCA's moved for specialling as acuity allowed 22 shifts) that required a HCA Enc. 2.5.2 Where we are, trends and patterns, Nursing hours: Planned Vs. Actual – PRUH
The summary below is based on 28 in-patient wards across the Denmark Hill site. Safe Staffing levels - taken from NHS choices - 31.12.2015 Hospital % Against Planned (RNs?)
RNy Da and Night Shift - The overall Planned versus actual Croydon University Hospital 100% RN nursing hours for December 2015 was 4% below plan. University Hospital Lewisham 96% This is a decrease of 2% from the previous month. Kings College Hospital - PRUH 96% HCAy Da and Night Shift - The overall Planned versus actual RN nursing hours for December 2015 was 8% above plan. This is an increase of 12% from the previous month.
Planned Vs Actual by month - PRUH
190% 175% 160% % Avg Fill rate RN Day and Night 145% % Avg Fill rate HCA Day and Night 130% Over 115% Under 100% 85% 70% Jan Feb Mar Apr May June July August Sept Oct Nov Dec
12 Enc. 2.5.2 Where we are, trends and patterns, Nursing hours: Planned Vs. Actual – PRUH
Ward Level performance – Planned Vs Actual Day and Night combined - PRUH
400% 385% 370% 355% 340% 325% 310% 295% 280% 265% 250% 235% 220% 205% 190% 175% 160% 145% AVG Combined RN 130% 115% 100% AVG Combined HCA 85% 70% 55% Over 40% Under Enc. 2.5.2 Exception Report – PRUH
HCA Staffing Levels Higher Than Planned
Day Shift % Average Fill Review by HON/Matron/Ward where 15% or more of nursing hours Division Ward HCA Planned H C A Actual rate HCA did not meet agreed staffing levels (Highlighted in red) 1 HCA used on 2 ONPs used for shift cover - noted as HCAs on the staffing app, plus Cardiac Coronary Care Unit (CCU) 200% 0 Occasions some specialling requirements
3 HCAs used instead The ward had a lot of medical outliers that are double handed, Surgery Surgical Ward 6 142% 2 on 23 Occasions some are confused needing supervision. Extra HCA booked
Night Shift % Average Fill Review by HON/Matron/Ward where 15% or more of nursing hours Division Ward HCA Planned H C A Actual rate HCA did not meet agreed staffing levels (Highlighted in red) 1 HCA used on 6 ONPs used for shift cover - noted as HCAs on the staffing app, plus Cardiac Coronary Care Unit (CCU) 600% 0 Occasions some specialling requirements
3 HCAs used instead The ward had a lot of medical outliers that are double handed, Surgery Surgical Ward 6 147% 2 on 26 Occasions some are confused needing supervision. Extra HCA booked
2 HCAs used on 10 Patient required 1:1 HCA care therefore night HCA staffing Network Chartwell Unit 139% 1 Occasions increased temporarily. 1 HCA used on 3 Additional staff on the night shift is only 5 shifts per month which is Children's Special Care Baby Unit 150% 0 Occasions within planned additional required for milk bank. We have had a lot of patients at risk of falling whereby we had 4 HCAs used instead T EAM Darwin 1 (S1) 125% 3 cohort three bays and also two patients wandering on the ward who on 24 Occasions were also at risk - hence the high fill rate of CSW. Enc. 2.5.2 Exceptions Report – PRUH cont…
Actual HCA Staffing Levels Lower than Planned
Day Shift % Average Fill Review by HON/Matron/Ward where 15% or more of nursing hours Division Ward HCA Planned H C A Actual rate HCA did not meet agreed staffing levels (Highlighted in red) We adjust staffing due to patient numbers and generally the 2 HCAs used instead Surgery Boddington (ORP) 53% 3 reduced staffing is because we have a lower number of patients on on 22 Occasions the ward. We adjust staffing due to patient numbers and generally the 1 HCA used instead Network Ontario (ORP) 47% 3 reduced staffing is because we have a lower number of patients on on 31 Occasions the ward.
Night Shift % Average Fill Review by HON/Matron/Ward where 15% or more of nursing hours Division Ward HCA Planned H C A Actual rate HCA did not meet agreed staffing levels (Highlighted in red) 0 HCAs used on 14 Vacancy currently exists for HCA so we are reducing staff to reflect Children's Childrens Ward 50% 1 Occasions the current activity.
0 HCAs used on 10 2 x HCA in pre-employment checks. NHSP unable to backfill all gaps CCTD Intensive Care Unit 67% 1 Occasions so escalated to Nurse in Charge/Matron to ensure ward was safe.
This ward is still in the process of piloting as an Acute Assessment Emergency Assessment Unit 3 HCAs used on 23 hub with a max length of stay of 16 hours and as such patients are T EAM 80% 4 (EAU) Occasions either moving onward to a ward or going home. During this change there is a review of staffing levels in particular the need for HCAs.
1 HCAs used instead S4 has been closed and nurses redeployed to other wards over the Surgery Surgical Ward 4 82% 2 on 6 Occasions christmas period
We adjust staffing due to patient numbers and generally the 1 HCA used instead Surgery Boddington (ORP) 56% 2 reduced staffing is because we have a lower number of patients on on 19 Occasions the ward. We adjust staffing due to patient numbers and generally the 1 HCA used instead Network Ontario (ORP) 52% 2 reduced staffing is because we have a lower number of patients on on 29 Occasions the ward.
Enc. 3.1
Report to: Board of Directors
Date of meeting: 2 February 2016
Subject: Monitor Submission Quarter 3, 2015/2016
Author: Tamara Cowan, Board Secretary
Presented by: Nick Moberly, Chief Executive
Status: For Approval
1. Overview
NHS Foundation Trusts are required to make in-year submissions on a quarterly basis during 2015/16. The submission is based on the Trust’s quarterly performance in finances, meeting national targets and indicators and any other areas pertinent to meeting conditions enshrined in the its licence.
The submission is made in the form of a comprehensive return to monitor which includes analysis of the financial position, performance against national targets, continuity of risk rating against the information submitted in the Trust’s annual plan, in addition to other information.
The Board delegated authority to the Finance & Performance Committee to review and approve the quarterly submissions to ensure that submission are made within the required timeframe to Monitor.
On 26 January the Committee considered the Trust’s performance during the quarter, 01 October – 31 December 2015, and decide how best to respond to the statements (Confirmed/Not Confirmed) below taking account of the latest reports on operational and financial performance.
2. Recommendation
The Committee: • Consider the rationale and proposed Board responses in Appendix 1 and offer any comments or suggested amendments; and
• To review the following key elements of the Monitor return: − Appendix 2: Continuity of Service Risk Rating and Financial Summary − Appendix 3: Declarations of risks against healthcare Targets and Indicators
• Agreed that BK and NM sign-off the final Board self-certification which was made on 28 January 2016.
Enc. 3.1
3. Key implications
Legal: Statutory reporting to Monitor. Financial: Trust reports financial performance against published plan. Assurance: The summary and appendices provide assurance that the Trust has met all targets and is compliant with its terms of authorisation. Clinical: There is no direct impact on clinical issues. Equality & Diversity: There is no direct impact on E&D. Performance: Quarterly performance against national targets. Strategy: Performance against the trust’s annual plan forecasts. Workforce None. Estates: There is no direct impact on Estates. Reputation: Trust’s quarterly results will be published by Monitor. Other (specify): None.
Enc. 3.1
Appendix 1: Board Declaration
PROPOSED Board Response For finance, that:
The board anticipates that the trust will continue to maintain a Continuity of Service risk rating of at least 3 over the next 12 months.
Rationale for signing not confirmed NOT The Trust is still reliant on the working capital facility from Monitor. CONFIRMED
The Trust Continuity of Service Risk Rating of 1 at the end of Quarter 2.
For governance, that:
The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.
Rationale for signing not confirmed The Trust self-certified that there was a risk it would not meet the following targets in its Annual Plan: − Referral to treatment targets – 18 weeks for admitted/non- admitted/incomplete; and NOT − A&E 4-hour target; and CONFIRMED − 62-day cancer waits; and − C.Diff – Quarters 1-4
In quarter 3 the Trust did not meet the following targets: − 18 weeks in aggregate incomplete pathway; and − A&E 4-hour target; and − The number of cases of c.diff is above trajectory
Otherwise:
The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework, Diagram 6) which have not already been reported.
CONFIRMED Rationale for signing confirmed − The Trust is not aware of any other matters arising that Monitor is not already aware.
Consolidated subsidiaries:
Number of subsidiaries included in the finances of this return. This template 1 should not include the results of your NHS charitable funds.
Enc. 3.1
Click to go to index Summary of Financial Statements for King’s College Hospital NHS Foundation Trust
Adjusted Forecast Audited For Plan For Actual For Variance For Plan For Actual For Variance For Plan For Simple Forecast Forecast Variance units sense PrevYE ending Month ending Month ending Month ending YTD ending YTD ending YTD ending Year ending Year ending Year ending Year ending 31-Mar-15 31-Dec-15 31-Dec-15 31-Dec-15 31-Dec-15 31-Dec-15 31-Dec-15 31-Mar-16 31-Mar-16 31-Mar-16 31-Mar-16
Summary Income and Expenditure Account
Operating income (inc in EBITDA) NHS Clinical income £m (+ve) 880.626 72.197 73.693 1.496 646.291 679.730 33.439 860.388 893.827 919.066 58.678 Non-NHS Clinical income £m (+ve) 16.345 1.888 2.222 0.334 15.072 19.545 4.473 19.783 24.256 24.256 4.473 Non-Clinical income £m (+ve) 186.811 11.820 10.972 (0.848) 106.383 93.757 (12.626) 141.844 129.218 129.218 (12.626) Total £m 1,083.782 85.904 86.887 0.983 767.746 793.032 25.286 1,022.015 1,047.301 1,072.540 50.525
Operating expenses (inc in EBITDA) Employee expense £m (-ve) (620.182) (51.539) (51.139) 0.400 (479.031) (472.594) 6.437 (628.355) (621.918) (625.998) 2.357 Non-Pay expense £m (-ve) (401.385) (27.900) (34.064) (6.164) (263.567) (304.855) (41.288) (345.619) (386.907) (394.069) (48.450) PFI / LIFT expense £m (-ve) (51.173) (5.202) (4.513) 0.689 (39.100) (41.518) (2.418) (53.891) (56.309) (56.309) (2.418) Total £m (1,072.740) (84.641) (89.716) (5.075) (781.698) (818.967) (37.269) (1,027.865) (1,065.134) (1,076.376) (48.511)
EBITDA £m 11.042 1.263 (2.829) (4.092) (13.952) (25.935) (11.983) (5.850) (17.833) (3.836) 2.014 EBITDA Margin % % 1.02% 1.47% (3.26%) (4.73%) (1.82%) (3.27%) (1.45%) (0.57%) (1.70%) (0.36%) 0.20%
Operating income (exc from EBITDA) Donations and Grants for PPE and intangible assets £m (+ve) - - 0.051 0.051 0.500 0.707 0.207 0.900 1.107 1.107 0.207
Operating expenses (exc from EBITDA) Depreciation & Amortisation £m (-ve) (22.152) (1.954) (2.002) (0.048) (17.584) (18.036) (0.452) (23.446) (23.898) (23.938) (0.492) Impairment (Losses) / Reversals £m (+/-ve) (4.535) (0.459) (0.458) 0.001 (4.125) (4.123) 0.002 (5.500) (5.498) (5.500) - Restructuring costs £m (-ve) ------Total £m (26.687) (2.413) (2.460) (0.047) (21.709) (22.159) (0.450) (28.946) (29.396) (29.438) (0.492)
Non-operating income Finance income £m (+ve) 0.969 0.202 0.009 (0.193) 1.818 0.080 (1.738) 2.500 0.762 0.702 (1.798) Gain / (Losses) on asset disposals £m (+/-ve) (0.285) - - - (0.233) 0.017 0.250 (0.350) (0.100) (0.100) 0.250 Gain on transfers by absorption £m (+ve) ------Other non - operating income £m (+ve) ------Total £m 0.684 0.202 0.009 (0.193) 1.585 0.097 (1.488) 2.150 0.662 0.602 (1.548)
Non-operating expenses Interest expense (non-PFI / LIFT) £m (-ve) (1.809) (0.337) (0.420) (0.083) (2.661) (2.856) (0.195) (3.670) (3.865) (4.795) (1.125) Interest expense (PFI / LIFT) £m (-ve) (17.279) (1.414) (1.414) - (12.721) (12.725) (0.004) (16.962) (16.966) (16.966) (0.004) PDC expense £m (-ve) (11.272) (0.961) (0.812) 0.149 (8.642) (8.150) 0.492 (11.523) (11.031) (10.501) 1.022 Other finance costs £m (-ve) (0.153) (0.013) (0.004) 0.009 (0.112) (0.092) 0.020 (0.150) (0.130) (0.150) - Non-operating PFI costs (e.g. contingent rent) £m (-ve) (6.163) (0.537) (0.547) (0.010) (4.839) (4.923) (0.084) (6.452) (6.536) (6.536) (0.084) Losses on transfers by absorption £m (-ve) ------Other non-operating expenses (including tax) £m (-ve) (0.250) ------Total £m (36.926) (3.262) (3.197) 0.065 (28.975) (28.746) 0.229 (38.757) (38.528) (38.948) (0.191)
Surplus / (Deficit) after tax £m (51.887) (4.210) (8.426) (4.216) (62.551) (76.035) (13.485) (70.503) (83.988) (70.513) (0.010)
Profit/(loss) from discontinued Operations, Net of Tax £m (+/-ve) ------
Surplus / (Deficit) after tax from Continuing Operations £m (51.887) (4.210) (8.426) (4.216) (62.551) (76.035) (13.485) (70.503) (83.988) (70.513) (0.010)
Memorandum Lines:
Surplus / (Deficit) before impairments and transfers £m (47.352) (3.751) (7.968) (4.217) (58.426) (71.912) (13.487) (65.003) (78.490) (65.013) (0.010)
One off income/costs £m (4.820) (0.459) (0.458) 0.001 (4.358) (4.106) 0.252 (5.850) (5.598) (5.600) 0.250 Normalised Surplus / (Deficit) £m (47.067) (3.751) (7.968) (4.217) (58.193) (71.929) (13.737) (64.653) (78.390) (64.913) (0.260) Normalised Surplus / Deficit Margin % % (4.34%) (4.36%) (9.16%) (4.81%) (7.56%) (9.06%) (1.50%) (6.31%) (7.47%) (6.04%) 0.30%
Summary Statement of Financial Position
Non-current Assets Intangible assets £m (+ve) 3.495 2.902 2.808 (0.094) 2.902 2.808 (0.094) 2.704 2.610 2.610 (0.094) Property, Plant & Equipment £m (+ve) 365.304 367.752 367.637 (0.115) 367.752 367.637 (0.115) 375.295 375.180 365.780 (9.515) On-balance sheet PFI £m (+ve) 247.392 252.959 242.411 (10.548) 252.959 242.411 (10.548) 258.148 247.600 247.600 (10.548) Other £m (+ve) 11.659 12.260 13.734 1.474 12.260 13.734 1.474 13.410 14.884 14.884 1.474 Total £m 627.850 635.873 626.590 (9.283) 635.873 626.590 (9.283) 649.557 640.274 630.874 (18.683)
Current Assets Cash and cash equivalents £m (+ve) 43.445 2.000 26.787 24.787 2.000 26.787 24.787 2.000 26.787 11.040 9.040 Other current assets £m (+ve) 115.307 109.876 138.361 28.485 109.876 138.361 28.485 112.578 141.063 146.168 33.590 Total £m 158.752 111.876 165.148 53.272 111.876 165.148 53.272 114.578 167.850 157.208 42.630
Current Liabilities Overdrafts and drawdowns in committed facilities £m (-ve) - (16.821) - 16.821 (16.821) - 16.821 (26.494) (9.673) - 26.494 PFI / LIFT leases £m (-ve) (3.550) (0.886) (0.887) (0.001) (0.886) (0.887) (0.001) (3.898) (3.899) (3.899) (0.001) Other borrowings £m (-ve) (4.074) (61.737) (93.770) (32.033) (61.737) (93.770) (32.033) (63.774) (95.807) (95.807) (32.033) Other current liabilities £m (-ve) (175.701) (125.916) (168.072) (42.156) (125.916) (168.072) (42.156) (134.804) (176.960) (153.090) (18.286) Total £m (183.325) (205.360) (262.729) (57.369) (205.360) (262.729) (57.369) (228.970) (286.339) (252.796) (23.826)
Non-current Liabilities PFI / LIFT leases £m (-ve) (155.109) (155.109) (155.109) - (155.109) (155.109) - (151.211) (151.211) (151.211) - Other borrowings £m (-ve) (67.462) (67.460) (67.462) (0.002) (67.460) (67.462) (0.002) (63.386) (63.388) (63.388) (0.002) Other non-current liabilities £m (-ve) (6.295) (6.295) (6.295) - (6.295) (6.295) - (4.995) (4.995) (4.995) - Total £m (228.866) (228.864) (228.866) (0.002) (228.864) (228.866) (0.002) (219.592) (219.594) (219.594) (0.002)
Reserves £m (+ve) 374.413 313.523 300.145 (13.378) 313.523 300.145 (13.378) 315.570 302.192 315.692 0.122
Summary Statement of Cash Flows
Surplus (Deficit) from Operations £m (15.645) (1.150) (5.238) (4.088) (35.161) (47.386) (12.226) (33.896) (46.122) (32.167) 1.729
Operating activities Non-operating and non-cash items in operating surplus/(deficit) £m (+/-ve) 26.648 2.642 4.605 1.963 12.259 13.850 1.591 17.350 18.941 20.755 3.405 Operating Cash flows before movements in working capital £m 11.003 1.492 (0.633) (2.125) (22.902) (33.536) (10.635) (16.546) (27.181) (11.412) 5.134
Movements in working capital £m (+/-ve) 48.424 (8.983) 11.963 20.946 (36.181) (26.787) 9.394 (29.445) (20.051) (48.132) (18.687) Increase/(Decrease) in non-current provisions £m (+/-ve) ------(1.300) (1.300) (1.300) - Net cash inflow/(outflow) from operating activities £m 59.427 (7.491) 11.330 18.821 (59.083) (60.323) (1.241) (47.291) (48.532) (60.844) (13.553)
Investing activities Capital Expenditure (Accruals basis) £m (-ve) i (49.147) (3.258) (1.400) 1.858 (29.123) (18.835) 10.288 (38.903) (28.615) (28.615) 10.288 Increase/(decrease) in Capital Creditors £m (+/-ve) (1.669) 0.100 - (0.100) 0.900 (0.051) (0.951) 1.200 0.249 1.231 0.031 Proceeds on disposal of PPE, intangible assets and investment property £m (+ve) 0.012 0.001 - (0.001) 0.015 0.001 (0.014) 0.021 0.007 0.007 (0.014) Other cash flows from investing activities £m (+/-ve) 0.213 0.012 0.009 (0.003) 0.108 (0.259) (0.367) 0.220 (0.147) 0.203 (0.017) Net cash inflow/(outflow) from investing activities £m (50.591) (3.145) (1.391) 1.754 (28.100) (19.144) 8.956 (37.462) (28.506) (27.174) 10.288
Financing activities Public Dividend Capital repaid £m (-ve) ------Repayment of borrowings £m (-ve) i (1.285) (0.645) - 0.645 (3.883) (1.951) 1.932 (3.883) (1.951) (1.951) 1.932 Capital element of finance lease rental payments £m (-ve) i (3.199) (0.296) (0.295) 0.001 (2.662) (2.662) - (3.550) (3.550) (3.550) - Interest element of finance lease rental payments £m (-ve) i (23.443) (1.951) (1.961) (0.010) (17.560) (16.007) 1.553 (23.414) (21.861) (21.861) 1.553 Interest paid on borrowings £m (-ve) (1.452) (0.654) (0.420) 0.234 (2.908) (2.912) (0.004) (2.908) (2.912) (2.912) (0.004) Other cash flows from financing activities £m (+/-ve) 9.462 - 6.419 6.419 55.922 86.341 30.419 50.561 80.980 85.887 35.326 Net cash inflow/(outflow) from financing activities £m (19.917) (3.546) 3.743 7.289 28.909 62.809 33.900 16.806 50.706 55.613 38.807
Opening cash and cash equivalents less bank overdraft £m (+/-ve) 54.526 (0.639) 13.105 13.744 43.453 43.445 (0.008) 43.453 43.445 43.445 (0.008) Net cash increase / (decrease) £m (11.081) (14.182) 13.682 27.864 (58.274) (16.658) 41.615 (67.947) (26.332) (32.405) 35.542 Changes due to transfers by absorption £m (+/-ve) ------Closing cash and cash equivalents less bank overdraft £m 43.445 (14.821) 26.787 41.607 (14.821) 26.787 41.607 (24.494) 17.113 11.040 35.534
Financial Sustainability Risk Rating
Capital Service Cover Revenue Available for Capital Service £m 11.761 (12.134) (25.855) (13.721) (3.350) (17.071) (3.134) 0.216 Capital Service £m (41.160) (35.520) (33.359) 2.161 (46.190) (44.029) (44.449) 1.741 Capital Service Cover metric 0.0x 0.29 (0.34) (0.78) (0.43) (0.07) (0.39) (0.07) 0.00 Capital Service Cover rating Score 1 1 1 1 1 1 Liquidity Working Capital for FSRR £m (+/-ve) (41.663) (110.574) (117.178) (6.604) (131.482) (138.086) (115.185) 16.297 Operating Expenses within EBITDA, Total £m (1,072.740) (781.698) (818.967) (37.269) (1,027.865) (1,065.134) (1,076.376) (48.511) Liquidity metric Days (13.982) (38.192) (38.632) (0.439) (46.050) (46.671) (38.524) 7.526 Liquidity rating Score 2 1 1 1 1 1 I&E Margin Normalised Surplus/(Deficit) £m (+/-ve) (47.067) (58.193) (71.929) (13.737) (64.653) (78.390) (64.913) (0.260) Adjusted Total Income for FSRR £m (+ve) 1,084.751 770.064 793.820 23.755 1,025.415 1,049.170 1,074.349 48.934 I&E Margin % (4.34%) (7.56%) (9.06%) (1.50%) (6.31%) (7.47%) (6.04%) 0.30% I&E Margin rating Score 1 1 1 1 1 1 I&E Margin Variance I&E Margin % (7.56%) (9.06%) (1.50%) (6.31%) (7.47%) (6.04%) 0.30% I&E Margin Variance From Plan % -4.37% (4.37%) -1.50% (4.37%) (1.17%) 0.26% I&E Margin Variance From Plan rating Score 1 2 1 2 4
Overall Financial Sustainability Risk Rating Score 1 1 1 1 2
Continuity of Service Risk Rating Score 2
Enc. 3.1
Click to go to index Declaration of risks against healthcare targets and indicators for 201516 by King’s College Hospital NHS Foundation Trust Annual Plan Quarter 1 Quarter 2 Quarter 3
Scoring Per Scoring Per Scoring Per Scoring Per Scoring Per Targets and indicators as set out in the Risk Assessment Framework (RAF) - definitions per RAF Appendix A Threshold Risk Risk Risk Risk Risk Risk NOTE: If a particular indicator does not apply to your FT then please enter "Not relevant" for those lines. or target Performance Declaration Comments / explanations Performance Declaration Comments / explanations Performance Declaration Comments / explanations Assessment declared Assessment Assessment Assessment Assessment YTD Framework Framework Framework Framework Framework
Key: must complete may need to complete
Target or Indicator (per Risk Assessment Framework) Referral to treatment time, 18 weeks in aggregate, incomplete pathways i 92% 1.0 Yes 1 0.0% Not met Data not submitted with agreed reporting1 suspension0.0% Not met Data not submitted with agreed reporting1 suspension0.0% Not met Data not submitted with agreed reporting1 suspension
A&E Clinical Quality - Total Time in A&E under 4 hours i 95% 1.0 Yes 1 89.9% Not met 1 91.8% Not met 1 89.3% Not met 1
Cancer 62 Day Waits for first treatment (from urgent GP referral) - post local breach re-allocation i 85% 1.0 Yes 84.6% Not met 86.4% Achieved 86.4% Achieved 1 1 0 Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - post local breach re-allocation i 90% 1.0 No 95.5% Achieved 92.6% Achieved 97.5% Achieved 0 Cancer 62 Day Waits for first treatment (from urgent GP referral) - pre local breach re-allocation i 0.0% 0.0% 0.0%
Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - pre local breach re-allocation i 0.0% 0.0% 0.0%
Cancer 31 day wait for second or subsequent treatment - surgery i 94% 1.0 No 98.8% Achieved 95.3% Achieved 99.4% Achieved
Cancer 31 day wait for second or subsequent treatment - drug treatments i 98% 1.0 No 0 99.5% Achieved 0 100.0% Achieved 100.0% Achieved 0
Cancer 31 day wait for second or subsequent treatment - radiotherapy i 94% 1.0 No 100.0% Achieved 100.0% Achieved 99.4% Achieved 0 Cancer 31 day wait from diagnosis to first treatment i 96% 1.0 No 0 98.4% Achieved 0 99.3% Achieved 0 99.1% Achieved 0
Cancer 2 week (all cancers) i 93% 1.0 No 97.0% Achieved 97.5% Achieved 95.1% Achieved 0 0 0 Cancer 2 week (breast symptoms) i 93% 1.0 No 99.1% Achieved 99.2% Achieved 98.7% Achieved 0 Care Programme Approach (CPA) follow up within 7 days of discharge i 95% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 0 0 Care Programme Approach (CPA) formal review within 12 months i 95% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 Admissions had access to crisis resolution / home treatment teams i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0 0 Meeting commitment to serve new psychosis cases by early intervention teams OLD measure - use until Q1 2016/17 i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0 0 Ambulance Category A 8 Minute Response Time - Red 1 Calls i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0 0 Ambulance Category A 8 Minute Response Time - Red 2 Calls i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0 0 Ambulance Category A 19 Minute Transportation Time i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0 0 C.Diff due to lapses in care (YTD) i 54 1.0 Yes 1 28 Not met 1 47 Not met 67 Not met 1 1 Total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) i 0 0 0
C.Diff cases under review i 0 0 0
Minimising MH delayed transfers of care i <=7.5% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0 0 Meeting commitment to serve new psychosis cases by early intervention teams NEW measure (scored from Q4 2015/16) i 50% 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant
Improving Access to Psychological Therapies - Patients referred within 6 weeks NEW measure (scored from Q3 2015/16) i 75% 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant
Improving Access to Psychological Therapies - Patients referred within 18 weeks NEW measure (scored from Q3 2015/16) i 95% 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant
Data completeness, MH: identifiers i 97% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0 0 Data completeness, MH: outcomes i 50% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0 0 Compliance with requirements regarding access to healthcare for people with a learning disability i N/A 1.0 No 0 N/A Achieved 0 N/A Achieved N/A Achieved 0 0 Community care - referral to treatment information completeness i 50% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant
Community care - referral information completeness i 50% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant 0
Community care - activity information completeness i 50% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0
Risk of, or actual, failure to deliver Commissioner Requested Services N/A N/A No No No
Date of last CQC inspection i N/A N/A 13/04/2015 13/04/2015 13/04/2015
CQC compliance action outstanding (as at time of submission) N/A N/A No Final CQC Inspection Report pending Yes Yes
CQC enforcement action within last 12 months (as at time of submission) N/A N/A No No No
CQC enforcement action (including notices) currently in effect (as at time of submission) N/A N/A No Final CQC Inspection Report pending No No Report by Moderate CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) i N/A N/A No Final CQC Inspection Report pending No We have requirement notices in place and must do's which we are addressingNo via our actionWe have plan requirement notices in place and must do's which we are addressing via our action plan Exception Major CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission) i N/A N/A No Final CQC Inspection Report pending No No
Overall rating from CQC inspection (as at time of submission) i N/A N/A N/A Final CQC Inspection Report pending Requires improvement Requires improvement
CQC recommendation to place trust into Special Measures (as at time of submission) N/A N/A No No No
Trust unable to declare ongoing compliance with minimum standards of CQC registration N/A N/A No No No
Trust has not complied with the high secure services Directorate (High Secure MH trusts only) N/A N/A N/A N/A N/A
0 i 0 0 0 Results left to complete: 0 i Checks Count: 0 i OK Checks left to clear: i 4 4 3 3 Service Performance Score
Enc. 3.2
Report to: Board of Directors
Date of meeting: 02 February 2016
Subject: Chair’s and Non-Executive Directors’ Activity Report
Presented by: Lord Kerslake, Chairman
Status: For information
1. Background/ Purpose This report details the activities undertaken by the Non-Executive Directors of the Board for the period from Monday 7 December 2015 to Friday 15 January 2016.
2. Action required The Board of Directors is asked to note the contents of this report.
Lord Kerslake - Chairman Date Activity
8 December Attended Council of Governors prep. meeting
Chaired Private Council of Governors Meeting 10 December Chaired Public Council of Governors Meeting
Met with Alix Pryde, NED
Chaired Public Board Meeting
15 December Attended Non Executive Directors’ Lunch
Chaired Private Board Meeting
Attended Finance & Performance Committee Meeting
Jon Cohen – Non-Executive Lead for Improving Quality of Patient Care Date Activity
Attended Public Board Meeting 15 December Attended Private Board Meeting
8 January Met with Simon Taylor
1
Enc. 3.2
13 January Met with TJ Lasoye
14 January Met with Geraldine Walters
Attended the Quality & Governance Committee Meeting
Met with Richard Trembath
Alix Pryde – Non Executive Director Lead for Move to Operational Sustainability Date Activity
Introduction with Judith Seddon, Interim Director of Corporate Affairs 8 December Introduction with Jez Tozer, Interim COO
10 December Attended Public Council of Governors Meeting
Call with Alan Goldsman, Interim CFO 11 December Introduction with Dawn Brodrick, Director of Workforce Development
Introduction with External Auditor (Craig Wisdom) accompanied by Chis Stooke (outgoing Audit Committee Chair) 14 December
Introduction with Nick Moberly, CEO
Met with Lord Kerslake, Chair
Attended Public Board Meeting 15 December Attended Non Executive Directors’ Lunch
Attended Private Board Meeting
11 January Met with External Auditor (Craig Wisdom)
13 January Call with Tamara Cowan re External Audit tender
2
Enc. 3.2
Introduction with Internal Auditor (Neil Hewitson, Rich Hewes) accompanied 14 January by Chis Stooke (outgoing Audit Committee Chair)
Introduction with Faith Boardman (Audit Committee member)
Chris Stooke – Chair of Audit and Board Integration Committees Date Activity
7 December Attended Savings Board Meeting
9 December Attended Commercial Services Board Meetnig
10 December Attended KCH Charity Meeting
Attended meeting with KCH Governors
14 December Attended meeting re. CEF recruitment
Lunch with Craig Wisdom (external auditor) and Alix Pryde
15 December Attended Public Board Meeting
Attended Private Board Meeting
Chaired Finance & Performance Committee Meeting
8 January Attended conference call with Simon Taylor and Jon Cohen
12 January Attended meeting with Colin Gentile and Jez Tozer
13 January Attended Delivery Board Meeting
14 January Attended meeting with KPMG and Alix Pryde
Attended KHP Board Meeting as substitute for Lord Kerslake
Faith Boardman – Non-Executive Director Lead for Organisational Development Date Activity
Interview Panel short-listing for COO position 9 December Pre-meet re. complaints
3
Enc. 3.2
Attended Meeting with Chair and CEO re. complaints performance 10 December
Attended Public Board Meeting
15 December Attended Private Board Meeting
Attended King's Fund briefing on the Spending Review
21 December Interview panel for COO
Attended meeting about Audit committee 14 January Attended Quality and Governance Committee Meeting
Sue Slipman – Non Executive Director Lead for Trust Strategy
Date Activity
8 December Attended Strategy Steering Group Meeting
Attended Commercial Services Board Meeting 9 December
Attended Public Board Meeting
15 December Attended Private Board Meeting
Attended Finance and Performance Committee Meeting
Professor Ghulam Mufti – Non Executive Director Lead of Trust Strategy (KHP)
Date Activity
Attended Public Board Meeting
15 December Attended Private Board Meeting
Go See Visit
14 January Attended Quality & Governance Committee Meeting
Erik Nordkamp – Non Executive Director Lead for Delivering Financial Plans and Commercial Services Date Activity
**Begins Board-related activity in second half of January 2016
4
Enc. 3.3.1a
King’s College Hospital NHS Foundation Trust - Finance & Performance Committee Minutes of the meeting of the Finance & Performance Committee held at 15:10 on Tuesday, 24 November 2015 in the Dulwich Committee Room, Denmark Hill site.
Present: Graham Meek (GM) Committee Chair/Non-Executive Director Lord Kerslake (BK) Trust Chair Chris Stooke (CS) Non-Executive Director Sue Slipman (SS) Non-Executive Director Nick Moberly (NM) Chief Executive Officer Jeremy Tozer (JT) Interim Chief Operating Officer Alan Goldsman (AG) Interim Chief Financial Officer Dawn Brodrick (DB) Director of Workforce and Development Trudi Kemp (TK) Director of Strategic Development Steve Leivers (SL1) Interim Director of Transformation and Turnaround Julia Wendon (JW1) Medical Director Dr Geraldine Walters (GW) Director of Nursing and Midwifery Judith Seddon (JS) Acting Director of Corporate Affairs
In attendance: Simon Dixon (SD) Director of Finance Tamara Cowan (TC) Board Secretary Silviyana Yankova (SY) Corporate Governance Assistant (Minutes)
Apologies: Ahmad Toumadj (AT) Interim Director of Capital Estates and Facilities
Item Subject Action
15/106 Apologies
The apologies for absence were noted.
15/107 Declarations of Interest
There were no declarations of interest reported.
15/108 Chair’s Actions
There were no Chair’s actions to report.
15/109 Minutes of the Previous Meeting
The minutes of the meeting held on 27 October 2015 were approved as a correct record.
15/110 Action Tracker
The action tracker was noted.
1 Enc. 3.3.1a
Item Subject Action
15/111 Finance Report - Month 7
The Committee received the month 7 finance report, which was discussed at length in the Public Board meeting, held earlier.
The Committee discussed the £11m CIPs gap, plan for next financial year and the cash forecast.
The following key points were reported: Spending controls continue in the division which is supporting the progress made in achieving the Trust’s CIP savings;
The Trust has identified substantial amount of CIPs in the first six months but this has tapered off in recent months;
The Trust would need to enhance efficiencies to increase and better utilise ward capacity at the Princess Royal University Hospital (PRUH) site and potentially Denmark Hill (DH) site;
Given the unstable financial position, the Trust has approached numerous suppliers and requested a discount for procurement services.
Accordingly the PRUH’s PFI supplier of soft facilities management services (soft FM), ISS, has offered substantial price reductions including upfront payment in return for a significant contract extension. A similar offer is currently being negotiated with the PFI supplier, Medirest on the DH site which will be subject to quality assurance.
The Trust needs to be mindful not to be in breach of tendering rules or associated inducements;
The asset valuation process is an opportunity for the Trust to improve its overall position by optimising the value of its estates and significantly reduce the financial burden. Whilst the Trust may not take an overly aggressive approach, it is an opportunity to improve the financial position, which should not be missed.
The modern equivalent asset valuation model will be used to evaluate the asset led by an independent professional company and it will go through a robust governance process that will be thoroughly audited by external auditors;
The Trust has been invited by NHS England (NHSE) and Monitor to offer up any underspend on its capital programme.
The current proposal is that if the Trust underspends on the capital programme safely and not against anything that is essential by simply shifting it with a few days or months, the Trust would be able to adjust its new reserves;
It is important for the Trust to get over the line in the current financial year in order to improve regulators overall confidence;
The Trust is booking a number of fines from commissioners but there may be opportunities to have commissioners reinvest these cost pressures;
The marginal rate of emergency tariff provides an opportunity for the Trust to receive additional funding which needs to be explored with local commissioners;
2 Enc. 3.3.1a
Item Subject Action
The Trust needs to revisit its radical actions list focusing on services which Clinical Commissioning Groups (CCGs) and NHSE will not fund and decide whether or not to continue to offer these clinical services at a lost;
The trade payables is £62m and average payment is 65 days which is not sustainable in the long term;
Conversely trade receivables has reached £74m and it was ascertained that the majority of debtors are other NHS bodies including NHSE;
The rising agency spend on medical staff continues to be an issue. A series of meetings have been scheduled and divisions will re-enact appropriate control processes;
In the long-run the Trust has to develop robust plans to address the use of bank and agency medical staff in order to minimise agency spend and ensure the Trust remains within the agency cap.
15/112 Treasury Management Report – Month 07
The Committee received and noted the Treasury Management Report for month 7.
15/113 Performance Report – Month 07
The Committee received and noted the performance report for month 07, which was discussed at length at the Public Board meeting, held earlier.
15/114 Any Other Business
There were no material matters of any other business raised for discussion.
15/115 Date of Next Meeting
Tuesday, 15 December 2015, 15:30-17:30 in the Dulwich Committee Room.
3
Enc. 3.3.1b
King’s College Hospital NHS Foundation Trust - Finance & Performance Committee Minutes of the meeting of the Finance & Performance Committee held at 15:15 on Tuesday, 15 December 2015 in the Dulwich Committee Room, Denmark Hill site.
Present: Chris Stooke (CS) Committee Chair/Non-Executive Director Lord Kerslake (BK) Trust Chair Sue Slipman (SS) Non-Executive Director Nick Moberly (NM) Chief Executive Officer Jeremy Tozer (JT) Interim Chief Operating Officer Ahmad Toumadj (AT) Interim Director of Capital Estates and Facilities Dawn Brodrick (DB) Director of Workforce and Development Steve Leivers (SL1) Interim Director of Transformation and Turnaround Julia Wendon (JW1) Medical Director Geraldine Walters (GW) Director of Nursing and Midwifery Judith Seddon (JS) Acting Director of Corporate Affairs
In attendance: Jane Badejoko (JB) Corporate Governance Officer (Minutes)
Apologies: Trudi Kemp (TK) Director of Strategic Development Alan Goldsman (AG) Interim Chief Financial Officer Simon Dixon (SD) Director of Finance
Item Subject Action
15/116 Apologies
The apologies for absence were noted.
15/117 Declarations of Interest
There were no declarations of interest reported.
15/118 Chair’s Actions
There were no Chair’s actions to report.
15/119 Minutes of the Previous Meeting
The minutes of the meeting held on 15 December 2015 were approved as a correct record.
15/120 Action Tracker
The action tracker was updated with the following: Action items 15/101 and 15/101 (from 27/10/2015) Financial Recovery Plan 5 year, Long Term Financial Model (LTFM) - Will be combined into one action which will be programmed for a Board Workshop; and
1
Enc. 3.3.1b
Item Subject Action
Item 15/102 (27/10/2015) Treasury Management Report Month 6- this item will be progressed by the finance director as part of business as usual.
15/121 Finance Report - Month 8
The Committee received the month 8 finance report, which was discussed at length in the Public Board meeting, held earlier.
The following key points were further noted: The Trust’s run rate CIPs are not progressing according to plan. The increased number of permanent staff have not produced the anticipated savings in pay expenditure. Current figures indicate that the Trust run rate is £17m off target;
There is need to explore what the drivers of the increased expenditures are, and put in place appropriate mitigations. The Trust must also think of the long term effect of any measures and ensure that efficiencies have lasting effects beyond the current year;
Given the unstable financial position of the Trust, the run rate needs to be reduced immediately. Actions to reduce pay expenditure may include capacity reviews within services and a pause on provision of loss making services;
The Trust will also focus on medical staffing expenditure. JW and SL1 will be meeting with divisional directors and working on producing guidance for booking of medical agency staff;
The Trust’s WAP/VAP process will also be subject to further scrutiny and restrictions;
Expenditure of non-clinical supplies within divisions has increased, the finance team will be carrying out a detailed analysis and review of these expenditures to ascertain the root cause;
While the Trust must focus on reduction of the run rate pay expenditure, it must not detract attention from its savings goals and financial targets for the year. Target achievement in the current year will improve regulator’s confidence in the Trust’s ability to meet stringent targets going into 2016/17;
There is, however, a real risk that the Trust will not achieve the Monitor £65m deficit target for 2015/16; and
The Trust should revisit its radical actions list focusing on services which Clinical Commissioning Groups (CCGs) and NHSE have not funded and negotiate a trade off with conditions that the Trust will only continue to provide said services for adequate funding.
It was agreed that PwC will produce a monthly detailed run rate report that will highlight staffing expenditure by professional groups and services.
15/122 Treasury Management Report – Month 08
The Committee received and noted the Treasury Management Report for month 8.
15/123 Performance Report – Month 08
The Committee received and noted the performance report for month 08, which was discussed at length at the Public Board meeting, held earlier.
2 Enc. 3.3.1b
Item Subject Action
15/124 Any Other Business
There were no material matters of any other business raised for discussion.
15/125 Date of Next Meeting
Tuesday, 26 January 2016, 09:00-11:00 in the Dulwich Committee Room.
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