Meeting of the Board of Directors

10.00am to 12.30pm on Thursday 28 July 2016

John Bull Conference Room, Worthing Health Education Centre, Worthing Hospital, Lyndhurst Road, Worthing, BN11 2DH

AGENDA – MEETING IN PUBLIC

1. 10.00 Welcome and Apologies for Absence Chair

2. 10.00 Declarations of Interests All

3. 10.00 Minutes of Board Meeting held on 30 June 2016 Enclosure Chair To approve

4. 10.05 Matters Arising from the Minutes Enclosure Chair To note

5. 10.10 Chief Executive’s Report Enclosure MG To receive and agree any necessary actions

PATIENT SAFETY/EXPERIENCE ITEMS

6. 10.25 Quality Report – Month 3 Enclosure GF/AP To receive and agree any necessary actions

7. 10.40 2015/16 Safeguarding Adults Annual Report Enclosure AP To receive and agree any necessary actions

8. 10.50 2015/16 Safeguarding Children Annual Report Enclosure AP To receive and agree any necessary actions

OPERATIONAL ITEMS

9. 11.00 Performance Report – Month 3 Enclosure PL To receive and agree any necessary actions

10. 11.15 Organisational Development and Workforce Performance Enclosure DF Report – Month 3 To receive and agree and necessary actions

11. 11.25 Financial Performance Report – Month 3 Enclosure KG To receive and agree any necessary actions

STRATEGIC ITEMS

12. 11.35 Patient First Programme Update Report – Month 3 Enclosure MG To receive and agree any necessary actions

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GOVERNANCE ITEMS

13. 11.50 Proposal to Amend the Trust Constitution Report Enclosure AG To receive and agree any necessary actions

14. 12.00 Patient First Strategy Deployment Reporting and Board Enclosure MJ/AG Assurance Framework Report – Quarter 1 To receive and agree any necessary actions

15. 12.05 NHS Improvement Self-Assessment Submission Report – Enclosure AG Quarter 1 To approve

OTHER ITEMS

16. 12.10 Other Business Verbal Chair

17. 12.15 Resolution into Board Committee Chair To pass the following resolution:

“That the Board now meets in private due to the confidential nature of the business to be transacted.”

18. 12.15 Date of Next Meeting Chair The next meeting in public of the Board of Directors is scheduled to take place at 10.00am on 29 September 2016 in the John Bull Conference Room, Worthing Health Education Centre, Worthing Hospital, Lyndhurst Road, Worthing, BN11 2DH

19. 12.15 Close of Meeting Chair

20. 12.15 Questions from the Public Verbal Chair to Following the close of the meeting there will be an opportunity for 12.30 members of the public to ask questions about the business considered by the Board

Andy Gray Company Secretary Tel: 01903 285288 / Mobile: 07785332416

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MINUTES OF A MEETING OF THE BOARD OF DIRECTORS IN PUBLIC HELD AT 10:00 ON 30 JUNE 2016 IN THE BATEMAN ROOM, CHICHESTER MEDICAL EDUCATION CENTRE, ST RICHARD’S HOSPITAL, SPITALFIELD LANE, CHICHESTER, PO19 6SE

Present: Mike Viggers Chair Joanna Crane Non-Executive Director Jon Furmston Non-Executive Director Lizzie Peers Non-Executive Director Mike Rymer Non-Executive Director Marianne Griffiths Chief Executive George Findlay Medical Director Karen Geoghegan Director of Finance Pete Landstrom Chief Operating Officer Amanda Parker Director of Nursing and Patient Safety

In Attendance: Andy Gray Company Secretary Mike Jennings Commercial Director Jenny Shore Deputy Director of Human Resources Dr Susie Jerwood Infection Control Doctor Consultant Microbiologist (Item 8) Helen Richards Lead Infection Control Nurse (Item 8) Carol Fenn Board Administrator (Minutes)

1. WELCOME

1.1 The Chair welcomed everyone to the meeting.

1.2 Apologies for absence were received from Bill Brown and Denise Farmer. Jenny Shore had attended the meeting in Denise Farmer’s stead.

2. DECLARATIONS OF INTERESTS

2.1 There were no interests to declare.

3. MINUTES

3.1 The Board received the minutes of the meeting held on 26 May 2016, copies of which had previously been circulated.

3.2 IT WAS RESOLVED THAT the minutes be approved for signature by the Chair.

4. MATTERS ARISING

4.1 A schedule of Matters Arising from the previous meeting, copies of which had previously been circulated, was considered.

4.2 It was noted that:  6.5, 7.5, 7.8 and 7.9 – these items had been addressed in the Quality Report; and  6.6 – this item would be discussed under item 6.

5. CHIEF EXECUTIVE

5.1 Marianne Griffiths presented her report, copies of which had previously been circulated.

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The following were highlighted:  Professor Donald Berwick – Professor Donald Berwick, one of the world’s foremost improvement experts, had visited the Trust at the invitation of diabetes consultant, Dr Gordon Caldwell. In addition to observing the Trust’s improvement initiatives, Professor Donald Berwick had delivered a visionary talk on health care, which correlated strongly with the Trust’s Patient First Programme;  “Colleagues as Carers” forum – following feedback received from the 2015 Staff Conference, a new “Colleagues as Carers” forum had been established, which would be supported and facilitated by Carers Support West Sussex;  Governor elections – Marianne Griffiths welcomed all new governors and thanked all members of the Trust who had voted in the elections, members of the public who had put themselves forward to represent their constituencies and governors who had served their term;  Nursing Times – the Trust had been shortlisted in three categories for the Nursing Times Patient Safety Awards. The categories were 1) best organisation, 2) board leadership and 3) technology and IT to improve patient experience. The winners would be announced on 5 July 2016; and  Annual General Meeting – the annual general meeting of the Council of Governors and annual members meeting was scheduled to take place on 21 July 2016.

6. QUALITY

6.1 George Findlay and Amanda Parker presented the Quality Report for Month 2, copies of which had previously been circulated. The following were highlighted:  Effectiveness o the crude non-elective mortality rate had fallen to 3.33% (April: 3.46%) and was slightly higher compared to last year (May 2015: 2.82%). The year-to-date (3.39%) and 12-month mortality rate (3.20%) were both slightly higher than the Trust’s limit (3.13%). These trends were normal given the proximity to the winter period; o the Dr Foster Hospital Standardised Mortality Ratio (“HSMR”) for the 12 months to February was 87.5 (100 being the level predicted by the Dr Forster model using the April 2015 benchmark). The slight difference in the HSMR for Worthing Hospital compared to St Richard’s Hospital continued to narrow to 90.3 and 84.1 respectively. The Trust was rated in the top 16% of trusts for its HSMR performance, which was a tremendous achievement; o the Summary Hospital-Level Mortality Indicator (“SHMI”) was 1.00 (1.00 being the national average) with the Trust banded “as expected”. The SHMI measured mortality after discharge. Unlike the HSMR, the SHMI provided limited granular diagnostic information for specialities. Like many trusts, there was a gap between the Trust’s HSMR and SHMI ratings; o there were two exception reports relating to: . the crude non-elective mortality rate for renal failure, which had further reduced to 20% (April: 27.3%). Whilst investigations had identified no deficiencies in care, monitoring would continue for the coming months; and . the HSMR for Worthing Hospital, which had progressively reduced from 116.4 in June 2015 to 77.3 in May 2016. This was a great achievement;  Safety o there were: . six Serious Incidents Requiring Investigation (April: 13); . 39 falls resulting in harm (benchmark: 43), none of which resulted in severe harm or death. In 10 instances, the patient had previously fallen during their inpatient stay; . no cases of MRSA bacteraemia; . six cases of hospital attributable C-difficile, four at Worthing Hospital and two at St Richard’s Hospital. Two related to lapses of care (dusty environment and commode cleanliness);

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. 21 Grade 2, three Grade 3 and one unstageable case of hospital acquired pressure ulcers. 157 patients had been admitted to the Trust from the community with pressure damage; o the Trust had delivered a harm-free care score of 95% (national target: 93.8%). 98.8% of inpatients were reported as having no new harms during their inpatient stay. The new national target of 99% remained challenging, particularly, as it was considerably higher than the national average (97.7%); o there was one exception report relating to the new national requirement to report on care hours per patient; o there had been no change in relation to the staffing levels for Broadwater and Barrow, which remained on the priority list for new nursing staff. The wards had over-recruited HCAs as a mitigation; and o the paediatrics wards had sufficient staffing levels for the summer period. Additional staffing would be considered for the winter period;  Patient Experience o the number of complaints had decreased to 51 (April: 63); o all Friends and Family Test (“FFT”) scores remained good against national benchmarks; o the previously reported fluctuations in Maternity FFT scores were attributable to the low number of responses received; o the report included additional information on the moves of dementia patients (Appendix 1); o there were two exception reports relating to: . a mixed sex accommodation breach, which had occurred in CDU due to bed pressures; and . MUST assessment compliance, which had remained challenging but was showing signs of improvement.

6.2 The Board commended the Trust’s excellent mortality performance.

6.3 In relation to inquiries from Joanna Crane:  Pete Landstrom advised that moves of dementia patients were sometimes triggered by sudden events, such as an infection control incident or other clinical reasons. All patients underwent assessments to evaluate the appropriateness of proposed moves. Where possible, moves of dementia patients were avoided; and  George Findlay advised that, during May, a number of staff had served slightly less than the required six-week notice period for leave. Ideally, the Trust should be aspiring to zero clinics cancelled with less than six-weeks’ notice for leave.

6.4 In relation to an inquiry from Jon Furmston, George Findlay commented that the

HMSR was a more reliable mortality indicator than SHMI as it adjusted for patients receiving palliative care. It was also the most widely used indicator across the health sector, which enabled appropriate benchmarking. The Trust did not treat many palliative patients.

6.5 Lizzie Peers commented that the additional information on moves of dementia patients (Appendix 1) was helpful. Lizzie Peers suggested that the Dementia Matron

should attend a future Board meeting to provide an update on the Trust’s dementia strategy.

6.6 In relation to a question from Lizzie Peers, Marianne Griffiths and Karen Geoghegan explained that the governance arrangements for equipment management at St Richard’s Hospital were being replicated at Worthing Hospital. Historically, there had been two different approaches across the sites. The Chair commented positively on the Trust’s arrangements and suggested that Lizzie Peers should visit the Trust’s equipment library for assurance.

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7. COMPLAINTS AND PALS

7.1 The Board received the Complaints and PALS Report for Quarter 4, copies of which had previously been circulated.

7.2 Amanda Parker explained that historically the report had outlined trends and themes specific to complaints and PALS. Going forward the report would also cover other forms of patient experience feedback (for example, FFT scores, national surveys and real time surveys).

7.3 The following were highlighted:  Plaudits – the Trust had received 877 plaudits. Key themes concerned staff values and behaviours; for example, staff being kind, friendly, caring and professional;  Lessons learnt – as outlined on pages 1 to 4 of the report, the resultant actions included training, clinical pathway reviews and recruitment;  Total complaints and PALS – 134 complaints and 1,235 PALS inquiries had been received, which was similar to previous quarters. The levels of complaints specific to point of delivery (i.e. inpatients and outpatients) remained favourable compared to the national average;  Resolution of cases – the data provided on pages 9 and 10 of the report demonstrated that the Trust was not responding to complaints in accordance with the required timeframes. Considerable work was underway to address this issue, including the trial of a new complaints process in Surgery; and  Reasons for complaints – as outlined on pages 16 to 18 of the report, key themes included appointment dates and communication.

7.4 In relation to an inquiry from the Chair, Amanda Parker and Pete Landstrom confirmed that the pilot in Surgery was progressing well. The new process was more

structured and streamlined and the division was more engaged and responsive.

7.5 In relation to inquiries from Mike Rymer:  George Findlay reported that the internal audit of the process for allocating

named consultants to patients had been useful. Work was underway to implement the recommendations. It was hoped that this would resolve the inconsistency in the coordination of medical treatment across the hospital sites; and

 George Findlay acknowledged that, whilst the ophthalmology pathway was well established, it continued to underperform as reflected by the high level of complaints and PALS inquiries reported. Efforts continued to address this.

7.6 In relation to inquiries from Jon Furmston, Amanda Parker confirmed that complaints were being correctly graded. Delays in responses were linked to process inefficiencies. Complainants’ expectations were being well managed. Joanna Crane added that the Patient Experience and Feedback Committee reviewed complaints files and commented on the diligence of the Complaints Team.

8. INFECTION CONTROL

8.1 The Board received the 2015/16 Infection Prevention and Control Annual Report, copies of which had previously been circulated.

8.2 Amanda Parker explained that the report provided an overview of the surveillance activity carried out by the Infection Prevention and Control Team and the Trust’s performance during 2015/16 across seven action areas outlined in “Winning Ways” (2003).

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8.3 Susie Jerwood and Helen Richards delivered a presentation highlighting the following:  MRSA – there had been three cases during the year, of which two were CCG apportioned and one attributable to a third-party. Screening was undertaken predominantly on a weekly basis. Slightly more audits had been undertaken at St Richard’s Hospital as the screening programme commenced slightly earlier there;  MSSA – there had been 67 non-Trust attributable cases and 17 Trust apportioned cases, of which nine occurred at Worthing Hospital and eight at St Richard’s Hospital. Four cases were deemed avoidable;  C-difficile – lapses of care had been identified in 20 cases (against a self-imposed stretch target of 18), of which 14 cases were linked to environmental/clinical hygiene issues and six to dirty commodes. The Trust’s rates had remained below the national average;  CPE – in response to this emerging threat, a new screening programme had been introduced for patients who have received healthcare abroad. Only one incidence had been detected in a laboratory. This concerned an outpatient who was not treated at the Trust;  Surgical Site Inspections (“SSIs”) – a number of areas required improvement, most notably, large joint replacements. There had also been some significant improvements, including for large bowel surgery at Worthing Hospital where the rate had reduced to 2.1% (against a national average of 9.9%); and  Antibiotics - work continued to ensure the prudent use of antibiotics, including daily EMPA reports, education and HAPPI audits.

8.4 In response to an inquiry from Lizzie Peers, Susie Jerwood and Helen Richards highlighted that the actions developed to reduce SSIs were based on NICE Quality Statements. They were optimistic that sustained improvement could be achieved. This was echoed by George Findlay and Pete Landstrom.

8.5 Amanda Parker highlighted that Public Health England attended the Trust’s infection control meetings and viewed the Trust as proactive.

8.6 In relation to an inquiry from Joanna Crane, Helen Richards explained that it was potentially more difficult to achieve a high score for a “spot check” than a PLACE assessment due to the granular nature of the former. Wards were consistently assessed as being very clean.

8.7 In relation to an inquiry from Marianne Griffiths, Susie Jerwood confirmed that national MRSA data for 2015/16 was due to be released in July.

8.8 The Board confirmed its endorsement of the assurance statement provided in the report.

9. INPATIENTS

9.1 The Committee received the 2015 CQC National Inpatient Survey Annual Report, copies of which had previously been circulated.

9.2 Amanda Parker explained that the Trust had delivered “amber” scores across each section of the 2015 CQC National Inpatient Survey. This indicated that there were significant opportunities to improve and ultimately achieve “green” across all areas.

9.3 Marianne Griffiths commented that the findings seemed inconsistent with the high level of overwhelmingly positive feedback received by the CQC ahead of its inspection of the Trust in December.

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9.4 It was suggested that it would be helpful for the Patient Experience Matron to attend a future meeting of the Board to discuss the proposed improvement strategy.

9.5 Jon Furmston commented that the report did not seem to clearly outline how the Trust had performed against its objectives for the year. This detail would be helpful in terms of formulating an action plan.

10. PERFORMANCE

10.1 Pete Landstrom presented the Performance Report for Month 2, copies of which had previously been circulated. The following were highlighted:  Activity o A&E attendances were up 7.4% compared to last year; o emergency admissions were up 10.9% compared to last year, particularly, for patients aged between 65 and 84 (up 15.1%) and 85 and over (up 11.3%); o delayed transfers of care levels increased slightly to 3.5% (April: 2.55%). However, this excluded patients medically fit for discharge but not yet declared as delayed transfers, which averaged c149; and o the occupancy of funded bed stock was 94.3%;  A&E o the Trust was compliant with 95.7% of patients waiting less than four hours from arrival at A&E for admission, transfer or discharge (against a national target of 95%), which exceeded the requirements of the Sustainability and Transformation Fund (“STF”) trajectory (95%); and o the Trust continued to rank fourth nationally and first in Surrey and Sussex for its performance;  Cancer o the provisional position for May indicated that the Trust was fully compliant against all seven cancer metrics and exceeded the requirements of the STF trajectory (85%); and o the latest published national data for April indicated that the Trust continued to benchmark well. 50.7% of trusts were non-compliant (Trust: compliant);  Referral to Treatment (“RTT”) o the Trust remained non-compliant with 88.15% of patients waiting more than 18 weeks for RTT (against a national target of 92%), which exceeded the requirements of the STF trajectory (86.6%); o the latest published national data for April indicated that national average compliance was 91.9% (Trust: non-compliant);  Fractured neck of femurs (“FNoFs”) o 95.1% of medically fit FNoF patients were operated on within 36 hours of admission (against a national target of 90%), which was a significant improvement on April (83.3%); and o the improvement was linked to the previously reported amendment to the escalation protocol during May;  Diagnostic test waiting times o 1.5% of patients had waited more than six weeks for diagnostic testing (against a national target of ≤1%), which reflected a significant improvement compared to April (2.52%) and exceeded the requirements of the STF trajectory (4.9%); o the latest published national data for April indicated that national average compliance was 1.8% (Trust: non-compliant); and o the number of breaches within the MRI modality had substantially reduced to 81 (April: 107 ).

10.2 The Chair requested that additional information on waiting times be included in the PL next report.

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11. ORGANISATIONAL DEVELOPMENT AND WORKFORCE PERFORMANCE

11.1 Jenny Shore presented the Organisational Development and Workforce Performance Report for Month 2, copies of which had previously been circulated. The following were highlighted:  Workforce capacity – there had been a further increase in substantive staffing and a reduction in the use of bank and agency staff following the closure of escalation wards. Nursing agency usage had reached its lowest level since September 2015;  Recruitment – recruitment activity remained a priority with the Trust reporting high levels of new recruits. The Trust’s “outstanding” CQC rating continued to have a positive effect on attracting candidates;  Junior doctors – a junior doctors’ referendum on the new contract proposed by the government was due to be held in July. Pending the outcome, the Trust continued to progress recruitment for the proposed guardian role. Detailed planning for the annual junior doctor changeover in August continued;  Chief of Service posts – Amanda Wellesley had been appointed Chief of Service for Medicine and David Beattie as Chief of Service for Core. Recruitment continued in respect of the other posts;  Appraisals – compliance had reached its highest level since June 2014 (82.2%), which was good progress. Efforts continued to further improve on this;  Staff FFT – the latest scores remained positive in terms of staff recommending the Trust to family and friends;  Violence and aggression – forums had been established to share the actions undertaken and work in-progress to address staff concerns about violence and aggression in the workplace;  Health and wellbeing – NHS England had released details of a new CQUIN for health and safety comprising three areas of focus. It was felt that the requirements to introduce health and safety initiatives and provide healthy food for staff, visitors and patients were achievable. The requirement to improve staff uptake of the flu vaccination was more challenging; and  Statutory and mandatory training – compliance had exceeded the Trust’s target of 90%.

11.2 Marianne Griffiths commented that improving staff uptake of the flu vaccination would be challenging as the Trust was unable to insist that staff received the

vaccine.

11.3 In response to a question from Joanna Crane, Jenny Shore advised that staff who had not had an appraisal since joining the Trust less than a year ago required an

initial objectives setting meeting.

11.4 In relation to an inquiry from Marianne Griffiths, Jenny Shore agreed to look into JS whether the timeframe for holding an appraisal could be suspended for legitimate reasons, such as long-term sickness leave.

12. FINANCE

12.1 Karen Geoghegan presented the Finance Report for Month 2, copies of which had previously been circulated. The following were highlighted:  Surplus – the Trust had delivered a cumulative surplus of £1.4m (£0.5m below plan). The position included a contribution of £2.2m from the STF;  Financial Sustainability Risk Rating (“FSRR”) – the Trust had reported a FSRR of 3. The Trust’s performance against all metrics had improved, with the exception of the liquidity ratio, which remained static;  Cash – the cash position was slightly ahead of plan;  Income – cumulative income was £1.2m below plan. Areas of underperformance included non-elective, PbR excluded items and private patients;

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 Operational costs – operational costs were favourable to plan with pay expenditure on plan and non-pay expenditure favourable to plan;  Agency expenditure – the level of agency expenditure had remained similar to April and below the Trust’s ceiling. Whilst there had been a slight improvement in nursing agency spend, this remained above its ceiling and unsustainable;  Capital – the Capital Programme had continued to underperform. The slippage was expected to be recovered during Quarter 2; and  Efficiency and Transformation Programme – cumulative savings of £2.8m had been delivered (95.5% delivery).

12.2 Karen Geoghegan reported that the Trust had signed a contract with Coastal West Sussex CCG for the commission of services during 2016/17. A contract for the commission of specialist services would be signed with NHS England shortly.

12.3 In relation to an inquiry from Joanna Crane, Karen Geoghegan explained that a lack of complexity in terms of casemix and sub-optimal activity volumes were attributable for the elective underperformance during May. Weekly focus meetings were being held to target improvements in certain specialities.

12.4 The Chair highlighted that NHS Improvement had not yet issued guidance on STF performance metrics and penalties.

13. PATIENT FIRST PROGRAMME

13.1 The Board received the Patient First Programme Update Report, copies of which had previously been circulated.

13.2 Marianne Griffiths gave an update on the progress made against the programme’s four pillars during April. The following were highlighted:  Sustainability – as already highlighted under item 12;  Our people – targeted Kaizen workshops, “green belt” training and the second wave of the Patient First Improvement System (“PFIS”) had continued to be well received and yield significant improvements;  Quality improvement – considerable work was underway to deliver the falls “breakthrough” objective. This included the development of “A3s” and display of visual management boards in all clinical areas. Early results were very encouraging; and  Systems and partnerships – work had continued to deliver the Non-elective and Elective Transformation Programmes.

13.3 In relation to the Falls Prevention Improvement Programme:  Marianne Griffiths commented that it would be useful to hold a Board Seminar in due course to highlight the progress being made;  Joanna Crane and Lizzie Peers highlighted the falls improvement “huddle” they had recently observed; and  George Findlay reported on the intensive work underway to target wards with a high incidence of falls (c20 falls per week). A limit of 10 falls per week had been set. Actions were being tailored to each ward. Early results indicated that falls had reduced to c13 per week, which was very assuring.

14. OTHER BUSINESS

14.1 Joanna Crane reported that she had recently attended a local safeguarding conference, which had been very interesting. Topics discussed included the abscondment of vulnerable adults from A&E, engagement of perpetrators of domestic violence, provision of domestic violence specialists in A&E and Multi-Agency Safeguarding Hub (also known as MASH).

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14.2 The Chair reported that Rob Haigh, Deputy Medical Director and Chief of Medicine, was leaving the Trust to join Portsmouth Hospitals NHS Trust. Rob Haigh would be sadly missed. On behalf of the Board, the Chair thanked Rob Haigh for his tremendous contribution to the Trust over many years.

14.3 The Chair further reported that Margaret Bamford’s tenure as Lead Governor had come to an end. On behalf of the Trust, the Chair thanked Margaret Bamford for her tremendous contribution to the Trust over the last three years. The Chair also highlighted and commended Margaret Bamford’s continued voluntary work.

15. NEXT MEETING

15.1 The next meeting would take place at 10.00am on 28 July 2016 in the John Bull Conference Room, Worthing Health Education Centre, Worthing Hospital, Lyndhurst Road, Worthing, BN11 2DH.

…………………………………………………. Mike Viggers, Chair Date:

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QUESTIONS FROM MEMBERS OF THE PUBLIC ATTENDING THE MEETING

Member Topic Response John Bull FNoF George Findlay advised that it was prudent to ensure that the Trust’s target for operating on medically fit FNoF patients within 36 hours of admission was well sustained before considering any stretch to the target. Other factors to be considered included the potential impacts a new stretch target could have on other services. Anita Junior doctors’ George Findlay commented that the loss of activity due to the junior MacKenzie strikes – doctors’ strikes during April was regrettable. Cancelled cancellations appointments and procedures were rescheduled as quickly as possible. Vicki King Quality George Findlay advised that April had historically been a difficult Scorecard for and busy month. There was no indication that the junior doctors’ April strike had resulted in adverse impacts for patients. The provision of cover by consultants had led to more patients being discharged and fewer deaths. It was prudent to err on the side of caution when considering a monthly variation and apply more emphasis to rolling year trends. Infection Vicki King commented that the report was well structured and Prevention and written. Control Annual Report C-difficile Amanda Parker confirmed that the Trust had two cases of c-difficile isolates on a ward during 2015/16. SSIs Marianne Griffiths highlighted that, whilst obliged to report on one speciality, the Trust voluntarily reported on the SSI rates for three specialities. George Findlay added that only four other trusts in the country reported on breast surgery. There were many small factors and no main factor attributable for the Trust’s underperformance. George Findlay was optimistic that SSI rates could be reduced. Barbara Diabetic Amanda Parker agreed to discuss Barbara Cook’s concerns after Cook retinopathy the meeting. RTT compliance Marianne Griffiths acknowledged that the Trust had not achieved its 18-week RTT target during the last 15-16 months. Contributory factors included the significant increase in ophthalmology referrals (up c15% since last year) and workforce constraints. Pete Landstrom added that diabetes was particularly struggling with patients waiting up to 30 weeks. The Trust had a robust recovery plan in place. It was hoped that compliance would be delivered across the majority of specialities by December. A&E and Pete Landstrom agreed to discuss Barbara Cook’s concerns after ophthalmology – the meeting. communication Margaret Dementia – The Chair acknowledged that it was unsettling for dementia Bamford patient moves patients to be moved. It was hoped that moves would be further reduced through the good work of the new Dementia Matron. Thank you Margaret Bamford commented that she had worked with great organisations and teams during her career in the health and social care sector over the last 52-53 years but none as positive as the team at the Trust. Margaret Bamford expressed her gratitude for being appointed as Lead Governor of the Trust in 2013. Whilst her tenure had come to an end, Margaret Bamford intended to continue her voluntary work for the Trust. Abigail Retail service The Chair confirmed that the Friends organisations had been Rowe tender – consulted initially in May on the retail service tender underway. The (written consultation Chair had subsequently met with each of the chairs of the three questions) organisations. The Trust intended to remain in consultation throughout the process.

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QUESTIONS FROM MEMBERS OF THE PUBLIC ATTENDING THE MEETING (Continued)

Member Topic Response Abigail Retail service The Chair confirmed that the impact on all those affected would be Rowe tender – impact considered as far as possible within the formal process. This (continued) included staff from the catering units and the Friends organisations. Retail service The Chair confirmed that, as part of the process, any organisation tender – values proposing to work with the Trust would be required to demonstrate that they were committed to providing a caring and supportive service in line with the Trust’s values.

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MATTERS ARISING Board in Public

Meeting Minute Action Person Deadline Status Ref Responsible To be included in the Organisational Provide an update on the consultant mentoring 26 May 2016 10.2 DF August 2016 Development and Workforce scheme in due course. Performance Report. Include additional information on waiting times in the Action completed – included in the 10.2 PL next Performance Report. report. 30 June 2016 Check and advise whether the timeframe for holding July 2016 Verbal update to be provided at the next 11.4 an appraisal can be suspended for legitimate reasons, JS meeting. such as long-term sickness leave.

To: Trust Board Date: 21 July 2016

From: Marianne Griffiths, Chief Executive Agenda Item: 5

FOR INFORMATION

CHIEF EXECUTIVE’S BOARD PAPER

1. Highlights and headlines

Praise from NHS Improvement’s Associate Medical Director - It was a pleasure to welcome leading NHS improvement expert Dr Ian Sturgess to St Richard’s and Worthing on 13 June. Dr Sturgess is the Associate Medical Director, Operational Improvement at NHS Improvement, and was accompanied on his fact-finding mission by Russell Enemy, Director of Emergency Care, Intensive Support Team and Emergency Care Improvement Programme.

They met some of our senior clinicians in A&E and Emergency Floor, as well as our director of improvement Anil Mathew. Dr Sturgess said there is an openness to learning and continuous improvement, adding that “the present challenges faced by the NHS have been perfectly designed to be where they are at the moment! If we want to change that we need to have a continuous improvement process and in this respect Western Sussex is bucking the trend.”

Dr Sturgess also commended our Patient First programme, describing the progress made here in the past two years as impressive, urging us to continue with our journey. “

Sharing our learning - I have also attended number of conferences, delivering presentations on our experiences and progress over recent years. The first of these was organised by Healthcare Conferences UK on June 21, in which I presented on the subject of “Developing a well-led organisation”. I was pleased to be able to describe the many leaders that exist throughout Western Sussex Hospitals and the contribution they make to patient care.

I was also delighted to share our patient First journey with colleagues from five NHS trusts, currently working with the Virginia Mason Institute. Dr George Findlay and I attended the event organised by NHS Improvement (the new body which replaces Monitor and the Trust Development Agency) and took the opportunity to describe the key elements of Patient First.

Trust’s first Safeguarding event – I was delighted to speak at the trust’s Safeguarding Conference, at St Richard’s on Tuesday 28 June. Chaired by Clinical Director Dr David Hunt, more than 150 attendees heard speakers from Sussex Police and the WORTH Independent Domestic Violence Advisor Services. The primary goal of the conference was to bring together professionals from key health and social care organisations and to demonstrate how we they can bring about positive change for the people who use our services.

Half of the delegates at the event were from partner organisations, such as Coastal West Sussex Clinical Commissioning Group, Sussex Partnership, West Sussex County Council, GP surgeries and other local health and social care organisations.

The event also demonstrated how the trust has implemented change through learning from real life cases, which the A&E speakers showcased brilliantly. The conference also highlighted the importance of raising concerns and of giving people the confidence to report any concerns they may have about an individual, while at the same time raising the profile of Adult Safeguarding in a positive way.

The Safeguarding Team commented on how satisfying and rewarding it was to bring together such a diverse group of healthcare professionals. Initial feedback has been very positive with delegates praising the informative speakers, helpful content and excellent networking opportunities.

Many also asked when the next event would be taking place and the Safeguarding Team has since revealed they hope to arrange a future event where they will focus on the Mental Capacity Act and Deprivation of Liberty Safeguards.

Valuing our colleagues from overseas - The EU referendum result has answered one important question about the future of our country, but the vote to leave has raised a whole set of new ones about what happens next – not least for everyone who works in the NHS.

While no-one knows yet what the full implications will be, one thing we can guarantee will not change at Western Sussex at least is our commitment to all of the staff who make this Trust the outstanding organisation it is today.

Like the NHS as a whole, Western Sussex benefits from being able to supplement our UK- trained workforce with skilled and dedicated staff from around the world. Together, we make a real difference to people’s lives.

Last month’s Patient First STAR Awards were a great, and timely, reminder of that – everyone present was touched by one great example after another of the collaborative spirit and teamwork displayed by our staff that underpins the outstanding care we provide to patients.

NHS Medical Director Sir Bruce Keogh has also reiterated that the delivery of high-quality care “is dependent on a workforce that feels valued and secure”, and that is a sentiment we all echo. The Patient First Awards exemplify the highest regard we all have for the people we work with, wherever they are from and whatever role they fill. That respect will never change.

Page 2 of 6 2. US popstar praises the Trust’s hospital heroes

Popstar Katrina, from Katrina and the Waves, paid tribute to staff at the Trust at our Patient First event last month (on Thursday (23 June). The singer, famed for her 1983 hit ‘Walking on Sunshine’, recorded a video message which was played at our annual staff recognition awards.

Our trust first came to the attention of Katrina when staff used her hit single as the backing track to a fun film they produced to celebrate their ‘outstanding’ CQC rating, awarded in April.

Speaking from USA, she said: “I want to congratulate you on your wonderful award and for all the work you have done as a fantastic team. We’re all very proud of you and I was very proud of your Walking on Sunshine video which was almost as good as the one I made with the Waves back in 1873! Keep up the work, have a fantastic time tonight and know that we all thank you so much for your gracious hard work.”

The message was a total surprise to the audience and was extremely well received by all the shortlisted nominees and guests waiting to find out who this year’s winners were. Our awards are sponsored by charity Love Your Hospital and homecare provider Comfort Keepers UK, and are the most uplifting event of the year. I feel so fortunate to work with such wonderful colleagues, who with such passion and vigour do their utmost to put our patients first, every day.

The past 12 months have been another record year for Western Sussex, during which we cared for more people than ever before and so it was only right that we received a record number of nominations as well, especially from members of the public and our patients.

Winners this year included Consultant Paediatrician Dr Asma Shah at St Richard’s who cares for children with life-limiting illnesses and Site Practitioner Phillip Morris who fulfilled a patient’s dying wish by arranging for them to wed in Worthing Hospital.

Our former lead governor, Margaret Bamford OBE, was honoured for her work helping more isolated patients receive Welcome Home Packs after staying in hospital and shared the Volunteer of the Year award with Chair of the Organ Donation and Transplant Committee, Angela Fisher, who tirelessly campaigns for those waiting on the organ donation list, drawing strength from her own personal loss.

Overall, there were 13 winners, including the trust’s End of Life Care service, which trust chairman Mike Viggers commended in special recognition of the proactive approach staff take to help patients die where they wish to, most often at home. In a fitting finale to the evening, the trust’s staff Ambassadors – who organised and produced the uplifting ‘Walking on Sunshine’ CQC celebration video – won the Governors’ Award for their unstinting commitment to continuously improving patient experience.

In April, the Care Quality Commission formally recognised the ‘outstanding’ quality of all our 6.500 members of staff and our award winners are the very best of them - they are without exception the most inspirational people to work with and our heartfelt congratulations go each and every one of them.”

Page 3 of 6 2016 Winners

 Patient’s Friend – Tim Hutson, General Manager for Cancer Services, for the ‘tremendous hard work he puts in every week and for consistent dedication to ensuring the best for cancer patients’.

 Mentor of the Year – Netce Sia, Overseas Practice Development Nurse, ‘friend, confidant, mentor and advisor’ helped new nurses from abroad settle to new life in West Sussex.

 Care for the Future – Dr David Secchi, Care of the Elderly Consultant, ‘is the next generation of medical consultant and he will change the practice in the future by being so thoroughly holistic’.

 Innovator of the Year – Acute Stroke Unit, Botolphs Ward, a national top-performing specialist unit about which a patient commented ‘they are clearly all professionals working tirelessly patients but I was most touched by their humanity’.

 Extra Mile – Phillip Morris, Site Practitioner, helped a couple’s dream of marrying each other become a reality on the Emergency Floor, arranging the chaplain, flowers and donations from Waitrose and staff and food for the family’s reception.

 Team of the Year – Barrow Ward, Worthing, have had an extraordinary year, doubling in size at the beginning of winter pressures and taking on new ways of working, priding themselves on the quality of end of life care they provide.

 Compassionate Care (sponsored by Comfort Keepers) – Dr Asma Shah, Consultant Paediatrician, goes beyond her job description to provide personalised out of hours care to children with cancer and their families enabling the youngsters to die at home as their families wished.

 Award for Excellence – Jackie Dominick, Matron Medicine Division, ‘leads by example, role modelling care, compassion and excellence to all the nurses who work with her, always with respect and encouragement’.

 Volunteer of the Year – (joint winners) former Lead Governor, Margaret Bamford OBE, played an instrumental role in the development of the trust at the helm of the Council of Governors for three years and Angela Fisher, Chair of the Organ Donation and Transplant Committee, campaigns tirelessly as an advocate for those people who are on the organ donation waiting list’.

 Hospital Hero – Elizabeth Berry, Intensive Care Technician, is the ‘jewel in her team’ and ‘nothing is ever too much trouble and she will solve any problem no matter how big or how small’ – ‘she has delivered some of the best patient care I have seen’.

Page 4 of 6  Employee of the Year – Sarah Griffin and team, Antenatal Clinic, St Richard’s for ‘displaying exceptional leadership which resolved a difficult situation with speed and efficiency’.

 Governors’ Award – Ambassadors, who are employees of the trust from across all divisions, departments and teams with a remit to create positive experiences for the people they meet, wherever they are, whether it’s patients, visitors, members of the public or colleagues.

 Chairman’s Award – End of Life Care award honours many staff groups and volunteers who truly go above and beyond and make a significant difference to a patient at the end of their life, whether that be ensuring patient transport arrives early so they can spend extra time at home or going to the shop to buy something special a patient suddenly really fancies to eat.

For further details and pictures of all the winners and runners up please visit www.westernsussexhospitals.nhs.uk/PFawards

3. Employee of the Month The Employee of the Month award for April 2016 was awarded to Sue Ray, Lymphodema nurse at Worthing. Sue was nominated for the award by Clare Dikken for her superb dedication to patients over many years and Clare explained how Sue had postponed her retirement to support the service, saying that patients love her and “we don’t want her to go”.

4. Nursing recruitment and staff retention The ‘one stop shop’ local recruitment events are continuing at regular intervals; Band 5 Nurses are invited to meet the trust’s senior nursing team, tour our hospitals, and be interviewed and tested all on the same day. Those successful leave with a firm job offer, subject to pre- employment checks. To book a place on any of the forthcoming dates please call 01243 788122 ext 33170.

August - St. Richard’s Saturday 13 and Wednesday 24

September - Worthing Saturday 10 and Wednesday 28

October – St. Richard’s Saturday 8 and Wednesday 26

We are still keen to hear from anyone who has a spare room which they might be willing to rent to our new nurses while they look for more permanent arrangements. Please call Sue Villis, Accommodation Manager, on 01903 285115.

Page 5 of 6 5. Welcome to new colleagues

Miss Angela Birnie, Consultant in Urology from 11 July 2016.

Mr Robert Frymann, Consultant in Urology from 11 July 2016.

Mr Roberto Lauro, Fixed Term Consultant in General Surgery (Worthing) from 18 July 2016.

Mr Gianluca Colucci, Consultant in General Surgery (Worthing) from 1 August 2016.

Dr Racheol Sierra, Consultant in Medical Microbiology (Worthing) from 1 August 2016.

Dr Aren Okello, Consultant in Neurology (Worthing) from 30 August 2016

We also wish the following colleagues farewell: Dr Rob Haigh, Chief of Service for Medicine, Deputy Director of Medicine and acute consultant who had been with the Trust for 21 years left at the beginning of July to take up a new role in Portsmouth. His friends and colleagues bid him a fond farewell and wished him every success for the future.

6. Events Our Annual General Meeting of the Council of Governors and Annual Members Meeting took place at Worthing Hospital on Thursday 21 July. It was a pleasure to review the Trust’s year as well as hear the clinical presentation from the teams working to reduce the number of falls in our hospitals.

I was also very proud to share our Annual Review, one of a series of publications documenting the performance of the Trust during 2015/16. All provide an overview of another busy year in the lives of our hospitals. You can find more detail on each of the Review’s component parts in its sister publications:

 Annual Accounts and Financial Statements  Quality Report 2015/16  Annual Report and Accounts 2015-16

Copies of each are available on our website www.westernsussexhospitals.nhs.uk in due course.

The Trust’s Council of Governors meet next on 11 October 2016, Mickerson Hall, Chichester Medical Education Centre (CMEC) St Richard’s Hospital. The meeting commences at 1.30pm and all are very welcome to attend.

Our next Stakeholder Forum will take place at Worthing Hospital in the Health Education Centre (WHEC) on Thursday 1 September, 10.30am. All welcome. To reserve a place at events please email [email protected] or call 01903 205111 ext 84038.

Page 6 of 6

To: Trust Board Date of Meeting: 28 July 2016 Agenda Item: 6

Title Quality Report – Month 3 Responsible Executive Director Dr George Findlay, Medical Director Amanda Parker, Director of Nursing and Patient Safety Prepared by Dr George Findlay, Medical Director Amanda Parker, Director of Nursing and Patient Safety Status Disclosable Summary of Proposal N/A Implications for Quality of Care Describes performance against quality outcome KPIs, including safety, infection control, experience, effectiveness and mortality. Link to Strategic Objectives/Board Assurance Framework This report pulls together key national, regional and local quality indicators relating to quality and safety providing assurance for the board and (if necessary) highlighting issues. Financial Implications Describes KPIs that have potential financial impact (e.g. CQUIN). Human Resource Implications Describes KPIs linked to workforce. Recommendation The Board is asked to NOTE the report. Communication and Consultation N/A Appendices 1: Summary of National Cancer Survey 2016 2: National Cancer Survey 2016 Full Report 3: Quality Scorecard 4: Ward Staffing Scorecard

1 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board

1 INTRODUCTION

1.1 This report brings together key national, regional and local quality indicators relating to quality and safety. The purpose of the report is to bring to the attention of the Trust Board quality performance within Western Sussex Hospitals Foundation Trust (WSHFT).

1.2 The paper describes performance on an exceptional basis determined by RAG (red/amber/green) ratings based on national, regional or local targets. Further quality items are shown as dashboards in the appendices.

2 2016/17 REFRESH

2.1 As part of the refresh of the Quality Strategy for 2016/17 that outline key quality objectives for the next years, this report will be refreshed and redesigned in line with the strategy objectives and to align to the Trust’s True North objectives.

2.2 There are revised targets for 2016/17 these have been calculated based on a similar logic to that applied for 2015/16:-  If 2015/16 Performance exceeded target, then 2015/16 actuals used as 2016/17 target  If 2015/16 Performance did not meet target then 2015/16 target remains for 2016/17  If national or set target then follow or continue  If no target for 2015/16 this also continues for 2016/17

The only new target for 2016/17 Scorecard is ‘Repeat Falls’ and this has been included with the target ‘tbc’.

3 KEY QUALITY OBJECTIVES

3.1 Dashboard Definitions

3.1.1 The full Clinical Quality Dashboard is presented as Appendix 3. Figures are in-month figures (e.g. the number of falls reported in October) unless otherwise stated. The dashboard shows 13 months to allow trends to be identified, although some data items are reported retrospectively. Year to date actuals/targets are based on financial years unless otherwise stated (e.g. standardised mortality ratios are recorded as 12 month positions). A subset of the key measures from the report is presented at 3.3.

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3.1.2 Exception reports are included under the relevant section of this report (i.e. under the broad headings Effectiveness, Safety and Experience).

3.1.3 Only the current financial year and year to date values are RAG rated, with the exception of those metrics reported in arrears with no data in the current financial year where the most recent data-point of last year is RAG rated.

3.2 Domain scores

3.2.1 The domain score is an overall indication of the performance in relation to each of the three areas. The score is calculated as follows: Each RAG rated indicator for a month is scored as follows: reds score 1, ambers score 2, greens score 3. These scores are then totalled and divided by the total number of indicators with RAG ratings to give a score for the domain as a whole between 1 and 3. This final score can then itself be RAG rated with >2.5 giving an overall green, 1.5 to 2.5 amber and <1.5 an overall red score for the domain as a whole. For example if a domain had two greens and a red the calculation would be as follows: 3 (green) + 3 (green) + 1 (red) = 7 7 / 3 (i.e. the total number of metrics) = 2.33 i.e. amber overall.

3.2.2 Year to date domain scores are calculated based on the year to date RAG ratings for each metric. Previous months are retrospectively updated to take account of any measures reported in arrears.

3.2.3 As with any aggregate indicator, it remains essential that the board retains sight of the individual elements as well as the domain score as a whole.

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3.3 Overview of Key Quality Objectives

3.3.1 The following table shows performance against key, top level quality objectives.

Indicator April May June 2016/17 2016/17 2016 2016 2016 to date Target / limit

Effectiveness Domain Score 2.35 2.57 2.71 2.50 2.5 Safety Domain Score 2.05 2.22 2.33 2.24 2.5 Experience Domain Score 2.20 2.26 2.0 2.13 2.5 E01 Trust crude mortality rate (non-elective) 3.46% 3.33% 2.57 3.12% 3.13% E03 Hospital Standardised Mortality Ratio for top 89.4 <92 56 diagnoses (Dr Foster, based on rolling 12 (12m to months) March) S06 Number of Serious Incidents Requiring 13 6 11 30 60 Investigation (number reported in month) S14 Numbers of hospital attributable MRSA 0 0 1 1 0 S28 Numbers of hospital C. diff where a lapse in 2 2 4 18 (national the quality of care was noted target = 39) X38 The Friends and Family Test: Percentage 95.4 Recommending Inpatients 95.3% 95.2% 95.5% X39 The Friends and Family Test: Percentage 91.5% Recommending A&E 92.1% 91.4% 90.9% X13 Mixed Sex Accommodation breaches 0 6 0 6 0 (number of breaches) X18 Number of complaints 63 51 58 172 570

4 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board

4 EFFECTIVENESS

4.1 Crude Trust Mortality

4.1.1 Due to the low level of mortality experienced in elective care, the Trust measures mortality in relation to non-elective activity. The Trust uses the previous year as a benchmark.

4.1.2 Crude non-elective mortality fell from 3.33% in May to 2.57% in June. This is lower than the equivalent month in 2015 (June 2015 = 2.99%). The number of nonelective patients who died in June was 146 (from 5678 discharges). The year to date mortality rate is 3.12% and the rolling 12 month mortality rate is 3.16%. The limit for both measures is 3.13%

4.2 Hospital Standardised Mortality Ratio (HSMR)

4.2.1 There is a delay in data being available in Dr Foster tools to allow for coding and processing by the Health and Social Care Information Centre and Dr Foster. The most recent data available is February 2016.

4.2.2 The Trust’s HSMR for the twelve months to March 2016 is 89.4 (where 100 is the level predicted by the Dr Foster model using the April 2015 benchmark). HSMR has been relatively stable at around 90 for the last 8 months, indicating that the significant improvements have been sustained.

4.2.3 The twelve month HSMR to January 2016 split by site is lower for St Richards (85.8) than for Worthing (92.2), however both are lower than 100.

4.2.4 This data is now rebased using the latest available benchmark (April 2015), this accounts for the observable increase at April 2015.

4.2.5 A further report is available to clinical leaders in the Trust showing the clinical diagnostic areas with high actual versus expected mortality and any mortality CuSum alerts.

4.2.6 The Trust has set the goal of achieving a position within the top 20% of Trusts as measured by HSMR. For the twelve months to February 2016 performance using this measure places us in the top 18% of Trusts

5 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board

WSHFT HSMR. Comparative performance against other Trusts and position related to top 20% Goal

4.3 Summary Hospital-Level Mortality Indicator (SHMI)

4.3.1 The latest data made available by the Health and Social Care Information Centre is for the period August 2015 to December 2015. The Trust value is 1.01 (where 1.00 is the national average), with the Trust banded as ‘as expected’.

4.4 Exception Reports Relating to Effectiveness 4.4.1 E13. Caesarean section rate. Caesarean section rate in June 2016 was 30%. The year to date figure is 27% (against a target of 26%). The directorate continues to scrutinise each case to ensure appropriate decision making and look for opportunities to increase non- operative delivery

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5 SAFETY

5.1 Central Alert System (CAS) Safety Alerts 5.1.1 There are no outstanding alerts for the Trust relating to June 2016 or earlier.

5.2 Serious Incidents Requiring Investigation (SIRIs) There were 11 incidents which were reported in June that have initially been graded as serious incidents requiring investigation. A detailed SIRI report is provided to the Committee section of the Trust Board. The Board should note there is a slight variation in the month by month numbers between the SIRI report and the scorecard as the scorecard assigns incidents to the month in which they occur whereas the latter assigns them to the month in which the SIRI was raised.

5.2.1 The 11 incidents related to 5 grade 3 pressure ulcers, 3 falls resulting in a fracture and 3 delays in treatment.

5.2.2 Recent actions undertaken/planned following SIRIs include; Reminders to staff groups on the need to check accurate postage for internal mail. Information on the availability of bedside testing equipment and actions that can be taken when urgent advice or sample testing is required was provided within maternity. Roll our of a new pressure ulcer assessment tool - Pupose T is due to commence this is a simpler form of assessment and has been proven to be effective in trials nationally.

5.3 Infection control 5.3.1 There was one cases of post 48 hour Methicillin-resistant Staphylococcus Aureus (MRSA) bacteraemia during June. While this is disappointing and there have been lessons to learn, this did not result from a contaminated sample and has recognised that actions can be taken within the pathway for fractured neck of femur patients to improve information or action to prevent action when there is MRSA colonisation prior to surgery. Additional actions recommended include standardisation of skin prep use within theatres and improved assessment and scoring of cannula sites.

5.3.2 There were 2 cases of hospital attributable Clostridium difficile during June one occurred at the Worthing site and one at St Richards.

5.3.3 The 2 cases in June equate to a rate of 7.31 cases of C diff per 100,000 bed days compared the national average for 2014/15 of 15.1 cases per 100,000 bed days (interquartile range 10.3 to 17.6) (source: https://www.gov.uk/government/statistics/clostridium-difficile-infection- annual-data).

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5.3.4 Of the 2 cases in June, root cause analysis identified both related to lapses in care, relating to a dusty environment, sample sending and antibiotic use.

5.3.5 The allocated trust target limit for 2016/17 remains at 39. A stretch target limit of 33 has been agreed for the trust as we aspire to improve on last year. We currently have reached a total of 13 cases for quarter 1, so are above trajectory. This has been recognized and at an extraordinary meeting additional actions were identified to remind staff of the collective actions required continuously to reduce the incidence of clostridium difficile at WSHT.

5.4 Falls

5.4.1 In June there were 39 falls resulting in harm against a benchmark of 43.

5.4.2 There were no falls resulting in severe harm or death in June. Of the 39 falls in June, 2 resulted in moderate harm to patients.

5.4.3 Ten wards are currently within a falls break through project, these wards have shown significant improvement in their patient fall numbers and have been sharing their learning with other wards.

5.5 Tissue Viability

5.5.1 As described previously, changes in the way the Trust reports pressure ulcers means that more grade 2 and grade 3 ulcers were reported in 2015/16 than previous years. This pattern of reporting will continue during 2016/17.

5.5.2 Based upon these reporting arrangements, during June the Trust reported 10 cases of grade 2 hospital acquired pressure ulcers.

5.5.3 In addition to this there were 2 hospital acquired pressure ulcers that were grade 3, and 3 deemed unstageable. None related to a medical device. Of these following a root cause analysis investigation, 3 were deemed unavoidable, 1 avoidable and 1 is awaiting executive review at the time of writing.

5.5.4 The incidence of pressure ulcers, Grade 2 and above (including those developing within 72 hours after admission) per 1000 bed days in June was 0.55. This compares to a national rate of 0.9% as recorded through the Safety thermometer nationally in March 2016.

8 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board

5.5.5 There were 132 patients admitted to the Trust from the Community with pressure damage.

5.5.6 The table below provides the information by site on pressure ulcers grade 2,3 and unstageable that developed or deteriorated during admission.

Hospital During admission Worthing 6 St Richards 9 Total 15

5.6 NHS Patient Safety Thermometer

5.6.1 The NHS Patient Safety Thermometer is used across all relevant acute wards. This tool looks at point prevalence of four key harms (falls, pressure ulcers, urinary tract infections and deep vein thrombosis (DVT) and pulmonary embolism (PE)) in all patients on a specific day in the month. A dashboard is available to each ward showing Trust-wide and ward-level data for each individual harm as well as the harm-free care score. These numbers are also shared via the new ward screens.

5.6.2 The harm-free care score for the Trust in June was 96.1% (indicator S02), better than the target of 93.8% (target based on national average for 2014/15).

5.6.3 The Safety Thermometer includes harms suffered by the patient in healthcare settings prior to admission. The actual number of patients with no new harms during their inpatient stay at WSHFT (indicator S03) was 98.47%. A new target of 99% of patients suffering no new harms following admission for 2015/16 has been set within the Trust Quality Account. This will prove a stretching target as it is considerably higher than the national average of 97.7%.

5.6.4 National data relating to the NHS safety thermometer is available here: http://www.safetythermometer.nhs.uk/

5.7 Exception reporting related to Safety

5.7.1 S09 Moderate/Severe incidents involving medication: Three incidents are noted as occurring during June, these will be investigated and and findings brought back to the committee board.

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6 PATIENT EXPERIENCE

6.1 PALS and Complaints 6.1.1 All complaints are responded to by the Trust Office. The process is administered by the Customer Relations Team. The Quarterly Complaints Report provides an in-depth analysis of trends and lessons learned. This is reviewed by the Patient Experience and Feedback Committee and is presented to the Trust Board.

6.1.2 During June 2016 the Trust received 58 complaints, these will all be responded to and the trust is working on improving its response time to complaints received.

6.2 Friends and Family Test (FFT)

6.2.1 Patients who access hospital services are asked whether they would recommend WSHFT to their friends or family if they needed similar treatment. Patients who access inpatient, outpatient, day-case, A&E and maternity are all offered the opportunity to respond to the question (plus a number of other areas outside the scope of the official friends and family data collection).

6.2.2 Immediate feedback is provided to wards and departments on a continuous basis to ensure staff can address problems or get positive feedback as quickly as possible. In addition to this a dashboard is available giving wards access to their individual scores and a poster printed with ward performance to display to the public. Ward recommend rates are also shown on the new screens installed on wards.

6.2.3 Friends and Family Test Response Rates: As described previously the criteria for inclusion in Friends and Family changed significantly for 2015/16 to include paediatric patients, day-cases and short-stay non-electives. As such the response rate fell considerably at the beginning of that year. Work continues to improve response rates and for the first quarter of 2016/17 we have seen the inpatient and daycase response rate achieve above 30%, and nearing our target this year of 40%.

6.2.4 Friends and Family Test Recommend Rates: In line with national guidance the Friend and Family test is now reported as a ‘percentage recommending’ score (calculated as the percentage of respondents indicating they were either ‘highly likely’ or ‘likely’ to recommend the service divided by the total respondents including ‘don’t knows’). National performance is published on the NHS England website: http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family- test-data/

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6.2.5 The table below shows the latest local scores against national benchmarks: Percentage recommending National median (April 2014 WSHFT in May (year to date in to March 2015)* brackets) Inpatient care 95.5% (95.3%) 94.1% A&E 90.9% (92.1%) 86.8% Maternity: Delivery care 95.9% (93.2%) 95.4% Outpatient care 94.1% (93.6%) No benchmark

Maternity: Antenatal care 93.1% (100%) 94.6% Maternity: Postnatal ward 95.9% (93.2%) 92.2% Maternity: Postnatal community 100% (100%) 96.6% care * Some caution should be undertaken using this benchmark due to the changes to the eligible patients noted above.

6.3 Exception Reports Relating to Experience

6.3.1 Exception Report: Indicator X14 and X15 – MUST Assessment in 24 hours and 7 days: Data on collection for MUST assessments remains a challenge, weekly reports are being provided to all wards and there is a continual improvement in 24 hour assessment recording with June achieving 70.4%%.

7 CARE QUALITY COMMISSION (CQC)

7.1 CQC Inspection 7.1.1 The CQC undertook inspection of the Trust on 8th to 11th December. A summary of actions on areas identified for improvement has been provided to the CQC. These actions are monitored through the CQC steering group and updates provided to the Trust Executive Committee each month and the action plan is overseen by the Quality and Risk Committee.

8 NATIONAL AND LOCAL REPORTS

8.1.1 The National Cancer survey for 2015 was made public on July 5th 2016. A summary of the report is attached as Appendix 1 and the full report at Appendix 2.

8.1.2 All cancer specialist nurses have been requested to review the relevant aspects of the report and create actions plans for their service area.

11 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board

9 RECOMMENDATION

9.1 The Board is asked to note the contents of this report.

12 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board

APPENDIX 1

Response to National Cancer Survey 2016

The National Cancer Survey report was published on 5/7/16. This year’s survey had some alterations made to it so comparative analysis with last year is likely to be challenging. Overall the response rate for our Trust was 71% (661 patients) which is higher than the national average (68%). Highest response rates were from patients with breast cancer and haematological cancer (164 & 179 respectively).

The overall rating for our care was 8.6/10, the national average was 8.7/10. 35% of our responses were 80% and above. This year the responses have been gathered adopting the CQC standard for reporting comparative performance, based on calculation of ‘expected ranges’, 78% of our responses fell within these ‘expected’ ranges. 14 questions were outside ‘expected range’ of these 6 score 77% and above. The areas out of expected range that need significant improvement include Q12-15 (deciding best treatment for you) and Q55 on care planning. Q49-51, 53 are around home care and community support.

Access to Clinical Nurse Specialists fell outside expected range but scored highly between 84-86%; since the survey data collection we have introduced improvements with band 4 support workers and an innovative post of a roaming CNS, further work is being done on improving access to CNS.

There are six areas which are being included in phase 1 of the National Cancer Dashboard and we largely scored well in these:

 75% of respondents said that they were definitely involved as much as they wanted to be in decisions about their care and treatment  86% of respondents said that they thought the GPs and nurses at their general practice would support them through their treatment  when asked how easy or difficult it had been to contact their Clinical Nurse Specialist84% of respondents said that it had been ‘quite easy’ or ‘very easy’  88% of respondents said that, overall, they were always treated with dignity and respect when they were in hospital  91% of respondents said that hospital staff told them who to contact if they were worried about their condition or treatment after they left hospital  57% thought that GPs and Nurses at their general practice definitely did everything they could to support them while they were having cancer treatment (sits within primary care rather than acute trust).

Overall we do fall in the middle for scoring and many of the scores are quite high. Areas for improvement look to be in improving patient’s understanding and helping the in decision making,

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providing better information and support, managing side effects of treatment and ensuring ward patients feel they can discuss their concerns.

We know that the clinical nurse specialists make a difference to the patients experience; we scored above 80% in each area for the CNS input. Therefore if we decided on a single action to improve a number of different outcomes would be to improve access to clinical nurse specialists, we have secured some extra funding to enable this to happen.

This survey may be a cancer patient survey but it is everyone’s business as cancer patients cross cut all our services. A presentation will be made to HONS in August and leads identified within divisions to develop action plans.

Claire Dikken July 2016

14 Western Sussex Hospitals Foundation NHS Trust – Quality Report for Trust Board National Cancer Patient Experience Survey

2015 Results

Western Sussex Hospitals NHS Foundation Trust

Published July 2016

The National Cancer Patient Experience Survey is undertaken by Quality Health on behalf of NHS England National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Introduction

The National Cancer Patient Experience Survey 2015 is the fifth iteration of the survey first undertaken in 2010. It has been designed to monitor national progress on cancer care; to provide information to drive local quality improvements; to assist commissioners and providers of cancer care; and to inform the work of the various charities and stakeholder groups supporting cancer patients.

The survey was overseen by a national Cancer Patient Experience Advisory Group. This Advisory Group set the principles and objectives of the survey programme and guided questionnaire development.

The survey was commissioned and managed by NHS England. The survey provider, Quality Health, is responsible for designing, running and analysing the survey.

Full national results and other reports are available at www.ncpes.co.uk

Further details on the survey methodology and changes to the 2015 survey can be found in the Annex. Note that a number of significant changes were made to the 2015 survey so caution should be taken in directly comparing data from the 2015 survey to the findings of the previous CPES surveys. No comparisons with previous surveys are presented in this report.

This report

The report shows how this Trust scored for each question in the survey, compared with national results. It is aimed at helping individual Trusts to understand their performance and identify areas for local improvement.

Note that responses for questions with 1-20 respondents have been suppressed. This is to protect patient confidentiality and because uncertainty around the result is too great.

Data tables

The data tables presented in this report show the following for each question:

• Column 1 shows the number of respondents to this question • Column 2 shows the unadjusted 2015 score for this Trust • Column 3 shows the case-mix adjusted 2015 score for this Trust • Column 4 shows the lower limit of the expected range of scores for this Trust (the top of the pale blue section on the Comparability chart - see below) • Column 5 shows the upper limit of the expected range of scores for this Trust (the bottom of the dark blue section on the Comparability chart - see below) • Column 6 shows the National Average score for this question.

2 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Results for individual response options are presented in the detailed data tables www.ncpes.co.uk Confidence Intervals for unadjusted and case-mix adjusted data are provided in these tables.

Expected ranges and 95% Confidence Intervals highlight the uncertainty around the results. The size of the expected ranges and confidence intervals will be different for each question, and depends on the number of respondents and the range of their responses.

For further details on case-mix adjustment and the scoring methodology used, please refer to the Annex.

Comparability charts

For the 2015 survey, we have adopted the CQC standard for reporting comparative performance, based on calculation of "expected ranges". This means that Trusts will be flagged as outliers only if there is statistical evidence that their scores deviate (positively or negatively) from the range of scores that would be expected for Trusts of the same size.

The Comparability charts in this report show a bar with these expected ranges (in grey), higher than expected (in dark blue), and lower than expected (in pale blue). A black dot represents the actual score of this Trust.

The same colour convention has been used in Column 3 of the Data tables.

For further details on expected ranges, please refer to the technical document at www.ncpes.co.uk

Tumour group tables

The final set of tables in this report show the scores for each question for each of the 13 tumour groups, with a comparative national score for that tumour group.

These breakdowns are intended as additional information for Trusts to understand the differences between the experiences of patients with different types of cancer. The numbers are generally relatively small and may not be statistically significant. They should therefore be treated with some caution.

Notes on specific questions

Question 5 in the survey has not been scored. However, the unscored data is useful and has been published alongside the other results in this report. This question asked respondents to "tick all that apply". The results show all of the responses given including where respondents chose two or more options.

Questions used to direct respondents to different parts of the survey (questions 4, 17, 24, 27, 40, 43, 46) and other demographic and information questions are not reported.

3 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

How to use the data

Unadjusted data should be used to see the actual responses from patients relating to the Trust.

Case-mix adjusted data, together with expected ranges, should be used to understand whether the results are significantly higher or lower than national results.

Case-mix adjusted data, together with (case-mix adjusted) Confidence Intervals (presented in the detailed data tables www.ncpes.co.uk ), should be used to understand whether the results are significantly higher or lower than the results for another Trust.

Response rates

Numbers of respondents by tumour group, age and gender can be found in the Annex.

4 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Executive Summary

Asked to rate their care on a scale of zero (very poor) to 10 (very good), respondents gave an average rating of 8.6 .

The following questions are included in phase 1 of the Cancer Dashboard developed by Public Health England and NHS England*:

• 75% of respondents said that they were definitely involved as much as they wanted to be in decisions about their care and treatment

• 86% of respondents said that they were given the name of a Clinical Nurse Specialist who would support them through their treatment

• when asked how easy or difficult it had been to contact their Clinical Nurse Specialist 84% of respondents said that it had been ‘quite easy’ or ‘very easy’

• 88% of respondents said that, overall, they were always treated with dignity and respect they were in hospital

• 91% of respondents said that hospital staff told them who to contact if they were worried about their condition or treatment after they left hospital

• 57% of respondents said that they thought the GPs and nurses at their general practice definitely did everything they could to support them while they were having cancer treatment.

Detailed results for these and other questions are set out in the sections that follow.

* www.cancerdata.nhs.uk/dashboard The questions were selected in discussion with the national Cancer Patient Experience Advisory Group and reflect four key patient experience domains: provision of information; involvement in decisions; care transition; interpersonal relations, respect and dignity. The figures presented above are all case-mix adjusted.

5 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Questions which scored outside expected range

2015 Case-mix Adjusted Percentagefor Upper limit of of Upper limit Lower limit of of Lower limit for this Trust this for respondents Numberof this Trust this expected expected expected expected Average National Score range range 2015 Question

Deciding the best treatment for you Q12 Patient felt that treatment options were completely explained 559 79% 80% 86% 83%

Q13 Possible side effects explained in an understandable way 620 67% 69% 76% 73% Patient given practical advice and support in dealing with side Q14 628 60% 62% 70% 66% effects of treatment Patient definitely told about side effects that could affect them in Q15 567 48% 50% 59% 54% the future

Clinical Nurse Specialist Patient given the name of the CNS who would support them Q17 632 86% 87% 93% 90% through their treatment Get understandable answers to important questions all or most Q19 460 84% 86% 91% 88% of the time

Support for people with cancer Q20 Hospital staff gave information about support groups 469 78% 78% 87% 83%

Hospital care as an inpatient Q29 Patient had confidence and trust in all doctors treating them 351 80% 80% 88% 84%

Hospital care as a day patient / outpatient Beforehand patient had all information needed about Q44 101 77% 79% 93% 86% radiotherapy treatment

Home care and support Hospital staff gave family or someone close all the information Q49 495 53% 53% 62% 58% needed to help with care at home Patient definitely given enough support from health or social Q50 282 43% 46% 62% 54% services during treatment Patient definitely given enough support from health or social Q51 154 34% 37% 53% 45% services after treatment

Care from your general practice Practice staff definitely did everything they could to support Q53 457 57% 58% 67% 63% patient

Your overall NHS care Q55 Patient given a care plan 497 25% 28% 38% 33% National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Trust results

Seeing your GP

Q1 Saw GP once / twice before being told had to go to hospital

Q2 Patient thought they were seen as soon as necessary

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Saw GP once / twice before being told had to go to Q1 479 78% 78% 72% 80% 76% hospital

Q2 Patient thought they were seen as soon as necessary 638 82% 81% 79% 85% 82%

No. Yes 513 No, I would have liked more written information 21 Beforehand, did you have all the Q5 No, I would have liked more verbal information 20 information you needed about your test? I did not need / want any information 11 Don't know / can't remember 10

7 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Diagnostic tests

Q6 The length of time waiting for the test to be done was about right

Q7 Given complete explanation of test results in understandable way

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

The length of time waiting for the test to be done was Q6 545 89% 88% 84% 89% 87% about right

Given complete explanation of test results in Q7 546 77% 75% 75% 82% 79% understandable way

8 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Finding out what was wrong with you

Q8 Patient told they could bring a family member or friend when first told they had cancer

Q9 Patient felt they were told sensitively that they had cancer

Q10 Patient completely understood the explanation of what was wrong

Q11 Patient given easy to understand written information about the type of cancer they had

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Patient told they could bring a family member or friend Q8 553 77% 76% 74% 83% 79% when first told they had cancer

Q9 Patient felt they were told sensitively that they had cancer 648 84% 83% 81% 87% 84%

Patient completely understood the explanation of what Q10 654 71% 71% 70% 76% 73% was wrong

Patient given easy to understand written information Q11 581 75% 73% 68% 75% 72% about the type of cancer they had

9 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Finding out what was wrong with you

Q12 Patient felt that treatment options were completely explained

Q13 Possible side effects explained in an understandable way

Q14 Patient given practical advice and support in dealing with side effects of treatment

Q15 Patient definitely told about side effects that could affect them in the future

Q16 Patient definitely involved in decisions about care and treatment

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Patient felt that treatment options were completely Q12 559 79% 79% 80% 86% 83% explained

Q13 Possible side effects explained in an understandable way 620 68% 67% 69% 76% 73%

Patient given practical advice and support in dealing with Q14 628 61% 60% 62% 70% 66% side effects of treatment

Patient definitely told about side effects that could affect Q15 567 47% 48% 50% 59% 54% them in the future

Patient definitely involved in decisions about care and Q16 616 76% 75% 74% 81% 78% treatment

10 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Clinical Nurse Specialist

Q17 Patient given the name of the CNS who would support them through their treatment

Q18 Patient found it easy to contact their CNS

Q19 Get understandable answers to important questions all or most of the time

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Patient given the name of the CNS who would support Q17 632 86% 86% 87% 93% 90% them through their treatment

Q18 Patient found it easy to contact their CNS 494 84% 84% 82% 91% 87%

Get understandable answers to important questions all or Q19 460 85% 84% 86% 91% 88% most of the time

11 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Support for people with cancer

Q20 Hospital staff gave information about support groups

Q21 Hospital staff gave information about impact cancer could have on day to day activities

Q22 Hospital staff gave information on getting financial help

Q23 Hospital staff told patient they could get free prescriptions

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Q20 Hospital staff gave information about support groups 469 79% 78% 78% 87% 83%

Hospital staff gave information about impact cancer could Q21 399 79% 78% 77% 85% 81% have on day to day activities

Q22 Hospital staff gave information on getting financial help 302 50% 49% 48% 62% 55%

Q23 Hospital staff told patient they could get free prescriptions 280 78% 75% 74% 86% 80%

12 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Operations

Q26 Staff explained how operation had gone in understandable way

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Staff explained how operation had gone in Q26 324 79% 78% 73% 82% 78% understandable way

13 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Hospital care as an inpatient (Part 1 of 3)

Q28 Groups of doctors or nurses did not talk in front of patient as if they were not there

Q29 Patient had confidence and trust in all doctors treating them

Q30 Patient’s family or someone close definitely had opportunity to talk to doctor

Q31 Patient had confidence and trust in all ward nurses

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Groups of doctors or nurses did not talk in front of patient Q28 350 82% 80% 77% 85% 81% as if they were not there

Patient had confidence and trust in all doctors treating Q29 351 81% 80% 80% 88% 84% them

Patient’s family or someone close definitely had Q30 292 73% 72% 67% 77% 72% opportunity to talk to doctor

Q31 Patient had confidence and trust in all ward nurses 351 69% 69% 66% 79% 72%

14 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Hospital care as an inpatient (Part 2 of 3)

Q32 Always / nearly always enough nurses on duty

Q33 All staff asked patient what name they preferred to be called by

Q34 Always given enough privacy when discussing condition or treatment

Q35 Patient was able to discuss worries or fears with staff during visit

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Q32 Always / nearly always enough nurses on duty 350 67% 66% 59% 73% 66%

All staff asked patient what name they preferred to be Q33 349 72% 72% 57% 76% 67% called by

Always given enough privacy when discussing condition Q34 348 83% 82% 81% 89% 85% or treatment

Patient was able to discuss worries or fears with staff Q35 251 47% 46% 46% 58% 52% during visit

15 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Hospital care as an inpatient (Part 3 of 3)

Q36 Hospital staff definitely did everything to help control pain

Q37 Always treated with respect and dignity by staff

Q38 Given clear written information about what should / should not do post discharge

Q39 Staff told patient who to contact if worried post discharge

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Q36 Hospital staff definitely did everything to help control pain 308 83% 82% 80% 88% 84%

Q37 Always treated with respect and dignity by staff 351 89% 88% 84% 91% 87%

Given clear written information about what should / should Q38 326 84% 83% 81% 88% 84% not do post discharge

Q39 Staff told patient who to contact if worried post discharge 332 92% 91% 91% 96% 94%

16 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Hospital care as a day patient / outpatient (Part 1 of 2)

Q41 Patient was able to discuss worries or fears with staff during visit

Q42 Doctor had the right notes and other documentation with them

Q44 Beforehand patient had all information needed about radiotherapy treatment

Q45 Patient given understandable information about whether radiotherapy was working

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Patient was able to discuss worries or fears with staff Q41 487 68% 67% 65% 75% 70% during visit

Doctor had the right notes and other documentation with Q42 583 97% 97% 94% 97% 96% them

Beforehand patient had all information needed about Q44 101 77% 77% 79% 93% 86% radiotherapy treatment

Patient given understandable information about whether Q45 90 61% 61% 49% 70% 60% radiotherapy was working

17 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Hospital care as a day patient / outpatient (Part 2 of 2)

Q47 Beforehand patient had all information needed about chemotherapy treatment

Q48 Patient given understandable information about whether chemotherapy was working

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Beforehand patient had all information needed about Q47 355 82% 82% 80% 88% 84% chemotherapy treatment

Patient given understandable information about whether Q48 317 67% 66% 63% 73% 68% chemotherapy was working

18 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Home care and support

Q49 Hospital staff gave family or someone close all the information needed to help with care at home

Q50 Patient definitely given enough support from health or social services during treatment

Q51 Patient definitely given enough support from health or social services after treatment

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Hospital staff gave family or someone close all the Q49 495 54% 53% 53% 62% 58% information needed to help with care at home

Patient definitely given enough support from health or Q50 282 44% 43% 46% 62% 54% social services during treatment

Patient definitely given enough support from health or Q51 154 35% 34% 37% 53% 45% social services after treatment

19 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Care from your general practice

Q52 GP given enough information about patient`s condition and treatment

Q53 Practice staff definitely did everything they could to support patient

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

GP given enough information about patient`s condition Q52 542 96% 96% 94% 97% 95% and treatment

Practice staff definitely did everything they could to Q53 457 57% 57% 58% 67% 63% support patient

20 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Your overall NHS care (Part 1 of 2)

Q54 Hospital and community staff always worked well together

Q55 Patient given a care plan

Q56 Overall the administration of the care was very good / good

Q57 Length of time for attending clinics and appointments was right

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Q54 Hospital and community staff always worked well together 630 61% 60% 56% 66% 61%

Q55 Patient given a care plan 497 26% 25% 28% 38% 33%

Overall the administration of the care was very good / Q56 634 89% 88% 86% 92% 89% good

Length of time for attending clinics and appointments was Q57 630 60% 61% 58% 73% 66% right

21 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Your overall NHS care (Part 2 of 2)

Q58 Taking part in cancer research discussed with patient

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

All scores presented in this chart are case-mix adjusted < lower Percentage score higher > RYR

2015 Case-mix Adjusted NationalAverageScore 2015Unadjusted Score Expected range upper- Expected Expected range lower- Expected respondents 2015Score Numberof

Question

Q58 Taking part in cancer research discussed with patient 620 22% 22% 20% 37% 28%

Q59 Patient`s average rating of care scored from very poor to very good

0 1 2 3 4 5 6 7 8 9 10

All scores presented in this chart are case-mix adjusted < lower Scale score higher > RYR

2015 Case-mix Adjusted 2015 Score for this Trust this 2015for Score NationalAverageScore 2015Unadjusted Score Upper limit of expected expected of Upper limit Lower limit of expected expected of Lower limit for this Trust this for Trust this for respondents Numberof range range Question

Patient`s average rating of care scored from very poor to Q59 629 8.6 8.6 8.5 8.9 8.7 very good

22 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Comparisons by tumour group for this Trust

The following tables show the unadjusted Trust and the national percentage scores for each question broken down by tumour group. Where a cell in the table contains an asterisk this indicates that the number of patients in that group was below 21 and too small to display. Where a cell in the table contains "n.a." this indicates that there were no respondents for that tumour group.

Seeing your GP

Q1. Saw GP once / Q2. Patient thought twice before being told they were seen as had to go to hospital soon as necessary

Cancer type This Trust $ National This Trust $ National Brain / CNS n.a. 60% n.a. 77% Breast 97% 93% 90% 88% Colorectal / LGT 79% 72% 79% 80% Gynaecological 86% 75% 72% 78% Haematological 64% 64% 77% 80% Head and Neck * 77% * 79% Lung * 69% 84% 83% Prostate 79% 79% 86% 85% Sarcoma * 64% * 69% Skin 91% 91% 87% 87% Upper Gastro * 70% 81% 78% Urological 79% 81% 88% 84% Other 81% 70% 73% 78% All Cancers 78% 76% 82% 82%

$ These are unadjusted scores

23 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Diagnostic tests

Q6. The length of time Q7. Given complete waiting for the test to explanation of test be done was about results in right understandable way

Cancer type This Trust $ National This Trust $ National Brain / CNS n.a. 87% n.a. 69% Breast 90% 90% 81% 82% Colorectal / LGT 84% 86% 83% 81% Gynaecological 100% 84% 83% 76% Haematological 88% 87% 66% 76% Head and Neck * 84% * 77% Lung 95% 87% 86% 78% Prostate 89% 85% 78% 79% Sarcoma * 81% * 77% Skin * 89% * 85% Upper Gastro * 83% * 77% Urological 88% 85% 85% 78% Other 93% 85% 70% 76% All Cancers 89% 87% 77% 79%

$ These are unadjusted scores

24 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Finding out what was wrong with you

Q8. Patient told they Q9. Patient felt they Q10. Patient Q11. Patient given could bring a family were told sensitively completely understood easy to understand member or friend that they had cancer the explanation of written information when first told they what was wrong about the type of had cancer cancer they had

Cancer type This Trust $ National This Trust $ National This Trust $ National This Trust $ National Brain / CNS n.a. 85% n.a. 79% n.a. 60% n.a. 62% Breast 85% 83% 89% 88% 80% 78% 79% 76% Colorectal / LGT 80% 83% 84% 85% 82% 79% 81% 71% Gynaecological 68% 75% 84% 83% 80% 73% * 69% Haematological 71% 75% 76% 83% 54% 60% 69% 74% Head and Neck * 73% * 85% * 75% * 61% Lung 77% 80% 88% 83% 76% 75% 71% 66% Prostate 63% 80% 78% 84% 65% 78% 68% 80% Sarcoma * 77% * 82% * 63% * 61% Skin * 71% 96% 90% 87% 83% * 84% Upper Gastro * 79% 95% 79% 76% 72% * 64% Urological 52% 74% 84% 82% 78% 76% 91% 71% Other 90% 77% 82% 82% 68% 72% 73% 61% All Cancers 77% 79% 84% 84% 71% 73% 75% 72%

$ These are unadjusted scores

25 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Deciding the best treatment for you

Q12. Patient felt that Q13. Possible side Q14. Patient given treatment options effects explained in an practical advice and were completely understandable way support in dealing with explained side effects of treatment

Cancer type This Trust $ National This Trust $ National This Trust $ National Brain / CNS n.a. 80% n.a. 71% n.a. 62% Breast 81% 84% 72% 76% 68% 69% Colorectal / LGT 88% 85% 72% 75% 64% 68% Gynaecological * 84% 75% 76% 75% 68% Haematological 75% 81% 59% 69% 55% 65% Head and Neck * 85% * 72% * 67% Lung * 84% 74% 74% 61% 69% Prostate 73% 80% 61% 71% 43% 61% Sarcoma * 82% * 75% * 66% Skin * 88% * 75% 76% 74% Upper Gastro * 83% 67% 72% 57% 66% Urological 82% 80% 77% 69% 65% 61% Other 74% 80% 68% 72% 51% 64% All Cancers 79% 83% 68% 73% 61% 66%

Q15. Patient definitely Q16. Patient definitely told about side effects involved in decisions that could affect them about care and in the future treatment

Cancer type This Trust $ National This Trust $ National Brain / CNS n.a. 56% n.a. 74% Breast 51% 55% 79% 79% Colorectal / LGT 49% 56% 81% 79% Gynaecological 52% 54% 83% 76% Haematological 40% 50% 71% 77% Head and Neck * 58% * 76% Lung * 54% 76% 78% Prostate 52% 63% 74% 79% Sarcoma * 54% * 77% Skin * 66% * 86% Upper Gastro * 53% * 77% Urological 62% 52% 76% 75% Other 37% 51% 74% 75% All Cancers 47% 54% 76% 78%

$ These are unadjusted scores

26 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Clinical Nurse Specialist

Q17. Patient given the Q18. Patient found it Q19. Get name of the CNS who easy to contact their understandable would support them CNS answers to important through their questions all or most treatment of the time

Cancer type This Trust $ National This Trust $ National This Trust $ National Brain / CNS n.a. 95% n.a. 84% n.a. 85% Breast 83% 94% 90% 85% 91% 88% Colorectal / LGT 90% 91% 73% 88% 73% 90% Gynaecological 100% 93% 85% 86% 92% 87% Haematological 85% 89% 85% 89% 85% 90% Head and Neck * 88% * 86% * 88% Lung 100% 93% 86% 89% 76% 89% Prostate 89% 89% 85% 83% 87% 88% Sarcoma * 87% * 86% * 88% Skin 86% 88% * 90% * 92% Upper Gastro 100% 92% 76% 87% * 88% Urological 84% 80% 88% 85% 95% 88% Other 72% 86% 75% 86% 89% 87% All Cancers 86% 90% 84% 87% 85% 88%

$ These are unadjusted scores

27 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Support for people with cancer

Q20. Hospital staff Q21. Hospital staff Q22. Hospital staff Q23. Hospital staff told gave information gave information gave information on patient they could get about support groups about impact cancer getting financial help free prescriptions could have on day to day activities

Cancer type This Trust $ National This Trust $ National This Trust $ National This Trust $ National Brain / CNS n.a. 85% n.a. 80% n.a. 72% n.a. 79% Breast 84% 88% 87% 85% 52% 60% 70% 80% Colorectal / LGT 70% 82% 78% 82% 43% 52% 91% 83% Gynaecological * 83% * 81% * 58% * 76% Haematological 77% 82% 77% 82% 49% 56% 86% 86% Head and Neck * 83% * 80% * 55% * 80% Lung * 82% * 80% * 68% * 85% Prostate 83% 85% 62% 81% * 41% * 76% Sarcoma * 82% * 80% * 57% * 75% Skin * 85% * 85% * 51% * 65% Upper Gastro * 82% * 78% * 57% * 83% Urological 82% 71% * 70% * 33% * 69% Other 78% 80% 73% 77% * 53% 79% 79% All Cancers 79% 83% 79% 81% 50% 55% 78% 80%

$ These are unadjusted scores

28 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Operations

Q26. Staff explained how operation had gone in understandable way

Cancer type This Trust $ National Brain / CNS n.a. 75% Breast 80% 77% Colorectal / LGT 82% 81% Gynaecological * 79% Haematological 68% 75% Head and Neck * 77% Lung * 76% Prostate * 76% Sarcoma * 80% Skin * 84% Upper Gastro * 81% Urological 81% 74% Other * 78% All Cancers 79% 78%

$ These are unadjusted scores

29 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Hospital care as an inpatient (Part 1 of 2)

Q28. Groups of doctors Q29. Patient had Q30. Patient’s family Q31. Patient had or nurses did not talk confidence and trust in or someone close confidence and trust in in front of patient as if all doctors treating definitely had all ward nurses they were not there them opportunity to talk to doctor

Cancer type This Trust $ National This Trust $ National This Trust $ National This Trust $ National Brain / CNS n.a. 68% n.a. 78% n.a. 65% n.a. 67% Breast 88% 89% 86% 86% 79% 73% 69% 74% Colorectal / LGT 71% 75% 78% 85% 69% 72% 59% 68% Gynaecological * 84% * 86% * 71% * 69% Haematological 82% 80% 77% 81% 77% 75% 73% 73% Head and Neck * 79% * 85% * 73% * 72% Lung * 75% * 82% * 71% * 73% Prostate * 84% * 87% * 72% * 75% Sarcoma * 82% * 85% * 75% * 70% Skin * 85% * 90% * 79% * 84% Upper Gastro * 75% * 83% * 72% * 70% Urological 86% 80% 89% 84% 76% 67% 82% 75% Other * 79% * 79% * 70% * 69% All Cancers 82% 81% 81% 84% 73% 72% 69% 72%

Q32. Always / nearly Q33. All staff asked Q34. Always given Q35. Patient was able always enough nurses patient what name enough privacy when to discuss worries or on duty they preferred to be discussing condition or fears with staff during called by treatment visit

Cancer type This Trust $ National This Trust $ National This Trust $ National This Trust $ National Brain / CNS n.a. 64% n.a. 69% n.a. 80% n.a. 44% Breast 69% 69% 67% 60% 83% 86% 42% 53% Colorectal / LGT 59% 61% 74% 70% 72% 84% 41% 54% Gynaecological * 65% * 63% * 82% * 50% Haematological 62% 63% 78% 67% 91% 86% 54% 55% Head and Neck * 67% * 66% * 85% * 50% Lung * 68% * 71% * 84% * 49% Prostate * 71% * 67% * 87% * 52% Sarcoma * 68% * 71% * 87% * 52% Skin * 81% * 67% * 89% * 61% Upper Gastro * 62% * 75% * 83% * 53% Urological 82% 68% 83% 71% 93% 84% * 46% Other * 62% * 66% * 82% * 48% All Cancers 67% 66% 72% 67% 83% 85% 47% 52%

$ These are unadjusted scores

30 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Hospital care as an inpatient (Part 2 of 2)

Q36. Hospital staff Q37. Always treated Q38. Given clear Q39. Staff told patient definitely did with respect and written information who to contact if everything to help dignity by staff about what should / worried post discharge control pain should not do post discharge

Cancer type This Trust $ National This Trust $ National This Trust $ National This Trust $ National Brain / CNS n.a. 82% n.a. 84% n.a. 79% n.a. 91% Breast 83% 86% 87% 88% 90% 90% 93% 95% Colorectal / LGT 77% 84% 87% 86% 75% 83% 89% 94% Gynaecological * 83% * 85% * 86% * 93% Haematological 89% 84% 92% 89% 81% 79% 96% 95% Head and Neck * 84% * 88% * 86% * 92% Lung * 83% * 87% * 81% * 92% Prostate * 85% * 91% * 87% * 94% Sarcoma * 86% * 91% * 83% * 94% Skin * 88% * 93% * 91% * 97% Upper Gastro * 83% * 86% * 79% * 93% Urological 92% 80% 96% 88% 89% 83% 96% 90% Other * 82% * 85% * 80% * 92% All Cancers 83% 84% 89% 87% 84% 84% 92% 94%

$ These are unadjusted scores

31 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Hospital care as a day patient / outpatient

Q41. Patient was able Q42. Doctor had the Q44. Beforehand Q45. Patient given to discuss worries or right notes and other patient had all understandable fears with staff during documentation with information needed information about visit them about radiotherapy whether radiotherapy treatment was working

Cancer type This Trust $ National This Trust $ National This Trust $ National This Trust $ National Brain / CNS n.a. 65% n.a. 94% n.a. 85% n.a. 52% Breast 74% 70% 98% 95% 84% 87% 63% 60% Colorectal / LGT 69% 73% 97% 95% * 85% * 55% Gynaecological * 70% 86% 96% * 85% * 64% Haematological 67% 74% 98% 97% * 82% * 64% Head and Neck * 69% * 95% * 86% * 60% Lung 62% 69% 91% 96% * 86% * 59% Prostate 63% 69% 97% 95% * 88% * 61% Sarcoma * 68% * 97% n.a. 88% n.a. 63% Skin * 73% * 96% * 81% * 63% Upper Gastro * 68% * 95% * 85% * 57% Urological 73% 65% 97% 95% * 81% * 53% Other 58% 67% 100% 95% * 83% * 59% All Cancers 68% 70% 97% 96% 77% 86% 61% 60%

Q47. Beforehand Q48. Patient given patient had all understandable information needed information about about chemotherapy whether treatment chemotherapy was working Cancer type This Trust $ National This Trust $ National Brain / CNS n.a. 82% n.a. 57% Breast 79% 83% 64% 62% Colorectal / LGT 75% 86% 70% 65% Gynaecological * 86% * 68% Haematological 84% 85% 82% 75% Head and Neck * 80% * 52% Lung * 85% * 68% Prostate * 83% * 69% Sarcoma * 82% * 70% Skin n.a. 92% n.a. 80% Upper Gastro * 83% * 64% Urological * 83% * 66% Other 96% 85% 67% 70% All Cancers 82% 84% n.a. 68%

$ These are unadjusted scores

32 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Home care and support

Q49. Hospital staff Q50. Patient definitely Q51. Patient definitely gave family or given enough support given enough support someone close all the from health or social from health or social information needed to services during services after help with care at home treatment treatment

Cancer type This Trust $ National This Trust $ National This Trust $ National Brain / CNS n.a. 56% n.a. 44% n.a. 44% Breast 60% 57% 41% 54% 35% 40% Colorectal / LGT 43% 60% 52% 62% * 52% Gynaecological 52% 56% * 52% * 42% Haematological 52% 60% 33% 52% 24% 43% Head and Neck * 59% * 53% * 50% Lung * 57% * 52% * 42% Prostate 38% 55% * 47% * 43% Sarcoma * 59% * 58% * 53% Skin * 67% * 58% * 61% Upper Gastro * 59% * 54% * 45% Urological 69% 55% * 47% * 44% Other 44% 54% * 55% * 48% All Cancers 54% 58% 44% 54% 35% 45%

$ These are unadjusted scores

33 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Care from your general practice

Q52. GP given enough Q53. Practice staff information about definitely did patient`s condition and everything they could treatment to support patient

Cancer type This Trust $ National This Trust $ National Brain / CNS n.a. 94% n.a. 59% Breast 99% 96% 61% 63% Colorectal / LGT 93% 95% 60% 63% Gynaecological * 95% 48% 59% Haematological 96% 96% 50% 61% Head and Neck * 93% * 60% Lung * 95% * 62% Prostate 97% 95% 66% 67% Sarcoma * 97% * 65% Skin * 97% * 71% Upper Gastro * 94% * 62% Urological 100% 95% 73% 64% Other 100% 95% 49% 61% All Cancers 96% 95% 57% 63%

$ These are unadjusted scores

34 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Your overall NHS care

Q54. Hospital and Q55. Patient given a Q56. Overall the Q57. Length of time for community staff care plan administration of the attending clinics and always worked well care was very good / appointments was together good right

Cancer type This Trust $ National This Trust $ National This Trust $ National This Trust $ National Brain / CNS n.a. 45% n.a. 29% n.a. 84% n.a. 60% Breast 62% 60% 35% 35% 89% 90% 58% 64% Colorectal / LGT 52% 60% 24% 36% 85% 88% 62% 68% Gynaecological 63% 58% * 29% 88% 89% 68% 66% Haematological 60% 63% 24% 33% 89% 92% 54% 62% Head and Neck * 58% * 34% * 89% * 65% Lung 68% 63% * 32% 83% 89% 70% 70% Prostate 61% 63% 24% 36% 83% 87% 69% 71% Sarcoma * 60% * 31% * 90% * 63% Skin 74% 69% * 39% 100% 89% 86% 73% Upper Gastro * 58% * 36% * 88% * 66% Urological 74% 62% 18% 26% 94% 84% 83% 73% Other 62% 56% 18% 29% 94% 87% 54% 61% All Cancers 61% 61% 26% 33% 89% 89% 60% 66%

Q58. Taking part in Q59. Patient`s average cancer research rating of care scored discussed with patient from very poor to very good

Cancer type This Trust $ National This Trust $ National Brain / CNS n.a. 32% n.a. 8.5 Breast 16% 28% 8.7 8.8 Colorectal / LGT 10% 22% 8.5 8.7 Gynaecological 23% 27% 8.6 8.7 Haematological 36% 36% 8.7 8.8 Head and Neck * 21% * 8.6 Lung 26% 34% 7.9 8.6 Prostate 45% 35% 8.4 8.6 Sarcoma * 29% * 8.7 Skin 9% 17% 8.9 8.9 Upper Gastro * 30% * 8.6 Urological 14% 14% 8.9 8.5 Other 20% 31% 8.7 8.6 All Cancers 22% 28% 8.6 8.7

$ These are unadjusted scores

35 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Annex

Methodology

The sample for the survey included all adult (aged 16 and over) NHS patients, with a confirmed primary diagnosis of cancer, discharged from an NHS Trust after an inpatient episode or day case attendance for cancer related treatment in the months of April, May and June 2015.

The patients included in the sample had relevant cancer ICD10 codes (C00-99 excluding C44 and C84, and D05) in the first diagnosis field of their patient records, applied to their patient files by the relevant NHS Trust, and were alive at the point at which fieldwork commenced. Deceased checks were undertaken on up to three occasions during fieldwork, to ensure that questionnaires were not sent to patients who had died since their treatment.

Trust samples were checked rigorously for duplicates and patient lists were also de-duplicated nationally to ensure that patients did not receive multiple copies of questionnaires.

The fieldwork for the survey was undertaken between October 2015 and March 2016.

For the first time, the survey used a mixed mode methodology. Questionnaires were sent by post with two reminders where necesssary, but also included an option to complete online. A Freephone helpline was available for respondents to ask questions about the survey, to enable them to complete their questionnaires over the phone, and to provide access to a translation and interpreting facility for those whose first language was not English.

The Health Research Authority supported the survey by granting Section 251 approval.

Further information

Further information on survey methodology, as well as all of the national and local reports and data, is available at www.ncpes.co.uk

36 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Redevelopment of the 2015 survey

A number of significant changes have been made to the National Cancer Patient Experience Survey in 2015: • the length of the questionnaire has been reduced • response options have been reviewed and changed to make them consistent throughout the survey • some of the questions and / or answer options have been changed so that they are now in line with questions in other patient surveys (e.g. the Care Quality Commission national patient surveys), to improve comparability between them • the topic areas within the questionnaire have been redesigned to capture the whole patient journey.

There are 50 questions in the questionnaire that relate directly to patient experience. Of these, 14 remain unchanged from previous years; and a further 21 have been slightly amended. We draw caution in directly comparing data from the 2015 survey to the findings of the previous CPES surveys, even for identical questions. Changes in the structure of the survey instrument (questionnaire) and also the administration of the survey (calendar period and length of time from sampling to field work start and completion) may influence nationwide averages, although these features will not greatly impact on relative comparisons (e.g. between patient groups or hospitals).

The other 15 questions are either new or substantially changed from previous years.

It is expected that there will be few, if any changes, to the questionnaire going forward so we will be able to compare the results year on year. Where changes are necessary they are expected to be for methodological reasons or to improve question reliability.

Another significant change in 2015 is that an online version of the questionnaire has been developed. The online version was developed to make the questionnaire more accessible for respondents. This may have an impact on the demographic characteristics of the respondents. This may be an improvement if previously underrepresented groups have responded. However, changes to the demographics of respondents may have implications on the overall results - and again, leads us to draw caution in directly comparing results with previous years.

Official Statistics

The 2015 survey data has been published for the first time as Official Statistics. The 2015 survey data has been produced and published in line with the Code of Practice for Official Statistics.

37 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Scoring methodologies

49 of the 50 questions relating directly to patient experience have been summarised as the score of the percentage of patients who reported a positive experience. For example:

• question 6 asks: "Overall, how did you feel about the length of time you had to wait for your test to be done?". Responses have been recorded as positive only for those patients who selected the first option ("It was about right") • question 11 asks: "When you were told you had cancer, were you given written information about the type of cancer you had?". Responses have been recorded as positive only for those patients who selected the first option ("Yes, and it was easy to understand").

Where options do not provide any information on positive/negative patient experience (e.g. "Don't know / can't remember"), they are excluded from the score.

The other question (question 59) asks respondents to rate their overall care on a scale of 0 to 10. Scores have been given as an average on this scale. A copy of the 2015 questionnaire, marked up with all of these scoring conventions, is available at www.ncpes.co.uk

Further details on the scoring methodology can be found in the technical document for the survey, available at www.ncpes.co.uk

Case-mix adjustment

For the first time in 2015, case-mix adjusted findings are being presented alongside unadjusted results for Trusts. Case-mix adjustment allows us to account for the impact that differing patient populations might have on results. By using the case-mix adjusted estimates we can obtain a greater understanding of how a Trust is performing given their patient population.

The factors taken into account in this case-mix adjustment are gender, age, ethnic group, deprivation, and tumour group.

For further details on case-mix adjustment, please refer to the technical document for the survey, available at www.ncpes.co.uk

38 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Response Rates

Sample Excluded Adjusted Not Blank / Completed Response Size Sample Returned Refused Rate National 116,991 8,719 108,272 33,168 3,918 71,186 66% RYR 995 68 927 227 39 661 71%

Respondents by tumour group

The tables below show the numbers of patients from each tumour group and the age and gender distribution of these patients.

Tumour Group Number of respondents* Brain / CNS 0 Breast 164 Gynaecological 27 Colorectal / LGT 92 Lung 30 Skin 23 Haematological 179 Upper Gastro 21 Other 35 Urological 38 Prostate 37 Sarcoma 5 Head and Neck 10

* These figures may not match the numerator for all questions in the ‘Comparisons by tumour group’ section of this report, because not all questions were answered by all respondents.

Respondents by age and gender

The questionnaire asked respondents to give their year of birth. This information has been amalgamated into 8 age bands. The age and gender distribution for the Trust was as follows:

16-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total

Male 0 1 3 15 57 118 75 16 285 Female 3 5 8 47 68 135 98 12 376 Total 3 6 11 62 125 253 173 28 661

39 National Cancer Patient Experience Survey 2015 Western Sussex Hospitals NHS Foundation Trust

Quality Health is a specialist health and social care survey organisation, working for public, private and not-for-profit sectors, in the UK and overseas.

Quality Health works with all acute hospitals in England, all independent providers of hospital care, and all Health Boards in Scotland, Wales and Northern Ireland.

Quality Health is an approved contractor for the Care Quality Commission's patient survey programmes, NHS England's National Staff Survey programme, and the national Patient Reported Outcome Measures (PROMs).

Further information on Quality Health is available at www.quality-health.co.uk

Further information on the National Cancer Patient Experience Survey, as well as all of the national and local reports and data, is available at www.ncpes.co.uk

40 Operational Planning and Performance: Quality

JUNE 2016 QUALITY SCORECARD YTD YTD Jul Aug Sep Oct Nov DEC JAN FEB MAR APR May JUN Target Trend Actual Target EFFECTIVENESS Effectiveness domain score 2.64 2.60 2.56 2.52 2.44 2.48 2.55 2.60 2.64 2.43 2.36 2.71 2.50 Trust-wide mortality E01 Trust crude mortality rate (non-elective) 2.66% 3.15% 2.70% 2.97% 3.56% 3.35% 3.45% 3.07% 3.57% 3.46% 3.33% 2.57% 3.12% 3.13% 3.13%

E02 Crude mortality rate (non-elective): 12 month rolling 3.26% 3.23% 3.22% 3.23% 3.30% 3.27% 3.21% 3.12% 3.13% 3.15% 3.20% 3.16% 3.16% 3.13% 3.13%

E03 Trust Hospital Standardised Mortality Ratio (HSMR) 93.5 91.2 90.3 89.5 90.7 90.0 89.6 87.5 89.4 89.4 92 92

E04 Summary Hospital-level Mortality Indicator (SHMI) (rolling 12M) 1.00 1.01 1.00 1 1 Improve mortality in specific conditions E07 Crude non-elective mortality for Renal failure 21.4% 14.8% 13.8% 9.8% 18.5% 28.2% 7.4% 9.5% 35.9% 27.3% 20.0% 6.7% 16.1% 18.60% 18.60% Reduce mortality following hip fracture E09 SMR for hip fracture (all diagnoses/procedures) 84.2 79.5 78.9 80.2 79.4 77.8 69.2 68.8 70.1 70.1 100 100

E09a Worthing SMR for hip fracture (all diagnoses/procedures) 109.6 100.1 99.0 96.3 92.3 91.1 80.5 77.3 78.1 78.1 100 100

E09b St Richard's SMR for hip fracture (all diagnoses/procedures) 51.0 51.9 52.7 57.0 59.5 58.6 54.0 57.4 58.8 58.8 100 100

E10 30 day mortaliy rate following hip fracture 7.5% 5.8% 6.0% 6.0% 5.9% 5.7% 5.0% 5.0% 5.2% 5% 5.70% 5.70% Reduce the rate of readmission following discharge from the Trust E11 Emergency readmissions within 30 days % 13.1% 12.6% 12.7% 13.5% 14.5% 13.8% 12.6% 14.2% 14.1% 12.9% 13.8% 13.7% 13.6% 13% 13% To improve maternity care by encouraging natural chilbirth E13 C-Section Rate 26.0% 24.9% 30.3% 27.8% 31.3% 24.6% 24.2% 28.7% 28.0% 25.8% 25.3% 30.0% 27.0% 26% 26%

E14 % Mothers requiring forceps for delivery 11.3% 15.7% 10.2% 12.0% 9.5% 10.6% 12.2% 10.1% 14.2% 12.1% 11.5% 11.5% 11.7% <15% <15%

E15 % Deliveries complicated by post-partum haemorrhage 0.0% 0.2% 1.1% 0.0% 0.7% 0.9% 1.2% 0.7% 0.2% 0.7% 0.5% 0.5% 0.6% 1% 1%

E16 Maternal deaths 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

E17 Admission of term babies to neonatal care 2.3% 1.0% 2.6% 3.6% 3.5% 3.2% 3.9% 3.4% 4.9% 1.9% 2.5% 3.4% 2.6% < 10% < 10% Caring for the elderly patient E18 % Emergency admissions staying over 72h screened for dementia 92.1% 91.3% 92.4% 93.0% 93.9% 93.6% 93.0% 93.5% 95.0% 92.0% 88.0% 94.0% 91.3% 90% 90% % Patients identified as at risk of dementia for whom further E19 91.7% 93.1% 91.2% 86.3% 91.5% 95.5% 91.1% 96.2% 94.0% 94.0% 89.0% 88.0% 90.3% 90% 90% investigations are carried out

E20 % Patients with identified dementia referred to specialist services 100.0% 100.0% 100.0% 96.3% 100.0% 100.0% 100.0% 100.0% 97.0% 100.0% 100.0% 100.0% 100.0% 90% 90%

E25 Number of admissions for patients with dementia flag 212 205 174 168 233 241 215 207 193 223 202 217 642 tbc tbc

E39 Ward moves for patients flagged with dementia 137 107 119 127 202 213 163 159 160 181 194 201 576 tbc tbc

E42 Night-time ward moves for patients flagged with dementia 34 39 35 30 45 52 42 35 40 34 44 48 126 tbc tbc Documentation Audit: % patients with dementia with Knowing Me E43 97.4% 99.7% 98.6% 98.2% 99.0% 100.0% 98.6% 100.0% 99.1% 97.7% 99.7% 99.4% 99.0% 75% 75% document

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JUNE 2016 QUALITY SCORECARD YTD YTD Jul Aug Sep Oct Nov DEC JAN FEB MAR APR May JUN Target Trend Actual Target Stroke care E26 % CT scans undertaken within 12 hours 94.0% 88.8% 89.6% 92.8% 94.1% 94.5% 97.8% 92.1% 93.3% 93.5% 96.8% 95.0% 95% 95%

E27 % Stroke thrombolysis within 60 minutes of hospital arrival 85.7% 70.0% 75.0% 28.6% 100.0% 68.4% 66.7% 66.7% 44.4% 80.0% 33.3% 62.5% 95% 95%

E28 % Swallow screen for stroke patients within 4 hours of admission 85.0% 81.5% 77.8% 81.1% 70.9% 75.4% 73.7% 93.1% 72.9% 77.1% 75.0% 76.6% 95% 95%

E29 % of stroke patients admitted to stroke unit within 4 hours of admission 83.0% 74.7% 78.8% 78.3% 78.8% 69.9% 75.0% 73.7% 69.3% 57.8% 74.2% 64.6% 90% 90%

E30 % high risk TIA patients seen within 24 hours 62.5% 77.8% 66.7% 65.0% 41.2% 43.8% 69.2% 100.0% 85.7% 66.7% 25.0% 37.9% 60% 60% Ensure active engagement with research E21 Patients recruited to interventional studies within CRN portfolio 14 14 15 25 11 18 21 20 24 12 22 26 60 tbc tbc

E22 Patients recruited to observational studies within CRN portfolio 38 27 26 55 25 17 40 39 24 32 33 31 96 tbc tbc

E23 Local Clinical Research Network (LCRN) Score 108 97 101 180 80 107 145 139 144 92 143 161 396 353 1410 Data Quality E24 NHS IC Data validity summary (YTD) 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 99.9 96.6 96.6

E37 % inpatients with electronic discharge summaries produced 84.0% 85.5% 84.3% 85.0% 80.8% 81.7% 81.0% 80.0% 76.2% 84.1% 85.4% 88.3% 86.9% tbc tbc

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JUNE 2016 QUALITY SCORECARD YTD YTD Jul Aug Sep Oct Nov DEC JAN FEB MAR APR May JUN Target Trend Actual Target SAFETY Safety domain score (Patient Aggregate Safety Score - PASS) 2.44 2.39 2.17 2.33 2.89 2.44 2.33 2.44 2.61 2.05 2.33 2.33 2.24 Safer staffing

S36 Safer Staffing: Average fill rate - registered nurses/ midwives (day shifts) 96.8% 95.9% 94.1% 97.2% 96.8% 95.9% 94.6% 95.4% 94.1% 95.8% 97.6% 98.1% 97.2% tbc tbc

Safer Staffing: Average fill rate - registered nurses/ midwives (night S37 98.2% 97.3% 97.0% 98.5% 97.7% 97.2% 98.0% 97.6% 95.6% 96.2% 97.3% 98.4% 97.3% tbc tbc shifts) S38 Safer Staffing: Average fill rate - care staff (day shifts) 91.0% 91.5% 88.9% 90.1% 87.8% 88.3% 87.5% 86.6% 85.5% 89.0% 92.5% 93.4% 91.6% tbc tbc

S39 Safer Staffing: Average fill rate - care staff (night shifts) 93.3% 93.6% 90.1% 93.0% 87.8% 90.7% 93.1% 92.4% 90.2% 89.1% 93.2% 93.9% 92.0% tbc tbc

S41 Care Hours Per Patient Day (CHPPD) 6.20 6.40 6.70 6.40 tbc tbc NHS safety thermometer S02 Safety Thermometer: % of patients harm-free 96.3% 95.6% 94.9% 95.8% 95.2% 96.0% 95.6% 95.5% 95.1% 95.1% 95.0% 96.1% 95.4% 95.70% 95.70%

S03 Safety Thermometer: % of patients with no new harms 98.2% 97.6% 98.4% 98.5% 98.2% 98.6% 98.2% 98.2% 98.2% 97.7% 98.8% 98.4% 98.3% 99% 99% % of patients with catheters and UTIs where best practice protocol was S29 0.00% 0.00% 0.00% 0.23% 0.00% 0.00% 0.11% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.1% 0.1% not followed. Monitoring of clinical incidents 2031- 8122 - S04 Total incidents 818 872 852 920 814 903 778 840 756 787 859 827 2473 2747 10988 S05 Total moderate, severe or death incidents 19 13 12 9 10 16 14 15 11 20 9 19 48 38 153

S06 Total serious incidents (SIRIs) 8 12 7 6 4 6 8 8 3 13 6 11 30 15 60

S07 Number of outstanding CAS alerts 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Improve safety of prescribing 1056 - S08 Total incidents involving drug/prescribing errors 107 106 89 104 106 99 93 85 67 94 104 80 278 264-357 1428 S09 Moderate/severe incidents involving drug/prescribing errors 1 0 1 0 0 1 0 0 1 1 0 3 4 1 5 Reduce incidence of healthcare acquired infections S14 Number of hospital attributable MRSA cases 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0

S15 Number of hospital C.diff cases 3 3 5 7 2 3 2 2 2 5 6 2 13 10 39

S28 Number of C. diff cases where a lapse in the quality of care was noted 1 0 3 5 1 3 2 1 1 2 2 2 6 5 18

S16 Number of reportable MSSA bacteraemia cases 6 5 10 6 11 9 7 8 5 7 12 11 30 tbc tbc

S17 Number of reportable E.coli cases 34 23 35 26 22 24 16 26 37 45 26 28 99 tbc tbc

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JUNE 2016 QUALITY SCORECARD YTD YTD Jul Aug Sep Oct Nov DEC JAN FEB MAR APR May JUN Target Trend Actual Target Improve theatre safety for patients S18 Full compliance with WHO Surgical Safety Checklist 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

S19 NEVER events 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0

S30 SSIs: Total hip replacement (YTD is rolling 12 months)

S33 SSIs: Total knee replacement (YTD is rolling 12 months)

S34 SSIs: Large bowel surgery (YTD is rolling 12 months)

S35 SSIs: Breast surgery (YTD is rolling 12 months) Reduce number of falls in hospital S21 Falls resulting in harm 35 39 45 41 34 40 44 40 34 45 39 38 122 114 456

S22 Falls resulting in severe harm or death 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1

S40 Repeat falls 9 14 10 14 11 11 8 11 9 14 11 8 33 tbc tbc

S23 Falls assessment within 24hrs of admission 91.8% 88.3% 95.5% 83.5% 87.4% 88.0% 67.5% 84.0% 81.2% 83.0% 82.0% 91.6% 85.5% 80% 80%

S24 Avoidable falls identified on the Safety Thermometer 0.69% 0.97% 0.94% 0.69% 0.58% 0.17% 1.21% 1.76% 0.79% 0.65% 0.54% 0.23% 0.47% 0.76% 0.76% Pressure ulcers S25 Grade 2 pressure ulcers 13 15 15 19 16 16 16 12 19 15 21 10 46 tbc tbc

S26 Grade 3 & 4 pressure ulcers 1 5 2 3 4 3 1 3 3 5 3 5 13 tbc tbc Other safety metrics S11 VTE Assessment Compliance 93.7% 94.1% 92.2% 93.9% 92.7% 91.0% 89.8% 91.3% 88.7% 91.0% 88.1% 89.2% 89.4% 95% 95%

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JUNE 2016 QUALITY SCORECARD YTD YTD Jul Aug Sep Oct Nov DEC JAN FEB MAR APR May JUN Target Trend Actual Target EXPERIENCE Experience domain score 2.00 2.13 2.23 2.07 2.40 2.13 2.00 2.40 2.53 2.20 2.26 2.00 2.13 Friends and Family Test X38 Trust Friends and Family Recommend %: Inpatient 95.5% 94.6% 94.0% 95.4% 95.5% 96.0% 96.2% 95.1% 95.5% 95.3% 95.2% 95.5% 95.4% tbc tbc

X39 Trust Friends and Family Recommend %: A&E 92.5% 90.6% 90.6% 90.2% 92.1% 92.1% 92.4% 92.4% 90.0% 92.1% 91.4% 90.9% 91.5% tbc tbc Maternity Friends and Family Recommend %: Antenatal care X40 100.0% 92.0% 88.9% 100.0% 100.0% 100.0% 100.0% 89.5% 96.0% 100.0% 93.8% 93.1% 95.5% tbc tbc (36 weeks) X41 Maternity Friends and Family Recommend %: Delivery care 93.0% 91.4% 95.3% 96.4% 100.0% 98.6% 94.1% 84.6% 98.5% 93.2% 100.0% 95.9% 95.9% tbc tbc

X42 Maternity Friends and Family Recommend %: Postnatal ward 93.0% 91.4% 95.3% 96.4% 100.0% 98.6% 94.1% 84.6% 98.5% 93.2% 100.0% 95.9% 95.9% tbc tbc

X43 Maternity Friends and Family Recommend %: Postnatal community care 100.0% 100.0% 80.0% 100.0% 100.0% 100.0% 100.0% 98.5% 100.0% 100.0% 100.0% 100.0% tbc tbc

X44 Trust Friends and Family Recommend %: Outpatient 87.9% 87.9% 91.6% 90.0% 89.9% 92.4% 93.5% 91.4% 95.4% 93.6% 95.0% 94.1% 94.2% tbc tbc Friends and Family Test response rates X24 Trust Friends and Family Response Rate: Inpatient 28.9% 25.2% 24.0% 23.9% 28.9% 25.6% 26.8% 24.8% 26.5% 35.1% 31.5% 38.3% 35.0% 30% 30%

X25 Trust Friends and Family Response Rate: A&E 20.9% 16.6% 18.9% 18.8% 16.2% 13.3% 16.7% 18.1% 14.4% 16.1% 17.3% 15.3% 16.3% 25% 25%

X33 Maternity Friends and Family Response Rate: Delivery care 9.0% 8.2% 9.6% 6.0% 13.1% 16.4% 8.5% 6.0% 15.4% 14.0% 9.3% 17.8% 13.7% tbc tbc Reduction in patients suffering a bad experience dealing with the Trust X08 Percentage of re-booked outpatient appointments 7.8% 7.9% 7.0% 7.3% 7.0% 7.8% 7.6% 8.4% 9.2% 9.0% 8.0% 8.9% 8.6% 7.80% 7.80%

X09 Clinics cancelled with less than 6 weeks notice for annual/study leave 33 35 14 30 15 25 33 12 22 22 22 15 59 70 281 PALS contacts relating to appointment problems (pior % of total appts X11 0.07% 0.09% 0.08% 0.08% 0.10% 0.09% 0.08% 0.09% 0.07% 0.08% 0.07% 0.08% 0.08% 0.08% 0.08% Apr16 onwards rate per 100,000 )

X12 Reduce patients cancelled on the day of surgery for non-clinical reasons 20 17 40 45 22 43 38 29 24 12 28 30 70 84 337

X13 Breaches of mixed sex accommodation arrangements 0 0 1 0 0 0 0 0 0 0 6 0 6 0 0 Nutritional Assessment X14 Compliance with MUST tool after 24 hours 80.5% 75.8% 44.1% 49.9% 46.5% 46.1% 45.3% 45.6% 55.7% 67.5% 70.4% 64.5% 80% 80%

X15 Compliance with MUST tool after 7 days 94.0% 90.3% 87.4% 91.8% 89.7% 89.5% 88.6% 89.1% 93.7% 96.0% 97.9% 95.9% 95% 95%

6b. Quality Scorecard.xlsm.Quality Scorecard Page 5 of 6 Printed 21/07/2016 10:44 Operational Planning and Performance: Quality

JUNE 2016 QUALITY SCORECARD YTD YTD Jul Aug Sep Oct Nov DEC JAN FEB MAR APR May JUN Target Trend Actual Target Cleanliness / PLACE Survey X16 Internal PLACE compliance : St Richard's Hospital 84% 90% 96% 91% 95% 98% 98% 84% 97% 93% 98% 94% 95% 95% 95%

X17 Internal PLACE compliance : Worthing Hospital 97% 95% 94% 94% 98% 92% 95% 97% 99% 96% 95% 94% 95% 95% 95%

Improve our customer service and become a more caring organisation

X18 Number of complaints 58 56 44 72 43 45 51 40 42 63 51 58 172 143 570

X19 Complaints where staff attitude or behaviour is an issue 11 6 4 3 3 2 3 6 5 2 3 5 10 14 54

X20 Complaints where staff communication is an issue 9 7 5 8 2 9 8 4 2 3 5 5 13 12 49

X21 Complaints about nursing 5 2 2 2 5 4 5 2 2 4 4 4 12 10 39

6b. Quality Scorecard.xlsm.Quality Scorecard Page 6 of 6 Printed 21/07/2016 10:44 Operational Planning and Performance: Quality

SAFER STAFFING SCORECARD - Registered Nurses June 2016 YTD Shift Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Trend Actual Day 96.8% 95.9% 94.1% 97.2% 96.8% 95.9% 94.6% 95.4% 94.1% 95.8% 97.6% 98.1% 97.2% WSHFT Night 98.2% 97.3% 97.0% 98.5% 97.7% 97.2% 98.0% 97.6% 95.6% 96.2% 97.3% 98.4% 97.3% Day 97.4% 98.4% 96.7% 97.7% 97.7% 96.5% 97.4% 96.6% 93.5% 96.0% 95.2% 98.0% 96.4% Acute Cardiac Unit Night 97.6% 98.4% 93.3% 97.6% 99.2% 96.0% 96.8% 97.4% 94.4% 95.0% 94.4% 99.2% 96.2% Day 99.3% 93.9% 95.6% 96.4% 96.3% 94.3% 96.4% 94.6% 89.2% 94.1% 93.9% 98.1% 95.4% Ashling Night 98.4% 87.1% 88.3% 93.5% 95.0% 88.7% 93.5% 87.9% 83.9% 86.7% 88.7% 96.7% 90.7% Day 97.2% 93.8% 92.4% 92.1% 87.1% 86.5% 86.9% 84.9% 88.8% 93.6% 94.9% 97.7% 95.4% Barrow Night 100.0% 100.0% 98.3% 96.8% 100.0% 96.8% 100.0% 96.6% 98.4% 98.3% 98.4% 100.0% 98.9% Day 98.1% 98.7% 97.0% 99.4% 97.7% 97.4% 99.4% 97.6% 98.4% 98.3% 100.0% 100.0% 99.5% Becket Night 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.9% 100.0% 100.0% 100.0% 100.0% Day 97.8% 100.0% 97.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.4% 100.0% 99.2% Beeding Night 98.9% 100.0% 98.5% 98.8% 98.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Day 100.0% 98.9% 95.8% 94.0% 96.6% 99.2% 95.9% 100.0% 87.9% 86.7% 96.7% 100.0% 94.1% Bluefin Night 98.9% 100.0% 98.9% 99.1% 98.2% 96.8% 93.2% 99.1% 88.1% 90.4% 97.2% 100.0% 95.5% Day 98.4% 96.0% 95.8% 97.2% 99.2% 94.8% 97.6% 97.4% 96.0% 96.3% 98.0% 97.9% 97.4% Bosham Night 100.0% 95.2% 91.7% 98.4% 100.0% 91.9% 95.2% 98.3% 95.2% 96.7% 96.8% 100.0% 97.8% Day 91.5% 92.9% 88.5% 93.7% 94.3% 92.6% 88.1% 90.5% 90.0% 93.5% 97.0% 98.1% 96.2% Botolphs Night 97.8% 91.4% 94.4% 98.9% 100.0% 95.7% 98.9% 96.6% 95.7% 98.9% 98.9% 98.9% 98.9% Day 94.8% 96.4% 98.3% 99.6% 94.6% 97.6% 98.0% 96.1% 97.2% 98.3% 97.6% 97.9% 97.9% Boxgrove Night 88.7% 91.9% 95.0% 98.4% 90.0% 96.8% 98.4% 91.4% 95.2% 98.3% 95.2% 96.7% 96.7% Day 99.1% 90.4% 92.0% 98.3% 95.0% 93.5% 79.8% 89.4% 87.5% 89.2% 95.2% 97.3% 93.9% Broadwater Night 100.0% 95.2% 100.0% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% 98.3% 98.4% 100.0% 98.9%

6c. Safer Staffing Scorecard.xlsx SaferStaffingWardNurseScorecard 1 of 10 21/07/2016 10:44 Operational Planning and Performance: Quality

SAFER STAFFING SCORECARD - Registered Nurses June 2016 YTD Shift Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Trend Actual Day 96.8% 95.9% 94.1% 97.2% 96.8% 95.9% 94.6% 95.4% 94.1% 95.8% 97.6% 98.1% 97.2% WSHFT Night 98.2% 97.3% 97.0% 98.5% 97.7% 97.2% 98.0% 97.6% 95.6% 96.2% 97.3% 98.4% 97.3% Day 96.7% 95.2% 85.1% 98.1% 97.0% 95.7% 83.1% 88.2% 85.6% 91.0% 97.6% 99.0% 95.9% BuckinghamAcute Cardiac Unit Night 100.0% 100.0% 98.3% 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Day 97.0% 91.2% 94.6% 96.6% 96.4% 93.5% 91.7% 95.8% 94.0% 94.6% 99.6% 98.2% 97.5% Burlington Night 100.0% 96.0% 98.6% 100.0% 98.6% 97.4% 100.0% 100.0% 98.7% 98.6% 100.0% 98.6% 99.1% Day 100.0% 100.0% 100.0% 100.0% 95.0% 94.6% 92.7% 92.3% 94.0% 97.2% 99.1% 96.9% 97.7% Castle Night 100.0% 100.0% 100.0% 100.0% 99.2% 97.6% 98.4% 99.1% 98.4% 97.5% 97.6% 98.3% 97.8% Day n/a n/a n/a n/a 95.8% 96.2% 96.7% 94.2% 93.8% 94.9% 97.6% 95.3% 96.0% Chichester Emergency Floor Night n/a n/a n/a n/a 94.6% 95.6% 96.5% 94.8% 93.9% 95.5% 97.4% 95.0% 96.0% Day 100.0% 98.6% 97.6% 97.7% 98.5% 98.1% 99.5% 99.0% 98.6% 98.1% 97.2% 99.0% 98.1% Chilgrove Night 100.0% 96.8% 95.0% 95.2% 96.7% 95.2% 98.4% 96.6% 98.4% 98.3% 93.5% 98.3% 96.7% Day 97.1% 95.2% 93.1% 97.1% 96.5% 97.6% 96.1% 96.9% 99.0% 100.0% 99.5% 99.5% 99.7% Chiltington Night 100.0% 98.4% 100.0% 100.0% 100.0% 98.4% 98.4% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0% Day 98.0% 96.4% 90.4% 96.8% 97.1% 96.8% 96.8% 95.7% 98.0% 99.6% 98.0% 98.8% 98.8% Clapham Night 100.0% 98.4% 98.3% 98.4% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 98.4% 93.3% 97.3% Day 90.7% 92.3% 89.2% 96.0% 98.8% 98.0% 95.6% 99.1% 96.0% 97.9% 98.4% 98.8% 98.4% Coombes Night 100.0% 98.4% 100.0% 100.0% 98.3% 100.0% 98.4% 100.0% 100.0% 98.3% 100.0% 100.0% 99.5% Day 96.4% 94.8% 92.5% 95.6% 97.5% 97.2% 96.0% 97.4% 92.3% 93.8% 98.4% 98.8% 97.0% Courtlands Night 96.0% 96.0% 95.8% 99.2% 98.3% 96.8% 99.2% 99.1% 96.8% 98.3% 98.4% 99.2% 98.6% Day 96.3% 95.9% 94.8% 97.7% 96.2% 93.5% 89.4% 95.6% 94.9% 97.1% 99.1% 98.1% 98.1% Ditchling Night 100.0% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Day 96.3% 93.5% 92.4% 97.2% 96.2% 93.1% 88.5% 90.6% 94.0% 98.6% 97.7% 98.1% 98.1% Durrington Night 100.0% 98.4% 100.0% 98.4% 98.3% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Day 98.2% 95.9% 91.9% 97.7% 94.8% 91.7% 83.9% 91.6% 91.7% 97.1% 98.6% 97.6% 97.8% Eartham Night 100.0% 100.0% 100.0% 100.0% 100.0% 96.8% 100.0% 98.3% 96.8% 100.0% 100.0% 100.0% 100.0% Day 96.4% 94.0% 80.0% 95.6% 97.1% 94.0% 91.5% 92.2% 91.1% 96.3% 98.4% 97.1% 97.3% Eastbrook Night 100.0% 96.8% 96.7% 98.4% 100.0% 100.0% 98.4% 98.3% 98.4% 100.0% 100.0% 100.0% 100.0%

6c. Safer Staffing Scorecard.xlsx SaferStaffingWardNurseScorecard 2 of 10 21/07/2016 10:44 Operational Planning and Performance: Quality

SAFER STAFFING SCORECARD - Registered Nurses June 2016 YTD Shift Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Trend Actual Day 96.8% 95.9% 94.1% 97.2% 96.8% 95.9% 94.6% 95.4% 94.1% 95.8% 97.6% 98.1% 97.2% WSHFT Night 98.2% 97.3% 97.0% 98.5% 97.7% 97.2% 98.0% 97.6% 95.6% 96.2% 97.3% 98.4% 97.3% Day 94.2% 92.3% 89.2% 95.8% 96.9% 94.0% 92.6% 96.0% 93.8% 0.0% 0.0% 0.0% 0.0% EmergencyAcute Cardiac Floor Unit Night 98.2% 95.0% 98.2% 98.2% 97.3% 96.8% 99.4% 98.4% 97.4% 0.0% 0.0% 0.0% 0.0% Day 100.0% 100.0% 99.2% 100.0% 100.0% 99.2% 96.0% 93.1% 97.6% 95.0% 100.0% 100.0% 98.4% Enhanced Surgical Care Unit Night 100.0% 100.0% 98.3% 100.0% 98.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Day 97.2% 93.5% 95.2% 99.1% 99.0% 95.4% 94.5% 98.5% 95.9% 100.0% 97.2% 100.0% 99.1% Erringham Night 100.0% 100.0% 98.3% 100.0% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0% Day 97.2% 98.8% 97.1% 96.8% 97.1% 97.6% 94.4% 94.4% 90.3% 95.0% 97.2% 96.7% 96.3% Fishbourne Night 96.8% 98.4% 93.3% 95.2% 96.7% 96.8% 91.9% 94.8% 80.6% 88.3% 93.5% 96.7% 92.9% Day 95.8% 98.4% 94.3% 96.1% 96.3% 97.4% 95.2% 96.2% 93.2% 90.3% 97.1% 95.7% 94.4% Ford Night 94.6% 97.8% 90.0% 96.8% 95.6% 96.8% 95.7% 94.3% 90.3% 84.4% 94.6% 96.7% 91.9% Day 100.0% 100.0% 100.0% 93.5% 99.2% 99.2% 99.2% 96.6% 96.0% 95.6% 99.2% 98.0% 97.6% Howard Children's Unit Night 100.0% 96.8% 100.0% 96.0% 92.4% 97.6% 96.6% 97.3% 96.7% 92.0% 98.2% 100.0% 96.5% Day 96.8% 96.4% 95.9% 97.5% 98.9% 98.9% 97.8% 97.7% 92.1% 96.3% 95.7% 97.4% 96.5% Lavant Night 95.2% 93.5% 90.0% 93.5% 96.7% 98.4% 96.8% 96.6% 82.3% 91.7% 91.9% 95.0% 92.9% Day 99.6% 98.0% 100.0% 98.4% 98.3% 98.4% 99.6% 100.0% 97.6% 96.3% 96.8% 97.9% 97.0% Middleton Night 98.4% 96.8% 98.3% 96.8% 96.7% 95.2% 100.0% 100.0% 91.9% 91.7% 91.9% 98.3% 94.0% Day 98.9% 100.0% 100.0% 100.0% 100.0% 98.9% 100.0% 100.0% 96.7% 100.0% 95.7% 98.7% 98.1% Neonatal Unit Night 98.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 94.4% 95.6% 93.5% 98.6% 95.7% Day 98.4% 98.4% 98.9% 99.5% 98.3% 99.5% 98.4% 98.3% 95.2% 94.4% 100.0% 98.9% 97.8% Petworth Night 100.0% 98.4% 98.3% 100.0% 96.7% 100.0% 100.0% 98.3% 91.9% 96.7% 100.0% 100.0% 98.9% Day 96.7% 96.6% 95.7% 96.7% 96.1% 96.3% 96.2% 95.5% 95.4% 97.4% 97.1% 97.4% 97.3% Selsey Night 95.7% 96.8% 96.7% 97.8% 95.6% 96.8% 95.7% 95.4% 95.7% 96.7% 97.8% 98.9% 97.8% Day 97.6% 98.8% 96.7% 96.4% 96.7% 95.2% 98.0% 97.4% 98.4% 98.3% 98.0% 97.9% 98.1% Wittering Night 95.2% 98.4% 93.3% 96.8% 93.3% 90.3% 93.5% 94.8% 96.8% 98.3% 95.2% 96.7% 96.7%

6c. Safer Staffing Scorecard.xlsx SaferStaffingWardNurseScorecard 3 of 10 21/07/2016 10:44 Operational Planning and Performance: Quality

SAFER STAFFING SCORECARD - Care Staff June 2016 YTD Shift Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Trend Actual Day 91.0% 91.5% 88.9% 90.1% 87.8% 88.3% 87.5% 86.6% 85.5% 89.0% 92.5% 93.4% 91.6% WSHFT Night 93.3% 93.6% 90.1% 93.0% 91.3% 90.7% 93.1% 92.4% 90.2% 89.1% 93.2% 93.9% 92.0% Day 92.3% 85.8% 93.3% 87.7% 90.7% 90.3% 89.7% 82.8% 91.0% 91.3% 98.7% 92.0% 94.1% Acute Cardiac Unit Night 80.6% 64.5% 70.0% 71.0% 83.3% 87.1% 74.2% 58.6% 77.4% 73.3% 93.5% 70.0% 79.1% Day 100.0% 95.4% 96.7% 94.0% 95.7% 91.7% 93.5% 95.1% 94.9% 93.8% 89.9% 92.9% 92.2% Ashling Night 100.0% 88.7% 88.3% 88.7% 90.0% 82.3% 90.3% 91.4% 90.3% 85.0% 79.0% 90.0% 84.6% Day 97.4% 93.3% 85.6% 80.1% 62.8% 55.6% 56.7% 54.6% 65.6% 74.0% 88.0% 89.0% 83.7% Barrow Night 98.4% 100.0% 93.3% 95.2% 95.0% 80.6% 93.5% 96.6% 91.9% 98.3% 98.4% 98.3% 98.4% Day 86.0% 90.3% 78.5% 81.9% 76.0% 75.3% 71.0% 76.5% 80.3% 86.0% 83.1% 84.9% 84.6% Becket Night 91.9% 98.4% 90.0% 90.3% 96.7% 90.3% 95.2% 96.6% 95.2% 91.7% 100.0% 95.0% 95.6% Day 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.7% 100.0% 100.0% 96.4% 100.0% 100.0% 98.6% Beeding Night 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.0% 100.0% 100.0% 98.8% Day 100.0% 93.5% 96.7% 100.0% 76.7% 83.9% 90.3% 86.2% 90.3% 83.3% 96.7% 90.0% 90.0% Bluefin Night 96.6% 86.7% 86.7% 86.7% 93.1% 87.1% 87.1% 69.0% 90.3% 93.3% 100.0% 93.3% 95.6% Day 85.2% 67.1% 87.3% 91.6% 79.3% 94.2% 95.5% 94.5% 91.0% 88.7% 96.1% 94.7% 93.2% Bosham Night 87.1% 64.5% 86.7% 96.8% 76.7% 95.2% 96.8% 94.8% 88.7% 80.0% 93.5% 95.0% 89.6% Day 86.3% 91.1% 86.6% 89.3% 83.1% 88.6% 79.6% 83.8% 91.1% 91.2% 90.7% 93.9% 91.9% Botolphs Night 93.5% 98.4% 96.7% 96.8% 91.7% 93.5% 98.4% 93.1% 96.8% 93.3% 93.5% 98.3% 95.1% Day 92.2% 91.2% 85.2% 90.8% 93.8% 91.7% 90.8% 93.6% 84.8% 94.8% 91.2% 98.1% 94.7% Boxgrove Night 85.5% 87.1% 63.3% 80.6% 85.0% 82.3% 82.3% 89.7% 79.0% 81.7% 82.3% 96.7% 86.8% Day 89.5% 87.4% 85.5% 86.1% 91.1% 95.9% 76.6% 66.5% 58.5% 70.8% 88.4% 94.6% 84.6% Broadwater Night 96.8% 95.2% 93.3% 88.7% 96.7% 91.9% 90.3% 87.9% 96.8% 90.0% 95.2% 100.0% 95.1%

6c. Safer Staffing Scorecard.xlsx SaferStaffingWardCareScorecard 4 of 10 21/07/2016 10:44 Operational Planning and Performance: Quality

SAFER STAFFING SCORECARD - Care Staff June 2016 YTD Shift Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Trend Actual Day 91.0% 91.5% 88.9% 90.1% 87.8% 88.3% 87.5% 86.6% 85.5% 89.0% 92.5% 93.4% 91.6% WSHFT Night 93.3% 93.6% 90.1% 93.0% 91.3% 90.7% 93.1% 92.4% 90.2% 89.1% 93.2% 93.9% 92.0% Day 96.1% 85.8% 84.0% 87.1% 88.0% 91.6% 65.2% 57.9% 54.8% 74.7% 94.2% 94.0% 87.7% BuckinghamAcute Cardiac Unit Night 100.0% 96.8% 91.7% 96.8% 91.7% 100.0% 93.5% 94.8% 87.1% 96.7% 98.4% 100.0% 98.4% Day 88.7% 92.7% 85.6% 96.0% 89.0% 88.7% 92.7% 75.9% 76.2% 95.2% 89.3% 91.8% 92.1% Burlington Night 95.2% 100.0% 95.0% 98.4% 96.7% 96.8% 100.0% 98.3% 95.2% 95.0% 100.0% 98.3% 97.8% Day 100.0% 99.2% 100.0% 100.0% 80.0% 78.2% 62.1% 69.0% 70.2% 91.7% 89.5% 84.2% 88.5% Castle Night 100.0% 100.0% 100.0% 100.0% 93.3% 93.5% 74.2% 89.7% 87.1% 93.3% 83.9% 83.3% 86.8% Day n/a n/a n/a n/a 92.3% 93.3% 93.3% 91.7% 89.9% 90.6% 93.0% 93.7% 92.4% Chichester Emergency Floor Night n/a n/a n/a n/a 75.9% 87.8% 87.6% 83.9% 87.8% 78.7% 84.9% 87.3% 83.7% Day 89.5% 85.5% 87.5% 83.9% 85.0% 92.7% 90.3% 83.6% 91.9% 82.5% 87.9% 92.5% 87.6% Chilgrove Night 90.3% 91.9% 88.3% 87.1% 85.0% 93.5% 95.2% 86.2% 96.8% 81.7% 87.1% 96.7% 88.5% Day 87.6% 91.3% 89.9% 85.6% 91.5% 82.5% 88.3% 89.0% 97.4% 94.2% 99.0% 97.9% 97.0% Chiltington Night 96.8% 98.4% 95.0% 100.0% 98.3% 91.9% 93.5% 93.1% 100.0% 100.0% 100.0% 96.7% 98.9% Day 89.7% 93.5% 90.7% 89.7% 90.0% 77.4% 87.1% 84.8% 87.1% 90.7% 96.1% 94.0% 93.6% Clapham Night 98.4% 96.8% 95.0% 98.4% 98.3% 90.3% 91.9% 96.6% 98.4% 98.3% 96.8% 95.0% 96.7% Day 80.0% 80.6% 77.3% 70.3% 77.3% 78.1% 78.1% 91.7% 89.0% 90.7% 94.2% 93.3% 92.7% Coombes Night 91.9% 96.8% 91.7% 98.4% 98.3% 90.3% 95.2% 93.1% 98.4% 95.0% 96.8% 90.0% 94.0% Day 98.4% 89.5% 85.0% 92.7% 78.3% 72.6% 69.4% 70.7% 73.4% 90.8% 84.7% 87.5% 87.6% Courtlands Night 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Day 85.5% 95.2% 92.2% 84.9% 75.0% 78.0% 78.0% 78.7% 69.4% 87.8% 94.6% 86.7% 89.7% Ditchling Night 93.5% 98.4% 95.0% 93.5% 83.3% 87.1% 91.9% 93.1% 90.3% 98.3% 100.0% 93.3% 97.3% Day 75.8% 86.6% 75.0% 79.0% 64.4% 63.4% 70.4% 75.3% 79.0% 73.3% 87.6% 88.9% 83.3% Durrington Night 93.5% 98.4% 88.3% 95.2% 95.0% 85.5% 90.3% 87.9% 88.7% 91.7% 96.8% 93.3% 94.0% Day 87.1% 86.9% 78.2% 70.5% 90.1% 88.4% 83.4% 75.2% 68.0% 80.9% 82.2% 96.5% 86.5% Eartham Night 90.3% 100.0% 95.0% 91.9% 98.3% 96.8% 96.8% 89.7% 90.3% 93.3% 96.8% 96.7% 95.6% Day 88.4% 97.4% 86.0% 96.8% 85.3% 93.5% 84.5% 74.5% 71.0% 78.7% 87.7% 98.7% 88.4% Eastbrook Night 91.9% 98.4% 88.3% 98.4% 93.3% 91.9% 93.5% 93.1% 79.0% 78.3% 96.8% 91.7% 89.0%

6c. Safer Staffing Scorecard.xlsx SaferStaffingWardCareScorecard 5 of 10 21/07/2016 10:44 Operational Planning and Performance: Quality

SAFER STAFFING SCORECARD - Care Staff June 2016 YTD Shift Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Trend Actual Day 91.0% 91.5% 88.9% 90.1% 87.8% 88.3% 87.5% 86.6% 85.5% 89.0% 92.5% 93.4% 91.6% WSHFT Night 93.3% 93.6% 90.1% 93.0% 91.3% 90.7% 93.1% 92.4% 90.2% 89.1% 93.2% 93.9% 92.0% Day 93.4% 94.1% 87.0% 91.8% 94.7% 93.8% 93.8% 95.5% 95.0% 0.0% 0.0% 0.0% 0.0% EmergencyAcute Cardiac Floor Unit Night 95.5% 97.4% 94.7% 94.8% 98.0% 91.6% 94.2% 93.8% 92.3% 0.0% 0.0% 0.0% 0.0% Day 100.0% 100.0% 98.3% 100.0% 95.0% 91.9% 96.8% 100.0% 95.2% 98.3% 96.8% 100.0% 98.4% Enhanced Surgical Care Unit Night 100.0% 100.0% 87.5% 100.0% 100.0% 62.5% 100.0% 87.5% 75.0% 88.9% 100.0% 100.0% 96.2% Day 89.8% 94.1% 91.1% 88.7% 94.4% 90.9% 94.6% 90.8% 88.2% 93.3% 95.7% 90.0% 93.0% Erringham Night 98.4% 96.8% 98.3% 98.4% 100.0% 100.0% 100.0% 100.0% 98.4% 100.0% 100.0% 100.0% 100.0% Day 82.3% 90.3% 91.7% 94.6% 91.1% 93.0% 95.7% 91.4% 88.2% 92.2% 90.3% 95.0% 92.5% Fishbourne Night 75.8% 88.7% 85.0% 91.9% 86.7% 91.9% 93.5% 89.7% 82.3% 86.7% 80.6% 93.3% 86.8% Day 85.8% 95.5% 90.0% 87.7% 86.7% 94.8% 94.2% 97.2% 87.7% 92.0% 93.5% 96.0% 93.8% Ford Night 88.7% 93.5% 88.3% 83.9% 80.0% 95.2% 95.2% 100.0% 88.7% 88.3% 91.9% 93.3% 91.2% Day 100.0% 100.0% 100.0% 96.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.8% 100.0% 98.9% Howard Children's Unit Night 87.1% 80.0% 93.3% 80.6% 75.0% 58.1% 90.3% 92.9% 77.4% 79.3% 77.4% 95.2% 82.7% Day 94.4% 90.7% 95.0% 94.8% 91.3% 92.3% 91.9% 94.8% 87.5% 86.3% 92.3% 92.9% 90.5% Lavant Night 85.5% 82.3% 86.7% 90.3% 80.0% 77.4% 82.3% 89.7% 71.0% 63.3% 77.4% 86.7% 75.8% Day 96.8% 89.7% 90.0% 93.5% 95.3% 94.2% 95.5% 99.3% 89.0% 93.3% 98.7% 98.7% 96.9% Middleton Night 96.8% 88.7% 88.3% 90.3% 93.3% 91.9% 93.5% 98.3% 87.1% 88.3% 98.4% 98.3% 95.1% Day 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.4% 100.0% 90.9% 96.7% 90.3% 96.4% 94.4% Neonatal Unit Night 96.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 93.5% 93.3% 100.0% 90.9% 94.8% Day 97.4% 92.9% 90.7% 93.5% 86.0% 91.6% 94.8% 95.2% 95.5% 92.0% 95.5% 94.0% 93.8% Petworth Night 98.4% 90.3% 83.3% 90.3% 80.0% 87.1% 93.5% 91.4% 93.5% 85.0% 95.2% 95.0% 91.8% Day 90.0% 94.8% 90.8% 97.4% 89.7% 87.9% 95.8% 92.7% 90.0% 91.4% 96.3% 97.3% 95.0% Selsey Night 90.3% 90.3% 83.3% 96.8% 85.0% 85.5% 93.5% 93.1% 83.9% 88.3% 93.5% 100.0% 94.0% Day 92.3% 92.3% 90.7% 95.5% 97.3% 98.1% 93.5% 92.4% 90.3% 82.7% 93.5% 86.7% 87.7% Wittering Night 88.7% 93.5% 85.0% 95.2% 96.7% 100.0% 91.9% 94.8% 91.9% 81.7% 91.9% 86.7% 86.8%

6c. Safer Staffing Scorecard.xlsx SaferStaffingWardCareScorecard 6 of 10 21/07/2016 10:44 Operational Planning and Performance: Quality

SAFER STAFFING SCORECARD - CHPPD June 2016 Care Hours Per Patient YTD Apr May Jun Trend Day (CHPPD) Average Nurse 3.8 3.9 4.1 3.9 WSHFT Care 2.4 2.5 2.7 2.5 Overall 6.2 6.4 6.7 6.4 Nurse 4.3 4.4 4.9 4.5 Acute Cardiac Unit Care 1.7 1.9 1.9 1.8 Overall 6.0 6.3 6.7 6.4 Nurse 3.3 3.3 3.5 3.4 Ashling Care 2.7 2.5 2.7 2.6 Overall 6.0 5.8 6.2 6.0 Nurse 1.7 1.7 1.7 1.7 Barrow Care 1.3 1.4 1.4 1.4 Overall 2.9 3.1 3.1 3.0 Nurse 5.0 5.0 5.0 5.0 Becket Care 2.6 2.6 2.6 2.6 Overall 7.6 7.6 7.5 7.6 Nurse 5.4 11.8 13.0 8.4 Beeding Care 1.7 4.2 4.5 2.8 Overall 7.1 16.1 17.5 11.3 Nurse 7.0 6.5 5.2 6.2 Bluefin Care 1.8 1.7 1.5 1.7 Overall 8.7 8.2 6.8 7.9 Nurse 3.4 3.4 3.4 3.4 Bosham Care 2.1 2.3 2.3 2.2 Overall 5.5 5.7 5.7 5.6 Nurse 3.7 3.8 4.0 3.8 Botolphs Care 3.3 3.2 3.5 3.3 Overall 7.0 7.0 7.4 7.2 Nurse 3.1 3.0 3.1 3.0 Boxgrove Care 2.6 2.5 2.8 2.6 Overall 5.6 5.5 5.8 5.7

6c. Safer Staffing Scorecard.xlsx SaferStaffingWardCHPPD 7 of 10 21/07/2016 10:44 Operational Planning and Performance: Quality

SAFER STAFFING SCORECARD - CHPPD June 2016 Care Hours Per Patient YTD Apr May Jun Trend Day (CHPPD) Average Nurse 3.8 3.9 4.1 3.9 WSHFT Care 2.4 2.5 2.7 2.5 Overall 6.2 6.4 6.7 6.4 Nurse 2.8 3.0 29.3 4.2 BroadwaterAcute Cardiac Unit Care 1.9 2.2 22.8 3.1 Overall 4.7 5.2 52.1 7.2 Nurse 2.2 3.3 3.3 2.8 Buckingham Care 1.5 2.6 2.6 2.1 Overall 3.7 5.9 5.9 5.0 Nurse 5.4 4.6 4.7 4.9 Burlington Care 3.7 3.0 3.1 3.2 Overall 9.1 7.6 7.8 8.1 Nurse 4.7 4.7 4.7 4.7 Castle Care 1.5 1.4 1.4 1.4 Overall 6.2 6.2 6.1 6.2 Nurse 4.2 4.5 4.6 4.4 Chichester Emergency Floor Care 2.2 2.4 2.5 2.3 Overall 6.4 6.9 7.1 6.8 Nurse 3.6 3.5 3.7 3.6 Chilgrove Care 2.0 2.2 2.4 2.2 Overall 5.6 5.7 6.1 5.8 Nurse 3.8 3.8 3.7 3.8 Chiltington Care 3.5 3.6 3.4 3.5 Overall 7.4 7.5 7.1 7.3 Nurse 3.2 3.1 3.2 3.2 Clapham Care 2.1 2.1 2.2 2.1 Overall 5.3 5.2 5.4 5.3 Nurse 3.2 3.1 3.1 3.1 Coombes Care 2.1 2.1 2.0 2.1 Overall 5.3 5.2 5.2 5.2

6c. Safer Staffing Scorecard.xlsx SaferStaffingWardCHPPD 8 of 10 21/07/2016 10:44 Operational Planning and Performance: Quality

SAFER STAFFING SCORECARD - CHPPD June 2016 Care Hours Per Patient YTD Apr May Jun Trend Day (CHPPD) Average Nurse 3.8 3.9 4.1 3.9 WSHFT Care 2.4 2.5 2.7 2.5 Overall 6.2 6.4 6.7 6.4 Nurse 6.1 6.6 6.5 6.4 CourtlandsAcute Cardiac Unit Care 1.9 1.9 1.9 1.9 Overall 8.0 8.5 8.4 8.3 Nurse 3.1 3.1 3.1 3.1 Ditchling Care 2.5 2.7 2.5 2.6 Overall 5.6 5.8 5.7 5.7 Nurse 3.3 3.3 3.2 3.3 Durrington Care 2.3 2.7 2.6 2.5 Overall 5.6 6.0 5.9 5.8 Nurse 3.5 3.6 3.5 3.5 Eartham Care 2.3 2.3 2.6 2.4 Overall 5.8 5.9 6.2 6.0 Nurse 3.7 3.7 3.7 3.7 Eastbrook Care 2.1 2.4 2.6 2.3 Overall 5.8 6.0 6.3 6.1 Nurse 4.9 5.0 5.0 5.0 Emergency Floor Care 3.8 3.8 3.7 3.8 Overall 8.8 8.8 8.7 8.8 Nurse 10.8 10.7 11.8 11.1 Enhanced Surgical Care Unit Care 4.2 4.0 4.5 4.2 Overall 14.9 14.7 16.3 15.3 Nurse 3.6 3.4 3.5 3.5 Erringham Care 3.1 3.0 2.9 3.0 Overall 6.7 6.5 6.4 6.5 Nurse 3.0 3.3 3.3 3.2 Fishbourne Care 2.4 2.4 2.6 2.4 Overall 5.4 5.7 5.8 5.7

6c. Safer Staffing Scorecard.xlsx SaferStaffingWardCHPPD 9 of 10 21/07/2016 10:44 Operational Planning and Performance: Quality

SAFER STAFFING SCORECARD - CHPPD June 2016 Care Hours Per Patient YTD Apr May Jun Trend Day (CHPPD) Average Nurse 3.8 3.9 4.1 3.9 WSHFT Care 2.4 2.5 2.7 2.5 Overall 6.2 6.4 6.7 6.4 Nurse 3.8 4.4 4.8 4.3 FordAcute Cardiac Unit Care 2.1 2.3 2.6 2.3 Overall 5.9 6.6 7.4 6.6 Nurse 6.5 8.2 6.7 7.1 Howard Children's Unit Care 1.6 1.9 1.8 1.8 Overall 8.2 10.1 8.5 8.9 Nurse 3.5 3.7 3.5 3.6 Lavant Care 2.7 3.1 3.0 3.0 Overall 6.2 6.8 6.6 6.5 Nurse 3.0 3.1 3.2 3.1 Middleton Care 2.0 2.2 2.3 2.2 Overall 5.0 5.4 5.5 5.3 Nurse 5.0 6.4 7.9 6.1 Neonatal Unit Care 1.6 1.9 2.5 1.9 Overall 6.6 8.3 10.4 8.0 Nurse 3.3 3.3 3.3 3.3 Petworth Care 2.7 2.8 2.8 2.8 Overall 5.9 6.1 6.1 6.1 Nurse 5.0 4.0 4.3 4.4 Selsey Care 3.5 3.0 3.3 3.2 Overall 8.5 6.9 7.6 7.6 Nurse 3.5 3.3 3.4 3.4 Wittering Care 2.0 2.2 2.1 2.1 Overall 5.5 5.5 5.5 5.5

6c. Safer Staffing Scorecard.xlsx SaferStaffingWardCHPPD 10 of 10 21/07/2016 10:44

To: Trust Board Date of Meeting: 28 July 2016 Agenda Item: 7

Title 2015/16 Safeguarding Adults Annual Report Responsible Executive Director Amanda Parker, Director of Nursing and Patient Safety Prepared by Annie Blackwell, Trust Lead for Safeguarding Adults Status Disclosable Summary of Proposal The purpose of this report is to provide an update on action taken in regard to adult safeguarding during 2015/16. Implications for Quality of Care The report enables us to identify areas of focus for 2016/17. Link to Strategic Objectives/Board Assurance Framework Supports the Patient First strategic priorities of; Quality Improvement, Our people and Systems and Partnerships. Financial Implications N/A Human Resource Implications 1. Professional performance management issues for individuals. 2. Learning and development requirements. 3. Organisational, behavioural and cultural issues. Recommendation The Board is asked to NOTE the report. Communication The report has been overseen by the Safeguarding Strategy Group and will be made available on StaffNet. Appendices N/A

This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288.

Annual Report Safeguarding Adults

June 2016

Prepared By: Annie Blackwell Trust Lead for Safeguarding Adults

Safeguarding Adults Annual Report 2015/16 Page 1

Table of Contents

1 INTRODUCTION AND EXECUTIVE SUMMARY …………………… 3

2 GOVERNANCE AND ACCOUNTABILITY ARRANGEMENTS …… 3

2.1 The Safeguarding Team at WSHFT …………………………………………… 3

2.2 Role & Responsibility of West Sussex Safeguarding Adults Board.. 4

2.3 NHS Professionals Forum ……………………………………………………………… 4

2.4 Adults Safeguarding Operational Group ………………………………………… 4

2.5 Adults & Children’s Safeguarding Strategic Committee ……………… 5

3 REVIEW OF THE YEAR ………………………………………………….. 5

3.1 National & Local Assessments and Policy Changes ………………………… 5

3.2 CQC Regulation 13-Safeguarding Service Users from Abuse…………. 6

3.3 West Sussex Safeguarding Adults Board ………………………………………. 7 3.4 Safeguarding Adults Policy and Procedures …………………………………. 7

3.5 Safeguarding Adults Review Protocol ……………..……………………………. 7

3.6 Safeguarding Activity-National and Local context …………………………. 7

3.7 Trust Safeguarding Activity ………………………………….. ………………………. 8

3.8 Domestic Homicide reviews and Safeguarding Adults Reviews …….. 12

3.9 Domestic Violence Referrals to WORTH …………………………………………. 12

3.10 Staff Training …………………………………………………………………………………… 12

4.0 REVIEW OF PRIORITIES FOR 2015-16 …………………...... 13

5.0 CONCLUSIONS & PRIORITIES FOR COMING YEAR ……………. 14

Safeguarding Adults Annual Report 2015/16 Page 2

1. Introduction and Executive summary

This report defines the structures and processes of the safeguarding adults services within the Trust and how these relate to wider safeguarding arrangements. Safeguarding adults is fundamental to the care delivered within the Trust, and continues to be “everyone’s business”. The annual safeguarding adults report provides an update on safeguarding adults activity relevant to Western Sussex Hospitals Foundation Trust from 1st April 2015- 31st March 2016 and compares this with the available activity data from the local authority. Key national and local developments are included in the report and in addition the major changes which have been made to the Care Act since March 2016 will also be outlined in the report. These changes include the updated guidance to the Care Act legislation in relation to safeguarding (published in April 2016) and the publication of the Safeguarding Adults Intercollegiate document, which details expectations for training provision. Under the Care Act, safeguarding duties apply to an adult aged 18 or over who:  has needs for care and support (whether or not the local authority is meeting any of those needs) and;  is experiencing, or at risk of, abuse or neglect; and  as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

The Care Act has fundamentally changed the safeguarding enquiry process, with the focus being on what the individual wants from it. In addition, the Act places legal duties on organisations to share information related to section 42 enquiries under the Act. The Care Act required that each partner organisation identify a Designated Adults Safeguarding Manager (DASM) who will be responsible for the management and overview of safeguarding enquiries involving members of staff. The DASM for the Trust was Deputy Director of Nursing Maggie Davies; however the revised care act guidance removed the requirement to have the DASM role. Safeguarding activity and uptake of training is detailed within the report and feedback on the quality of training is excellent.

2. Governance and Accountability Arrangements

2.1 The Safeguarding Adults Team at WSHT The safeguarding adults team consists of an executive lead and a small team. Amanda Parker Executive Lead Annie Blackwell Trust Lead for Safeguarding Adults Pam Mariner Safeguarding Nurse Specialist Nikki Mardell Mental Capacity Act Lead Marianna Wilmott Team Administrator

The expansion of the safeguarding team has enhanced the quality of service able to be delivered as there is now a greater capacity to visit the wards and deliver ad hoc training on a regular basis.

Safeguarding Adults Annual Report 2015/16 Page 3

2.2 Role and Responsibility of the West Sussex Safeguarding Adults Board (WSSAB) The Care Act 2014 required each Local Authority to establish a Safeguarding Adults Board (SAB) by April 2015. The main objective of a SAB is to assure itself that local safeguarding arrangements and partners act to help and protect adults in its area who meet the criteria set out in the Act. The Safeguarding Adults Board has three core duties:

 It must publish a strategic plan for each financial year that sets out how it will meet its main objective and what the members will do to achieve this. The plan must be developed with local community involvement, and the SAB must consult the local Healthwatch organisation. The plan should be evidence based and make use of all available evidence and intelligence from partners to form and develop its plan.

 It must publish an annual report detailing what the SAB has done during the year to achieve its main objective and implement its strategic plan, and what each member has done to implement the strategy as well as detailing the findings of any Safeguarding Adults Reviews and subsequent action.

 It must conduct any Safeguarding Adults Review in accordance with Section 44 of the Act.

Western Sussex Hospitals Foundation Trust is represented on this Board by the Deputy Director of Nursing, Maggie Davies.

2.3 NHS Professionals Forum This forum has been in operation since 2007 in a number of different formats. Currently this is a meeting open to all safeguarding adults professionals within the NHS in West Sussex. Meetings are quarterly and are informal in nature, enabling safeguarding professionals to discuss cases, issues and share knowledge and experience. Western Sussex Hospitals Foundation Trust is represented at these meetings by Trust Lead for Safeguarding Adults, Annie Blackwell.

2.4 The Adults Safeguarding Operational Group (WSHFT) This year has seen the re-launch of the Adult Safeguarding Operational Group, with a revised membership and Terms of Reference and regular standing agenda items. The purpose of the group is as follows:  To ensure that Safeguarding Adults procedures are in place across the Trust and they are adhered to.  To act as a link between WSHFT and the county Safeguarding Adults Board and its sub-groups, and to disseminate information between these groups.  To recommend to the Quality Board those policy changes that are required as the result of local or national developments.  To recommend to the Quality Board those policy & practice changes that are required as a result of learning from safeguarding investigations.  To monitor the implementation of the Care Act 2015 within WSHFT.

Safeguarding Adults Annual Report 2015/16 Page 4

2.5 Safeguarding Strategy Committee This year also saw the launch of the Safeguarding Strategy Committee, which is a group with combined membership from adults and children’s teams. The first meeting was held in July 2015. The purpose of the Committee is as follows:  Ensure there are mechanisms in place to alert staff to safeguarding policies and procedures.  Ensure relevant staff have appropriate training in relation to national safeguarding requirements for both adults and children (i.e. Intercollegiate Guidance 2014) and the clinical divisions are able to demonstrate compliance.  Scrutiny of the training strategy in line with local and national learning opportunities available.  To consider progression of annual report development.  Ensure dissemination of information from local Safeguarding Children’s Board and Safeguarding Adults Board.  Review any new guidance and set the direction for safeguarding strategy.  Identify, monitor and ratify guidelines and procedures, making recommendations on changes aligned to national best practice. These will then be deemed ready for ratification at the Quality and Risk Committee, and onward cascade into the organisation.  To consider audit recommendations, taking forward any action points through relevant fora e.g. Patient Safety. The Executive Lead is Amanda Parker and Non-Executive Director is Joanna Crane and both attend these meetings, which are also attended by the Safeguarding Leads for Adults and Children and by the Adults and Children’s safeguarding doctors.

3. Review of the Year:

3.1 National and Local Assessments and policy changes. Care Act 2014

The Care Act 2014 was the most significant piece of legislation relating to safeguarding adults and social care for 60 years. The Act has resulted in significant changes to the safeguarding adults process. It sets out a clear legal framework for how local authorities and other parts of the system should protect adults at risk of abuse or neglect. The local authority now has the statutory duty for undertaking enquiries (investigations) or for causing enquiries to be made where there are concerns about an adult who meets the criteria for safeguarding duties identified in section 1 above.

Safeguarding alerts are now termed “concerns”. Any concern which meets the 3 key tests should be managed via a Section 42 enquiry (section 42 refers to that part (section) of the Act). The 3 key tests are as follows: o Is experiencing or is at risk of abuse and neglect o Has care and support needs o As a result of these care and support needs is unable to protect themselves from harm or abuse

Other changes to the safeguarding adults process include the following:

Safeguarding Adults Annual Report 2015/16 Page 5

 Adult safeguarding duties apply equally regardless of whether the care needs are being met and regardless of setting. The safeguarding duties are a legal requirement and apply to organisations other than the local authority, for example the NHS and the Police

 The creation of Safeguarding Adults Boards, with members including the NHS and Police

 The Act places safeguarding duties on various organisations including the NHS

 Serious Case Reviews will be replaced by Safeguarding Adults Reviews which are undertaken when someone with care and support needs dies as a result of neglect or abuse and there is a concern that more could have been done to protect them

 The Act requires multi-agency co-operation and information sharing

 Initially there was a requirement that each partner agency must appoint a Designated Adults Safeguarding Manager (DASM) with responsibility for the management and oversight of complex cases and co-ordination where allegations are made about a person e.g. employee, volunteer, student, paid or unpaid.

The revised guidance, published in April 2016 clarified or amended the original guidance. The requirement for the DSAM role was removed, although the need for an oversight of complex cases involving members of staff remains. Clarification around self-neglect was provided; people who are failing to care for themselves are not normally appropriate for Section 42 enquiries under the Act; Section 42 is aimed at those suffering abuse or neglect from a third party.

3.2 CQC Regulation 13-Safeguarding Service Users from Abuse and Improper Treatment

From 1st April 2015 the new Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3) and Care Quality Commission (Registration) Regulations 2009 (Part 4) came into force.

These regulations introduced the new “Fundamental Standards of Care”. These are standards below which the provision of regulated activities and the care provided to people by the provider must not fall, and the Care Quality Commission (CQC) are entitled to take appropriate enforcement action where they find it does.

As part of the new Fundamental Standards the CQC have introduced Regulation 13- Safeguarding Service Users from Abuse and Improper Treatment. The regulation sets out the clear requirements for providers to ensure the safety of their service users by ensuring adherence to the following:  Systems and processes must be established and operated effectively to prevent abuse of service users.  Systems and processes must be established and operated effectively to investigate, immediately upon becoming aware of any allegation or evidence of such abuse.  Care or treatment of the service users is provided in the way set out in the regulation.  A service user is not deprived of their liberty for the purpose of receiving care or treatment without lawful authority.  Restraint of the service user is only undertaken in accordance with the requirements of the regulations.

Safeguarding Adults Annual Report 2015/16 Page 6

Compliance with these standards is monitored in the Adult Safeguarding Operational Group meetings. Following the inspection in December 2015, the CQC report cited the strong arrangements for safeguarding adults and children and the robust governance structure as well as good staff awareness of responsibilities.

3.3 West Sussex Safeguarding Adults Board (WSSAB)

The purpose of the WSSAB is detailed in Section 2, page 4 of this paper. The WSSAB structure and purpose has been reviewed and strengthened to ensure compliance with the Care Act. WSHFT is a member of the Board, with the Deputy Director of Nursing representing WSHFT at the Board meetings.

3.4 West Sussex Safeguarding Adults Policy and Procedures

The Sussex Safeguarding Policy and Procedures were re-written to reflect the new statutory duties placed on partners following the implementation of the Care Act, but are currently about to be re-written again with an estimated completion date of April 2017.

3.5 Safeguarding Adults Review Protocol The Care Act replaced Serious Case Reviews with Safeguarding Adults Reviews. There are three purposes to be fulfilled by a Safeguarding Adult Review (SAR): 1. To establish whether there are lessons to be learned about the way in which local professionals and agencies work together to safeguard adults. 2. To establish what those lessons are, how they will be acted upon, by whom and what is expected to change as a result. 3. From 2 above, to improve multi-agency working to better safeguard adults.

Details of the number of SARs that WSHFT contributed to can be found in section 3.7.

3.6 Safeguarding Activity-National and Local context

Nationally there has continued to be reports of safeguarding cases which have continued to raise public awareness of the issue of adult abuse. In the local area, the Orchid View report and recommendations has continued to be at the forefront of the Safeguarding Adults Board’s work. Locally, this increasing awareness of safeguarding issues is evident by the increased number of safeguarding concerns reported by trust staff.

Table 1: Safeguarding concerns in WSCC The data given in Table 1 is taken from the West Sussex Adult Safeguarding Board Annual Report 2014/15, and was the most recent data available at the time of writing the WSHFT annual safeguarding report. The data given in the Safeguarding Board’s report is based on information relating to all safeguarding work, both incidents and concerns. The author of the Safeguarding Board’s annual report added the following caveat:

Safeguarding Adults Annual Report 2015/16 Page 7

“The Department of Health introduces amendments to the way data is collected each year and for the 2014/15 report this necessitated some changes to recording and reporting systems in West Sussex. Locally service redesign work for WSCC Adults Services and preparation for the incoming Care Act have also required changes to reporting systems. The combined impact of these changes has made some year on year comparisons of activity in this report more difficult.”

Table 1: Safeguarding cases reported to WSCC

3500

3000

2500

2000 2012/13

1500 2013/14 2014/15 1000

500

0 Safeguarding cases reported to WSCC

3.7 Trust safeguarding activity The thresholds for safeguarding alerts (referred to as concerns under the Care Act) were changed in 2011, with the effect that some issues were dealt with as incidents rather than progressing to full safeguarding investigations. The cases that did progress to safeguarding investigations tended to be more complex. The changes under the Care Act altered these thresholds once again, so that any case which meets the “three key tests” should be managed via a Section 42 enquiry.

The current position in terms of reporting for women referred is that this will be through Child Access Point, in the interest of “Think Family”. However, should there be an adult concern, without a child interface, which could be the case in gynaecology or sexual health the likely referral would be through adult social care.

Table 2 shows a comparison of all safeguarding activity within WSHFT for the years 2014/15 and 2015/16. The safeguarding concerns data includes external and trust concerns, Safeguarding Adults Reviews and “Requests for Information” (RFI) for external cases. These “RFIs” can involve supplying information and reports for external safeguarding enquiries and is a requirement under the Care Act. It can be seen that activity levels have continued to increase, and this is particularly evident in the number of DoLS referrals. It is anticipated that, following the appointment of the Mental Capacity Act Lead and as awareness of mental capacity and DoLs issues increases, the figure will continue to increase.

Safeguarding Adults Annual Report 2015/16 Page 8

Table 2: Comparison of all Safeguarding activity within WSHFT 2014-2016.

200 180 160 140 120 100 2014/15 80 2015/16 60 40 20 0 Concerns RFI SAR DHR DoLS MHA

Key: RFI Request for Information SAR Safeguarding Adult Review DHR Domestic Homicide Review DoLS Deprivation of Liberty Safeguards MHA Mental Health Act Detentions

The following tables give the detail of all Trust safeguarding activity, a comparison of concerns related to Trust care for the period 2013-2016 and details on the concerns related to Trust care for the period 2015/16. Table 3 gives the detail of all safeguarding activity within WSHFT including external safeguarding concerns (raised by Trust staff) and Requests for Information (for other Section 42 enquiries) and Serious Adults Reviews. Table 4 compares the numbers of concern raised about Trust Care for the period 2013- 2016. Table 5 provides data on the numbers of concerns raised about trust care for 2015/16. Both tables 3 and 5 include data by division. The concerns relating to the medical division are further divided into the concerns raised by A&E and those concerns related to care in A&E.

Table 3: All Safeguarding activity in WSHT 2015/16 Total Site/Division Safeguarding Concerns raised with Adults Services Referrals

Worthing Q1 Apr - Jun Q2 Jul - Sept Q3 Oct-Dec Q4 Jan-Mar 15/16

Medicine 13 17 30 32 92 A&E (included in Medicine (10) (11) (12) (8) (41) figures) Surgery 2 4 1 0 7

Safeguarding Adults Annual Report 2015/16 Page 9

St Richards Q1 Apr – Q2 Jul - Sept Q3 Oct-Dec Q4 Jan-Mar 15/16 Jun Medicine 13 13 21 12 59 A&E (included in (7) (8) (6) (2) (23) Medicine figures) Surgery 1 0 1 4 6

All Sites Q1 Apr - Jun Q2 Jul - Sept Q3 Oct-Dec Q4 Jan-Mar 15/16 Women & 0 0 0 1 1 Children Core 0 2 2 5 9 All Sites Q1 Apr - Jun Q2 Jul - Sept Q3 Oct-Dec Q4 Jan-Mar 15/16 Other Activity RFI 5 6 5 3 19

SAR 0 0 2 0 2

DHR 0 2 0 0 2 Total safeguarding 29 36 55 54 174 referrals Total Activity 34 44 62 57 197 2015/16

Key: RFI-Request for Information, SAR-Serious Adults Review, DHR-Domestic Homicide Review

The figures for safeguarding concerns had remained fairly steady over recent years at around 132 per year. However, there has been a noticeable increase following the Care Act legislation and with the changes in language from “alert” to “concerns”, and it is anticipated that the numbers may continue to rise. This should be seen positively as an indication that training has raised an awareness of the issue of adult abuse amongst both staff and the public.

Table 4: Numbers of concerns raised about Trust care 2013-2016

Year Number of Cases relating to Trust Care

2015/16 40 (16 deemed Section 42 enquiries)

2014/15 39

2013/14 53

It is worth noting that despite an increase in the total number of safeguarding concerns reported in 2015/16, the actual number of Trust cases progressing to Section 42 enquiries has reduced.

Safeguarding Adults Annual Report 2015/16 Page 10

Table 4: Concerns raised that relate to care delivered within the Trust 2015/16

Site/Division Q1 Q1 Q2 Q2 Q3 Q3 Q4 Q4 Total Total Apr- Trust Jul- Trust Oct- Trust Jan- Trust Trust Section Jun Sec. Sept Sec. Dec Sec. Mar Sec. Alerts 42 42 42 42 42 2015/16 enquiries Worthing

Medicine 1 (1) 5 (0) 7 (3) 8 (5) 21 (9) confir med A&E 0 0 0 0 0 0 0 0 0 0 (included in Medicine figures) Surgery 0 0 3 (1) 1 0 0 0 4 (1)

St. Richards

Medicine 3 (0) 0 (0) 5 (2) 5 (3) 13 (5) confir med A&E 2 0 0 0 0 (1) 0 0 2 (1) (included in Medicine figures) Surgery 0 (0) 0 (0) 1 (0) 1 (1) 2 (1) confir med

All Sites

Women and 0 0 0 0 0 0 0 0 0 0 Children

Core 0 0 0 0 0 0 0 0 0 0

Grand Totals 6 (1) 8 (1) 13 (6) 14 (9) 40 16

For the cases related to trust care, the initial impact of the Care Act was that fewer cases were deemed as reaching the threshold for a safeguarding Section 42 enquiry, and this is reflected in the Trust data: 60% were deemed as not requiring further investigation under the safeguarding procedures. It is anticipated that the number of Section 42 enquiries relating to Trust care will increase in the coming year as social care staff become more familiar with the process.

Safeguarding Adults Annual Report 2015/16 Page 11

3.8 Domestic Homicide Reviews and Safeguarding Adults Reviews Changes in legislation have resulted in Domestic Homicide Reviews (DHR) now being included in safeguarding adults’ activity. During 2015/16 the Trust Safeguarding Adults Lead received requests for information in relation to two Safeguarding Adults Reviews (SAR) (previously called Serious Case Reviews) and two Domestic Homicide reviews. The Trust had had little or no contact with the individuals concerned and the Safeguarding Lead had no further involvement in the cases.

3.9 Domestic Violence referrals to WORTH As a result of previous domestic homicide reviews, the procedure for recognising and reporting concerns relating to domestic abuse was reviewed. Staff from WORTH began delivering training to staff in the A&E departments on both sites and a session on domestic violence was included as part of the safeguarding children’s session on the Health & Safety day. At the time of writing, data was only available for the period October 2015-April 2016 following the re-launch of the training. The geographical area covered for the referral data was Worthing/Adur and Chichester/Arun. Table 5 demonstrates the significant rise in the number of referrals made to WORTH relating to domestic violence concerns. WORTH expect that the figure will continue to increase for the rest of 2016. The data for 2015-16 commences in October, after the re- launch of the training and awareness raising.

Table 5: Comparison of Referrals to WORTH 2014-15 (Apr-Mar) and 2015-16 (Oct-Apr only)

80 70 60 50 40 2014-15 30 2015-16 (Oct-Apr) 20 10 0 Referrals to Worth

3.10 Staff Training The delivery of safeguarding training was a challenge initially due to resource issues, but since the appointment of the safeguarding nurse specialist and Mental Capacity Lead, the capacity to deliver training has improved greatly. This is evident in the training figures which have increased from 76.1% in May 2013 to 96% in April 2016. The first Safeguarding Adults Intercollegiate document for roles and competencies for health care staff was published in February 2016 (it is currently being amended). This sets out the required levels of training required for staff depending upon their role.

Safeguarding Adults Annual Report 2015/16 Page 12

The safeguarding training is currently being reviewed to ensure compliance with the requirements of this document.

4.0 Review of this year’s priorities

The priorities set for this year were as follows: PRIORITY 1: Strengthen the safeguarding adults team through the recruitment of a Mental Capacity/CQUIN Lead and a Safeguarding Specialist Nurse Achievements:  The MCA CQUIN Lead commenced in post in August 2015  The targets of the MCA CQUIN were achieved  The MCA post was made substantive from the end of March 2016  Work is on-going to raise awareness and understanding of capacity issues and the appropriate use of the deprivation of liberty safeguards

PRIORITY 2: Continue and strengthen proactive work to safeguarding adults covered by the Care Act through further training opportunities for staff Achievements:  The appointment of a safeguarding nurse specialist in October 2016 further strengthened the safeguarding team and increased the capacity to deliver training  In addition to mandatory training, ward based training and ward “drop in” sessions have been delivered this year  The training content of the mandatory training has been reviewed and updated

PRIORITY 3: Identify priorities of work and monitor developments through the Adult Safeguarding Operational Group. These will include:  Change to the safeguarding concern referral process and the introduction of an electronic referral system  Monitoring of the Care Act Implementation Plan  Monitoring of safeguarding concern referral rates  Monitoring of the Domestic Action Plan Achievements:  The electronic referral system has been implemented and is working well  The monitoring of the care Act Implementation Plan continued via the Adult Safeguarding Operational Group  The safeguarding referral rates continued to be monitored and quarterly audits of the quality of the safeguarding referral forms commenced in January 2016.

Safeguarding Adults Annual Report 2015/16 Page 13

5.0 Conclusions and priorities for forthcoming year

Conclusions The ability to respond to the increase in safeguarding activity has been strengthened by the additional team members. This year has seen an increase in reporting, both of safeguarding concerns and requests for DoLS authorisations which is evidence of increased awareness of the issues. The Safeguarding Team continue to meet any new challenges as they are presented, and strive to actively embed safeguarding practice throughout the whole Trust. The effectiveness of the safeguarding team was acknowledged in the CQC report. The changes related to the Care Act continue to become embedded in practice, with local solutions being agreed between health and social care to improve the safeguarding enquiry process. It will take time for the new process to fully embed throughout the organisation and the amendments to the Care Act guidance has not assisted this process, but excellent interagency working between the trust and adult social care means that the challenges are being met and overcome together.

Priorities for 2016-17 The priorities of the Western Sussex NHS Trust for the following year are to:

1. To review the safeguarding adults training and ensure that it meets the requirements of the intercollegiate document

2. To develop specific in-house training for Enquiry Officers (Level 3 training)

3. To introduce a new e-learning training package for safeguarding and mental capacity act training

4. To hold the Trust’s first ever safeguarding conference

5. To further improve information sharing by granting named social care staff access to the safeguarding referrals inbox.

Safeguarding Adults Annual Report 2015/16 Page 14

To: Trust Board Date of Meeting: 28 July 2016 Agenda Item: 8

Title 2015/16 Safeguarding Children Annual Report Responsible Executive Director Amanda Parker, Director of Nursing and Patient Safety Prepared by Cathy Coppard, Named Nurse Children’s Safeguarding Status Disclosable Summary of Proposal The purpose of this report is to provide an update on action taken in regard to children’s safeguarding during 2015/16. Implications for Quality of Care The report enables us to identify areas of focus for 2016/17. Link to Strategic Objectives/Board Assurance Framework Supports the Patient First strategic priorities of; Quality Improvement, Our people and Systems and Partnerships. Financial Implications N/A Human Resource Implications 1. Professional performance management issues for individuals. 2. Learning and development requirements. 3. Organisational, behavioural and cultural issues. Recommendation The Board is asked to NOTE the report. Communication The report has been overseen by the Safeguarding Strategy Group and will be made available on StaffNet. Appendices N/A

This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288.

Annual Report Safeguarding Children June 2016

Prepared By:

Catherine Coppard Named Nurse for Safeguarding Children

Safeguarding Children Annual Report 2015/2016

Table of Contents 1 INTRODUCTION AND EXECUTIVE SUMMARY ……………………………… 2 GOVERNANCE & ACCOUNTABILITY ARRANGEMENT…………………….

2.1 The Safeguarding Team at WSHFT……………………………………………. 2.2 WSHFT Children's Safeguarding Infrastructure………………………………….... 2.3 Role and Responsibility of West Sussex Safeguarding Children's Board (WSSCB)..…………… 2.4 WSSCB Subgroups…………………………………………………………….. 2.5 WSHFT Safeguarding meetings……………………………………………………

3 REVIEW OF THE YEAR………………………………………………………………………

3.1 Evaluation of Progress against priorities set last year………………………………

3.2 National and Local Assessments and policy changes……………………………………

3.3 Safeguarding Referrals and Concerns raised WSHFT2015/16…………………

3.4 Number of Child Protection Medicals performed………………………………………

3.5 FGM …………………………………………………………………………………………

3.6 Sudden Unexpected Deaths……………………………………………..……………… 3.7 Staff Training…………………………………………………………………………………

3.8 CP-IS……………………………………………………………………………………...... 3.9 Audits ………………………………………………………………………………………

3.10 Serious incidents and Serious Case reviews

4 CONCLUSIONS AND PRIORITIES FOR FORTHCOMING YEAR……………… Conclusions……………………………………………………………………………….. Priorities………………………………………………………………………………………… 5 GLOSSARY OF TERMS ………………………………………………………………… APPENDIX1: SECTION 11 AUDIT TOOL KIT AND ACTION PLAN…………………… APPENDIX 2: TRAINING STRATEGY

Safeguarding Children Annual Report 2015/2016

1 INTRODUCTION AND EXECUTIVE SUMMARY

This report defines the structures and processes for safeguarding children within the Trust and how these relate to wider safeguarding arrangements. The task of safeguarding children and young people is guided by the following principles;

• Children have a right to be safe and should be protected from all forms of abuse and neglect;

• Safeguarding children is everyone’s responsibility;

• It is better to help children as early as possible, before issues escalate and become more damaging; and

• Children and families are best supported and protected when there is a co-ordinated response from all relevant agencies.

Working Together (2015)

This report outlines new local and national guidance and policy, collaborative working, local improvement and WSHT children’s safeguarding activity. The report also identifies areas requiring further improvement which include;  promoting early help for children and families;  ensuring the ‘voice of the child’ is influential and heard;  strengthening our response to sexual abuse and exploitation,  strengthening our risk assessment through ‘signs of safety’,  improving the quality of our information sharing processes including referrals  updating our performance measures  joint working with our partner agencies for looked after children

Overall the past year has seen a continued increase in safeguarding activity across the trust and noticeably on the Worthing site. The on-going challenge is ensuring safeguarding arrangements are maintained and effective through continuous improvement of processes including, training, information sharing and communication; whilst maintaining the focus of care on the needs of the child.

A self-evaluation of our statutory obligations are detailed in the section 11 audit (appendix 1). This is submitted to the CCG and WSSCB to provide assurance of trust processes.

Safeguarding Children Annual Report 2015/2016

2 Governance and Accountability Arrangements

In compliance with The Children Act 2004 (section 11) WSHT has statutory responsibilities to co-ordinate and ensure the effectiveness of what is done for the purposes of safeguarding and promoting the welfare of children. It remains the responsibility of organisations to develop and maintain quality standards and assurance, to ensure appropriate systems and processes are in place and to embed a safeguarding culture within the organisation through mechanisms such as safe recruitment processes including use of vetting and barring, staff induction, effective training and education, patient experience and feedback, critical incident analysis, risk assessments and risk registers, cyclical and other reviews and audits, annual staff appraisal and revalidation of professional staff. It is also important to be aware of the role of external regulators such as CQC in monitoring safeguarding systems within organisations. WSHFT safeguarding team continue to lead and support the trust in the continuous improvement of children’s safeguarding processes; training, guidelines, information sharing, auditing and performance. Quarterly reports are provided to the safeguarding strategic committee, W&C Division, CCG and WSSCB. The updated section 11 audit which outlines WSHFT compliance to our statutory obligations is included in appendix 1.

2.1 WSHFT Safeguarding Children Team

The Children’s Act 2004 placed ‘a requirement on each acute trust to appoint named professionals to take the professional lead for safeguarding children within the Trust and to advise all staff employed by the Trust on awareness and processes related to child protection.’

Amanda Parker Executive Lead Denise Matthams Trust lead & (Prevent lead) Tim Taylor & Pauline Shute: Named Doctors Cathy Coppard Named Nurse Gail Addison Named Midwife and (FGM lead ) Joan Davidson Safeguarding Nurse Clare Hosking & Sarah Barwick Safeguarding Midwives Kathy Walker, Susannah Hutchby & Julie-Ann Harper Safeguarding and liaison nurses Helen McCutchan Sexual Health Matron & (CSE Lead) Rachel Lee Sexual Health Lead Safeguarding Doctor Helen Milne ED Consultant (WH) Katie Manning ED Consultant (SRH) Designated Doctor and Nurse NHS Sussex Designated Consultant Nurse: Sarah Smith NHS Sussex Designated Doctor: Dr Jamie Carter

2.2 WSHFT Safeguarding Infrastructure

Safeguarding Children Annual Report 2015/2016

West Sussex Safeguarding Children Board (WSSCB) Board

LSCB Executive

WSHFT Safeguarding Strategy Group

LSCB Sub groups: WSHFT  Quality Assurance Performance Safeguarding Children  Case Review Operational Committee  CDOP  Improving Practice  Multi agency child sexual exploitation (MACSE)  NHS Professionals Forum WSHFT Safeguarding Children  Multi agency safeguarding hub Supervision Forum (MASH) Short term- operational group  Neglect (short term)

Monthly Peer Review: Weekly Meeting Monthly Meeting Monthly Meeting Medical Supervision Paediatric & A&E Antenatal Safeguarding Meeting WH &SRH Safeguarding at Safeguarding at Sexual Health WH & SRH WH & SRH

2.3 Role and Responsibility of the West Sussex Safeguarding Children’s Board (WSSCB)

Safeguarding Children Annual Report 2015/2016

WSSCB was established in compliance with The Children Act 2004 (Section 13) and The Local Safeguarding Children Boards Regulations 2006. The work of WSSCB is governed by the statutory guidance in Working Together to Safeguard Children, which sets out how organisations and individuals should work together to safeguard and promote the welfare of children, and the Local Safeguarding Children Board Regulations 2006 which sets out the functions of Local Safeguarding Children Boards.

Under section 11(4) of the Children Act 2004 which covers the legislative requirements and expectations on individual services to safeguard and promote the welfare of children and provides a clear framework for Local Safeguarding Children Boards (LSCBs) to monitor the effectiveness of local services. Statutory objectives and Functions of LSCBs:

 To coordinate what is done by each person or body represented on the Board for the purposes of safeguarding and promoting the welfare of children in the area; and

 To ensuring the effectiveness of what is done for those purposes.

The work of the WSSCB is part of the wider context of Children’s Trust arrangements, now named Think family Partnership and Safer West Sussex Partnership with a clear governance agreement between these two boards and the Health and Wellbeing Board. The LSCB Business Plan Priorities for 2016/19 are:  Neglect  Early help  Exploitation and abuse  A:CSE, Missing, Local Trafficking, E-safety  B:FGM, Forced Marriage, Honour Based Violence, Human Slavery, Radicalisation  Emotional Health and Wellbeing (this will be delivered through scrutiny of other partnerships)

2.4 WSSCB Sub groups

The following subgroups are attended by WSHFT safeguarding team;

2.4.1 Quality Assurance and Performance Group (QAPG) and Improving practice group The purpose of the Improving Practice Group is to;  Coordinate partner agencies improvements and ensure their effectiveness within statutory obligations  Explore and respond to areas of practice change  Disseminate learning and best practice  Strategic oversight of training, including monitoring and evaluation The named nurse is a member of the improving practice group. Strategic overview is provided by the Quality Assurance and Performance Group which is chaired by the director of nursing/ executive lead for children’s safeguarding WSHT.

Safeguarding Children Annual Report 2015/2016

2.4.2 NHS Professionals Forum This quarterly forum is open to all safeguarding children professionals working within the NHS in West Sussex. Meetings are informal in nature enabling safeguarding professionals to discuss cases, issues and share experience. Its key terms of references are:  To coordinate child protection and safeguarding developments for NHS staff within West Sussex.  To provide professional advice and support to the WSSCB.  To develop a safeguarding clinical network across West Sussex that supports senior practitioners in undertaking their role.  To consider and review the findings and recommendations from Serious Case Reviews and Internal Managements Reviews in respect to practice and training implications for the Health Service.  To promote and support audit.

2.4.3 Multi agency Child Sexual Exploitation (MACSE) A multi-agency monthly meeting is held where children at risk of child sexual exploitation (CSE) are discussed. The purpose of these meetings is to share information, clarify concerns and establish level of risk, agree action and make recommendations. These meetings are attended by the Matron for Sexual Health or named nurse and support information sharing and the safeguarding work within sexual health services and the trust. Ongoing work is being undertaken to ensure this relevant information is also appropriately shared with A&E to support children’s safeguarding.

2.4.4 Multi agency safeguarding hub (MASH) Operational Group (Short term) The named professionals are members of this short term operational group which feeds into a MASH strategic group. The purpose of this short term group was to participate as a stakeholder in the implementation of the Multi-Agency Safeguarding Hub (MASH). The MASH is a single point of contact for all safeguarding concerns regarding children and young people in West Sussex and includes Early Help and replaces the separate Children’s Access Point (CAP).

The MASH brings together expert professionals, from services that have contact with children, young people and families, and makes the best possible use of their combined knowledge and resources to keep children safe from harm and promote these and their families wellbeing.

The function of the MASH is to:

 Act as a front door to manage all safeguarding concerns  Research information held on professional databases to inform decisions  Continue to provide support to professionals working in Early Help. Especially identifying families who need Think Family Keyworker Services and other key working services, and family network responses  Provide a secure and confidential environment for professionals to share information

Safeguarding Children Annual Report 2015/2016

 Identify low –level repeat referrals which taken in isolation may not appear concerning, but do when the child’s journey is reviewed  Access quickly and efficiently the child protection investigation staff both within children’s social care, the Police and Health (holding strategy discussion centrally

2.5 WSHFT Safeguarding Meetings 2.5.1 Safeguarding children case discussion meetings;  Weekly Meeting Paediatric & A&E Safeguarding at WH & SRH  Monthly maternity meeting  Monthly sexual health meeting These well attended weekly multi-disciplinary meetings provide a forum for supervision, decision making and learning through discussion of concerns, formulating plans and gaining feedback on the actions of professionals and subsequent resolution of concerns.

Staff from A&E and CAMHS, attend the weekly meetings; community Health Visiting attend the monthly maternity meeting and it is planned to invite the Looked after Children’s Nursing team and the West Sussex CSE nurse (when appointed) to the monthly sexual health meetings. These meetings provide an excellent forum for case discussion, information sharing and provide a valuable link between WSHFT and partner agencies.

2.5.2 Peer Review: Monthly Medical Supervision Meeting at WH &SRH Chaired by the named doctor and attended by consultant paediatricians and named nurse. The purpose of this meeting is as follows; 1. To promote a proactive culture of learning and professional support, drawing on the existing evidence base relevant to child abuse. 2. Provide assurance that practitioners meet a measure of standard and are therefore more reliable in their practice. 3. To reduce professional isolation and improve sharing of best practice with discussion of complex patients in a challenging but supportive way. 4. To provide a regular documented review of practice as expected by the judiciary, GMC and RCPCH; evidence of involvement should be provided for consultant appraisal and revalidation.

2.5.3 Children’s Safeguarding Forum (WSHFT) This group meets quarterly and provides a forum for group supervision and review of cases of interest or learning. This forum is open to all staff that have a leadership role for safeguarding children within the following areas; A&E, paediatrics, outpatients, sexual health and maternity.

2.5.4 Safeguarding Children’s Operational Group This year has seen the launch of this meeting with a revised membership and terms of reference. The purpose is to be responsible for the effective operational implementation and

Safeguarding Children Annual Report 2015/2016 performance of the safeguarding children framework within the Trust. More specifically the group will;  Ensure there are mechanisms in place to alert staff to Safeguarding policies and procedures.  Ensure there is sufficient safeguarding training to enable staff to carry out their duties to safeguard children.  To ensure adequate communication cascades exist to alert staff regarding national guidance as it becomes available.  Ensure dissemination of information from local Safeguarding children’s board and subgroups, including relevant serious case reviews.  Identify guidelines & procedures for update making recommendations on changes aligned to national best practice. These will then be deemed ready for Divisional ratification at the Divisional Governance meeting and onward cascade through divisions and the Trust Safeguarding Strategic Group  To consider the annual audit plan and recommendations, taking forward any action points through relevant fora.  Track progress on any SCR action plans.  Monitor additional actions and learning needs identifying learning events as required.

2.5.5 Safeguarding Strategy Committee

This year also saw restructuring of the Safeguarding Strategy Committee which now combines adults and children safeguarding. It is responsible for assuring the effective implementation and performance monitoring of the safeguarding framework within the Trust adhering to Section 11 of the Children Act 2004/ 2010, the Care Act and other statutory requirements delivered by the safeguarding committees. More specifically the committee purpose is to;  Ensure there are mechanisms in place to alert staff to Safeguarding policies and procedures.  Monitor training compliance, ensuring relevant staff have appropriate training in accordance with the Intercollegiate Guidance (RCPCH 2014) Scrutiny of the training strategy in line with local and national learning opportunities.  Oversee the provision and development of the annual safeguarding report.  Monitor the dissemination of information from local Safeguarding Children’s Board and subgroups, including relevant serious case reviews.  Review any new guidance and set the direction for safeguarding strategy.  Identify, Monitor and ratify guidelines & procedures, making recommendations on changes aligned to national best practice. These will then be deemed ready for ratification at the Quality and Risk Committee, and onward cascade into the organisation.  To consider audit recommendations, taking forward any action points through relevant forum e.g. Patient Safety.  To receive the minutes from the Dementia Strategy Group and Learning Disability Group  Review of safeguarding team structures and ability to discharge statutory responsibilities  Review and act upon safeguarding training feedback

Safeguarding Children Annual Report 2015/2016

3 Review of the Year:

3.1 Evaluation of progress against priorities set in the annual report 2015;

Priority 1: Embed the early help agenda including referral pathways to; WSYPSMS, Worth and explore the referral process for early help and the use of the Holistix system. Early help is fully embedded in the maternity service and has resulted a fall in the volume of referrals to MASH (in the maternity data early help is recorded as a concern). Maternity use the Holistix system and the benefits of using the Holsitix system by the trust safeguarding team will be further explored. Referral by WSHFT staff to the WSYPSMS (drug and alcohol support for 13-25 year olds) and WORTH (domestic abuse) has increased.

Priority 2: Embed the Signs of safety risk assessment tool into practice. The Signs of Safety assessment tool is integral to the new electronic updated concerns and referral forms and is now included in safeguarding training.

Priority 3: Implement a safe and secure electronic referral process to children’s social care (2015) The maternity service has successfully piloted an electronic concerns form (part A). We are now ready to launch an electronic concerns form (part A) and referral form (part B), which will be made available via StaffNet for wider trust use In July 2016. The part B form is in a format agreed by the WSSCB. A privacy impact assessment was undertaken and approved by the WSHFT information governance team.

Priority 4: CP-IS There was a delay is going live in Autumn 2015 due to technical problems experienced by the local authority, however went live in A&E across the trust, May 2016. See section 3.8 for further detail.

Priority 5: Update the WSHFT Child Protection & Safeguarding guidelines to reflect changes outlined in the Working Together to Safeguard Children (2015) which includes referral of allegations to those who work with children. A new WSHFT Safeguarding Children Policy (June 2016) is available on StaffNet and includes a section on allegations against staff.

Priority 6: Review and update the training and supervision strategy This is included in new WSHFT Safeguarding Children Policy (June 2016) Please see section 3.7 for further details on training

Priority 7: Embed the new safeguarding governance structure This has been fully implemented and the changes are outlined in section 2

Safeguarding Children Annual Report 2015/2016

Priority 8: Training on domestic abuse, CSE and FGM Sessions on domestic abuse, CSE and FGM have been provided in level 3 training throughout the year. The NHS England CSE film has also been used as part of the educational materials. The WSSCB e-learning for FGM and CSE has also been recommended as part of the level 3 training for this year. Staff are advised to keep a certificate as evidence of completion.

Priority 9: Increase WSHFT health representation at safeguarding case strategy meetings Invitation is not consistent. It is envisaged with the formation of the MASH, which will include a representative from health, this should improve and will be monitored.

Priority 10: Launch a monthly newsletter to include new guidance, learning from serious case reviews and to advertise training opportunities. A monthly newsletter is provided by the safeguarding children’s team and cascaded to safeguarding leads, HONS, paediatric staff and also posted on StaffNet.

3.2 National and Local assessments and policy changes.

3.2.1 CQC review of looked after children and safeguarding across West Sussex The CQC report that followed the review of looked after children and safeguarding in West Sussex in February 2016, was published in November 2015. The report and recommendations relate to the inspection of children’s services across the whole West Sussex health economy. This review focused on:

 Evaluating the quality and impact of local health arrangements for safeguarding children.

 Improving healthcare for children who are looked after.

CQC.CLAS_West_Sussex_Final_Report. November 2015

In light of the CQC report, WSHFT are contributing to the action plan for West Sussex. Specialist midwifery services have implemented changes to ensure support is provided for expectant mothers with substance misuse or mental health issues and also domestic abuse. Since January 2016 a member of drug and alcohol misuse service, CGL (Change Grow Live) attends the antenatal safeguarding meetings. This has proved really useful in alerting maternity services to women with a substance misuse concern. The maternity services are also now alerted of domestic abuse notifications and provide information to MARAC.

3.2.2 CQC Inspection December 2015 Following the inspection in December 2015 the report was published in March 2016 and the summary of the relevant findings are as follows; The Trust had strong arrangements for the safeguarding for both adults and children. The child safeguarding team is extensive and comprehensive including a named executive lead, trust

Safeguarding Children Annual Report 2015/2016 lead, named doctor, nurse and midwife. Roles relating to sexual health and emergency department are also included. • The child safeguarding team also produced an annual report for the Trust board that is comprehensive in content. The supporting governance structure allows for escalation, reporting and planning of safeguarding and had a clear link into the county Safeguarding Children Board. • The Trust had a full safeguarding children policy and core services demonstrated an understanding of how and when to access the policy. Training of staff was up to date and at an appropriate level. • The arrangements in maternity were particularly impressive with planned pathways and support for vulnerable women, female genital mutilation, first time mothers, teenagers and drug and alcohol dependency all in place. Staff also had access to safeguarding supervision. There was one ‘should do’ action recommended for OPD & Diagnostics; ‘The trust should ensure staff who work in the diagnostic imaging department and who provide care to children have the appropriate level of safeguarding training’. Staff currently receive level 2 training therefore position details were amended for workforce reports to reflect the level of training they are receiving which is accordance with the Intercollegiate guidance (RCPCH 2014) It was felt that consultant radiologists should receive level 3 training and appropriate and target training has been booked for July and August 2016. The workforce report has been amended to take account of this change.

3.2.3 Independent Inquiry into Child Sexual Abuse (IICSA) (Goddard Inquiry) Last year, all Chief executives received a letter form the IICSA requesting that until further notice all health records must be kept and not destroyed and the following key issues to be considered;

 Are you satisfied any investigation was thoroughly carried out?  Can you access promptly case notes / evidence / Board reports?  Can you demonstrate your organisation has learnt from the investigation?  Are you confident that your services meet the needs of victims / survivors?  Has your organisation signed up to the Child Protection Information Sharing project? A checklist has been completed and returned to the CCG which highlights the following areas for further action by WSHFT, which will be monitored through safeguarding governance;

 A further review of the chaperone policy.

 An operational policy for the management of allegations against staff to include a flow chart which outlines the WSHFT process, guidance on the storage of HR records, a flagging system and a system for recording referrals to the local authority designated officer (LADO).

The children’s safeguarding team have been keeping all safeguarding children records since early 2015.

Safeguarding Children Annual Report 2015/2016

3.2.4 Safeguarding Vulnerable People in the NHS – Accountability and Assurance Framework (NHS England, July 2015) NHS England safeguarding-accountability-assurance-framework.July 2015Reporting mechanisms are in place to provide assurance to the CCG through the annual assurance and quarterly exception reports.

3.2.5 Victims of modern slavery – frontline staff guidance (Home office, March 2016) Victims-of-modern-slavery-frontline-staff-guidance. (Home Office, March 2016) This guidance tells you how to:  identify potential victims of modern slavery in England and Wales because they are a potential victim of human trafficking or because they are a potential victim of slavery, servitude, or forced or compulsory labour (identified in England and Wales)  identify potential victims of human trafficking in Scotland and Northern Ireland  refer potential victims to the NRM  make sure victims have access to the services they are entitled to

The Modern Slavery Act 2015 contains 2 main modern slavery offences, punishable by up to life imprisonment:  slavery, servitude and forced or compulsory labour  human trafficking Modern slavery, including child trafficking, is child abuse. The home office classifies health as a first responder; if a child is identified as a potential victim of modern slavery, first responders are required to notify children’s social care and the police but are also required to refer all potential victims of trafficking and modern slavery to the national referral mechanism (NRM). A referral to the NRM is non mandatory. The NRM is a victim identification and support process which is designed to make it easier for all the different agencies that could be involved in a trafficking and now modern slavery case – eg police, Home Office UK Visas and Immigration Directorate, local authorities, Health and Social Care.

Human trafficking is included in safeguarding training. The implications of the guidance and the process for referral to NRM will need to be further explored.

3.2.6 Early Help involves local resourcing of collaborative early intervention services for vulnerable children and families, leading to the provision of an ‘early help offer’ for families whose needs do not meet the criteria for children’s social care services. In accordance with the Early Help and Think Family partnerships the principles are:

 Working with a whole family approach.  An assertive approach for families we feel need support

Safeguarding Children Annual Report 2015/2016

 Sharing information according to the spirit of the Working Together Guidance  Collaborative working with families, seeking their views at the earliest opportunity and ensuring we obtain their feedback on the outcomes achieved  Open and honest communication with families and each other  Using the Signs of Safety approach to ensure the safeguarding of children  Working in partnership with others involved in supporting families and taking a solution focused view to providing help at the right time  Using simple processes and early help plans to support families to reach the right service/resources  Feeding back the shared outcomes achieved for families and measure the difference this has made  A regular review of the provision of services to respond to changes in needs and demand  Working together with local communities to build the resilience of families to sustain successful outcomes and be able to cope with future life events.

Early Help replaces the CAF (common assessment framework) system in West Sussex. Access to Early Help plans are made via the Holistix electronic case management information system, which is currently used by the maternity service.

Referrals to Early Help, from the rest of the trust, are made through MASH using the general referral/request for support form (part B). The benefits of access to the Holistix system will also be explored for other specialities within the trust.

Early Help has progressed within WSHFT through training and development in specialist areas and through the strengthening of the information sharing and referral process to the following agencies;

 WORTH for adult presentations of domestic abuse;

 West Sussex Young Persons Substance Misuse Service (WSYPSMS) for young people aged between 13-25 years

 Find it Out centres which provide advice, information, guidance and support for young people aged between 13-25 years.

The maternity service has also developed a young parent’s pathway which supports Early Help and information sharing.

3.2.7 Working Together to Safeguard Children (DfE 2015) Updated in 2015, the revisions include changes to:

 The referral of allegations to those who work with children

Safeguarding Children Annual Report 2015/2016

The government have removed the proposed expectation that allegations against those who work with children should be routed through children’s social care. They have instead stated that allegations and referrals relating to concerns about a child should be dealt with in a “coordinated manner”. In addition they have decided upon a new expectation that those managing allegations should be sufficiently qualified and experienced.

 Notifiable incidents involving the care of the child

The updated Working Together (DfE 2015) states that “if an incident meets the criteria for a Serious Case Review then it will also meet the criteria for a notifiable incident. However, there will be notifiable incidents that do not proceed through to Serious Case Review.” It is acknowledged that the change will mean an increase in the number of SCRs carried out however it is felt this positive learning will be gained.

The definition of a notifiable incident involving the care of a child has been clarified as;  A child has died (including cases of suspected suicide), and abuse or neglect is known or suspected;  A child has been seriously harmed and abuse or neglect is known or suspected;  A looked after child has died (including cases where abuse or neglect is not known or suspected);  A child in a regulated setting or service has died (including cases where abuse or neglect is not known or suspected).

 The definition of serious harm for the purposes of serious case reviews

The updated working together (DfE 2015) sets out to clarify the term “seriously harmed” and the definition now reads “cases where the child has sustained, as a result of abuse or neglect, any or all of the following;

 A potentially life-threatening injury;  Serious and / or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.

The definition is not exhaustive and even if a child recovers, this does not mean that serious harm cannot have occurred. LSCBs should ensure that their considerations on whether serious harm has occurred are informed by available research evidence.

3.2.8 Female Genital Mutilation -Guidance for Professionals Multi-Agency Statutory Guidance on FGM (HM Government April 2016) FGM Risk and Safeguarding; guidance for professionals (DFE May 2016) Since October 31st 2015 a mandatory duty to report cases of FGM has been placed through the Serious Crime Act 2015. All regulated health staff or social care professionals must report cases of FGM to the police if;

Safeguarding Children Annual Report 2015/2016

 A girl under 18 tells them they have had FGM

 They see physical signs that a girl has had FGM

There are also safeguarding responsibilities for the children and unborn child and the safeguarding children’s team are alerted. Updated WSHFT FGM trust guidelines and FGM Mandatory Reporting – support pack for health professionals are available via StaffNet. An FGM risk assessment system is also now available via Summary care records application and requires practitioners to use the FGM risk assessment tool. The risk will highlight a child at risk of FGM throughout their childhood. The named midwife is the trust lead for FGM and participated in the WSSCB FGM working group, developing a FGM strategy in West Sussex.

3.2.9 Private fostering and parental responsibility guidance (WSSCB) westsussexscb.org.uk/private-fostering/

A private fostering arrangement is one that is made privately by a parent, without the involvement of a local authority, for the care of a child under the age of 16 (under 18, if the child is disabled) with the intention that it should last for 28 days or more. However, if the 28 days is broken, for example by a weekend visit home, it is still considered private fostering. Private foster carers may be from the extended family such as a cousin or a great aunt.

WSSCB provide guidance to professionals as follows; ‘If you know of a child who is privately fostered you should not ignore this. It is a legal requirement that the local council is informed. If it is appropriate to do so, speak to the parent or carer before contacting your local authority’. Guidance on private fostering and parental responsibility is provided in the updated WSHFT (2016) Safeguarding Children Policy.

3.3 Safeguarding Activity: Referrals and Concerns raised WSHT 2015/16 The following data details safeguarding activity captured by the children’s safeguarding throughout the trust using the part A (concern) and Part B (referral) during 2015-2016.

Table 1 Total Total Department Children’s Social Care Referral – 2015 / 16 - SRH 2014/15 Referrals St Richards Q1 Apr - Jun Q2 Jul - Sept Q3 Oct - Dec Q4 Jan - Mar 15/16

Maternity 98 22 24 18 21 85

Paediatrics 33 10 7 10 8 35

A & E 93 22 14 13 11 60

Sexual Health 5 4 0 2 2 8

Safeguarding Children Annual Report 2015/2016

Other - - - 3 0 3

229 TOTAL Referrals 191 Total Total Department Safeguarding Concern Form Completed – 2015/16- SRH Concerns 2014/15

St Richards Q1 Apr - Q2 Jul - Sept Q3 Oct - Dec Q4 Jan - Mar 15/16 Jun

Maternity 114 50 18 17 21 106

Paediatrics 89 52 63 47 42 204

A & E 271 80 105 104 104 393

Sexual Health 5 4 20 15 3 42

Other - - - 3 5 8

479 TOTAL Concerns 753

SRH Total Safeguarding Activity: 944

Total Total Department Social Services Referral – 2015 / 16 - WGH Referrals 2014/2015

Worthing Q1 Apr - Q2 Jul - Sept Q3 Oct - Dec Q4 Jan - Mar 15/16 Jun Maternity 123 28 24 20 12 84

Paediatrics 69 19 24 20 12 75

A & E 123 37 33 52 45 167

Sexual Health 25 16 8 3 4 31

Other - - - 2 4 6

340 TOTAL Referrals 363 Total Total Department Safeguarding Concern Form Completed – 2015 / 16 WGH Concerns 2014/15

Worthing Q1 Apr - Q2 Jul - Sept Q3 Oct - Dec Q4 Jan - Mar 15/16 Jun Maternity 287 116 95 63 84 358

Paediatrics 304 71 48 62 37 218

Safeguarding Children Annual Report 2015/2016

A & E 364 121 71 132 162 486

Sexual Health 38 15 28 20 20 83

Other - - - 4 25 29

993 TOTAL Concerns 1,174

Worthing Total Safeguarding Activity: 1,537

Total Total Department Safeguarding Forms Completed – 2015 / 16- WGH Concerns 2014/15

Crawley Q1 Apr - Q2 Jul - Sept Q3 Oct - Dec Q4 Jan - Mar 15/16 Sexual Health Jun Referrals 2 3 0 1 1 5

Concerns 5 5 14 10 8 37

Crawley Total safeguarding activity: 42 Summary of WSHT Safeguarding Yearly Activity 2012-2016

Table 2 Maternity Paediatrics A&E Sexual health Other Referrals SRH WH SRH WH SRH WH SRH WH Crawley SRH WH 2012/13 96 78 25 216 59 328 0 2 0 2013/14 101 73 36 198 51 297 1 17 2 2014/15 98 123 33 69 93 123 5 25 2 2015/16 85 84 35 75 60 167 8 31 5 3 6

Maternity Paediatrics A&E Sexual health Other Concerns SRH WH SRH WH SRH WH SRH WH Crawley SRH WH 2012/13 134 298 37 185 80 403 0 0 0 2013/14 147 175 73 302 89 437 6 26 11 2014/15 114 287 89 304 271 364 5 38 5 2015/16 106 358 204 218 393 486 42 83 37 8 29

3.3.1 Summary of safeguarding activity by principle concern ( Oct15 to March16) Table 3 ( NB: this does not include maternity safeguarding data) Principal Concern SRH WH Crawley & Littlehampton

Safeguarding Children Annual Report 2015/2016

Adult drug/alcohol misuse 7 13 1 Adult mental health 26 77 0 Assault 17 35 1 Behavioural Issues (incl. anger 10 19 0 management problems) Bullying 1 2 0 Child death 3 3 0 Concealed Pregnancy 1 1 0 CSE 5 16 11 DNA hospital appointment 2 15 0 Dog bite 7 11 0 Domestic abuse 10 24 1 Drug/alcohol problems 28 33 2 Failure to thrive 1 1 0 FGM 0 1 0 FII (factitious/ fabricated induced illness) 1 2 0 Frequent attender 15 26 0 Housing/financial issues 6 5 0 Mental health issues (incl. anxiety) 46 62 3 Neglect 9 13 0 Poor parenting:/lack of supervision/ 16 24 0 Pregnancy (<18yrs ) 1 7 1 Preventable accident 35 36 0 Self-harm 40 83 0 Unexplained bruise/mark/injury 11 33 0 Vulnerable young adult 7 13 5

The safeguarding team are continuing to develop new processes to ensure capacity to manage the increase in safeguarding activity and associated statutory information sharing requirements are maintained.

Self -harm and mental health Safeguarding children who present to A&E with self- harm and mental health issues has been supported by collaborative working with CAMHS A&E liaison nurse at both WH and SRH sites. This is a new role and it is hoped that this will continue and provided an extended service.

Adult mental health Collaborative working with the adult mental health liaison teams in A&E is well established and working well and supports relevant information sharing for the children of the adults who present to the hospital with significant mental health issues. This model of collaborative working is in the early stages of being developed at SRH however is dependent on the development of adult t mental health liaison in A&E at SRH.

Drug and alcohol A new process was introduced with support of the adult alcohol nurse to ensure all children who attend A&E with a drug and alcohol issue, are referred to WSYPSMS for ongoing support.

CSE There has been a strong focus on CSE training every the year with some training sessions delivered by

Safeguarding Children Annual Report 2015/2016

Barnardos who provide specialist support for children who have experienced or at risk of CSE.

Domestic abuse Collaborative working with the domestic abuse WORTH service through training and new referral processes has increased referrals to WORTH and also identification of children at risk. 38 referrals have been made to Worth for 2015/16 from the following areas; ; 30 A&E, 1 ward, 3 midwifery, 1 physio and 3 mental health liaison team in A&E. Which is a significant increase compared to the year before which was less than 10. Sexual health are planning to implement routine enquiry for domestic abuse as currently practised in maternity Services in order to improve recognition of domestic abuse.

The safeguarding children’s team and maternity team contribute to the four area MARAC Multi agency risk assessment conferences monthly by sharing relevant information in accordance with the information sharing agreement for those adults who present to hospital and have children. It is hoped that the safeguarding adults team will be able to also contribute to these conferences for adults who present to the trust due to domestic abuse.

Dog Bites To protect children who attend hospital with dog bites New WSHT Safeguarding children from dangerous dogs guidelines have been developed in line with national best practice and in accordance with the amended dangerous dogs act in 2014. Children and families who attend ED following a dog bite/graze are given education details of the dog smart campaign (dogs trust).

3.4 Number of Child Protection Medicals performed (2014/2015)

Table 4

5 6

/1 /1

Total 2014 Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Total 2015 WH 77 5 3 5 2 5 9 2 8 4 6 8 2 59 SRH 16 0 0 1 3 5 2 0 3 0 1 1 1 17

Child Protection medicals at WH are undertaken by the community paediatricians based in the Child Development Centre. At SRH child protection medicals are undertaken by acute paediatrics as a result of an on-going vacancy in community paediatrics at Chichester.

3.5 Female Genital Mutilation (FGM) There were 7 cases reported for this year compared to 5 reported cases for the previous year 2014/15.

FGM activity is reported to the trust through informatics and shared with the Department of Health.

Table 5. 2015-2016 Reported FGM cases by type; Sep 15 1 Sexual Health, Crawley Hospital, no children, Type 3

Safeguarding Children Annual Report 2015/2016

Nov 15 1 Sexual Health, Crawley Hospital, no children, Type 2 Jan 16 3 Gynae SRH, unknown re children, Type 4 Midwifery SRH, Pregnant, Type 4 Midwifery SRH, Pregnant, Type 4 Feb 16 1 Midwifery SRH, Pregnant, Type 4 Mar 16 1 Sexual Health, Crawley Hospital, mother of 1 child, Type 3

The type 4 piercings appear to be adult females who have chosen to have piercings done at an adult age. The type 2 and 3 cases are episodes of historical FGM’s which were done when these adults were children.

3.6 Unexpected Child Death 2015/2016 There have sadly been 8 unexpected deaths of children across both WH and SRH which all prompted the unexpected child death rapid response process in accordance with procedures. A medical cause was found in 5 of the children. The cause of death was inconclusive for 2 children. A cause of death is still awaited for one of the children.

Training in the process for unexpected child death has been delivered to A&E and paediatric doctors and nurses at WH and SRH, by the clinical Child Death Overview Panel members (CDOP-LSCB sub group) and relevant learning from deaths in the west Sussex has been cascaded by the CDOP to the safeguarding team which included the recommendation for the use of translation cards for those children with allergies when going abroad. The WSHFT unexpected child death procedures have been updated to improve compliance in practice, especially with regards to the management of samples for forensic evidence.

3.7 Staff Training

The training strategy was updated June 2016 (Appendix 2)

Safeguarding training is defined in accordance with the Intercollegiate Guidance (RCPCH 2014). A summary of the changes to the previous guidance are outlined as follows;

 Obstetricians require level 3 training (previously level 2)  Annual appraisal will be crucial in determining individual’s attainment and maintenance of required knowledge, skills and competence. (Currently compliance assurance is provided by training figures through L&D)  Employers need to be assured that appraisers have the necessary knowledge, skills and competence to undertake appraisals and for medical and nursing staff to oversee revalidation. (RCPCH 2014) pg. 11  The guidance emphasises a blended approach to learning which maximises learning opportunities and includes multiagency training for staff requiring level 3 training  All levels have explicit learning outcomes and a recommended length of time  Safeguarding specialist staff (excluding named professionals) require a more detailed specialist level 3 training programme

Safeguarding Children Annual Report 2015/2016

Performance for safeguarding training compliance has reduced over the last year. This is partly due to increased requirements outlined in the intercollegiate guidance (RCPCH 2014). This includes the requirements for doctors in obstetrics and gynaecology to achieve level 3 training and radiology. Discussions have been held with learning and development (L&D) and the Head of IT to develop a workable solution using the smart cards and ESR system to enable access to the validated e-learning that includes level 3 training via www.e-lfh.org.uk

Safeguarding Children Training Figures as at 07/06/2016

Table 6. Safeguarding Training by Division ALL WSHT STAFF (Excluding MEDICS ONLY NON MEDICS Bank) Division % Up Total Up % Up To Total Up % Up To Total Up Heads Heads Heads To To Date Date To Date Date To Date Date Core Services 1490 1448 97.2% 49 26 53.1% 1441 1422 98.7% Corporate 755 739 97.9% 77 75 97.4% 678 664 97.9% Facilities & 615 600 97.6% 0 0 - 615 600 97.6% Estates Medicine 1888 1830 96.9% 258 229 88.8% 1630 1601 98.2% Surgery 1337 1264 94.5% 262 234 89.3% 1075 1030 95.8% Women & 800 738 92.3% 123 73 59.3% 677 665 98.2% Children Total 6885 6619 96.1% 769 637 82.8% 6116 5982 97.8%

Table 7. Safeguarding Training by Level Required ALL WSHT STAFF (Excluding MEDICS ONLY NON MEDICS Bank) Level Required % Up Total Up % Up To Total Up % Up To Total Up Heads Heads Heads To To Date Date To Date Date To Date Date Level 1 1992 1947 97.7% 0 0 - 1992 1947 97.7% Level 2 4244 4104 96.7% 625 564 90.2% 3619 3540 97.8% Level 3 649 568 87.5% 144 73 50.7% 505 495 98.0% Total 6885 6619 96.1% 769 637 82.8% 6116 5982 97.8%

3.7.1 Evaluation and Audit of training The feedback and evaluation of the level 3 training is reported as good - excellent and well regarded by our internal and external stakeholders. Staff report they have a good understanding of their role and responsibility. Level 2 training is delivered through the H&S mandatory study

Safeguarding Children Annual Report 2015/2016 day and currently no evaluation is received for this training. A request has been made to L&D for staff feedback following safeguarding training delivered at the H&S days to be obtained. Safeguarding activity and an update of the current training provision is detailed within the report. Level 3 Feedback has highlighted the following areas for improvement:  Access to an e-learning process which is of quality and validated (e-learning for health) but can also be recorded by the trust mandatory training report systems.

 Introduction of a training passport which will recognise recent safeguarding training undertaken at previous organisations

 Ensuring those undertaking e-learning also receive guidance at induction or an update about the local safeguarding processes.

 Improved information on venue location

3.7.2 Supervision training Training was provided for safeguarding practitioners in February 2016 and supervision framework included in the new Safeguarding children Policy 2016.

3.8 CP-IS The Child Protection Information Sharing (CP-IS) Project is an NHS England sponsored programme and will support the sharing of information between health and social care for children that are subject to Child Protection Plan (CPP) and for Looked after Children (LAC). It will make CPP/ LAC information held in social care systems available across England to unscheduled healthcare professionals to support child protection decision making and support more collaborative working.

WSHFT agreed to sign up to the system in June 2014 and went live in both A&E departments in May 2016 as phase 1 using a manual process via the Summary Care Record Application (SCRa). Whilst the manual process is used compliance with the process requires daily monitoring by the safeguarding team and departments. One of the additional benefits of using the SCRa process is that it has introduced many staff to the benefits of using SCRa for many aspects of clinical care. The disadvantages of using this process are that it is a manual process and is subject to risk when not used for every child’s attendance. It is hoped there will be a phase 2 i.e an integrated IT solution with semahelix.

It is planned to introduce the CP-IS in other unscheduled areas where children and unborn babies are seen (inpatient paediatrics and maternity) in September 2016.

3.9 Audits A retrospective review of the quality of acute paediatric safeguarding documentation within the patient case notes was undertaken and completed June 2016. This audit was a recommendation

Safeguarding Children Annual Report 2015/2016 following a SIRI in 2015.The following recommendations will be actioned and monitored through safeguarding and paediatric governance;  Improve compliance with current WSHFT safeguarding policy particularly in relation to identifying and documenting the ‘signs of safety’; being clear what the concerns are and what is being requested, in all communication  Improve compliance with the WSHFT safeguarding policy and investigation of unexplained injury  Improve compliance with the referral process in particular with the faxing of referrals and documentary evidence. (note a new electronic referral process to go live)  Feedback to WSHFT medical and nursing staff the importance of clear, detailed documentation of all conversations – internally and with other agencies  Share findings with WSHFT Executive Team.  Education events for clinical staff within A&E and Paediatrics to include the safeguarding referral process, documentation and unexplained injury pathway and documentation requirements.  Share learning through safeguarding training and educational forums.

3.10 Serious incidents and Serious Case reviews An IMR was undertaken for a local child sexual exploitation serious case review (SCR Key) which involved 5 girls who attended our services (A&E, sexual health and maternity services) between 2012 and 2015. The final report and recommendations are expected to be published in September 2016 when the wider learning will be shared.

An RCA investigating the pathway for investigating suspected non- accidental head injury (NAHI) following a SIRI was undertaken following an allegation made in court during a family court case that a baby was wrongly separated from its parents for a period of 8 months. The concerns were raised during the family court case where the Local Authority sought to withdraw the child’s care order as Western Sussex Hospitals Foundation Trust (WSHFT) had not followed an accepted pathway for investigating suspected Non- Accidental Head Injury (NAHI) in November 2014. The case and action plan has been monitored through paediatric and safeguarding governance structures and learning shared through a joint teaching session with Southampton general hospital neurosurgeons in October 2015, clinical governance and peer review. Further training in NAHI has been provided and Named doctor has provided feedback to the LSCB. A review of actions taken will be provided and reported back to the SIRI committee and safeguarding committee.

4 Conclusions and priorities for forthcoming year

Conclusions Safeguarding practice at WSHFT continues to be tested with increased safeguarding activity each year. Improved processes, effective interagency working and a supportive culture with staff clear of their safeguarding responsibilities supports the safeguarding of children. The

Safeguarding Children Annual Report 2015/2016 safeguarding team continue to meet any new challenges as they are presented, review practice, share learning and strive to actively embed safeguarding practice throughout the whole Trust.

Considerable progress has been made in improving communication, information sharing and training and providing accessible up to date and relevant guidance via StaffNet and a monthly newsletter supports staff and processes. The team have actively contributed to the work of the LSCB, working with partner organisations to support the interagency challenges ahead.

Priorities The child safeguarding priorities for Western Sussex Hospitals NHS Foundation Trust for the following year are shown as follows;

1. Improve the prevention and protection of children at risk of or experiencing Neglect 2. Training; a. Introduce a new e-learning training package (eLFH) for safeguarding to compliment existing face to face training.

b. Achieve rates of training for medical staff above 95%

c. Provide targeted level 3 training for medical staff in obstetrics and gynaecology and for consultant radiologists. 3. Finalise the Management of suspected NAHI pathway and include in the safeguarding training and policy 4. Implement the electronic referral and concern process via StaffNet and include in safeguarding training 5. Introduce the CSE assessment tool in A&E 6. Review processes for Identifying and supporting victims of modern slavery 7. Ensure the trust has systems in place for identifying parental responsibility & correct process for private fostering 8. Introduce CP-IS to the urgent care settings in paediatrics and maternity 9. Domestic abuse; review process for flagging MARAC notifications on semahelix.

5. GLOSSARY OF TERMS

CCG Clinical Commissioning Group

CGL Change grow live, formerly known as CRI (Crime reduction initiative)

CP-IS Child Protection information sharing system

CQC Care Quality Commissioning

CSE Child Sexual Exploitation

Safeguarding Children Annual Report 2015/2016

DFE Department for Education

FGM Female Genital Mutilation

HSCIC Health and Social Care Information Centre

LSCB Local Safeguarding Children’s Board

MACSE Multi agency Child sexual exploitation

MARAC Multi-agency risk assessment conference

NAHI Non-accidental head injury

QAPG Quality Assurance and Performance Group

WSHFT Western Sussex Hospitals NHS Foundation Trust

WSSCB West Sussex Safeguarding Children Board

WSYPSMS West Sussex young people substance misuse service

(CGL-Change Grow Live-formerly known as CRI- Crime reduction initiative)

Safeguarding Children Annual Report 2015/2016

Appendix 1 - section 11 audit tool kit and action plan.

Name of agency

Reference Standard RAG rating Action needed Timescale Lead officer No Number

1 2.1 Green CP safeguarding policy approved June 2016 C Coppard

2 6.1 Green R&S policy with TEC for approval J Fanning 3 6.7 Green Investigation policy with TEC for approval J Fanning 4 9.1 NEW Amber The Children Acts of 1989 and 2004 introduced legislation July 2016 C Coppard to safeguard children who are Privately Fostered. As a result, local authorities must be notified about all Private Fostering arrangements. Frontline workers in your service who work directly with children, are made aware of this expectation Include in training and add to policy and procedures 5 9.2 NEW Amber Staff understand the definition of a “close” relative, under July 2016 C Coppard the terms of the Children Act relating to Private Fostering.

Need to include the following in training and policy: Private fostering is when a child under the age of 16 (under 18 if disabled) is cared for by someone who is not their parent or a 'close relative'. This is a private arrangement made between a parent and a carer, for 28 days or more. Close relatives are defined as step-parents, grandparents, brothers, sisters, uncles or aunts (whether of full blood, half blood or marriage/affinity).

Safeguarding Children Annual Report 2015/2016

Appendix 2 Training Strategy (2016)

Safeguarding Children (Child Protection) training is mandatory for all staff at Western Sussex hospitals NHS foundation Trust. All staff should ensure they attend the correct level training applicable to their job role and responsibility. Level 2 and Level 3 training is provided in the trust. Training dates are available via the StaffNet. Staff may apply by an e-mail from your manager confirming authorisation to attend to [email protected] quoting which level is required.

Training level requirements are set in accordance with safeguarding children and young people: roles and competences for healthcare staff intercollegiate guidance (RCPCH 2014) Professionals have a responsibility to actively maintain and improve their professional knowledge and competence in accordance with the intercollegiate guidance. Evidence of compliance will need to be provided at appraisal and for revalidation. Guidance for all staff is detailed in the training framework and advice on which training level to attend can be sought via department managers or by contacting the Safeguarding Children’s team on 01243 831780 or 01903 286769 or email: [email protected]

It is the responsibility of the board and senior management to ensure staff access training appropriately. Evidence of attendance or e-learning training needs to be provided to L&D in order to inform training database reports provided by workforce information department. The quality of training programmes will be monitored evaluated through audit, staff evaluation, case review and appraisals.

Training delivering will be both flexible and formal in order to meet statutory obligations and maximise learning opportunities. As a minimum staff should receive training every 3 years and should encompass a blended learning approach. Written updates, briefings and learning will be circulated via the monthly safeguarding children newsletter and through training.

Education and training passports are accepted and can be used as evidence to prevent the need to repeat learning where individuals have moved areas and can demonstrate up to date competence, knowledge and skill. Individuals do however need to ensure they are competent with local procedures.

Training will include multiagency, multidisciplinary and delivered internally and externally to the organisation. The following accredited e-learning packages can also be used as evidence of training www.e-lfh.org.uk/programmes/safeguarding-children or www.westsussexscb.org.uk/professionals/e-learning-courses/. Multi agency training can be accessed through www.westsussexscb.org.uk/professionals/training/ . Evidence of attendance or completion of these courses needs to be forwarded to children’s safeguarding team who will forward to L&D to ensure mandatory training records are updated.

Safeguarding Children Annual Report 2015/2016

Training Strategy Framework:

Level & Opportunity Frequency Accessed via Staff group

Induction Programme 40 minute session & handout Human Resources (HR) & All staff at induction coordinated by Learning and Development (L&D) Requirement (minimum 30 mins at level 1)

Level 1 training Annual 30 minute session Volunteer coordinator All Volunteers as part of All volunteers annual training Delivered alongside adult safeguarding training

(minimum 2 hours every 3 years)

Level 2 training Annual 1 hour session L&D or e-learning via All staff as part of All non - clinical and clinical staff who www.e-lfh.org.uk mandatory training (unless do not work directly with Children, meeting level 3 Young people and families. requirements)

(minimum 3-4 hours every 3 years)

Level 3 core training Full day course every 3 years or L&D for Full day courses All clinical staff working in All clinical staff working with children, Annual 2 hour modulated urgent or unscheduled care; young people and/or their training culminating in a full level Safeguarding children team for Paediatrics, Sexual Health, 3 training covering full spectrum modular annual training Maternity (midwives & parents/carers of competencies every 3 years. obstetricians), A&E, fracture

Safeguarding Children Annual Report 2015/2016

(a blended training approach with a clinic; lead anaesthetists for minimum of 6 hours every 3 years) (Level 3 training to be safeguarding completed within 6 months of starting with the trust)

Level 3 specialist training Annual or 3 yearly Children’s safeguarding team; All paediatricians, and WSSCB multi agency training specialist safeguarding Reflection, case discussion/peer review and e-learning specialist nurses/midwives meetings, supervision, multi-disciplinary courses and interagency training (minimum of 12-16 hours over 3 years)

Level 4 Internal & external multiagency Named Professionals Specialist clinical & non clinical training training and specialist external (management/peer training conferences support/supervision) (minimum of 24 hours over 3 years)

Board Level Annual 40 minutes session Children’s safeguarding deliver Board Level for CEO, Level 1 knowledge required (minimum at board meeting Trust executive, NED: of 2 hours every 3 years) and in Senior managers & exec addition board level specific learning leads with board outcomes (RCPCH 2014) p73 responsibilities

Safeguarding Children Annual Report 2015/2016

To: Trust Board Date of Meeting: 28 July 2016 Agenda Item: 9

Title Month 3, 2016-17 Performance Report Responsible Executive Director Peter Landstrom, Chief Operating Officer Prepared by Adam Creeggan, Director of Performance Giles Frost, Assistant Director - Operational Planning and Performance Status Disclosable Summary of Proposal The paper sets out organisational compliance against national and local key performance metrics. The report summarises both in year and projected year end performance for Western Sussex Hospitals NHS Foundation Trust, as detailed in dedicated performance scorecards relating to Quality Board indicators aligned to the Quality Strategy, the Monitor Risk Assessment Framework and, when relevant, other efficiency indicators. This paper describes performance on an exceptional basis determined by RAG rating, key national/regulatory significance, or in year trend analysis.

Implications for Quality of Care Describes Quality Outcome KPIs Link to Strategic Objectives/Board Assurance Framework Trust Strategic Theme B - Provide the highest possible quality of care to our patients. This we will do through focusing on a range of measures to improve clinical effectiveness. Trust Strategic Theme G - Ensure the sustainability of our organisation by exceeding our national targets and financial performance and investing in appropriate infrastructure and capacity. Trust Strategic Theme F - Improve our performance against a range of quality, access and productivity measures through the introduction and spread of best practice throughout the organisation. Financial Implications Describes KPIs linked to financial performance Human Resource Implications Describes KPIs linked to workforce Recommendation The Board is asked to: NOTE Communication and Consultation Not applicable Appendices Appendix 1: Key Performance Deliverables, Operational Performance Scorecard, Monitor Risk Assessment Framework Scorecard.

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To: Trust Board Date: 28 July 2016

From: Pete Landstrom, Chief Operating Officer Agenda Item: 9

FOR INFORMATION

WSHFT PERFORMANCE REPORT: MONTH 3, 2016/17

1. INTRODUCTION

1.1 This report summarises both current in year and projected performance for Western Sussex Hospitals NHS Foundation Trust, with further detail provided in the appendices relating to: • The Monitor Risk Assessment Framework • Key Performance Deliverables Report • Operational Performance Scorecard

1.2 This paper provides the Board with an update on performance on a specific basis determined by RAG rating, national significance, or in year trend analysis.

1.3 Introduced in 2016/17 as a condition of the National Sustainability and Transformation Programme and funding, all Trusts have submitted joint performance plans on the key areas of A&E, RTT, Cancer, and Diagnostics. The detailed tracking of the Trust’s performance against this trajectory is provided to the monthly Finance and Investment Board Committee, and performance against this requirement is summarised in this report for each relevant performance area.

2. SUMMARY PERFORMANCE

2.1 Based on provisional Month 3 positions, the Monitor Risk Assessment Framework performance is an in month notional 1 point for June.

2.2 The Risk Assessment Framework formally assesses Trust performance on an aggregated quarterly basis with the exception of Referral to Treatment (RTT). The one area of non- compliance against the framework relates to RTT as part of the agreed recovery programme with the Trust’s commissioners and regulators.

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2.3 June has continued to see high levels of A&E demand and non-elective admissions. Key operational indicators during June to note:

• 11,792 A&E attendances compared to 11,505 in June 2015 (representing a +2.5% increase on this time last year). • 4,715 emergency admissions compared to 4,140 in June 2015 (representing a +13.8% increase on this time last year). • The emergency admission age profile has changed when compared to this month last year with a +14.7% increase in 65-84 years and a +11.5% increase in >=85 years. This reflects our local population’s changing demographic, and is an indicator of the increasing frailty of our emergency patients. • Formally reportable Delayed Transfers of Care totalled 3.82% for June 2016. This is an increase on the previous month’s DTOC levels. • Inpatient Bed Occupancy on average in June was 92.9%.

3. KEY AREAS OF PERFORMANCE

3.1 A&E Compliance

3.1.1 The Trust was fully compliant in June, with 95.64% of patients waiting less than four hours from arrival at A&E to admission, transfer, or discharge, against the national target of 95.0%.

3.1.2 This exceeded this month’s delivery requirements of the Sustainability and Transformation Fund trajectory for WSHFT of 95.0%.

3.1.3 Access to beds due to delayed transfers of care (DTOC) increased to 3.82% in June 2016 when compared to May 2016 (3.54%). During June, DTOCs peaked at 4.3% at both sites in the week commencing 6th June.

3.1.4 In real terms, this reflects an impact in ‘lost’ beds that fluctuated between a minimum of c24 beds and a high of c32 beds during the month. This excludes the effect of patients who are medically fit for discharge (MFFD), but have yet to be declared ‘delayed transfers’ following a full multi- disciplinary assessment. The inclusion of patients defined as MFFD significantly increases the effect on available bed stock, and in June there were, on average, 146 patients who were medically fit for discharge each day compared to 149 in May. While the reduction in patients is modest, the associated average beddays lost has decreased by -9.3% in the same period from 1,605 to 1,444.

3.1.5 The Trust continues to significantly exceed the national performance. National data shows aggregate compliance of 85.4% for Type 1 A&E units across England for the most recent published period (May 2016), with only 7% of NHS Trusts in England achieving compliance of

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95% or more in-month. Regionally compliance for the South of England was 86.7%, with Surrey/Sussex Trusts (excluding WSHFT) generating aggregate compliance of 86.8%.

3.1.6 The publication of national data for May 2016 confirms that WSHFT compliance was the 6th highest nationally of 140 provider Trusts, and the highest in Surrey/Sussex and the South of England respectively.

3.2 Cancer

3.2.1 The provisional position for June shows the Trust to be fully compliant against all 7 Cancer metrics.

3.2.2 This exceeds this month’s delivery requirements of the Sustainability and Transformation Fund trajectory for WSHFT of 85.1%, with the Trust’s provisional June compliance against treatment within 62 days for all two week rule and screening patients at 87.2%.

3.2.3 Trust Board is asked to note that this position is subject to further revision relating to pathways delivered at tertiary centres, outcomes of pathology, etc., and that Monitor compliance assessment is contingent on quarterly aggregate performance due to inherent variability by month.

3.2.4 Current performance is set within the context of a 10.1% increase in cancer referrals in June 2016 compared to this time last year. In response, the Trust delivered a 5.1% increase in treatment activity in June 2016 compared to the same time last year.

3.2.5 The Trust continues to exceed the national performance. For context, comparative latest nationally published data relating to May 2016 shows national aggregate compliance for the cancer attendance to be:

• 94.0% for 2 week rule (target 93.0%) compared to WSHFT performance of 96.9%. • 92.1% for symptomatic breast (target 93.0%) compared to WSHFT performance of 96.9%. • 81.5% for treatment within 62 days (target 85.0%) compared to WSHFT performance of 85.4%. In May 2016, 56.0% of Trusts in England were non-compliant against Cancer standards.

3.3 Referral to Treatment (RTT/18 Weeks)

3.3.1 The Trust completed 13,010 RTT patient pathways in June, exceeding agreed recovery plan by 651 pathways (+5.3%). This reflects the highest volume of pathway completions in WSHFT history, contributing to incomplete compliance improvement to 88.35% in June 2016 from 88.15% in May.

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3.3.2 Although not yet meeting the national target of 92%, this exceeded the month’s Sustainability and Transformation Fund recovery trajectory delivery requirement of 87.3%. The Trust also met the requirement that no patient be actively waiting more than 52 weeks for treatment.

3.3.3 The total waiting list size in Quarter 1 has reduced from 36,332 on 1 April 2016 to 34,317 at 30 June 2016 (-5.6%). The backlog component of the waiting list has been reduced from 4,958 to 3,997 cases (-19.4%) in the same period. This is lowest backlog size since 2013/14.

3.3.4 Latest published national data relates to May 2016 and shows overall national compliance at 91.8%. This figure is exclusive of independent sector providers and does not reflect a number of large acute NHS providers that currently are not reporting RTT positions as part of agreed ‘special measure’ arrangements. Inclusion of the last known positions for these organisations reduces the formally reported England compliance position to 91.3%, with 27.3% of Trusts non- compliant in the period.

3.4 Fractured Neck of Femur (#NOF) operation within 36 hours of admission

3.4.1 During June, 76.19% of medically fit Fractured Neck of Femur (#NoF) patients were operated on within 36 hours of admission against a target of 90%.

3.4.2 There was a significantly lower number of #NOF patient in totality in June compared to the average (-30% reduction). As a result a single period of sustained pressure over the 3 day period 10th-12th June on the Worthing Site, with increased non hip trauma demand, and higher than normal clinical priority of other trauma cases, resulted in the overall percentage reduction. The newly implemented review and resilience processes introduced in May are continuing to operate and July to date (as at 22nd) is fully compliant at 95.45%.

3.5 Diagnostic Test Waiting Times

3.5.1 Compliance against the 6 weeks waiting time for diagnostic tests improved from 1.50% in May to 1.28% end June 2016, against the national target of 1.0%. This represents 73 patients waiting longer than 6 weeks.

3.5.2 This exceeded this month’s delivery requirements of the Sustainability and Transformation Fund trajectory for WSHFT of 4.2%.

3.5.3 As previously shared with Board, the key diagnostic area where patients are waiting longer than the target remains Magnetic Resonance Imaging (MRI). Recovery actions introduced to mitigate the impact of continued workforce challenges and significantly increased demand throughout

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2015/16 have reduced the number of patients breaching in that test modality from 189 in March to 62 in June.

3.5.4 For comparative purposes, the most recent national data (May 2016) shows 28% of organisations in England were non-compliant against the diagnostic target, with the national average compliance level being 1.4%.

3.5.5 Within the region WSHFT is performing better than peers, with South of England Region aggregate compliance of 1.8%, and Surrey/Sussex acute Trusts (excluding WSHFT) generating aggregate compliance of 2.5%.

4 RECOMMENDATION

4.1 The Board is asked to receive the Month 3 position, which shows a compliance score of 1 point (Amber/Green) against the Monitor Risk Assessment Framework, and confirms full compliance against the delivery requirements of the Sustainability and Transformation Fund.

Adam Creeggan, Director of Performance Giles Frost, Assistant Director - Operational Planning and Performance

22nd July 2016

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Mark Dennis, Head of Information Services t: 01903 285273 (ext 5273)

Key Performance Deliverables Report JUNE 2016

A&E 4-hour waiting time target Description / Comments / Actions Target Month YTD Projected O/T Patients can expect to be admitted, transferred or discharged in 4 hours from arrival in A&E 95% 95.64% 95.85% >95%

100% Sustained increases in underlying demand and acuity. Increased demand challenging ability to maintain hospital/system flow essential to delivery of A&E waiting time. 95% 90% 85% 80% Actions: 75% 1. Enhanced discharge planning arrangements 70% 2. Augmented patient flow arrangements in conjunction with external partners 65% 3. Dedicated operational delivery review cycle under the leadership of the Chief Operating Officer 60% 55% 50% Jul Jan Jun Oct Apr Sep Feb Dec Aug Nov Mar May June

Cancer - Two weeks from urgent GP referral to first appointment Description / Comments / Actions Target Month YTD Projected O/T Patients can expect to be seen within 2 weeks following an urgent GP referral for suspected cancer. 93.0% 96.92% 96.52% >93% Significant and sustained increases in demand level. 100% 95% 90% 85% 80% Actions: 75% 1. Management/tracking oversight through DDO led Cancer Delivery Group 70% 2. Dedicated weekly review led by Chief Operating Officer 65% 60% 55% 50% Jul Jan Jun Oct Apr Feb Sep Dec Aug Nov Mar May June

Cancer - Two weeks from urgent GP referral to first appt - Breast symptoms Description / Comments / Actions Target Month YTD Projected O/T Patients with breast symptoms can expect to be seen within 2 weeks following an urgent GP referral. 93% 96.92% 96.93% >93%

100% Significant and sustained increases in demand level. 95% 90% 85% 80% Actions: 75% 1. Management/tracking oversight through DDO led Cancer Delivery Group 70% 2. Dedicated weekly review led by Chief Operating Officer 65% 60% 55% 50% Jul Jan Jun Oct Apr Feb Sep Dec Aug Nov Mar May June

Cancer - 62 days from referral to treatment following screening contact Description / Comments / Actions Target Month YTD Projected O/T Patients with cancer can expect to commence treatment within 62 days following referral after a positive screening test. 90% 92.59% 94.08% >90%

100% Delays in receipt of onward referral from screening which reduces the time to secure capacity to treat patients. 95% 90% 85% 80% Actions: 75% 1. Management/tracking oversight through DDO led Cancer Delivery Group 70% 2. Dedicated weekly review led by Chief Operating Officer 65% 60% 55% 50% Jul Jan Jun Oct Apr Feb Sep Dec Aug Nov Mar May June

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Key Performance Deliverables Report JUNE 2016

Cancer - 62 days from referral to treatment following urgent referral by a GP. Description / Comments / Actions Target Month YTD Projected O/T Patients with cancer can expect to commence treatment within 62 days following urgent referral by a GP. 85% 85.42% 85.97% >85%

100% Demand pressure exposing pathway efficiencies. Reduces the time to secure capacity 95% to treat patients. 90% 85% 80% Actions: 75% 1. Management/tracking oversight through DDO led Cancer Delivery Group 70% 2. Dedicated weekly review led by Chief Operating Officer 65% 60% 55% 50% Jul Jan Jun Oct Apr Feb Sep Dec Aug Nov Mar May June

Referral to treatment - Incomplete Pathways Description / Comments / Actions Target Month YTD Projected O/T All patients can expect to commence treatment within 18 weeks of a referral to consultant. 92.0% 88.35% 87.59% >92%

100% Non-compliance an expected outcome of planned RTT recovery programme. 98% 96% 94% 92% Actions: 90% 1. Increase in internal capacity as per Monitor/NHSE agreed Joint Recovery Plan 88% developed with support from IMAS 86% 2. CCWSCCG commitment to reduced demand levels as supporting component of Joint Recovery Plan. 84% 3. Dedicated weekly Divisional review meeting, with overarching assurance review by 82% Chief Operating Officer (also weekly) 80% 4. System Summit meetings with Monitor/NHSE to ensure partner deliver of agree Jul Jan Jun Oct Apr Feb Sep Dec Aug Nov Mar Joint Recovery Plan actions. May June

% Medically fit hip fracture patients going to theatre within 36 hours Description / Comments / Actions Target Month YTD Projected O/T To ensure the best possible outcomes, hip fracture patients who are medically fit should be operated on within 36 hours of admission. This standard is part of the 'Best 90% 76.19% 87.73% >90% Practice Tariff' payment process under PbR. 100% Increased volume of demand and variation of demand have impacted sustained 90% compliance. 80% 70% 60% Actions: 50% 1. Improved tracking and escalation processes in place to manage fluctuations in 40% demand on a daily basis 30% 2. Revised protocol introduced based on four key demand based triggers to ensure 20% early escalation/intervention in periods of abnormal demand. 10% 0% Jul Jan Jun Oct Apr Feb Sep Dec Aug Nov Mar May June

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OPERATIONAL PERFORMANCE JUNE 2016 SCORECARD 2016/17 2016/17 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May JUN YTD Target Trend NATIONAL AND OPERATIONAL PERFORMANCE TARGETS A&E : Four-hour maximum wait from arrival to admission, transfer O01 97.39% 97.71% 97.28% 94.80% 95.47% 96.14% 93.66% 95.29% 94.40% 96.12% 96.28% 95.67% 95.64% 95.85% 95% or discharge 1 O02 Cancer: 2 week GP referral to 1st outpatient 94.14% 93.68% 93.21% 94.00% 97.82% 97.85% 98.06% 96.91% 97.75% 98.24% 95.42% 97.18% 96.92% 96.52% 93%

1 O03 Cancer: 2 week GP referral to 1st outpatient - breast symptoms 92.27% 96.55% 93.18% 83.24% 97.85% 98.54% 96.32% 97.99% 97.30% 96.67% 96.75% 97.24% 96.92% 96.93% 93%

1 O04 Cancer: 31 day second or subsequent treatment - surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.00% 94%

1 O05 Cancer: 31 day second or subsequent treatment - drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98%

1 O06 Cancer: 31 day diagnosis to treatment for all cancers 98.84% 99.59% 99.57% 100.00% 98.88% 99.18% 100.00% 100.00% 100.00% 99.13% 99.14% 99.62% 99.63% 99.5% 96%

1 O07 Cancer: 62 day referral to treatment from screening 100.00% 94.44% 97.96% 100.00% 90.20% 98.53% 96.43% 100.00% 97.30% 100.00% 93.62% 96.08% 92.59% 94.1% 90%

1 O08 Cancer: 62 day referral to treatment from hospital specialist 85.7% 78.1% 86.2% 81.5% 77.4% 69.2% 60.0% 100.0% 95.5% 95.0% 76.9% 76.9% 90.0% 82.61% N/A

1 O09 Cancer: 62 days urgent GP referral to treatment of all cancers 84.72% 87.50% 87.60% 88.00% 85.61% 85.45% 87.31% 86.96% 84.90% 86.36% 86.09% 86.45% 85.42% 85.97% 85%

O14 RTT - Incomplete - 92% in 18 weeks 87.66% 85.81% 84.99% 85.70% 86.61% 87.02% 86.87% 87.48% 87.97% 86.35% 86.95% 88.15% 88.35% 87.59% 92%

RTT delivery in all specialties O15 12 10 12 11 12 11 14 12 12 13 11 11 11 11 0 (Incomplete pathways)

O16 Diagnostic Test Waiting Times 1.44% 3.43% 4.56% 6.28% 4.28% 1.43% 1.69% 2.24% 2.43% 3.52% 2.41% 1.50% 1.28% 1.73% <1%

O17 Cancelled operations not re-booked within 28 days 0 2 0 1 1 0 0 3 0 0 0 1 0 0 -

O18 Urgent operations cancelled for the second time 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -

Clinics cancelled with less than 6 weeks notice for annual/study O19 26 33 35 14 30 15 25 33 12 22 22 22 15 15 - leave

O20 Mixed Sex Accommodation breaches 0 0 0 1 0 0 0 0 0 0 0 6 0 0 0

2 O33 Delayed transfers of care 3.43% 3.42% 3.17% 3.97% 3.41% 3.88% 3.59% 3.43% 3.80% 2.55% 3.54% 3.54% 3.82% 3.63% 3.5%

IMPROVING CLINICAL PROCESSES

O23 % hip fracture repair within 36 hours 93.7% 95.5% 90.6% 84.0% 93.9% 89.5% 79.4% 90.3% 86.9% 67.2% 88.3% 95.1% 76.2% 87.7% 90% Patients that have spent more than 90% of their stay in hospital on 1 O24 94.4% 92.9% 94.4% 92.5% 82.0% 94.7% #N/A 86.9% 80% a stroke unit+

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OPERATIONAL PERFORMANCE JUNE 2016 SCORECARD 2016/17 2016/17 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May JUN YTD Target Trend OPERATIONAL EFFICIENCY

O36 Average length of stay - Elective 3.09 3.12 2.86 3.05 3.10 3.10 2.99 3.05 2.97 3.32 2.93 3.49 3.04 3.16 3.72

O37 Average length of stay - Non-elective Surgery 5.06 5.44 4.96 5.49 6.01 5.13 5.57 5.41 5.34 5.89 5.65 5.66 5.77 5.69 6.07

O38 Average length of stay - Non-elective Medicine 7.59 7.34 7.20 7.70 7.28 7.77 7.52 7.61 7.63 7.60 8.05 7.43 7.58 7.69 7.80

Day case rate (CQC day case basket of procedures) O39 84.24% 87.12% 87.30% 89.58% 90.15% 90.67% 87.25% 90.48% 90.96% 90.57% #N/A #N/A #N/A #N/A 75.0% source: Dr Foster (reported 2-3 months in arrears)

O40 Elective day of surgery rate (DOSR) 98.0% 97.1% 98.7% 99.1% 98.8% 98.3% 98.3% 98.5% 99.1% 97.8% 98.4% 98.4% 98.6% 98.4% 90.0%

O41 Did not attend rate (outpatients) 6.59% 6.46% 6.76% 7.18% 6.87% 6.48% 6.70% 6.66% 6.47% 6.69% 6.71% 6.88% 7.25% 6.90% 7.65%

SUSTAINABILITY

O43 Bank staff - % of all staff pay 6.20% 8.82% 6.76% 6.31% 6.51% 6.70% 6.22% 5.98% 6.24% 7.58% 6.37% 5.88% 6.32% 6.19% 7%

O44 Agency staff - % of all staff pay 6.48% 5.61% 8.54% 9.03% 10.36% 9.75% 10.69% 10.01% 9.40% 8.25% 7.45% 7.18% 6.22% 6.95% 2%

O45 Nurse : occupied bed ratio 1.944 1.949 1.982 1.875 1.844 1.826 1.904 1.800 1.789 1.813 1.795 1.824 1.868 1.860 -

O46 % nurses who are registered 71.65% 71.69% 71.64% 71.56% 71.42% 71.16% 70.76% 70.44% 70.37% 69.88% 69.92% 69.99% 69.84% 69.92% -

O47 % Staff appraised 76.69% 77.40% 78.70% 78.29% 79.41% 81.80% 81.90% 79.70% 78.23% 79.94% 79.82% 82.20% 81.12% 81.12% 90%

Sickness Absence: % Sickness 3 O48 3.65% 3.93% 3.86% 3.74% 3.83% 4.04% 4.14% 4.08% 3.78% 3.73% 3.66% 3.45% #N/A 3.82% 3.3% (reported one month in arrears)

O49 Staff Turnover: Turnover rate (YTD position) 8.87% 9.01% 9.16% 9.51% 9.37% 9.35% 9.18% 9.16% 9.13% 8.73% 8.54% 8.49% 8.44% 8.44% 11%

ACTIVITY

A01 Day Cases 5,395 5,518 4,950 5,252 5,491 5,600 5,220 5,320 5,437 5,099 5,232 5,231 5,840 16,303 15,214

A02 Elective Inpatients 819 836 671 679 685 687 586 605 534 499 605 650 683 1,938 2,101

A03 Non-elective inpatients 5,174 5,441 5,062 5,112 5,572 5,383 5,752 5,448 5,616 5,973 5,507 5,698 5,667 16,872 16,452

A04 Outpatient First attendances 17,861 16,981 14,319 17,079 15,991 16,775 15,202 15,310 15,692 15,681 15,705 16,142 17,429 49,276 49,172

A05 Outpatient Follow-up attendances 29,938 28,932 24,129 28,198 27,850 28,193 25,502 27,241 27,258 26,583 26,652 27,487 28,555 82,694 82,821

A06 Outpatients with procedure 6,095 5,878 5,095 5,761 5,541 5,377 5,412 5,714 5,618 5,206 5,551 5,871 6,147 17,569 17,064

A07 A&E Attendances 11,508 12,068 11,682 11,276 11,651 10,880 10,820 10,904 10,951 12,455 11,170 12,453 11,793 35,416 34,634 Notes 1 National reporting for these performance measures is on a quarterly basis. Data are subject to change up to the final submission deadline due to ongoing data validation and verification. 2 Data are provisional best estimates and will be amended to reflect the position signed-off in the relevant statutory returns in due course. 3 Staff sickness is reported one month in arrears.

9b. Operational performance scorecard.xlsx.SCORECARD Page 2 of 3 Printed 22/07/2016 09:27 Activity Trending

Activity

Day cases Elective Inpatients Non-elective Inpatients 2016/17 2014/15 2015/16 2016/17 2014/15 2015/16 6,000 900 2016/17 2014/15 2015/16 6,500 5,500 800 6,000 5,500 5,000 700 5,000 4,500 4,500 600 4,000 4,000 3,500 3,500 500 3,000 3,000 400 M02 (May) M04 (Jul) M04 M10 (Jan) M10 M07 (Oct) M07 M03 (Jun) M03 M01 (Apr) M11 (Feb) M11 M12 (Mar) M09 (Dec) M09 M06 (Sep) M06 M05 (Aug) M08 (Nov) M08 M02 (May) M04 (Jul) M04 M04 (Jul) M04 M10 (Jan) M10 M07 (Oct) M07 M03 (Jun) M03 M01 (Apr) M10 (Jan) M10 M07 (Oct) M07 M11 (Feb) M11 M03 (Jun) M03 M01 (Apr) M12 (Mar) M11 (Feb) M11 M09 (Dec) M09 M06 (Sep) M06 M05 (Aug) M08 (Nov) M08 M12 (Mar) M09 (Dec) M09 M06 (Sep) M06 M05 (Aug) M08 (Nov) M08 M02 (May) First Outpatients Follow-up Outpatients Outpatients with procedure 2016/17 2014/15 2015/16 2016/17 2014/15 2015/16 2016/17 2014/15 2015/16 16,000 27,000 6,500 6,000 15,000 25,000 5,500 14,000 23,000 5,000 4,500 13,000 21,000 4,000 12,000 19,000 3,500 11,000 3,000 17,000 2,500 10,000 15,000 M11 M12 M09 M06 M08 M05 M02 (Feb) (Mar) (Dec) (Sep) (Aug) (Nov) (May) M04 (Jul) M10 M03 M07 M01 M04 (Jul) M04 M11 M12 M09 M06 M08 M05 M02 (Jan) (Oct) (Jun) (Apr) (Feb) M10 (Jan) M10 M07 (Oct) M07 M03 (Jun) M03 M01 (Apr) (Mar) (Dec) (Sep) M11 (Feb) M11 (Aug) (Nov) M12 (Mar) M09 (Dec) M09 M06 (Sep) M06 (May) M05 (Aug) M08 (Nov) M08 M02 (May) M04 (Jul) M04 M10 (Jan) M10 M07 (Oct) M07 M03 (Jun) M03 M01 (Apr) A&E Attendances (age 0-64) A&E Attendances (age 65-84) A&E Attendances (age >85) 2016/17 2014/15 2015/16 2016/17 2014/15 2015/16 2016/17 2014/15 2015/16 10,000 2,600 1,200 2,500 9,000 1,100 2,400 8,000 2,300 1,000 2,200 7,000 2,100 900 2,000 6,000 800 1,900 5,000 1,800 700 1,700 4,000 1,600 600 Notes M04 (Jul) M04 M04 (Jul) M04 M10 (Jan) M10 M04 (Jul) M04 M07 (Oct) M07 M03 (Jun) M03 M01 (Apr) M11 (Feb) M11 M12 (Mar) M09 (Dec) M09 M06 (Sep) M06 M05 (Aug) M08 (Nov) M08 M10 (Jan) M10 M07 (Oct) M07 M10 (Jan) M10 M03 (Jun) M03 M07 (Oct) M07 M02 (May) M01 (Apr) M03 (Jun) M03 M01 (Apr) M11 (Feb) M11 M11 (Feb) M11 M12 (Mar) M09 (Dec) M09 M12 (Mar) M06 (Sep) M06 M09 (Dec) M09 M06 (Sep) M06 M05 (Aug) M08 (Nov) M08 M05 (Aug) M08 (Nov) M08 M02 (May) M02 (May) Emergency Admissions (age 0-64) Emergency Admissions (age 65-84) Emergency Admissions (age >85) 2016/17 2014/15 2015/16 2016/17 2014/15 2015/16 2016/17 2014/15 2015/16 2,600 1,800 950 2,400 1,700 900 2,200 1,600 850 2,000 1,500 1,800 1,400 800 1,600 1,300 750 1,400 1,200 700 1,200 1,100 650 1,000 1,000 600 M12 M12 M09 M09 M06 M06 M08 M08 M05 M05 M02 M02 (Mar) (Mar) (Dec) (Dec) (Sep) (Sep) (Aug) (Aug) (Nov) (Nov) Notes (May) (May) M04 (Jul) M04 (Jul) M04 M10 (Jan) M10 (Jan) M10 M07 (Oct) M07 (Oct) M07 M03 (Jun) M03 (Jun) M03 M01 (Apr) M01 (Apr) M11 (Feb) M11 (Feb) M11 M04 (Jul) M04 M10 (Jan) M10 M07 (Oct) M07 M03 (Jun) M03 M01 (Apr) M11 (Feb) M11 M12 (Mar) M09 (Dec) M09 M06 (Sep) M06 M05 (Aug) M08 (Nov) M08 M02 (May)

Please Note: Outpatient currencies have excluded physiotherapy and clinical physiology from trend information as these currencies distort numbers due to changes to counting for these areas.

Page 3 of 3 22/07/20169b. Operational performance scorecard.xlsx Mark Dennis, Head of Information Services t: 01903 285273 (ext 5273)

JUNE 2016 Monitor Risk Assessment Framework Weighted Weighted Weighted Weighted Score Threshold Apr May Jun Q1 Score Jul Aug Sep Q2 Score Oct Nov Dec Q3 Score Jan Feb Mar Q4 (Forecast) ACCESS Maximum time of 18 weeks from point of referral to treatment in M3 92% 86.95% 88.15% 88.35% 86.95% 1.0 aggregate – patients on an incomplete pathway A&E: maximum waiting time of four hours from arrival to M5 95% 96.28% 95.67% 95.64% 95.85% 0.0 admission/transfer/discharge

M6a All cancers : 62-day wait for first treatment following urgent GP Referral 85% 86.09% 86.45% 85.42% 85.97% 0.0 All cancers : 62-day wait for first treatment following consultant screening M6b 90% 93.62% 96.08% 92.59% 94.08% service referral All cancers : 31-day wait for second or subsequent treatment - surgery M7a 94% 100.00% 100.00% 100.00% 100.00% treatments 0.0 All cancers : 31-day wait for second or subsequent treatment - drug M7b 98% 100.00% 100.00% 100.00% 100.00% treatments

M8 All cancers : 31-day wait from diagnosis to first treatment 96% 99.14% 99.62% 99.63% 99.48% 0.0

M9a Cancer : two week wait from referral to date first seen - All patients 93% 95.42% 97.18% 96.92% 96.52% 0.0 Cancer : two week wait from referral to date first seen - Symptomatic M9b 93% 96.75% 97.24% 96.92% 96.93% breast patients OUTCOMES

M17 Clostridium Difficile – meeting the Clostridium Difficile objective 39 5 6 2 13 0.0 Certification against compliance with requirements re access to healthcare M27 YES YES YES YES YES 0.0 for people with a learning disability Monitor Compliance Framework Score 1

Green : 0 Amber/Green : 1 Amber : 2 Amber/Red : 3 Red : 4 or more Notes

9c. Monitor scorecard.xlsx.SCORECARD Page 1 of 1 Printed 22/07/2016 09:27

To: Trust Board Date of Meeting: 28 July 2016 Agenda Item: 10

Title: Organisational Development and Workforce Performance Report Responsible Executive Director Denise Farmer, Director of Organisational Development and Leadership Prepared by: Jo Fanning, Head of Employee Relations Status: Disclosable Summary of Proposal: This report details the Trust’s performance in relation to the supply, development and engagement of its workforce and the organisations culture. Implications for Quality of Care: Provision of high quality, engaged staff has a direct impact on the quality of care. Financial Implications: Supports good financial performance. Human Resource Implications: As described. Recommendation The Board is asked to NOTE the report. Consultation: N/A Appendices: 1: New Staff Engagement Questionnaire 2: Workforce Scorecard

This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288.

To: Trust Board Agenda Item: 10

From: Denise Farmer, Director of Organisational Development and Leadership Date of Meeting: 28 July 2016

FOR INFORMATION

ORGANISATIONAL DEVELOPMENT AND WORKFORCE REPORT

1.00 INTRODUCTION 1.01 This sets out the key headlines relating to the Trust’s workforce at 30 June 2016.

2.00 SUMMARY OF PROPOSAL 2.01 Workforce Capacity The funded establishment was reduced in June, this reflected our expectation of reducing beds however those beds did remain open during the month due to activity pressures.

The number of substantive staff employed in the Trust increased again by a further 19 during June and accounted for 89% of total capacity used. This increase has been experienced across all divisions, except Corporate areas, and reflects the continuing activities to recruit and retain staff.

Since June 2015 the number of staff employed has grown by 269 wte, reflecting the significant investment made in our workforce.

The level of temporary staffing used fell below 10% in month and is at its lowest level over the last 12 months. Agency usage decreased to 3.5% of total capacity used. Spend fell by £231k in month with a £108k reduction in nurse agency spend. Whilst reducing our reliance, and spend, on temporary staffing remains a challenge, wards in particular are working very hard to develop and deploy a range of strategies to reduce reliance on agency staff.

With effect from 1 July 2016, the new price caps (i.e. maximum rates payable to individuals) were implemented. These have been reinforced with agencies and are being applied and monitored on a weekly basis. Daily approval of agency requests continues to be in place.

2.02 Recruitment Local recruitment of Band 5 qualified nurses is nearing saturation and in an effort to re-vitalise and widen interest, an innovative Facebook campaign has been developed with support from the Communications team. This will be piloted for registered nurses in the first instance from the beginning of August and if successful has the potential to be rolled out for medical, scientific, professional and technical staff.

A Trust-wide careers fayre is currently being scoped to take place during early October. This will provide an opportunity to learn more about the range of careers available in the Trust and invite applications for vacancies. Further details will be provided during September.

2.03 Staff retention Staff retention has improved again in month and is currently 8.4% over a rolling 12 month period. The Core Division continues to be above average at 10.8% and is being reviewed through a divisional working group.

A new starters forum for nursing staff has been established and a series of events have been held where staff can talk about what motivates and engages them as well as concerns and issues in the workplace. This well-attended forum, led by Kimberly O’Hara and Nikki Kriel, will take place on a monthly basis across the Trust and themes emerging, that cannot be immediately addressed, will be collated to inform corporate retention initiatives.

2.04 Postgraduate Doctors in Training Following the outcome of the junior doctors’ referendum to reject the new terms and conditions of service, implementation of the new contract will now proceed without agreement. The timetable for implementation has been revised and will mean that with the exception of paediatrics, roll out will move from October 2016 to January 2017, when the majority of junior doctors in other specialties will rotate.

This revised timetable does provide time to design and cost the rosters in line with the new safety rules prior to implementation. Project management will recommence following the changeover on 3 August 2016.

At this stage it is unknown whether further industrial action will follow and it remains the Trust’s intention to seek early engagement with junior doctors and their representatives over the introduction of the revised terms and conditions.

In the meantime, Dr Patrick Carr, has been appointed as the Trust’s Guardian for Safe Working Hours.

2.05 Junior doctor changeover Changeover of junior doctors commences on 3 August, with induction and shadowing of Foundation Year 1 taking place between 28 July and 2 August. At the time of writing 40.8 wte posts remain vacant, the majority of which are within Medicine (Elderly Medicine and Accident and Emergency). Recruitment will continue and efforts to secure temporary staffing are being made.

2.06 Appointment to Chief of Service posts With the exception of the Surgery Division, appointments have been made to the Chiefs of Service and Deputy Medical Director posts, effective from 1 August, as follows:

Medicine Division – Dr Amanda Wellesley Core Division – reappointment of Mr David Beattie Women and Children – reappointment of Dr Tim Taylor Deputy Medical Director – Dr Tim Taylor

The Board will want to acknowledge and thank Mr Paul Carter, Consultant Urologist and outgoing Chief of Surgery, for his significant contribution over the last 4 years.

2.07 Equality and Diversity The Trust’s Workforce Race Equality Standard (WRES) action plan approved by the Board last month has now been uploaded on the website. Progress of the action plan will continue to be monitored through the Diversity Matters steering group.

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I am pleased to advise that Anil Mathew, Director of Continuous Improvement, has agreed to lead the recently established Celebrating Cultures forum supporting us to re-engage and reach out to our culturally diverse staff.

2.08 Workforce Efficiency During May sickness absence fell to 3.4% across all divisions resulting in a rolling 12 month sickness rate of 3.8%. Whilst short term absence decreased in month, there was a small rise in the percentage of staff on long term sickness specifically within Corporate areas where stress-related absence increased.

There is a renewed focus to address absence within nursing areas and understand the root causes within Theatres and the Emergency Floors where high sickness is a significant contributor to the staffing pressures they experience.

2.09 Appraisals The appraisal rate at the end of June was 81%, representing a small reduction since last month. Divisions have been asked to ensure that a short objective setting meeting is held within the first 3 months for a new starter. The appraisal status of a new starter does not commence until month 4 in-post and this intervention will therefore improve compliance. Managers are also reminded to undertake a short appraisal prior to a member of staff starting maternity leave.

2.10 Staff Family and Friends Test During June 81 staff participated in the Staff Family and Friends Test with 75.9% recommending the Trust as a place to work and 91.4% happy with the standard of care if a friend or relative needed treatment.

Since 11 July, staff attending the revised health and safety training day are being asked to complete a new staff engagement questionnaire as part of a facilitated session. This incorporates the 9 questions used in the annual staff survey to measure engagement and enables us to reproduce, on a monthly basis, that staff engagement score. This will be available from next month. A copy is attached in appendix 1. Based on the response to date, it is anticipated that more staff will complete the questionnaire, providing richer feedback.

2.11 Workforce Skills and Development Statutory and Mandatory Training Attendance on all mandatory training is above the Trust’s target of 90% on all core mandatory modules. The high volume of new starters (120 in June) is continuing to provide challenges and cost pressures to provide sufficient training for all new staff.

A new enhanced “Your Health & Safety Day” was launched on 11 July. The old Health & Safety Update has been extended to a day (9.00-16.00) to emphasise its importance in helping staff keep themselves and patients safe, and equipping staff to do a good job. It now includes a session on the Western Sussex Way customer care programme, and a session on Patient First. The day included a number of participative activities and entertaining film clips. Feedback on the Western Sussex Way session was extremely positive and included; ”engaging”, “lively and fun”, “a great way to start the day”. The feedback on the first Patient First session indicated that getting some of the new concepts across to staff is challenging and so, in true continuous improvement style, some changes have already been implemented. A full evaluation of the new style day will be undertaken at the end of September. Page 3 of 7

During the day delegates were also asked to participate in a short Staff Engagement survey. We were delighted to achieve a 99% level of participated in the first week. The results of these surveys will be published monthly and used to identify ways of improving the experience of our staff in support of the Trust’s Patient First programme.

Progress re staff who have never attended any mandatory training The number of staff who have never attended any mandatory training (and started in the Trust more than 3 months ago) has decreased and is currently 3 (figure for last month was 7).

All of those who have not completed any mandatory training are Medical staff. Two of the three on the list have joined the Trust in the last 6 months and are yet to complete their Induction. The names of all the individuals will be escalated to Chiefs/ DDOs and we will continue to work with Divisions to ensure that these individuals completed their training as soon as possible. Staff Conference This year’s Staff Conference, “Where Better Never Stops”, will be held at Fontwell Park Race- course on 25 October and 1 November. There will be an opportunity for 600 staff to attend one of these events (10%) of the workforce. In addition the conference will be filmed this year and the presentations will be available to other staff as Ted Talk type video clips on Staffnet. This year’s theme is innovation and we will be presenting some of the Trust’s biggest achievements in innovation in the last 12 months.

2.12 Communications and Engagement Annual General Meeting The Communications team has been working with the Company Secretary, Finance and Research and Development teams to organise the Trust’s Annual General Meeting and Annual Members Meeting. This includes finalising the Trust’s Annual Report and Accounts for 2016/17. The report was submitted to Parliament on Friday 24 June and presented to the Council of Governors at the AGM on 21 July. There are a number of additional publications available, both as printed copies and on our website, including the Trust’s Annual Review, Quality Report and At-a-Glance.

Recruitment The Communications team has continued to support recruitment activities and has used social media channels, including Facebook and Twitter, to promote the trust as an excellent place to work. A recruitment brochure and additional content has also been produced, which is available view on the trust’s website at www.westernsussexhospitals.nhs.uk/Recruitment.

Patient First STAR Awards The second annual Patient First staff recognition awards took place on Thursday 23 June. More than 170 guests attended the event, sponsored by LYH Charity and Comfort Keepers UK at Fontwell Racecourse. The winners were also revealed live on the Trust’s Facebook and Twitter accounts and can also be found in the news pages of the Trust website along with a film of the evening.

Patient First video Contributions have been sought from a wide variety of colleagues to a new film about the Patient First programme being produced by the Communications team. The project seeks to explain to staff how the trust’s improvement initiative is evolving across the organisation and aims to inspire and empower them to participate in the “continuous improvement” journey. The film will be made available at westernsussexhospitals.nhs.uk at the end of July.

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High profile visits The Trust continues to receive interest from high-profile global healthcare professionals and improvement experts and the Communications team has supported their visits and resultant events for staff. In the past month guests have included representatives from Salford Royal NHS Foundation Trust.

Board Meetings Members of the public are welcome to attend our Trust Board meetings which begin at 10am on the following dates:

 28 July 2016 | John Bull Conference Room, Worthing Hospital  There is no board meeting planned in August 2016  29 September 2016 | John Bull Conference Room, Worthing Hospital  27 October 2016 | Bateman room, St Richard’s Hospital  1 December John Bull Conference Room, Worthing Hospital  There is no board meeting planned in late December 2016

The Trust’s Council of Governors meetings are also open to the public and we look forward to welcoming you to the next meeting on 11 October 2016, Mickerson Hall, Chichester Medical Education Centre (CMEC) St Richard’s Hospital. Meeting commences at 1.30pm.

There is no requirement to register your attendance at Trust board or Council of Governors meetings.

Stakeholder Forum Our next event will take place at Worthing Hospital in the Health Education Centre (WHEC) on Thursday 1 September, 10.30am. All welcome. To reserve a place at this event please email [email protected] or call 01903 205111 ext 84038.

3.0 RECOMMENDATION The Board is asked to NOTE the report.

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Staff Engagement - Where better never stops!

Staff Engagement is very important in this organisation. Individuals who are highly engaged in their work think and behave positively, are emotionally resourceful and have better health. This leads to increased levels of performance at work and ultimately improves the experience of our patients. Happy staff, happy patients. We have identified key questions that will help the Trust measure staff engagement in the organisation. Please read each question carefully, and give your immediate response by putting an X in the box which best matches your personal view. Please then hand the completed questionnaire to a member of the Learning & Development Team at the end of the day. The responses you provide will remain anonymous and will be used to inform how we can improve the experience of our staff in support of the Trust’s Patient First Improvement Programme. We will publish the results monthly together with how we intend to respond and what actions and interventions have been taken as a result. Core Corporate Facilities & Medicine Surgery Women & What division do you Estates Child Health work for?

Admin & Allied Health Estates and Nursing & Prof Medical & Other What is your staff Clerical Professional Ancillary Midwifery Scientific Dental group? s Technical

Neither To what extent do these statements reflect Extremely Extremely Unlikely likely nor Likely your view of your organisation as a whole? unlikely likely unlikely

How likely are you to recommend WSHFT to friends and family as a place to work? 1 2 3 4 5 How likely are you to recommend WSHFT to friends and family if they needed care or treatment? 1 2 3 4 5

Neither To what extent do these statements reflect Strongly Strongly Disagree agree nor Agree your view of your organisation as a whole? disagree agree disagree

Care of patients / service users is my

organisation’s top priority. 1 2 3 4 5

For each of the statements below, how often Never Rarely Sometimes Often Always do you feel this way about your job?

I look forward to going to work. 1 2 3 4 5

I am enthusiastic about my job. 1 2 3 4 5

Times passes quickly when I am working. 1 2 3 4 5

Neither To what extent do you agree or disagree with Strongly Strongly Disagree agree nor Agree the following statement about your work? disagree agree disagree

There are frequent opportunities for me to show

initiative in my role. 1 2 3 4 5

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I am able to make suggestions to improve the work

of my team / department. 1 2 3 4 5

I am able to make improvements happen in my

area of work. 1 2 3 4 5 Thank you for your time.

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WSHFT WORKFORCE SCORECARD June 2016

2016/17 Target/ Key performance Indicators Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun YTD Ceiling Amber Limit Trend 1) WORKFORCE CAPACITY NB Budgeted FTE 6437.3 6439.3 6520.1 6537.5 6538.4 6572.0 6602.0 6603.3 6603.5 6603.5 6638.6 6650.0 6626.5 6638.4 N/A N/A

Total FTE Used 6339.3 6337.6 6524.3 6362.1 6451.8 6481.0 6558.3 6431.0 6593.0 6653.5 6602.7 6570.1 6566.7 6579.8 N/A N/A

Total FTE Used Variance from Budget -98.1 -101.8 4.3 -175.4 -86.5 -91.0 -43.6 -172.3 -10.4 50.1 -35.8 -79.9 -59.8 N/A N/A N/A

Total FTE Used Vacancy Factor 1.5% 1.6% -0.1% 2.7% 1.3% 1.4% 0.7% 2.6% 0.2% -0.8% 0.5% 1.2% 0.9% 0.9% N/A N/A

Substantive Contracted FTE 5646.9 5627.8 5797.8 5641.8 5677.9 5703.5 5741.8 5774.7 5816.5 5863.7 5873.0 5896.5 5915.5 5895.0 N/A N/A

Substantive FTE Worked 5540.3 5531.8 5547.4 5496.1 5540.4 5603.8 5623.0 5654.1 5716.7 5757.1 5773.7 5798.9 5810.9 5794.5 N/A N/A

Substantive FTE Used Vacancy Factor 12.3% 12.6% 11.1% 13.7% 13.2% 13.2% 13.0% 12.5% 11.9% 11.2% 11.5% 11.3% 10.7% 11.2% N/A N/A

Bank Usage As % Of Total FTE Used 7.9% 7.2% 7.3% 7.3% 7.0% 7.3% 7.0% 5.0% 6.9% 7.1% 6.6% 6.2% 6.4% 6.4% N/A N/A

Agency Usage As % Of Total FTE Used 3.0% 4.0% 3.8% 4.0% 5.0% 4.7% 5.5% 5.2% 4.9% 4.7% 4.5% 4.1% 3.5% 4.0% N/A N/A 2) WORKFORCE EFFICIENCY NB Rolling 12 Month Sickness Absence 1 4.1% 4.1% 4.1% 4.1% 4.0% 4.0% 4.0% 3.9% 3.9% 3.8% 3.9% 3.8% N/A 3.3% 3.3%

In Month Sickness Absence % 3.7% 3.9% 3.8% 3.7% 3.8% 4.0% 4.1% 4.1% 3.8% 3.7% 3.7% 3.4% 3.6% 3.3% 3.3%

In Month Maternity Leave % 2.5% 2.5% 2.5% 2.6% 2.5% 2.5% 2.5% 2.4% 2.3% 2.2% 2.2% 2.1% 2.1% N/A N/A

In Month Other Absence % 1.3% 1.3% 1.0% 1.5% 1.5% 1.9% 1.4% 1.5% 1.6% 1.7% 1.7% 1.7% 1.7% N/A N/A

In Month Total Absence % 7.5% 7.7% 7.3% 7.8% 7.9% 8.4% 8.0% 8.0% 7.7% 7.6% 7.6% 7.3% 7.4% N/A N/A

Sickness Episodes 1170 1168 1095 1220 1393 1327 1432 1472 1379 1512 1336 1243 N/A

Maternity Heads 193 179 183 186 181 184 185 175 173 168 169 161 N/A N/A N/A

In Month Long Term Sickness Absence % (28 Days Or More) 1.9% 2.1% 2.0% 1.9% 1.8% 1.9% 2.1% 1.8% 1.6% 1.5% 1.5% 1.7% 1.6% N/A N/A

In Month Short Term Sickness Absence % (<28 days) 1.7% 1.8% 1.7% 1.9% 2.0% 2.1% 2.0% 2.2% 2.2% 2.3% 2.1% 1.8% 1.9% N/A N/A

In Month Stress Related Sickness Absence % 0.7% 0.7% 0.6% 0.6% 0.6% 0.7% 0.6% 0.6% 0.7% 0.6% 0.5% 0.6% 0.5% N/A N/A

In Month Musculo Skeletal Sickness Absence % 0.7% 0.9% 0.8% 0.8% 0.7% 0.9% 0.9% 0.7% 0.7% 0.6% 0.7% 0.6% 0.6% N/A N/A

Number of Staff breaching Management Triggers for sickness absence 1003 1025 1011 989 977 979 943 939 950 962 988 1002 N/A

% of Staff (headcount) 15.1% 15.4% 15.2% 14.9% 14.6% 14.5% 14.0% 13.8% 14.0% 13.9% 14.3% 14.5% N/A

Rolling 12 Month Turnover 8.9% 9.0% 9.2% 9.5% 9.4% 9.4% 9.2% 9.2% 9.1% 8.7% 8.5% 8.5% 8.4% N/A 11.0% 11.0% 3) TRAINING & PERSONAL DEVELOPMENT NB % Appraisals Up To Date 76.7% 77.4% 78.7% 78.3% 79.4% 81.8% 81.9% 79.7% 78.2% 79.9% 79.8% 82.2% 81.1% N/A 90.0% 80.0%

% In Date - All Mandatory Training 2 82.9% 81.5% 80.5% 79.6% 80.4% 81.5% 83.8% 82.2% 81.8% 81.5% 81.0% 84.0% 84.0% N/A 90.0% 80.0%

% In Date - Fire 90.9% 89.1% 89.8% 89.8% 90.2% 90.6% 92.6% 91.2% 90.6% 90.3% 89.0% 92.2% 91.1% N/A 90.0% 80.0%

% In Date - Infection Control (Role Specific) 91.3% 89.0% 89.5% 88.4% 89.2% 90.2% 92.3% 90.7% 90.5% 89.3% 88.6% 91.6% 91.1% N/A 90.0% 80.0%

% In Date - Back Training (Role Specific) 92.0% 91.3% 91.7% 91.5% 92.3% 91.7% 92.8% 92.6% 92.6% 92.8% 92.5% 94.1% 94.3% N/A 90.0% 80.0%

% In Date - Child Protection (Role Specific) 97.5% 96.1% 96.2% 96.0% 96.1% 95.9% 96.6% 95.9% 96.1% 95.9% 95.3% 96.3% 96.4% N/A 90.0% 80.0%

% In Date - Information Governance 90.7% 88.3% 87.5% 87.3% 87.7% 88.2% 90.7% 89.2% 89.3% 88.6% 88.1% 91.1% 90.4% N/A 90.0% 80.0%

% In Date - Adult Protection 90.2% 89.6% 90.9% 92.2% 93.6% 94.2% 95.5% 95.3% 95.8% 95.8% 95.6% 97.1% 97.2% N/A 90.0% 80.0%

Number of Staff with no mandatory training 9 6 8 7 6 11 13 13 12 7 8 7 3 N/A

Number of Staff > 12 months since any mandatory training 0 0 0 0 0 0 0 0 0 0 0 0 0 N/A 4) REAL-TIME STAFF FEEDBACK NB Total Respondents To Survey 158 52 91 112 80 46 29 107 1 30 116 82 81 279 N/A N/A

% Respondents who would recommend this trust as a place to work 69.8% 63.5% 83.5% 83.0% 71.3% 69.6% 72.4% 75.7% 100.0% 86.7% 85.3% 84.1% 75.9% 82.3% N/A N/A

% Respondents happy with standard of care if a friend/relative needed treatment 83.0% 80.8% 89.0% 91.1% 88.8% 80.4% 89.7% 86.9% 100.0% 93.3% 91.4% 96.3% 91.4% 92.8% N/A N/A

Notes: 1 Absence data is available one month in arrears 2 An employee is counted as being up to date with all their mandatory training if their Fire, Infection Control, Back, Child Protection amd Information Governance training is up to date.

To: Trust Board Date of Meeting: 28 July 2016 Agenda Item: 11

Title Financial Performance Report – Month 3 Presented by Karen Geoghegan, Director of Finance Prepared by Alison Ingoe, Deputy Director of Finance David Lowe, Assistant Director of Finance Status Disclosable Summary of Proposal At the end of June, the Trust is reporting an underlying deficit (excluding STF income) of £0.73m compared to a planned deficit of £0.75m. Delivery of the financial control total along with the agreement of trajectories for key access targets means that the Trust will receive £3.3m of income from the Sustainability and Transformation Fund for Q1. The Trust is reporting an FSR rating of '3' in line with its financial plan. The attached report provides further commentary and analysis of the financial position. Implications for Quality of Care Financial planning principles have been established to ensure that expenditure budgets reflect anticipated activity levels and that agreed staffing levels are maintained. Support for/integration with Corporate Objectives and Strategies G1. Maintain an acceptable financial risk rating. Financial Implications These are noted within the Financial Performance Report. Human Resource Implications N/A Recommendation The Board is asked to NOTE the report. Consultation N/A Appendices N/A

This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288. Finance Report M3 2016/17

Summary At the end of June, the Trust is reporting an underlying deficit (excluding STF income) of £0.73m compared to a planned deficit of £0.75m. Delivery of the financial control total along with the agreement of trajectories for key access targets means that the Trust will receive £3.3m of income from the Sustainability and Transformation Fund for Q1. The Trust is reporting an FSR rating of '3' in line with its financial plan.

Financial Sustainability Risk Rating G Control Total (exc STF) Surplus £k G Agency Ceiling £k G

Plan Actual / Forecast Plan Actual / Forecast Plan Actual/Forecast Year to Date 3 3 Year to Date £k (753) (726) Year to Date £k 6,227 4,899 Year End Forecast 4 4 Year End Forecast £k 3,234 3,234 Year End Forecast £k 17,249 17,249

The Trust is reporting a Financial Sustainability Risk Rating (FSRR) of '3' at the At the end of Q1, the Trust has achieved its financial trajectory, excluding STF Agency expenditure decreased by £0.25m in June with reductions in both nurse agency and end of June, in line with its financial plan. funding. Income over performed against plan and the underlying non pay allied health professionals. The Trust is £1.33m below the ceiling for Q1. Nurse agency expenditure, adjusting for PbR excluded drugs and devices; was on trajectory. Pay spend reduced in month but remains above ceiling and is offset by other staff groups. was adverse to plan in June but has been offset by income over-performance.

Income £k G Operating Costs £k A Agency Expenditure A Expenditure as % of Total Paybill (monthly) 2014/15 2015/16 2016/17 Plan Actual / Forecast Plan Actual / Forecast Medical 12.5% 11.0% 6.9% Year to Date £k 108,166 108,471 Year to Date £k (99,239) (99,844) Nursing 4.4% 6.6% 8.4% Year End Forecast 434,915 434,915 Year End Forecast £k (392,958) (392,958) Other Staff Groups 3.1% 2.5% 3.1% All Agency 6.3% 6.5% 6.2% At the end of June income is 0.3m above plan. Income from activities is £0.9m Pay is above plan in June within both Nursing and Allied Health Professionals. Use of above plan due to high activity levels and increased PbR excluded drugs beds above planned levels and recruitment challenges in key staff groups meant that Nurse agency continued to reduce and spend in month was £0.76m. Continued and focused expenditure. Private patient income continues to under-perform. although expenditure reduced it did not achieve planned reductions in full. Vacancies effort will be need to ensure that spend in this area continues to reduce. Compliance with in the other staff groups are partially offsetting the staff groups above plan. Non pay is capped rates declined in June and so further work is required in clinical staff groups to above plan, with the largest drivers being PbR excluded drugs and clinical supplies. improve compliance with capped rates for individual assignments. The underlying non-pay position is on plan.

Cash £k A Capital £k A Efficiency and Transformation Programme £k A

Plan Actual Plan Actual / Forecast Plan Actual / Forecast Year to Date £k 2,697 6,042 Year to Date £k 5,322 1,386 Year to Date £k 4,532 4,337 Year End Forecast £k 12,931 12,931 Year End Forecast £k 16,812 16,812 Year End Forecast £k 19,159 18,865

The cash position is ahead of plan due to the impact of slippage on the capital The capital programme under-spent by £3.9m due to later start dates on some At the end of June, the Efficiency Programme delivered cumulative savings of £4.3m against programme. programmes. Slippage is expected to be recovered during Q2 so that projects are a plan of £4.5m (95.7%). not delayed.

Key Risks: 1. Ability to exit premium rate workforce arrangements. Vacancies and long-term sickness in key staff groups are driving agency expenditure. The Workforce Transformation Group is overseeing action plans to increase recruitment, redesign workforce roles and manage sickness, rostering and retention issues. Opportunities to move to framework agency and reduce rates paid per shift are also being explored. A weekly review of tactical actions to manage pay expenditure is taking place. 2. Management of patient flow to ensure that activity is able to be delivered within funded capacity and that numbers of patients medically fit for discharge are minimised and elective throughput is maximised. The Trust is working closely with health economy partners to ensure that the levels of fit for discharge patients and community bed capacity is managed. 3. Delivery of commissioner QIPP plans and impact on affordability for commissioners if plans do not deliver in full. The Trust is working in partnership with the CCG to agree implementation plans and monitoring arrangements. 4. Achievement of financial control on a quarterly basis and delivery of access trajectories to secure access to the Sustainability and Transformation Funds. The Trust needs to deliver further improvements in the financial position in order to secure the remaining £9.9m of STF funds. Q1 review meetings have been arranged with Divisions to review their current and forecast financial position. Finance Report M3 2016/17 G

The Trust is reporting a Financial Sustainability Risk Rating (FSRR) of '3'. The liquidity metric has remained as a 2, with the metric improving due to the in-month surplus and slippage on the capital programme. The remaining metrics have all improved since May, due to the improved run rate in month.

Financial Sustainability Risk Rating Plan Plan Actual Actual YTD Metric Rating Metric Rating Liquidity Ratio (7.9) 2 (7.3) 2

Capital Servicing Capacity Ratio 3.2 4 3.1 4

Income and Expenditure Margin 2.8% 4 2.6% 4

Variance in I&E margin as a % of income (1.8%) 2 (0.2%) 3

Financial Sustainability Rating 3 3

Financial Criteria SFP Weight Metric to be Definition Rating categories 4 3 2 1

Liquidity Ratio 25% Liquidity ratio (days) Working capital balance x 360 0.0 (7.0) (14.0) <(14.0) Annual operating expenses

Revenue available for capital service Capital Servicing Capacity Ratio 25% Capital servicing capacity (times) Annual debt service 2.5x 1.75x 1.25x <1.25x

Surplus/(Deficit) before exceptional items 1% 0% (1.0%) <(1.0%) Income and Expenditure Margin 25% I&E Margin (%) Total Operating and Non Op Income

Variance in I&E margin as a % of Actual Surplus/(Deficit) - Planned Surplus/(Deficit) 0% (1.0%) (2.0%) <(2.0%) I&E Plan Variance 25% income Operating Income Finance Report M3 2016/17 Surplus G

At the end of Q1 the Trust an underlying control total deficit £0.7m, in line with the plan for the same period. Achievement of the planned trajectory will result in the receipt of £3.3m of funding from the Strategic Transformation Fund. This will result in a reported surplus of £2.6m.

Year To Date Year Forecast Plan Actual Variance Plan Forecast Variance £k £k £k £k £k £k (Surplus) Deficit 2,547 2,574 27 (Surplus) Deficit 16,434 16,434 -

Income from activities increased during June, specifically within day cases and outpatients. Non elective activity remained above plan. For the first time this year, pay is adverse to plan in month despite a reduction in agency expenditure of £0.25m. Nursing costs remain high in substantive and bank as there are additional beds above planned levels and additional resources continue to be used to care for patients with Mental Health needs. Non Pay is above plan as a result of PbR excluded drug issues in June. Excluding these items, non-pay is on plan in totality.

Year to Date Full Year Prev Yr Actual Plan Actual Variance Plan Forecast Variance £k £k £k £k £k £k £k Income 99,013 108,166 108,471 304 Income 434,915 434,915 - Pay (65,709) (69,817) (70,057) (239) Pay (275,545) (275,545) - Non-Pay (tariff) (21,265) (22,092) (22,109) (17) Non-Pay (tariff) (91,096) (91,096) - Non-Pay (PbR exc) (7,392) (7,329) (7,678) (349) Non-Pay (PbR exc) (26,316) (26,316) - EBITDA * 4,646 8,927 8,626 (301) EBITDA * 41,957 41,957 -

Profit / Loss on Disposal of Fixed Assets 1 - 5 5 Profit / Loss on Disposal of Fixed Assets - - - Interest Payable (221) (228) (211) 17 Interest Payable (914) (914) - Interest Receivable 12 8 9 1 Interest Receivable 32 32 - Depreciation (3,542) (3,815) (3,701) 114 Depreciation (15,263) (15,263) - Impairments - - - - Impairments - - - Public Dividend Capital Dividend (1,879) (1,890) (1,890) 0 Public Dividend Capital Dividend (7,559) (7,559) - Net Surplus / (Deficit) (983) 3,002 2,838 (164) Net Surplus / (Deficit) 18,253 18,253 - less: Impairment - - - - less: Impairment - - - Retained Surplus/(Deficit) (983) 3,002 2,838 (164) Retained Surplus/(Deficit) 18,253 18,253 - Donated Assets (195) (658) (570) 88 Donated Assets (2,630) (2,630) - Donated Asset Depreciation and Amortisation 212 203 305 102 Donated Asset Depreciation and Amortisation 811 811 - Control Total including STF (967) 2,547 2,574 27 Underlying Operational Performance 16,434 16,434 - less Sustainability and Transformation Fund - (3,300) (3,300) - less Sustainability and Transformation Fund (13,200) (13,200) - Underlying Performance against Control Total excluding STF (967) (753) (726) 27 Performance against Control Total 3,234 3,234 - * EBITDA Earnings before Interest Taxation Depreciation and Amortisation

Control Total by Month Cumulative Control Total by Month 3,500 18,000

16,000 3,000 14,000 2,500

12,000

2,000 10,000

Budget Budget £000s 1,500 Actual £000s 8,000 Actual 6,000 1,000 4,000 500 2,000

0 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Finance Report M3 2016/17 Sustainability and Transformation Fund G

Guidance on how the access criteria for the Sustainability and Transformation fund will be applied was released at the beginning of July. Trusts are eligible to access the STF if, and only if they have delivered their year to date financial control total (excluding STF). If eligible then 70% of the available funds are released for delivery of the control total. The remaining 30% is dependent on delivery of trajectories for access targets. In Q1, funding is released if access trajectories have been agreed. Eligibility and delivery will be assessed on a quarterly basis.

At the end of Q1, the Trust delivered its control total and was therefore eligible for STF funding. The Trust has agreed performance trajectories with NHS Improvement for the access targets. The Trust therefore earned £3.3m of STF income, which was the maximum available for the quarter. This amount is secure and is not dependent on any future performance.

Actual Actual Actual Actual Apr-16 May-16 Jun-16 Q1 Q2 Q3 Q4 2016/17

Plan £000s (502) (264) (753) (753) 159 2,534 3,234 3,234 Financial Control Total (exc STF) Actual £000s (680) (791) (726) (726)

Eligible for STF Funding Yes

STF Income Available £000s 3,300 3,300 3,300 3,300 13,200

Delivery of Financial Control Total Achieved? No No Yes Yes Income 70.0% 2,310

A&E Waiting Times Achieved? Yes Yes Yes Yes Income 12.5% 413

RTT Achieved? Yes Yes Yes Yes Income 12.5% 413

Cancer Achieved? Yes Yes Yes Yes Income 5.0% 165

Diagnostic Waiting Times Achieved? Yes Yes Yes Yes Income 0.0% 0

Total STF Income Achieved (£000s) 3,300 Finance Report M3 2016/17 Income G

At the end of June income is 0.3m above plan. Income from activities is £0.9m above plan due to high activity levels and increased PbR excluded drugs expenditure. Private patient income continues to under-perform.

Year To Date Year End Forecast Prev Yr. Actual Plan Actual Variance Plan Forecast Variance £k £k £k £k £k £k £k Total Income 99,013 108,166 108,471 304 Total Income 434,915 434,915 0

At the end of June income from activities is £0.9m ahead of the Trust operational plan. Activity and income was above plan in month for Non-elective admissions, A&E attendances, Daycases and Outpatients. Elective activity was below plan in month. PbR excluded drugs cumulatively are ahead of plan by £0.3m. The reported income position includes £558k of seasonal resilience monies to reflect the initiatives agreed for M1 - M3 with the CCG and £3,300k of income from the Strategic Transformation Fund.

Private Patient activity has increased in June compared to May with a richer casemix of patients being treated, however, this area remains behind plan.

Year to Date Full Year Prev Yr Actual Plan Actual Variance Plan Forecast Variance Income £k £k £k £k Income £k £k £k

Clinical Commissioning Groups 83,980 77,297 78,205 908 Clinical Commissioning Groups 310,805 310,805 0 Specialist LAT 3,795 11,977 12,560 584 Specialist LAT 48,196 48,196 0 WSCC - Sexual Health 621 1,521 1,285 (236) WSCC - Sexual Health 5,973 5,973 0 NCA 595 2,253 1,885 (368) NCA 9,067 9,067 0 Other Trust Income 250 4,064 4,029 (35) Other Trust Income 16,762 16,762 0 Income From Activities 89,241 97,111 97,964 853 Income From Activities 390,802 390,802 0 Private Patients 1,516 2,052 1,592 (460) Private Patients 7,537 7,537 0 Education, Training and Research 2,560 3,375 3,559 184 Education, Training and Research 13,492 13,492 0 Donated Asset / Grant Income 195 658 570 (88) Donated Asset Income 2,630 2,630 0 Other Income 5,500 4,970 4,786 (184) Other Income 20,455 20,455 0 Other Operating Income 9,772 11,055 10,507 (549) Other Operating Income 44,113 44,113 0 Total Income 99,013 108,166 108,471 304 Total Income 434,915 434,915 0 of which : PbR Drugs/Devices 4,723 7,329 7,678 349

Monthly Income Monthly Income Yearly Comparison 37,500 38,000 37,000 37,000 36,500 36,000

36,000 35,000

35,500 34,000 £000 35,000 £000 33,000 34,500 32,000 34,000 31,000 33,500 30,000 29,000

33,000

Jul

Jan

Jun

Oct

Apr

Sep Feb

Dec

Aug Nov

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

Budget Actual 2015-16 2016-17 Finance Report M3 2016/17 Contract Performance G

The Trust reports income based on the contract monitoring position for prior months and an estimate of income for the current month based on priced and coded activity in the month as available. An estimate is made for the value of uncoded spells and missing days and included within the reported income position.

1) Context

The main contract with Coastal West Sussex CCG and associate CCGs was signed in early June. The contract with NHS England was signed at the end of June.

Baselines reflect out-turn position 15/16 plus growth. Coastal West Sussex CCG have included £2,172k of RTT activity in their contract offer. This reflects the CCG's estimate of the impact of QIPP schemes in relation to elective activity. Mechanisms to ensure close monitoring of activity levels and financial position are being established with CCG and NHSE in line with contractual agreements.

BPAS and Integrated Sexual Health Service (ISHS) contracts are in year 3 of 3 year contracts. ISHS with WSCC has moved to a cost per case tariff.

2) YTD Report

Trust internal monitoring information shows overperformance against the internal plan for NHSE and for the main CCG contract. Activity has been high in June, with A&E attendances, Daycases, Outpatients and non-elective admissions higher than planned, as outlined in the income report.

It is important to note that the performance indicated is compared to the Trust's plan and does not reflect the over-performance against commissioner contracts.

Table 1. Total Financial Values by Contract Table 2. Activity and Income by Point of Delivery

Activity Volumes £'000 Estimated Values for YTD June 2016 (incl CQUIN) £'000 Point of Delivery YTD Plan YTD Actual YTD Var YTD Plan YTD Actual YTD Var FYE Plan YTD Plan YTD Actual YTD Var Daycases 15,214 16,303 1,089 9,765 10,304 549 Coastal West Sussex (and associate CCGs) 310,805 77,297 78,205 908 Elective Spells 2,111 1,978 (133) 6,750 6,471 (279) NHS England 48,196 11,977 12,560 584 Elective Excess Bed days 526 599 73 138 138 (1) Integrated Sexual Health Services 5,973 1,521 1,285 (236) Non Elective Spells 13,713 13,829 116 25,681 26,451 801 Non Contract Activity 9,067 2,253 1,899 (354) Non Elective short-stay 2,739 3,043 304 2,469 2,391 122 - - - Non Elective Excess Bed days 6,559 7,705 1,145 1,443 1,735 292 Total 374,041 93,047 93,949 902 Outpatients 149,057 149,539 482 16,002 16,398 498 A&E 34,634 35,416 782 3,911 3,923 12 NB: Variances are reported against Western Sussex Hospitals Planned Income Levels PbR exclusions 7,329 7,748 419 Critical Care 3,546 3,649 103 Maternity Pathway 2,877 2,649 (228) OP Diagnostic Imaging 2,173 2,536 363 Sexual Health 1,274 1,255 (19) Direct Access Pathology 1,892 2,194 303 Other Direct Access (Imaging and Dietetics) 734 684 (50) Breast Screening 840 840 - Other 4,189 2,487 (2,044) CQUIN 2,035 2,095 61 Total 93,047 93,949 902

Table 3. - Reconciliation to Income Reporting Table 4. Contract Income by CCG and NHS England £000s FYE Plan YTD Plan YTD Actual SUSSEX CCGs and NHS ENGLAND £'000 This table represents the Trusts Contract Monitoring Performance 91,854 YTD Plan YTD Actual YTD Var assessment of the performance CQUIN 2.3% 2,095 NHS COASTAL WEST SUSSEX CCG 72,798 73,676 878 against commissioners only with NHS HORSHAM AND MID SUSSEX CCG 1,165 1,176 11 whom a Contract SLA has been Total Contracted Income 374,041 93,047 93,949 NHS BRIGHTON AND HOVE CCG 1,225 1,329 104 agreed. NHS HIGH WEALD LEWES HAVENS CCG 49 54 6 Income Recharged non-contract NHS CRAWLEY CCG 181 92 (89) There are some differences between Strategic Transformation Fund 13,200 3,300 3,300 NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG 55 62 7 the Trust's income plan and the Seasonal Resilience funding 3,000 557 558 NHS HASTINGS AND ROTHER CCG 32 16 (16) agreed contract values due to QIPP Horsham Older People's service 360 99 99 NHS SOUTH EASTERN HAMPSHIRE CCG 1,469 1,488 19 assumptions Maternity pathway payment (14) NHS PORTSMOUTH CCG 154 150 (4) Cystic Fibrosis 202 109 109 NHS FAREHAM AND GOSPORT CCG 66 121 55 NCA credit notes (36) NHS GUILDFORD AND WAVERLEY CCG 103 40 (63) Subtotal CCG Acute Contracts 77,297 78,205 908 Total Income from Activities 390,802 97,111 97,964 NHS England 11,977 12,560 584 Total 89,273 90,765 1,492

Page 6 Finance Report M3 2016/17 Operating Costs A

Pay is adverse to plan for the first time this year, despite a reduction in agency expenditure of £0.25m in June. Nurse agency expenditure reduced in June but remains above the ceiling at the end of Q1. This is offset by medical agency which remains below ceiling meaning that cumulatively the Trust is £1.33m below its agency ceiling at the end of Q1. Non Pay is above plan, primarily relating to PbR excluded drugs, tariff expenditure is on plan in totality.

Year To Date Year Forecast Prev Yr Actual Plan Actual Variance Plan Forecast Variance £k £k £k £k £k £k Pay (65,709) (69,817) (70,057) (239) Pay (275,545) (275,545) - Non Pay (28,658) (29,422) (29,788) (366) Non Pay (117,413) (117,413) - Operational Costs (94,367) (99,239) (99,844) (605) Operational Costs (392,958) (392,958) -

Pay: Pay is adverse to plan with the most significant pressure in nursing. Approximately 50 beds were open above planned levels throughout the month and additional resources were required to provide care to patients with Mental Health needs. Continuing recruitment pressures within Allied Health Professionals, predominantly Medical Imaging, continue to impact on agency expenditure, although new recruits are expected to join the Trust in September which will reduce expenditure in the latter half of the year. Expenditure on Medical staff remains below plan. WLI and Locum expenditure is increasing slightly ahead of trajectory but significant reductions in agency expenditure are being achieved. The reductions within Medical agency expenditure have played a pivotal role in agency expenditure being £1.33m below the agency ceiling limit at the end of Q1. Continued vacancies within Management and Admin are offsetting pressures experienced in Clinical staff groups. Non Pay: Drugs are the main area of high expenditure with drugs excluded from tariff being above plan at the end of Q1. The most significant pressures within clinical supplies and services are across Medicine with an increase in Cardiology pacemaker implants and Surgery with increased hire of surgical equipment. Pathology charges also remain high within Core Services.

Year to Date Full Year Prev Yr Actual Plan Actual Variance Plan Forecast Variance £k £k £k £k £k £k £k Pay Pay Management & Admin (9,056) (9,848) (9,527) 320 Management & Admin (40,395) (40,395) - Medical and Dental Staff (18,578) (19,483) (19,324) 159 Medical and Dental Staff (76,931) (76,931) - Nursing & Midwifery (24,914) (26,579) (27,058) (479) Nursing & Midwifery (102,263) (102,263) - Other Healthcare (9,077) (9,765) (10,030) (265) Other Healthcare (39,589) (39,589) - Estates (4,084) (4,048) (4,117) (68) Estates (15,982) (15,982) - Other Staff - (94) - 94 Other Staff (385) (385) - Total Pay (65,709) (69,817) (70,057) (239) Total Pay (275,545) (275,545) - Non-Pay Non-Pay Services from Other NHS Bodies (871) (859) (995) (137) Services from Other NHS Bodies (3,448) (3,448) - Purchase of Healthcare from Non NHS Bodies (923) (853) (625) 229 Purchase of Healthcare from Non NHS Bodies (3,576) (3,576) - Drugs & Medical Gases - tariff (2,704) (3,117) (2,900) 217 Drugs & Medical Gases 10,627 10,627 - Drugs & Medical Gases - PbR excluded (6,454) (5,484) (6,073) (589) Drugs & Medical Gases - PbR excluded (20,456) (20,456) - Drugs & Medical Gases - Cancer Drug Fund (1,080) (834) 247 Drugs & Medical Gases - Cancer Drug Fund (2,801) (2,801) - Supplies and Services - Clinical (8,360) (8,350) (8,777) (427) Supplies and Services - Clinical (29,989) (29,989) - Supplies and Services - Clinical PbR Excluded (939) (765) (772) (7) Supplies and Services - Clinical Pbr Excluded (3,060) (3,060) - Supplies and Services - General (1,056) (1,058) (1,122) (64) Supplies and Services - General (4,106) (4,106) - Establishment Expenses (1,722) (1,362) (1,265) 98 Establishment Expenses (5,388) (5,388) - Premises (3,846) (3,739) (3,792) (53) Premises (14,840) (14,840) - Education and Training (75) (339) (208) 131 Education and Training (1,358) (1,358) - Clinical Negligence Premium (432) (1,815) (1,815) 0 Clinical Negligence Premium (7,261) (7,261) - Other Non-Pay (1,275) (599) (611) (12) Other Non-Pay (31,756) (31,756) - Total Non-Pay (28,658) (29,422) (29,788) (366) Total Non-Pay (117,413) (117,413) - Total Expenditure (94,367) (99,239) (99,844) (605) Total Expenditure (392,958) (392,958) -

Monthly Pay Monthly Non Pay 24,000 11,000

10,500

22,000 10,000

£000s 9,500 £000s 20,000 9,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 8,500 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Budget Actual Budget Actual

Monthly Operating Costs Monthly Pay Yearly Comparison 35,000 24,000

34,000 23,500

33,000 23,000

32,000 22,500 £000s £000s 31,000 22,000 30,000 21,500 29,000 21,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Budget Actual 2015-16 2016-17 Finance Report M3 2016/17 Payroll & Agency Costs A

Agency Year To Date Compliance with Agency Cap Rates 2014/15 2015/16 Ceiling Actual Variance Proportion of Shifts Complying with Capped Rates £k £k £k £k £k Target Actual Medical and Dental Staff (2,143) (1,840) (2,825) (1,313) 1,512 Medical and Dental Staff 40% 23% Nursing & Midwifery (1,135) (1,600) (2,367) (2,657) (289) Nursing & Midwifery 0% 0% Other Healthcare (414) (467) (785) (684) 102 Other Healthcare 73% 77% Management & Admin (86) (89) (129) (119) 10 Management & Admin 100% 100% Estates (165) (105) (120) (127) (7) Estates 100% 100% - - (3,943) (4,101) (6,227) (4,899) 1,328

Agency Expenditure Comparison Agency Type Comparison 3,000 3,000 2,500 2,500

2,000

2,000

1,500 £000s 1,500 2015-16 1,000 £000s 2016-17 500 1,000

500

Jul

Jan

Jun

Oct

Apr

Sep Feb

Dec

Aug

Nov Mar

May 0 Medical and Nursing & Other Management Estates 2015-16 2016-17 Ceiling Dental Staff Midwifery Healthcare & Admin

Payroll Year To Date Staff in post incl Bank Year To Date Prev Yr Actual Plan Actual Variance Prev Yr Actual Plan Actual Variance £k £k £k £k WTE WTE WTE WTE Medical and Dental Staff (16,738) (17,612) (18,011) (399) 688 770 705 (57) Nursing & Midwifery (23,314) (24,227) (24,401) (174) 2,528 2,794 2,649 (146) Other Healthcare (8,610) (9,642) (9,347) 296 913 1,100 973 (70) Management & Admin (8,967) (9,832) (9,409) 423 1,226 1,279 1,238 (25) Estates (3,979) (3,965) (3,990) (25) 684 688 666 (76) Other Staff - (94) - 94 - (6) - 1

(61,608) (65,372) (65,158) 214 6,040 6,626 6,231 (372) Finance Report M3 2016/17 Divisional Performance A

Surgery: The division is performing above their income plan at the end of Q1 and activity has Medicine: Non Elective income increased in June due to a lower proportion of short-stay Core: Income from Direct Access activity is above plan at the end of Q1, with activity increases increased compared to May, particularly within Critical Care Services which have received patient. This has resulted in beds which were expected to be closing during the month, delivered in Pathology, Physiotherapy and Radiology. Pay expenditure is adverse to plan as a previous underperformance. Underperformance within T&O inpatients is being offset by remaining open. There have been further reductions in nursing agency spend for specialling result of agency staff covering vacancies in a number of departments within the division. In increased Ophthalmology activity. Pay is above plan with a key driver being nursing costs and vacancy cover, however usage still remains in excess of 15/16 outturn. Medical agency addition, due to the scarcity of Radiology agency staff, it is difficult to obtain staff with capped within Theatre. This is expected to improve in Q2 when a number of staff will complete their spend has reduced in month as the division continues to pursue opportunities to secure rates, incurring additional premium costs. The Division is developing a detailed plan to reduce supernumerary periods. Using Medical Staff Locums to cover vacancies continues to create a agency doctors on NHS locum contracts. There are still challenges securing cover for their dependency on agency throughout the year and reduce pay expenditure in the latter cost pressure particularly in MFU, Anaesthetic and Orthopaedics. The impact of fewer T&O vacancies which is resulting in significant pressure and reliance on existing staff. Outpatient quarters. Overall Non pay is favourable to plan with high expenditure on Pathology inpatients being treated than plan has resulted in reduced prosthetic expenditure, however this activity has exceeded the plan for the first time this year as funded capacity has increased. consumables being offset by reduced mobile van hire. is being offset by high costs on surgical equipment and equipment hire. Increased implantation of pacemakers within Cardiology has resulted in expenditure above plan in Non Pay, PbR excluded drugs are also above plan, however they are matched by income.

Year To Date Year To Date Year To Date PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG £k £k £k £k £k £k £k £k £k £k £k £k Contract Income 26,385 27,478 28,179 701 G Contract Income 40,442 37,182 38,579 1,397 G Contract Income 6,994 10,177 10,912 735 G Other Income 548 539 534 (5) A Other Income 778 699 688 (12) A Other Income 2,765 2,988 3,031 43 G Total Income 26,933 28,018 28,713 696 G Total Income 41,220 37,882 39,267 1,385 G Total Income 9,759 13,165 13,943 778 G Pay (15,571) (15,572) (15,984) (412) R Pay (19,899) (21,629) (21,662) (33) R Pay (11,933) (13,636) (13,842) (206) R Non Pay (5,410) (5,369) (5,620) (250) R Non Pay (8,044) (8,085) (8,637) (552) R Non Pay (5,664) (6,005) (5,991) 14 G Total Expenditure (20,982) (20,941) (21,604) (663) R Total Expenditure (27,943) (29,714) (30,299) (585) R Total Expenditure (17,597) (19,641) (19,834) (193) R

EBITDA Surplus/(Deficit) 5,952 7,076 7,109 33 G EBITDA Surplus/(Deficit) 13,277 8,168 8,968 800 G EBITDA Surplus/(Deficit) (7,838) (6,476) (5,890) 585 G

Women & Children: Divisional activity is favourable to plan in June, but remains adverse year Facilities & Estates: Pay is above plan due to high use of estates bank and ancillary agency Corporate: Income for the private patient suites is higher in June than in May due to a richer to date. Maternity activity is below plan due to redcued bookings and lower births. Outpatient staff in the portering, housekeeping and estates management teams. The division are actively case mix of activity undertaken. However, activity is at a similar level to last month on both activity delivery has been impacted by vacancies in Q1, but there has been an increase in recruiting and are planning to continue to reduce agency expenditure during the next quarter sites and remains below plan due to NHS patients on both private wards. Vacancies in Outpatient appointments in June resulting in activity delivering above plan in month. Locum and to stop usage completely by September. Non-pay expenditure is overspent due to corporate departments continue to contribute to the overall pay underspend. Tight controls on costs are slightly higher than anticipated, where substantive staff have been able to provide additional utilities charges and increased provision costs. Additional income from catering discretionary expenditure remain in place and are delivering a favourable position within non additional cover but Pay costs overall are underspent. A longer term agency doctor has been services is offsetting some of the increased spend on provisions. pay. recruited to cover in Paediatrics until the recently appointed ROCCs take up post in order to deliver otupatient capacity.

Year To Date Year To Date Year To Date PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG PY Actual Plan Actual Variance RAG £k £k £k £k £k £k £k £k £k £k £k £k Contract Income 14,958 15,466 14,688 (778) R Contract Income - - - - Contract Income - - - - Other Income 234 206 204 (2) A Other Income 1,357 1,280 1,342 62 G Other Income 3,619 3,525 3,045 (480) R Total Income 15,192 15,672 14,892 (780) R Total Income 1,357 1,280 1,342 62 G Total Income 3,619 3,525 3,045 (480) R Pay (7,727) (7,854) (7,747) 107 G Pay (4,170) (4,092) (4,209) (117) R Pay (6,385) (4,466) (4,304) 161 G Non Pay (2,417) (2,710) (2,738) (28) G Non Pay (3,842) (3,558) (3,653) (95) R Non Pay (3,475) (2,513) (2,410) 103 G Total Expenditure (10,144) (10,563) (10,485) 78 G Total Expenditure (8,012) (7,651) (7,863) (212) R Total Expenditure (9,859) (6,978) (6,714) 264 G

EBITDA Surplus/(Deficit) 5,048 5,109 4,407 (702) R EBITDA Surplus/(Deficit) (6,655) (6,371) (6,521) (149) R EBITDA Surplus/(Deficit) (6,240) (3,453) (3,669) (215) R Finance Report M3 2016/17 Statement of Financial Position

The Trust Balance Sheet is produced on a monthly basis, and reflects changes in the asset values, as well as movement in liabilities.

Year to Date Full Year Plan Actual Variance Notes Plan Forecast Variance Notes £k £k £k £k £k £k Property, Plant and Equipment 276,422 280,222 3,800 1 Property, Plant and Equipment 276,177 283,197 7,020 1 Intangible Assets 279 446 167 Intangible Assets 279 279 - Other Assets - - - Other Assets - - - Non Current Assets 276,701 280,668 3,967 Non Current Assets 276,456 283,476 7,020 Inventories 5,794 6,157 363 Inventories 6,161 6,161 - Trade and Other Receivables 34,055 32,277 (1,778) 2 Trade and Other Receivables 34,587 34,587 - 2 Cash and Cash Equivalents 2,697 6,042 3,345 Cash and Cash Equivalents 12,931 12,931 - Non Current Assets Held for Sale - - - Non Current Assets Held for Sale - - -

Current Assets 42,546 44,476 1,930 Current Assets 53,679 53,679 - Trade and Other Payables (43,057) (43,785) (728) 3 Trade and Other Payables (40,354) (40,354) - 3 Borrowings (2,224) (2,224) 0 Borrowings (2,114) (2,114) - Other Financial Liabilities - - - Other Financial Liabilities - - - Provisions (673) (423) 250 Provisions (901) (901) - Other Liabilities - - - Other Liabilities - - - Current Liabilities (45,954) (46,432) (478) Current Liabilities (43,369) (43,369) - Borrowings (24,479) (24,479) 0 Borrowings (22,964) (22,964) - Trade and Other Payables - - - Trade and Other Payables - - - Provisions (2,965) (2,861) 104 Provisions (2,704) (2,704) - TOTAL ASSETS EMPLOYED TOTAL ASSETS EMPLOYED 245,849 251,372 5,523 261,098 268,118 7,020 Financed by: Financed by: Public Dividend Capital 239,191 239,191 0 Public Dividend Capital 239,191 239,191 - Retained Earnings (36,107) (41,335) (5,228) Retained Earnings (20,858) (24,589) (3,731) Surplus/(Deficit) for Year - - - (Surplus)/Deficit for Year - - - Revaluation Reserve 42,765 53,516 10,751 Revaluation Reserve 42,765 53,516 10,751 TOTAL TAXPAYERS EQUITY TOTAL TAXPAYERS EQUITY 245,849 251,372 5,523 261,098 268,118 7,020

1. The variance on Property, Plant and Equipment is due to the plan being set prior to the impact of the Trust's year end valuation, this has been reflected in the forecast position. 2. Within trade and other receivables, there has been a £1.8m decrease versus the plan due to a lower out-turn debtor position in 2015/16 than the original expectation in the 2016/17 plan. 3. Trade and other payables are higher than plan, which is due to extended payment timescales. Finance Report M3 2016/17 Cash A

The cash position is ahead of plan, however, this is largely due to slippage on capital expenditure, which is contributing £4.1m to the cash position. The underlying operational performance has had a adverse impact of £0.3m on the cash position.

Year To Date Full Year Plan Actual Variance Plan Forecast Variance £k £k £k £k £k £k Cash Balance 2,697 6,042 3,346 12,931 12,931 -

Year to Date Full Year Plan Actual Variance Plan Forecast Variance £k £k £k £k £k £k EBITDA 8,914 8,641 (273) EBITDA 41,902 41,902 - Movement in Working Capital (6,875) (7,538) (663) Movement in Working Capital (7,306) (7,306) - Provisions (76) 42 118 Provisions (304) (304) - Cashflow from Operations 1,963 1,146 (817) Cashflow from Operations 34,292 34,292 - Capital Expenditure (5,510) (1,394) 4,116 Capital Expenditure (16,673) (16,673) - Cash receipt from asset sales - - - Cash receipt from asset sales - - - Cashflow before financing (3,547) (249) 3,299 Cashflow before financing 17,619 17,619 - PDC Received - - - PDC Received - - - PDC Repaid - - - PDC Repaid - - - Dividends Paid - - - Dividends Paid (8,649) (8,649) - Interest on Loans and leases (216) (202) 14 Interest on Loans and leases (864) (864) - Interest received 8 8 1 Interest received 30 30 - Donations received in cash - - - Donations received in cash - - - Drawdown on debt - - - Drawdown on debt - - - Repayment of debt (500) (500) (0) Repayment of debt (2,158) (2,158) - Cashflow from financing (709) (695) 14 Cashflow from financing (11,641) (11,641) - Net Cash Inflow / (Outflow) (4,256) (943) 3,313 Net Cash Inflow / (Outflow) 5,978 5,978 - Opening Cash Balance 6,953 6,986 33 Opening Cash Balance 6,953 6,953 - Closing Cash Balance 2,697 6,043 3,346 Closing Cash Balance 12,931 12,931 - Finance Report M3 2016/17 Aged Debtors

The Trust debtors are a mixture of invoiced debtors, accrued income and prepayments as set out in the table below. The Trust has outstanding debtors of 31 days or more of £6.6m, this is a small decrease since May of £0.1m. The most significant component of outstanding debtors greater than 90 days relates to NHS foundation trusts income of £1.2m, relating to service level agreements for drugs costs and staff recharges. NHS debt has increased by £4.8m between May and June due to £2.5m raised to Health Education England for medical training for Q2 (£2.4m of which was paid on the 1st July) and £0.8m of invoices related to the differences between the interim values used to invoice in 2016/17 and the agreed contract values (paid on the 1st July). Non NHS debt has increased by £0.8m in the month, £0.4m due to Sexual Health invoice for the contract with West Sussex County Council being raised, which is due for payment in July; £0.1m due to the quarterly mortuary invoice.

Invoiced Debtors Overdue Within Total Debtors Terms 31-60 61-90 1-30 days > 90 days days days £k £k £k £k £k £k CCG's 1,187 1,066 75 3,050 159 5,537 NHS England (in Health 2,941 327 50 9 126 3,453 3,129k Education England) 3,864k NHS Trusts 7 1,097 79 39 694 1,917 Foundation Trusts 118 792 44 63 1,224 2,240 1-30 days Other NHS 0 7 (2) 4 51 60 31-60 days Non-NHS 646 575 93 10 875 2,198 61-90 days Total 4,899 3,864 339 3,175 3,129 15,406 32% 25% 2% 21% 20% > 90 days

Provision for Bad Debts (including RTA Provision) (917) Accrued Income (including Work in Progress) 9,358 3,175k 339k Prepayments 4,052 Other Debtors 4,378 Total Trade & Other Receivables 32,277

Other debtors consists of £2.0m of RTA debtors, £1.3m of Private Patients and £1.0m relates to Charity (this is made up of £0.4m from the League of Friends and £0.6m from LYH relating to the capital programme) £0.3m of the balance from LYH is due to be paid in July. Accrued income consists of £4.0m of commissioner income, £0.6m of provider to provider income, £0.6m of medical training income, non-contracted activity £0.3m, drugs/pharmacy £0.5m, private patients £0.1m, work-in-progress £2.7m and £0.5m of other income recharges including radiology, catering and clinical excellence awards. Finance Report M3 2016/17 Capital A

The capital programme is under-spent by £3.9m. This is due to slippage against the Southlands Ophthalmology project which has a revised monthly forecast in terms of expenditure but which is still forecast to be completed within the original timeframe; and slippage within Estates and Facilities schemes which are due to move closer to plan by quarter 2 following the approval of business cases. Medical equipment priorities have been agreed and orders are being placed for approved items.

Year To Date Year End Forecast Plan Actual Variance Plan Forecast Variance £k £k £k £k £k £k Total Capital 5,322 1,386 3,936 Total Capital 16,812 16,812 -

Capital Year to Date Full Year Budget Actual Variance Plan Forecast Variance Source of Funds £k £k £k Source of Funds £k £k £k Depreciation (net of IFRIC 12) 3,815 3,701 (114) Depreciation (net of IFRIC 12) 15,340 14,870 (470) Loan Repayments (500) (500) - Loan Repayments (1,158) (1,158) - Charitable Funds - - - Charitable Funds 1,104 1,189 85 Donation/Grants - - - Donation/Grants 1,526 1,526 -

3,315 3,201 (114) 16,812 16,427 (385)

Application of Funds Application of Funds Endoscopy 523 - 523 Endoscopy 1,066 1,066 - Southlands Ophthalmology 1,638 625 1,012 Southlands Ophthalmology 6,550 6,550 - MSK - - - MSK 500 500 - Equipment Replacement - Imaging 500 - 500 Equipment Replacement - Imaging 1,000 1,000 - Other Service Developments 216 28 188 Other Service Developments 1,166 1,166 - Medical Equipment 1,008 129 879 Medical Equipment 1,655 1,655 - Facilities & Estates 1,623 83 1,539 Facilities & Estates 5,290 5,290 - Information Technology 840 457 383 Information Technology 3,683 3,683 - Miscellaneous - 65 (65) Miscellaneous - - - Overprogramming (1,025) - (1,025) Overprogramming (4,098) (4,098) - Total Expenditure 5,322 1,386 3,936 Total Expenditure 16,812 16,812 - Finance Report M3 2016/17 Efficiency and Transformation Programme A

At the end of June, the Efficiency Programme has delivered savings of £4.3m against a plan of £4.5m (95.7%). Slippage on Phase 1 bed configuration, delivery of the Trust's trajectory for compliance with capped rates for agency staff, reduction in Therapies agency use and Commercial schemes have been mitigated in part by over-delivery within the Back Office, Core & Procurement work-streams.

Year to Date Forecast Out-turn Workstream Plan Actual Variance Plan Forecast Variance £k £k £k £k £k £k

FYE 15/16 1,848 1,653 (196) 3,525 3,361 (164) Back Office & Corporate Support 76 96 21 557 561 3 Commercial Opportunities 383 335 (48) 2,149 2,142 (7) Core 128 141 13 856 864 8 Estates & Facilities 24 42 18 814 814 0 Medicine 112 94 (18) 277 259 (18) Medicines Management 12 9 (3) 125 125 0 Procurement 293 435 143 2,023 2,023 0 Surgery 231 216 (15) 602 602 - Women & Children 29 32 3 301 301 1 Workforce 945 826 (118) 4,802 4,700 (101) Medical Workforce 461 457 (4) 1,899 1,899 - Nursing Workforce (9) 0 9 201 186 (15) Transformation - - - 1,027 1,027 - Efficiency Plan Total 4,532 4,337 (195) 19,159 18,865 (293)

Month 3 Cumulative (June) Plan vs Actual 2,000

1,500

1,000 Plan

£000s Actual 500

0 FYE 15/16 Back Office & Commercial Core Estates & Facilities Medicine Medicines Procurement Surgery Women & Children Workforce Medical Workforce Nursing Workforce Corporate Support Opportunities Management

(500)

To: Trust Board Date of Meeting: 28 July 2016 Agenda Item: 12

Title Patient First Programme Report – Month 3 Responsible Executive Director Marianne Griffiths, Chief Executive Prepared by Anil Mathew, Director of Continuous Improvement Status Disclosable Summary of Proposal The purpose of this paper is to provide the Trust Board with an update on the implementation of the Trust’s Patient First Programme, our trust-wide approach to improving the experience and quality of care we offer patients. The Patient First Programme Board will oversee and assure delivery of all improvement and transformation work in the Trust. Implications for Quality of Care The Patient First Programme’s key aim is to improve the quality of care for patients and improve patient experience and outcome. Link to Strategic Objectives/Board Assurance Framework Links across all of the Trust’s Strategic Objectives. Financial Implications A number of workstreams within the Patient First Programme have resource implications and savings targets. These are now consolidated into and tracked through the Trust Efficiency and Transformation Programme. Human Resource Implications A Workforce Transformation Workstream and an Organisational Development Workstream are now in place. Workforce impact will be assessed through these groups. Recommendation The Board is asked to NOTE progress on the development of the Patient First Programme. Communication and Consultation Communication Strategy has been approved by the Patient First Programme Board. Appendices N/A

Patient First Programme – Update Report JUNE 2016

a) Introduction The Patient First Programme is continuing to develop and implement change reflecting the increasing maturity of the Patient First Improvement Programme and the need to focus attention more closely on the delivery of the Trust’s True North metrics and breakthrough objectives through Strategy deployment. A new format report has been presented to the Board that tracks delivery of the agreed metrics that support strategy deployment. This report provides more detail on how the Patient First Programme will be developed in 2016/17 and provides a summary of delivery against current work programmes.

b) Patient First Themes

a) Sustainability: At the end of June the Trust is reporting full delivery of its control total. Before the inclusion of Sustainability and Transformation funds, the Trust is reporting a deficit of £0.73m against a planned deficit of £0.75m. In June, the Trust delivered an underlying deficit, however, this will need to be improved upon in order to continue to deliver the planned financial trajectory. Key areas of focus will be delivering the elective capacity plan and management of agency spend.

In June the Trust reported a further fall in the level of agency expenditure from £1.7m in May to £1.5m in June. Nurse agency expenditure reduced in June, however, this area remains above the ceiling and further reductions will be required to deliver the year-end position. Bilateral meetings have been held with Heads of Nursing and Matrons and ward level plans agreed to exit or reduce agency usage. After a significant increase in expenditure in May, expenditure on Allied Health Professionals reduced to April’s level. Agency usage in this staff category has been volatile so far this year and an Executive bilateral review is being carried out to understand the key drivers and actions required to exit placements.

c) Our People: The Patient First Kaizen team are focussed on delivering the Patient First Improvement Programme objectives alongside supporting a number of other high priority areas for improvement including targeted Kaizen workshops at Ophthalmology, Diabetes and Intensive Care Unit process areas including coaching and mentoring. Following the classroom training of Green Belts (lean), the participants have been actively working on delivering improvement projects in Orthopaedics, Endoscopy, Bed turnaround, Discharge lounge and Stroke. Yellow Belt training sessions have been continuing in recent months with the aim to train 200-250 of our staff by year end. The trained Yellow Belts have made a commitment to identify and make improvements within their own area of work.

The second wave of the Patient First Improvement System (PFIS) is now in progress in Theatres, Outpatients, Selsey Ward and Lavant Ward. Learning from the first

wave has been captured and used to develop the system for subsequent waves. Plans for Wave 3 are now confirmed and will commence from September 2016.

a. Quality Improvement: The development of a Falls Prevention Improvement Programme for 2016/17 – Falls is the breakthrough objective for harm free care for 2016/17. This programme aims to deliver a 30% reduction in falls in 1 year. The programme focuses on improvement cycles in the ten wards/clinical areas within the Trust identified as having the highest numbers of falls. Progress to date includes the development of a mother A3, A3s for each clinical area, the implementation of visual management boards in each clinical area and the initiation of weekly falls meetings. Facts and data show the programme is starting to make a significant impact on falls reduction.

In June, the lowest number of falls was recorded for any month to date. All 10 wards have ‘Falls Improvement boards’ with weekly review of progress against plans. 5 wards have achieved a 50% reduction for June. Last year there were 20 falls per week (on the top 10 wards) and this has now reduced to 13 falls per week. Implementation of Baywatch is showing positive outcomes and wards are working to expand participation through the MDT. Some investment is also needed to help support bay watch. SWARM review has shown variation in approach and to avoid any confusion about expectations, a protocol has been developed which will be fully rolled out through August.

d) Systems and Partnerships: The Non-elective and Elective programmes have been refreshed for 2016/17 with new objectives, and alignment with the Trust’s True North objectives. The Non-Elective programme, has moved from the implementation phase, to operational delivery and monitoring of the bed capacity programme, with specific improvement activity focused on achieving best practice flow management including increasing the availability of bed capacity in the morning, and the reduction of fit for discharge patients as one of the Trust’s breakthrough objectives. Importantly these programmes are aligned to support the trust in achieving the Referral to Treatment (RTT) and A&E waiting times targets. The RTT incomplete position is now discussed through the newly implemented Strategy Deployment Review (SDR) , the structured improvement plans have been updated and Quarter 1 RTT performance is ahead of the improvement trajectory. The A&E 4hr position also forms part of the SDR discussions and the Quarter 1 target was achieved,

e) The Patient First Programme in 2016/17: The level of recognition, and impact, of our Patient First programme on the organisation was a key feature of our CQC inspection and report. As we move into 2016/17, the key feature of our work is continuing to develop and embed the programme. Executives are currently progressing the Trust North metrics, Strategic Initiatives and Breakthrough objectives and developing plans for embedding them throughout the organisation through Strategy deployment.

We are more than half way through the formal support programme for the Patient First Improvement programme roll out. The key objective for 2016/17 is the on-going development of ‘Lean’ Capability within the Trust through PFIS, Yellow & Green Belt training supplemented by coaching and mentoring by the Kaizen Office team during Improvement Workshops and managing the transition from external support to internal sustainability of the programme is progressing well. This will act as a critical enabler to leading and supporting key improvement projects that result in measurable delivery of objectives against True North and the Patient First programme. The review of our Road Map in terms of KPMG / Thedacare resource, coaching and mentoring for the remaining period has started and will eb shared with The Board in August.

The plans in the coming months by the Kaizen Office team are:  Data gathering and gemba for Intensive Care Unit Kaizen Workshop has started, and dates for the Kaizen Workshop expected in the next few weeks.  Green Belt projects for Orthopaedics, Bed Turnaround, Discharge Lounge, Stroke and Endoscopy will be reviewed by the Executive through a Lunch & Learn “progress update” session planned in July. This is also an opportunity to showcase the internal “Lean” capability that is being developed.  Continue to embed standard work principles with coaching sessions with the Executive team in readiness for the next Strategy Deployment (True North) performance review meeting.  Develop, and start to deliver the PF/Lean Awareness training for all staff at the revised Health and Safety day.

To: Trust Board Date of Meeting: 28 July 2016 Agenda Item: 13

Title Proposal to Amend the Trust Constitution Report Responsible Executive Director Andy Gray, Company Secretary Prepared by Andy Gray, Company Secretary Status Disclosable Summary of Proposal As the Trust nears its 3-year anniversary of authorisation as a Foundation trust it is timely to review and update the Constitution to reflect changes in practice and new election processes. The Trust Board is asked to APPROVE amendments to Annex 4 (Composition of the Council of Governors) and Annex 5 (Model Election rules- Part 5 only) as detailed in the main paper. The Council of Governors approved the amendments at their meeting held on the 14 July 2016. Implications for Quality of Care No direct implications. Link to Strategic Objectives/Board Assurance Framework No direct implications. Financial Implications Cost savings achieved through reduction in Election costs. Human Resource Implications No direct implications Recommendation The Board is asked to APPROVE the amendments. Communication and Consultation Chair, Lead Governor, Board, NHS Improvement Appendices 1: Updated Annex 4 2: Updated Annex 5

This report can be made available in other formats and in other languages. To discuss your requirements please contact, Company Secretary, on [email protected] or 01903 285288.

To: Trust Board Date: 28 July 2016 From : Andy Gray, Company Secretary Agenda Item: 13

FOR DECISION

PROPOSAL TO AMEND THE TRUST CONSTITUTION

INTRODUCTION

1.1. The Trust Constitution sets out the way in which the Trust will be governed and will operate its key governance structures.

1.2. The Constitution is based on the Foundation Trust national model.

1.3. The recent general election for Governors has highlighted some inconsistencies that it is timely to review and amend as appropriate.

1.4. The Trust Board is asked to approve amendments to Annex 4 (Composition of the Council of Governors) and Annex 5 (Model Election rules) only.

1.5. It should be noted that amendments to the Trust Constitution require the dual approval of the Council of Governors and the Trust Board. Following approval the updated Constitution is lodged with NHS Improvement. The Council of Governors approved the amendments at their meeting held on the 14 July 2016.

2. ANNEX 4 : COMPOSITION OF THE COUNCIL OF GOVERNOS - PROPOSED AMENDMENTS

2.1 At the time of authorisation as a Foundation Trust both Coastal West Sussex Clinical Commissioning Group and Healthwatch West Sussex were offered the opportunity to nominate an Appointed Governor. Both organisations declined to do so due to potential conflicts of interest and this was agreed by the Council at that time. The proposal therefore is to delete these organisations as Partnership organisations for the purposes of the Constitution.

2.2 It should be noted that both the Clinical Commissioning Group and Healthwatch engage with Trust through other forums.

2.3 Alongside the Friends organisations the Constitution states that the WRVS will be a nominated Partner organisation. At no time since its inception in shadow form has the WRVS been engaged in, or sought to be engaged in, representation at the Council.

2.4 The relationship with the Friends organisations is different to that with the WRVS, who operate rather more at ‘arms-length’. It is therefore proposed to delete WRVS from the list of potential Partnership organisations.

2.5 The wording in the Constitution relating to how the three Friends organisations rotate their membership of the Council is misleading. Revised wording is proposed in order to clarify the situation.

3. ANNEX 5 : MODEL ELECTION RULES - PROPOSED AMENDMENTS

3.1. To date all elections to the Council of Governors have been carried out by postal ballot. Amendments are proposed to allow for an e-voting method of polling via a dedicated, secure website for Governor Elections.

3.2. Where a member has provided an email address the intention is that all communication about the election is sent electronically via email. The method of voting will be via a secure website run by Election Reform Services who run the Trust’s elections. It should be noted that where a member does not have an email address communication regarding the elections will continue to be sent by post.

3.3. It is proposed that in future all members will have the option of voting on-line.

3.4. The benefits of enabling e-voting include:

 An expected increased turnout – as members are able to action voting as soon as they receive and open an email

 Reduction in the use of paper

 Cost savings in terms of reduction of postal costs and paper

3.5. Appendix C sets out the proposed updated Annex 5 – Part 5 only.

4. RECOMMENDATION

4.1. It is recommended that the Trust Board approve the amendments to Annex 4 and Annex 5 (Part 5 only) of the Constitution.

Page 2 of 2 Appendix 1 ANNEX 4 – COMPOSITION OF COUNCIL OF GOVERNORS

Elected Governors

Constituency Area/Class Number Public Adur 2 Public Arun 4 Public Chichester 3 Public Horsham 1 Public Worthing 3

Patients None 3

Staff Medical and Dental (registered practitioners) 1 Staff Nursing & Midwifery 1 Staff Scientific, Technical and Professional (including Allied Health Professionals) 1 Staff Additional Clinical Services 1 Staff Estates and Ancillary 1 Staff Administrative and Clerical 1 Total Number of Elected Governors 22

Appointed Governors

Type Governor Appointed By: Number Local Authority Chichester District Council 1 Worthing Borough Council 1 West Sussex County Council 1 Partnership * Brighton & Sussex Medical School 1 Partnership Coastal West Sussex Clinical Commissioning Group 1 Partnership Healthwatch West Sussex 1 Partnership * University of Brighton 1 Partnership * A governor shall be appointed by one of the following organisations from time to time for a 3-year appointment per governor per organisation (by rotation in the order listed in the absence of agreement between the organisations) and the organisation from which such a governor is appointed, or in default of agreement the organisation that is entitled to appoint a governor at any relevant time, shall be a "partnership organisation" for the purposes of Schedule 7 of the National Health Service Act 2006 (as amended from time to time) at such time: 1 A governor shall be appointed, by agreement amongst all the following organisations, from time to time for a 3-year appointment (Subject to Section 13.3 and 13.4 of the constitution). In the absence of agreement amongst the organisations, the appointment shall be by rotation in the order listed below. A governor appointed by these organisations may hold office for a period of up to 3 years and at the end of his/her term s/he shall be eligible for re-appointment for one

1 further term of up to 3 years only – maximum of 6 years

The Friends of Chichester Hospitals The Friends of Worthing Hospitals The League of Friends of Southlands Hospital WRVS Total Number of Appointed Governors 6 8

Total Number of Governors 28 30 *Note: For the purposes of the Trust Constitution a Partnership organisation is a body as detailed in Schedule 7 of the National Health Service Act 2006 (as amended from time to time).

2

Part 5 – Contested elections

19. Poll to be taken by ballot – (1) The votes at the poll must be given by secret ballot.

(2) The votes are to be counted and the result of the poll determined in accordance with Part 6 of these rules.

(3) The corporation may decide that voters within a constituency or class with a constituency, may, subject to rule 19.4 cast their votes at the poll using such different methods of polling in any combination as the corporation may determine.

(4) The corporation may decide that voters within a constituency or class within a constituency for whom an e-mail address is included in the list of eligible voters may only cast their votes at the poll using an e-voting method of polling.

(5) Before the corporation decides, in accordance with rule 19.3 that an e- voting method of polling will be made available for the purposes of the poll, the corporation must satisfy itself that :

(a) If internet voting is to be a method of polling, the internet voting system to be used for the purpose of the election is : (i) Configured in accordance with these rules ; and (ii) Will create an accurate internet voting record in respect of any voter who casts his or her vote using the internet voting system;

20. The ballot paper – (1) The ballot of each voter (other than a voter who casts his or her ballot by an e-voting method of polling) is to consist of a ballot paper with the persons remaining validly nominated for an election after any withdrawals under these rules, and no others, inserted in the paper.

(2) Every ballot paper must specify –

(a) the name of the corporation, (b) the constituency, or class within a constituency, for which the election is being held, (c) the number of members of the council of governors to be elected from that constituency, or class within that constituency, (d) the names and other particulars of the candidates standing for election, with the details and order being the same as in the statement of nominated candidates, (e) instructions on how to vote, by all available methods of polling, including the relevant voter’s vote ID number if one or more e-voting methods of polling are available, (f) if the ballot paper is to be returned by post, the address for its return and the date and time of the close of the poll, and (g) the contact details of the returning officer.

(3) Each ballot paper must have a unique identifier.

(4) Each ballot paper must have features incorporated into it to prevent it from being reproduced.

21. The declaration of identity (public and patient constituencies) – (1) In respect of an election for a public or patient constituency a declaration of identity must be issued with each ballot paper.

(2) The declaration of identity is to include a declaration –

(a) that the voter is the person to whom the ballot paper was addressed, (b) that the voter has not marked or returned any other voting paper in the election, and (c) for a member of the public or patient constituency, of the particulars of that member’s qualification to vote as a member of the constituency or class within a constituency for which the election is being held.

(3) The declaration of identity is to include space for –

(a) the name of the voter, (b) the address of the voter, (c) the voter’s signature, and (d) the date that the declaration was made by the voter.

(4) The voter must be required to return the declaration of identity together with the ballot paper.

(5) The declaration of identity must caution the voter that, if it is not returned with the ballot paper, or if it is returned without being correctly completed, the voter’s ballot paper may be declared invalid.

Action to be taken before the poll

22. List of eligible voters – (1) The corporation is to provide the returning officer with a list of the members of the constituency or class within a constituency for which the election is being held who are eligible to vote by virtue of rule 27 as soon as is reasonably practicable after the final date for the delivery of notices of withdrawals by candidates from an election.

(2) The list is to include, for each member:

(a) a mailing address; and (b) the member’s e-mail address, if this has been provided to which his or her voting information may, subject to rule 22.3 be sent

(3) The corporation may decide that the e-voting information is to be sent only by e-mail to those members in the list of eligible voters for whom an e-mail address is included in that list.

23. Notice of poll - The returning officer is to publish a notice of the poll stating–

(a) the name of the corporation, (b) the constituency, or class within a constituency, for which the election is being held, (c) the number of members of the council of governors to be elected from that constituency, or class with that constituency, (d) the names, contact addresses, and other particulars of the candidates standing for election, with the details and order being the same as in the statement of nominated candidates, (e) that the ballot papers for the election are to be issued and returned, if appropriate, by post, (f) the methods of polling by which votes may be cast at the election by voters in a constituency or class with a constituency, as determined by the corporation in accordance with rule 19.3, (f) the address for return of the ballot papers, and the date and time of the close of the poll, (g) the uniform resource locator (url) where, if internet voting is a method of polling, the polling website is locates (h) the address and final dates for applications for replacement ballot papers, and (i) the address for return of the ballot papers, and the date and time of the close of the poll, and (j) the contact details of the returning officer.

24. Issue of voting documents by returning officer – (1) As soon as is reasonably practicable on or after the publication of the notice of the poll, the returning officer is to send the following documents to each member of the corporation named in the list of eligible voters–

(a) ballot paper and ballot paper envelope, (b) declaration of identity (if required), (c) information about each candidate standing for election, pursuant to rule 59 of these rules, and (d) a covering envelope.

(“postal voting information”)

(2) Subject to rules 24.3 and 24.4, as soon as is reasonably practicable on or after the publication of the notice of the poll, the returning officer is to send the following information by e-mail and / or by post to each member of the corporation named in the list of eligible voters whom the corporation determines in accordance with rule 19.3 and/ or rule 19.4 may cast his or her vote by an e-voting method of polling:

(a) instructions on how to vote and how to make a declaration of identity (if required), (b) the voter’s voter ID number (c) information about each candidate standing for election, pursuant to rule 64 of these rules, or details of where this information is readily available on the internet or available in such other formats as the Returning Officer thinks appropriate, (d) contact details of the returning officer,

(“e-voting information)

(3) The corporation may determine that any member of the corporation shall: (a) only be sent postal voting information; or (b) only be sent e-voting information; or (c) be sent both postal voting information and e-voting information; for the purposes of the poll.

(4) If the corporation determines, in accordance with rule 22.3, that the e-voting information is to be sent only by e-mail to those members in the list of eligible voters for whom an e-mail address is included in that list, then the returning officer shall only send that information by e-mail.

(5) The voting information is to be sent to the postal address and/ or e-mail address for each member, as specified in the list of eligible voters.

25. Ballot paper envelope and covering envelope – (1) The ballot paper envelope must have clear instructions to the voter printed on it, instructing the voter to seal the ballot paper inside the envelope once the ballot paper has been marked.

(2) The covering envelope is to have –

(a) the address for return of the ballot paper printed on it, and (b) pre-paid postage for return to that address.

(3) There should be clear instructions, either printed on the covering envelope or elsewhere, instructing the voter to seal the following documents inside the covering envelope and return it to the returning officer –

(a) the completed declaration of identity if required, and (b) the ballot paper envelope, with the ballot paper sealed inside it.

26. E-voting systems (1) If internet voting is a method of polling for the relevant election then the returning officer must provide a website for the purpose of voting over the internet (in these rules referred to as "the polling website").

(2) The returning officer shall ensure that the polling website and internet voting system provided will: (a) require a voter to: (i) enter his or her voter ID number; and (ii) where the election is for a public or patient constituency, make a declaration of identity; in order to be able to cast his or her vote; (b) specify: (i) the name of the corporation, (ii) the constituency, or class within a constituency, for which the election is being held, (iii) the number of members of the council of governors to be elected from that constituency, or class within that constituency, (iv) the names and other particulars of the candidates standing for election, with the details and order being the same as in the statement of nominated candidates, (v) instructions on how to vote and how to make a declaration of identity, (vi) the date and time of the close of the poll, and (vii) the contact details of the returning officer;

(c) prevent a voter from voting for more candidates than he or she is entitled to at the election; (d) create a record ("internet voting record") that is stored in the internet voting system in respect of each vote cast by a voter using the internet that comprises of- (i) the voter’s voter ID number; (ii) the voter’s declaration of identity (where required); (iii) the candidate or candidates for whom the voter has voted; and (iv) the date and time of the voter’s vote, (e) if the voter’s vote has been duly cast and recorded, provide the voter with confirmation of this; and (f) prevent any voter from voting after the close of poll

The poll

27. Eligibility to vote – An individual who becomes a member of the corporation on or before the closing date for the receipt of nominations by candidates for the election, is eligible to vote in that election.

28. Voting by persons who require assistance – (1) The returning officer is to put in place arrangements to enable requests for assistance to vote to be made.

(2) Where the returning officer receives a request from a voter who requires assistance to vote, the returning officer is to make such arrangements as he or she considers necessary to enable that voter to vote.

29. Spoilt ballot papers (1) – If a voter has dealt with his or her ballot paper in such a manner that it cannot be accepted as a ballot paper (referred to a “spoilt ballot paper”), that voter may apply to the returning officer for a replacement ballot paper.

(2) On receiving an application, the returning officer is to obtain the details of the unique identifier on the spoilt ballot paper, if he or she can obtain it.

(3) The returning officer may not issue a replacement ballot paper for a spoilt ballot paper unless he or she –

(a) is satisfied as to the voter’s identity, and (b) has ensured that the declaration of identity, if required, has not been returned.

(4) After issuing a replacement ballot paper for a spoilt ballot paper, the returning officer shall enter in a list (“the list of spoilt ballot papers”) –

(a) the name of the voter, and (b) the details of the unique identifier of the spoilt ballot paper (if that officer was able to obtain it), and (c) the details of the unique identifier of the replacement ballot paper.

30. Lost ballot information – (1) Where a voter has not received his or her voting information by the fourth day before the close of the poll, that voter may apply to the returning officer for a replacement voting information.

(2) The returning officer may not issue a replacement ballot paper for lost voting information unless he or she –

(a) is satisfied as to the voter’s identity, (b) has no reason to doubt that the voter did not receive the original voting information , and (c) has ensured that the declaration of identity if required has not been returned.

(3) After issuing a replacement voting information in respect of lost voting information , the returning officer shall enter in a list (“the list of lost ballot documents ”) –

(a) the name of the voter, and (b) the details of the unique identifier of the replacement ballot paper, if applicable (c) the voter ID number of the voter. 31. Issue of replacement voting information – (1) If a person applies for a replacement voting information under rule 29 or 30 and a declaration of identity has already been received by the returning officer in the name of that voter, the returning officer may not issue a replacement voting information unless, in addition to the requirements imposed rule 29(3) or 30(2), he or she is also satisfied that that person has not already voted in the election, notwithstanding the fact that a declaration of identity if required has already been received by the returning officer in the name of that voter.

(2) After issuing a replacement voting information under this rule, the returning officer shall enter in a list (“the list of voting information”) –

(a) the name of the voter, and (b) the details of the unique identifier of the replacement ballot paper issued under this rule. (c) the voter ID number of the voter

32. Declaration of identity for replacement ballot papers (public and patient constituencies) – (1) In respect of an election for a public or patient constituency a declaration of identity must be issued with each replacement ballot paper.

(2) The declaration of identity is to include a declaration –

(a) that the voter has not voted in the election with any ballot paper other than the ballot paper being returned with the declaration, and (b) of the particulars of that member’s qualification to vote as a member of the public or patient constituency, or class within a constituency, for which the election is being held.

(3) The declaration of identity is to include space for –

(a) the name of the voter, (b) the address of the voter, (c) the voter’s signature, and (d) the date that the declaration was made by the voter.

(4) The voter must be required to return the declaration of identity together with the ballot paper.

(5) The declaration of identity must caution the voter that if it is not returned with the ballot paper, or if it is returned without being correctly completed, the replacement ballot paper may be declared invalid.

Polling by internet 33. Procedure for remote voting by internet (1) To cast his or her vote using the internet, a voter will need to gain access to the polling website by keying in the ‘URL’ of the polling website provided in the voting information.

(2) When prompted to do so, the voter will need to enter his or her voter ID number, (3) If the internet voting system authenticates the voter ID number , the system will give the voter access to the polling website for the election in which the voter is eligible to vote. (4) To cast his or her vote, the voter will need to key in a mark on the screen opposite the particulars of the candidate or candidates for whom he or she wishes to cast his or her vote, (5) The voter will not be able to access the internet voting system for an election once his or her vote at that election has been cast.

Procedure for receipt of envelopes

34. Receipt of voting documents – (1) Where the returning officer receives a

(a) covering envelope, or (b) any other envelope containing a declaration of identity if required, a ballot paper envelope, or a ballot paper, before the close of the poll, that officer is to open it as soon as is practicable; and rules 35 and 36 are to apply.

(2) The returning officer may open any ballot paper envelope for the purposes of rules 35 and 36, but must make arrangements to ensure that no person obtains or communicates information as to –

(a) the candidate for whom a voter has voted, or (b) the unique identifier on a ballot paper.

(3) The returning officer must make arrangements to ensure the safety and security of the ballot papers and other documents.

35. Validity of votes – (1) A ballot paper shall not be taken to be duly returned unless the returning officer is satisfied that it has been received by the returning officer before the close of the poll, with a declaration of identity if required that has been correctly completed, signed, and dated.

(2) Where the returning officer is satisfied that paragraph (1) has been fulfilled, he or she is to –

(a) put the declaration of identity if required in a separate packet, and (b) put the ballot paper aside for counting after the close of the poll.

(3) Where the returning officer is not satisfied that paragraph (1) has been fulfilled, he or she is to –

(a) mark the ballot paper “disqualified”, (b) if there is a declaration of identity accompanying the ballot paper, mark it as “disqualified” and attach it the ballot paper, (c) record the unique identifier on the ballot paper in a list (the “list of disqualified documents”); and (d) place the document or documents in a separate packet.

(4) An internet vote shall not be taken to be duly returned unless the returning officer is satisfied that the internet voting record has been received by the returning officer before the close of the poll, with a declaration of identity if required that has been correctly made.

(5) Where the returning officer is satisfied that rule xxx has been fulfilled, he or she is to : (a) mark the internet voting record “disqualified”. (b) record the voter ID number on the internet voting record, in the list of disqualified documents; and (c) place the document or documents in a separate packet.

36. Declaration of identity but no ballot paper (public and patient constituency) – Where the returning officer receives a declaration of identity if required but no ballot paper, the returning officer is to – (a) mark the declaration of identity “disqualified”, (b) record the name of the voter in the list of disqualified documents, indicating that a declaration of identity was received from the voter without a ballot paper; and (c) place the declaration of identity in a separate packet.

37. De-duplication of votes (1) Where different methods of polling are being used in an election, the returning officer shall examine all votes cast to ascertain if a voter ID number has been used more than once to cast a vote in the election.

(2) If the returning officer ascertains that a voter ID number has been used more than once to cast a vote in the election he or she shall: (a) only accept as duly returned the first vote received that was cast using the relevant voter ID number; and (b) mark as “disqualified” all other votes that were cast using the relevant voter ID number

(3) Where a ballot paper is disqualified under this rule the returning officer shall: (a) mark the ballot paper “disqualified”, (b) if there is an ID declaration form accompanying the ballot paper, mark it “disqualified” and attach it to the ballot paper, (c) record the unique identifier and the voter ID number on the ballot paper in the list of disqualified documents; (d) place the document or documents in a separate packet; and (e) disregard the ballot paper when counting the votes in accordance with these rules.

(4) Where an internet voting record is disqualified under this rule the returning officer shall: (a) mark the internet voting record “disqualified”, (b) record the voter ID number on the internet voting record in the list of disqualified documents; (c) place the internet voting record in a separate packet, and (d) disregard the internet voting record when counting the votes in accordance with these rules.

38. Sealing of packets – As soon as is possible after the close of the poll and after the completion of the procedure under rules 35 and 36, the returning officer is to seal the packets containing–

(a) the disqualified documents, together with the list of disqualified documents inside it, (b) the declarations of identity if required, (c) the list of spoilt ballot papers, (d) the list of lost ballot papers, (e) the list of eligible voters, and (f) the list of tendered ballot papers.

Part 6 - Counting the votes

39. Arrangements for counting of the votes – The returning officer is to make arrangements for counting the votes as soon as is practicable after the close of the poll.

40. The count – (1) The returning officer is to – (a) count and record the number of ballot papers that have been returned, (b) the number of internet voting records that have been created and (c) count the votes according to the provisions in this Part of the rules

(2) The returning officer, while counting and recording the number of ballot papers and internet votes and counting the votes, must make arrangements to ensure that no person obtains or communicates information as to the unique identifier on a ballot paper.

(3) The returning officer is to proceed continuously with counting the votes as far as is practicable.

41. Rejected ballot papers – (1) Any ballot paper –

(a) which does not bear the features that have been incorporated into the other ballot papers to prevent them from being reproduced, (b) on which votes are given for more candidates than the voter is entitled to vote, (c) on which anything is written or marked by which the voter can be identified except the unique identifier, or (d) which is unmarked or rejected because of uncertainty, shall, subject to paragraphs (2) and (3) below, be rejected and not counted. (2) Where the voter is entitled to vote for more than one candidate, a ballot paper is not to be rejected because of uncertainty in respect of any vote where no uncertainty arises, and that vote is to be counted.

(3) A ballot paper on which a vote is marked –

(a) elsewhere than in the proper place, (b) otherwise than by means of a clear mark, (c) by more than one mark, is not to be rejected for such reason (either wholly or in respect of that vote) if an intention that the vote shall be for one or other of the candidates clearly appears, and the way the paper is marked does not itself identify the voter and it is not shown that he or she can be identified by it.

(4) The returning officer is to –

(a) endorse the word “rejected” on any ballot paper which under this rule is not to be counted, and (b) in the case of a ballot paper on which any vote is counted under paragraph (2) or (3) above, endorse the words “rejected in part” on the ballot paper and indicate which vote or votes have been counted.

(5) The returning officer is to draw up a statement showing the number of rejected ballot papers under the following headings –

(a) does not bear proper features that have been incorporated into the ballot paper, (b) voting for more candidates than the voter is entitled to, (c) writing or mark by which voter could be identified, and (d) unmarked or rejected because of uncertainty, and, where applicable, each heading must record the number of ballot papers rejected in part.

42. Equality of votes – Where, after the counting of votes is completed, an equality of votes is found to exist between any candidates and the addition of a vote would entitle any of those candidates to be declared elected, the returning officer is to decide between those candidates by a lot, and proceed as if the candidate on whom the lot falls had received an additional vote.

Part 7 – Final proceedings in contested and uncontested elections

43. Declaration of result for contested elections – (1) In a contested election, when the result of the poll has been ascertained, the returning officer is to –

(a) declare the candidate or candidates whom more votes have been given than for the other candidates, up to the number of vacancies to be filled on the council of governors from the constituency, or class within a constituency, for which the election is being held to be elected, (b) give notice of the name of each candidate who he or she has declared elected– (i) where the election is held under a proposed constitution pursuant to powers conferred on the Western Sussex Hospitals NHS Trust by section 33(4) of the 2006 Act, to the chairman of the NHS Trust, or (ii) in any other case, to the chairman of the corporation; and (c) give public notice of the name of each candidate whom he or she has declared elected.

(2) The returning officer is to make –

(a) the total number of votes given for each candidate (whether elected or not), and (b) the number of rejected ballot papers under each of the headings in rule 39(5), available on request.

44. Declaration of result for uncontested elections – In an uncontested election, the returning officer is to as soon as is practicable after final day for the delivery of notices of withdrawals by candidates from the election –

(a) declare the candidate or candidates remaining validly nominated to be elected, (b) give notice of the name of each candidate who he or she has declared elected to the chairman of the corporation, and (c) give public notice of the name of each candidate who he or she has declared elected. Part 8 – Disposal of documents

45. Sealing up of documents relating to the poll – (1) On completion of the counting at a contested election, the returning officer is to seal up the following documents in separate packets –

(a) the counted ballot papers internet voting records , (b) the ballot papers endorsed with “rejected in part”, (c) the rejected ballot papers, and (d) the statement of rejected ballot papers. and ensure that complete electronic copies of the internet voting records created in accordance with rule 26 are held in a device suitable for the purpose of storage.

(2) The returning officer must not open the sealed packets of –

(a) the disqualified documents, with the list of disqualified documents inside it, (b) the declarations of identity, (c) the list of spoilt ballot papers, (d) the list of lost ballot papers, (e) the list of eligible voters, and (f) the list of tendered ballot papers. or access the complete electronic copies of the internet voting records created in accordance with rule 26 and held in a device suitable for the purpose of suitable for the purpose of storage.

(3) The returning officer must endorse on each packet a description of –

(a) its contents, (b) the date of the publication of notice of the election, (c) the name of the corporation to which the election relates, and (d) the constituency, or class within a constituency, to which the election relates.

46. Delivery of documents – Once the documents relating to the poll have been sealed up and endorsed pursuant to rule 45the returning officer is to forward them to the chair of the corporation.

To: Trust Board Date of Meeting: 28 July 2016 Agenda Item: 14

Title Patient First Strategy Deployment Reporting and Board Assurance Framework Report Responsible Executive Director Mike Jennings, Commercial Director Prepared by Mike Jennings, Commercial Director Status Disclosable Summary of Proposal Quarter 1 reports for the Patient First Metrics and the BAF form this report. It is acknowledged both documents are under development, and work is underway to fully align these documents ahead of Quarter 2 reporting.

PATIENT FIRST METRICS QUARTER 1 The purpose of this report is to update the Trust Board on True North Metrics alongside Breakthrough Objectives, Strategic Initiatives and Corporate Projects. Work continues to align internal processes to support this new way of working at Executive Level and reporting to Trust Board. The Board is asked to note that some areas are still under development as the report is evolves. Work is underway to further align the BAF and True North metrics reporting.

BOARD ASSURANCE FRAMEWORK QUARTER 1 The Board Assurance Framework (BAF) report has been restyled to reflect the Trusts’ focus on its True North and Breakthrough Objectives. Further options are being considered to better align risk reporting to the Trust key objectives and initiatives. Work continues to develop the Strategic Initiatives and Corporate Objectives reporting and these will be incorporated from Quarter 2. All areas have been reviewed by Lead Executive Directors for Quarter 1. The Board should note the following:

 there have been no changes to any post mitigation risk scores.  there are no items designated with a ‘High Risk’ score.  the Board should note that there are currently two True North metrics where the post mitigation risk score is greater than the target risk score, these are; o Quality Improvement : Avoid Harm; and o Systems and Partnership : Referral to Treatment Compliance  the Board should also note that the Breakthrough Objective relating to People has been further developed since the draft BAF presented to the Board, the risk clarified and initial actions set out. Work will continue to further enhance this reporting against this objective; and  except for the Breakthrough relating to People all post mitigation risk scores exceed the risk target value. However, improvement in some of these would be expected as the year progresses.

This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288.

Implications for Quality of Care The Patient First Improvement Programme, under which the True North metrics have been developed, is the Trusts key quality improvement initiative. Link to Strategic Objectives/Board Assurance Framework Links to the Trusts Patient First Improvement Programme. Financial Implications No specific issues identified at this stage. Human Resource Implications No specific issues identified at this stage. Recommendation The Board is asked to NOTE the report. Communication and Consultation Trust Board and Trust Executive Committee. Appendices Appendix 1: True North Metric Report. Appendix 2: Board Assurance Framework.

This report can be made available in other formats and in other languages. To discuss your requirements please contact Andy Gray, Company Secretary, on [email protected] or 01903 285288.

Patient First Metrics – July 2016

True North

Family and Friends Budget Staff HSMR Patient Safety Referral to A&E 4 Hours Score Management Engagement Thermometer Treatment Time

Breakthrough Arrows indicate: Objectives Improving metrics Reduce the Reduce numbers Reduce the Staff are able to numbers of Falls of MFFD patients amount of Agency make spend Improvements Stable metrics

Worsening metrics

Strategic Achieving target/ On track Initiatives Not achieving target/ Not on track Patient First Sustainability & Outpatient Workforce Improvement Transformation Transformation Transformation Programme Plan

Corporate Projects

WS Eye Care @ CWS MSK Junior Doctor Clinical Document Acute Surgical Carter Review Pathology LIMS Southlands Integrated Contract Management Review Services Portal True North

What are we trying to achieve? How are we doing? What is important to know?

Friends and Family Test - Positive Recommendation rate % • For all FFT areas positive Aim to achieve rates >97% positive 100% Target, 97% recommendations >94%

recommendation, not exceed 0.7% not 95% • ‘Not recommended’ for all areas recommend and a response >40% for Friends and 1.3% or greater inpatients 90% Family Score • Inpatient return rate 38.4%

Inpatient positive recommendation rate Patient 85% • A&E and maternity response rate for FFT returns = 95.5% in June. Apr-14 Aug-14 Dec-14 Apr-15 Aug-15 Dec-15 Apr-16 Aug-16 <20% - focused activity in these source: Dr Foster areas

Financial Variance From Budget (£000s) • The Trust has delivered the plan for

5,000 The Trust is required to deliver it’s Q1 (£0.7m deficit) and the STF financial plan in order to fund service 3,000 funding is secured Budget developments and ensure sustainability. 1,000 • Income from activities is £0.9m Management (1,000) above plan to date. (3,000) Metric is variance to financial plan. • Pay spend is £0.3m above plan due

(5,000) Sustainability Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 to overspends within nursing and AHPs.

All staff are not fully engaged in the work of the Trust which could compromise our As from July staff feedback is being monitored using surveys at Health

ability to deliver our vision Staff Three. key elements – Able to make and Safety days. Engagement improvements: Baseline data will be available for the next report. Score Healthy climate – would recommend as People place to work and/or be treated: Motivation at work

Hospital Standardised Mortality Ratio • The latest HSMR is 89.4 (12 Mortality rate for non-elective patients is 105 months to March 2016) 100 too high. We want to reduce the number Nat. 20th • This represents 1775 deaths (v of potentially avoidable deaths 95 percentile, 90 1986 expected) HSMR Dr. Foster HSMR provides a measure 90 • The performance in this period 85 against expected deaths. 100 is as puts WSHFT in the top 18% Quality 80

expected. Lower is better. We wish to be Feb-14 Jun-14 Oct-14 Feb-15 Jun-15 Oct-15 Feb-16 Jun-16 • HSMR by site SRH 85.8 WH 92.2 Improvement in top 20% of Trusts source: Dr Foster True North

What are we trying to achieve? How are we doing? What is important to know?

• 98.4% no new harms in June Patient Safety Thermometer - % Patients with no new harms Too many patients suffer harm during 100%

• Falls are top cause of harm Target, 99% their stay in WSHT. This impacts on 98% • Falls Reduction Programme has wellbeing, length of stay and Patient Safety 96% already shown a positive impact recommendation 94% Thermometer • Pressure damage next highest cause

. 92% Quality

Harm is measured once per month using audited % Patients • Weekly RCA panels reviewing all 90% the National Safety Thermometer Apr-14 Aug-14 Dec-14 Apr-15 Aug-15 Dec-15 Apr-16 Aug-16 pressure damage with learning Improvement source: Board Quality Scorecard directing educational input.

RTT Incomplete pathways - % waiting less than 18 weeks •

95% Compliance improved from May to

Too many patients are waiting an Target, 92% 88.4% in June unacceptable time for elective treatment, 90% • Performance exceeds STF delivery resulting in a poor patient experience. Referral to 85% trajectory (Plan = Green) Treatment Time 80% • Elective activity increased and

Metric is % of incomplete patient 75% above plan for June

Partnership Systems and Systems pathways that are waiting less than 18 Apr-14 Aug-14 Dec-14 Apr-15 Aug-15 Dec-15 Apr-16 Aug-16 • Backlog >18 weeks decreased to weeks source: RTT Monthly Return <4,000

A&E - % Patients seen within 4 hours • Zero >12hr breaches and 95.64%

Demands in the urgent care system lead 100% Target, 95% patients <4hrs to patient flow being compromised, which 95% • Performance exceeds the STF A&E leads to a poor patient experience. 90% delivery trajectory (Plan = Green) 85% • Q1 compliance 95.85% exceeding 4 Hours 80%

Metric is % of patients attending A&E seen 75% target and STF trajectory Partnership Apr-14 Aug-14 Dec-14 Apr-15 Aug-15 Dec-15 Apr-16 Aug-16 and Systems within 4 hours. source: A&E Monthly Return Breakthrough Objectives

What are we trying to achieve? How are we doing? What is important to know?

Number of Falls • Total falls in 2015/16 2502 Too many patients suffer falls in our Trust. 230 • Top 10 fall areas completed A3s

This causes harm and has an impact on 180 • Weekly progress review by MD Reduce the length of stay and reputation. • 7 /10 top wards have achieved 130 Target (30% Number of Falls reduction), their target 50% reduction for 130 week ending 17/7 Quality Falls are measured continuously via Datix 80 system Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 • Trust target of 30% reduction Improvement met for week ending 17/7

MFFD – Average Patient Days Delayed • DTOC has remained static in

2,080 The number of medically fit for discharge June patients within hospital beds is 1,580 • MFFD average delayed days Reduce the compromising patient flow. This has an 1,080 Target, 750 decreased in June by 10% number of MFFD impact on A&E wait, length of stay. 580 • Improvements made in SCT Patient Delays delays with reduced volumes

Medically fit for discharge patients in 80 Partnership hospital. Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 and reduced delay to access and Systems community beds

Agency Spend (£000s) Level of agency staffing spend 5,000 • Agency £1.3m below threshold unsustainable. Spend has increased Reduce the 3,000 • Nurse agency £289k above significantly year on year. Have been set 1,000 amount of threshold target. Extra beds and annual expenditure ceiling by NHSI and (1,000) specials key drivers requirement to comply with capped rates. Agency Spend (3,000) • Medical agency under threshold

Total agency expenditure against a (5,000) but offset by other medical pay Sustainability Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 maximum ceiling for the year. costs

Highlight findings from wave 1 PFIS wards: Staff have the opportunities, tools and Progress will be monitored using • Learning is an important part of our daily support to identify and make surveys in four areas: Staff are able to work: 97% (baseline: 82%) improvements in their area of work • Patient First Improvement System • Visual displays of data are reviewed and used make PFIS • Target areas (Estates and Facilities for improvement: 86% (45%) Improvements PF /Lean training including Awareness for and Admin and Clerical People • Staff suggestions to improve performance are all staff • Health and Safety days beginning actively solicited: 83% (32%) Management/Leadership development in July 2016. Strategic Initiatives

What are we trying to achieve? How are we doing? What is important to know?

Development of Continuous The Patient First programme is Improvement (Kaizen) culture within continuing to grow under each of Patient the Trust that empowers staff to solve the Pillars shown with a lot of problems and make improvements in First support, interest and excitement support of True North and Patient first shown from Execs & the wider Patient objectives Trust.

To build a self-sufficient (high performing) • The Kaizen Office team Performance Kaizen team and internal network of Board reviews progress against our Kaizen ‘Lean’ professionals that are able to aligned objectives on a Weekly basis. Office deliver training, solve problems and make • This includes a process for Escalation to improvements. the Exec if matters cannot be resolved

within the Team. Sustainability

Strategy deployment is the process • Monthly Strategy deployment that links the organisation to the True reviews take place monthly to

North metrics and objectives of review progress against True Strategy Patient First North, Breakthrough and Strategic Deployment Objectives. • Standard work with clear roles and People responsibilities ensure full compliance to the SDR process.

Lean management systems (PFIS) • As part of PFIS Wave 2 roll out of 4

implemented across the whole Units, the photo shows Trauma organisation with full support and Theatre team running a Safety and PFIS engagement from all teams, Improvement Huddle. operationalised to the required • Nick Jarrett and the team gather standard allowing staff to make every morning at 0830 to discuss, Quality

improvements to their area prioritise and progress Improvement Improvement tickets for Patient First. Strategic Initiatives

What are we trying to achieve? How are we doing? What is important to know?

• A number of trained Yellow Belts To ensure all staff have knowledge, are utilised to support PFIS as part

skills to participate in Lean based of the roll out to their Wards or Capacity and improvement activities in helping to Areas. Capability build a culture of Continuous • It also provides the Trust with the Improvement in supporting True added Lean capability to People North and objectives of Patient First independently identify and solve a problem in their own area of work.

Robust process in place for identifying, • The 6 projects are led by Kaizen Office and supplemented by the

resourcing and deployment of Lean improvement projects with full Green Belt “trainees”. Projects support from “internal” Lean network • Lunch & Learn sessions held to

showing tangible improvements showcase to the Exec the progress Quality against True North metrics and patient and learnings to date. first programme Improvement Strategic Initiatives

What are we trying to achieve? How are we doing? What is important to know?

• Deliver a system wide plan for a 5 year • Draft plan submitted on the 30th June forward view and close gaps in health and We do not yet have a Sustainability 2016. wellbeing, care and quality and finance comprehensive plan that and • More detailed financial template to be across Sussex and East Surrey. sufficiently closes the gaps. submitted by the end of July

Transformation Patient Plan

• A population based approach for A new programme Director has • A stakeholder away day to review and Coastal West Sussex, delivered been appointed and project relaunch the programme is being held through increasing integration in structure is under review to th Coastal Care on the 29 July 2016. order to improve standards, manage facilitate delivery. demand and make the system financially sustainable. Includes Health and Social Care. Sustainability

• Ensure the provision of high quality CWS CCG and WSHFT have stroke services and meet the clinical • CCG & WSHFT are in process of collaborated to implement the activity, standards as detailed in the National FrontStroke Door bed capacity and financial analysis re- agreeing a joint recommendation. Stroke Strategy 2007. work recommended by Clinical Senate. which will need to take into account ReconfigurationA&E • Sussex-wide review supported by the the STP planning process. Quality Sussex Collaborative Delivery Team and

Improvement funded by the seven Sussex Clinical Commissioning Groups. Strategic Initiatives

What are we trying to achieve? How are we doing? What is important to know?

To improve every interaction a • Improvement approach and patient has with the Trust programme priorities discussed at regarding their outpatient Board Seminar May 2016 Outpatient appointments. We aim to improve • Inaugural Outpatient Steering Group Transformation patient experience whilst being held on 29th July simultaneously make the best use Patient of Trust resources through this ambitious change programme.

Worthing SRH Worthing SRH MSK

Once a referral is received, Week Ending • Outline Business Case scheduled for

manual processes are 2WW 2WW registration Registration Registration Business Case Scrutiny Review early Within 24 Within 14/07/2016 10 days 3 days 2 days needed. Achieving best hrs 24 hrs August Within 24 Within Time taken to 08/07/2016 7 days 2 days 6 days practice could reduce the hrs 24 hrs • If approved, a procurement process Within 24 process time taken to manage and 01/07/2016 Daily Daily Within 24 hrs 2 days will commence hrs referrals grade referrals by an average 24/06/2016 Daily Daily 4 days 4 days 10 days • Expected contract award February

of 8 days. 17/06/2016 Daily Daily 16 days 4 days 9 days 2017 for deployment in 2017/18 Sustainability 10/06/2016 Daily Daily 15 days 4 days 4 days

This transformational programme • Whilst some specialties have • Prioritisation assessment criteria under

will support specialties to review reviewed clinic templates, there development and initial conversations clinic capacity . We anticipate this has not been a systematic and with Clinical Divisions underway Demand and will reduce on-day delays and evidence based approach. • Support and facilitation approach being Capacity improve overall capacity to see • The baseline for this metric will defined for presentation at the

more patients with the same need to be established. Outpatient Steering Group July 2016 Systems and Systems resource. Partnerships

When patients come to our • The Trust is performing better than the Outpatients, they are waiting too long national average for > 15 minute wait

to be seen. One third of patients wait (38%). Patient on more than 15 minutes, 21% of those • Worthing and Southlands are a wave 2 site waiting waited more than 30 minutes. Our PFIS unit times objective is to reduce these waiting • The driver metric is the Friends and Quality

times - prioritising specialties with Family Test Improvement longer waits • The watch metric is start/finish times

Strategic Initiatives

What are we trying to achieve? How are we doing? What is important to know?

Workforce

Transformation People

• Workforce Transformation Staff Group Est In post • Four key areas have been Closing the Strategic Initiative over 3-5 years RNs/MWs 1918 1682 identified. skills/capacity sets objectives to address long • A baseline has been established for gap in some standing workforce gaps. Jnr docs 169 158 each area. • Specific initiatives designed to professional Therapists 325 297 • Staff group meetings are being staff groups increase the supply of groups of (Prof & Tec) scheduled through July/August to professional staff; Junior Doctors,

develop A3s. People Registered Nurses, Therapists and Scientists 373 325 (Prof allied to Scientists will be taken forward Medicine ) alongside consideration of new roles and new models of care, Theatres 111 102

which require a different skill mix.

People WS WS EyeCare @ Junior Doctor Doctor Junior Management Southlands Integrated Document CWS CWS MSK Contract Service Clinical Clinical Portal

CorporateProjects 2020 by paperless be to WSHFT at Patient records • • • • • position. Still awaiting information on national forward. To performance RTTweek 18 the to improvedemand, anticipated meetProvide sufficientto capacity Ophthalmology by centre care To control health economy costs. economy health control outcomes, parties to and third collaboratively with SCFT Lead Rheumatology). and Orthopaedics (Physio, care Pain, outpatient and Pathways for MSK electiveRedesign

What are we trying to to achieve? trying areWhat we provide a sustainable moving sustainable service provide a Southlands as an ambulatory develop on on

delivering newdelivering improved patient improved patient shorten shorten relocating relocating

waiting times and and timeswaiting

pathways pathways

Target Date .

May-17 Mar-17 Aug-16 Aug-16 Dec-16 Feb-16 Feb-16 Oct-17 Oct-16 Jan-16 Jul-16 Jul-16 supplied supplied from August 2016 Usage fordata case ingested willnotes be Redesigned MDTsRedesigned operational managementSelf service commences (subject to support)CCG Clinical information System rolled out (subject to support)CCG Develop plansdetailed for specialist MDT pathways Introduce Triage and Treatment service Await response from toCCG phased introduction approach Develop service plan formanagement self hub Present work to date to CCG. Develop plansdetailed for triage and treatment service Detailed staff, patients and public engagement Develop Overarching Clinical Pathway Evaluate system and service issues/ solutions How are we doing? we are How Action

Completeness not started not started not started not started not started awaited 100% 100% 100% 100% 100% 75% • • • • • mitigated through 2016/17 through mitigated delay financial and time both be can impact it removal,isthat asbestos hoped further need for the delay due Potential 3 week plans. and workforcecommunications clinical pathways, procurement, equipment working Programme • • • • CCG Clinicalreview with held sessionthe model new lead the Deputy elements agreementbut Clinicalworking approach partnership all Ophthalmology go patients Paediatric go Paediatric Outpatients adopters on go track to Programme – What know? isWhat to important through the enabling enabling works, the through

who were content with the the with content who were Director(MSK) Board and and Board Steering complex

Inpatients service on on financial/commercial leading status. leading red to through mobilisation. through go started started

- live - live Julylive - live with early early with live Group Group Sept on on 4 - live Nov live

proposal. proposal.

th

July to to July well

Systems and Patient People Systems and Patient PartnershipsPartnership PathologyLIMS Acute Surgery Clinical Portal Clinical Carter Review Pathology Review LIMS

CorporateProjects forWSHFT. and fully siteup lab cold set hot automated managed as part of the system comms order and system management To

• install a new laboratory install laboratory information a new hours service. of out sustainable surgical acute fora plan implementation an agreeand configuration, future developfor options Trust, the associatedat and servicessurgery ofa emergencyreview To perform workstreams isworkstreams underway. acrossReview Carter of ofrequirements Scoping What are we trying to to achieve? trying areWhat we equipment service equipment

Abbott Abbott – pathology pathology

enabling enabling a

September/October in event Stakeholder August. stakeholders during clinical to communicated be to forchange Case Stakeholder Group meetings of similarexamples provide and challenge, provide external NHS working through issues.these through working have been trust and from supplier teams project The months. delayed for18 has livedifficulties,go that been meaning technical run into severalhas project The Elect to to interviews, Elect facilitate stakeholder How are we doing? we are How groups in in development.groups commenced work. Fortnightly work. Fortnightly

, Internal Internal PID

and and

Steering

plan complete.plan livego when new to F&I brought be to update detailed livego willand set.more be A date discussion,commercial and a plan project new will which pending supplier, be evaluated the delays. solution by A technical offered been has costsof asa ofresultthe Trust somerecoup is to negotiation underway A commercial • meeting took place 19 July 2016 July 19 took place meeting established, first group Steering • • for: need know? isWhat to important The critical care Twounits maternityand two take undifferentiated serviceswith led A&E Two consultant scope is constrained by the by scope is constrained

units

Patient Patient Patient BOARD ASSURANCE FRAMEWORK : QUARTER 1 2016/17

Risk Description Gross Risk Rating Existing Controls Sources of Assurance Control / Assurance Gap Net Risk Rating Action Plan

ie. Actions already fully implemented to ie. Evidence relating to the specific measures what additional actions need to be manage risk under 'Existing Controls'. Can be positive (+) taken to manage this risk OR what or negative (-) : State whether assurances are additional assurance do we need TARGET RISK

(+) or (-) and the Date received / Frequency to seek SCORE Risk Exec Lead Exec Risk

Likelihood Impact Total Likelihood Impact Total

True North

True North : Patient : Friends and Family Score Improvements TARGET :To achieve a postive response score of >97% and to DNPS As a result of Patients having a poor 3 4 12 Provision of patient monthly safety metrics to National in-patient and out-patient surveys, Gap: delayed receipt of National 3 3 9 2 x 3 = 6 Negative FFT scores to form reduce the negative response score experience we incur adverse feedback which provide public assurance. and monitoring of action plans at Board Inpatient Survey report - delay to part of reporting to newly impacts on our Friends and Family Test and/or Patient Experience and Feedback actions to address 2016 survey developed Strategy scores. Review of RTPE feedback to ensure that Committee (+) which commences August 16 Deployment Review meeting. public concerns are identified and resolved in Monthly Quality report and Board, including a timely fashion. RTPE data & Friends & Family Test (+) National inpatient survey report now received, action plan to CQC Hospital inspection Report. Healthwatch - Quarterly meetings established September Trust Board.

Stakeholder engagement and feedback Friend & Family test results

Partnership working with HealthWatch, the RTPE and real time staff survey responses. Clinical Commissioning Group and Governorses. Governors, CCG and Healthwatch involved in Patient Engagement and Experience National Patient Survey Results. committee

Friends & Family Test scores

Routine meetings with CCG Lead of Quality

True North : Sustainability : Budget Management TARGET : To achieve a Break Even against the Financial Plan DoF Ability to manage financial pressures 4 4 16 Financial Plan reviewed at F&I and approved Monthly financial performance report to Income / Activity reporting developed 3 4 12 3 x 4 = 12 Ongoing discussion to generated from additional demand and deliver at Board Board and F&I Committee and presented to Finance and conclude 2015/16 contract. productivity improvements required. Local Investment Committee Health Economy Sustainability and ability of Efficiency programme reports to F&I 2016/17 Contract with CCG commissioners to afford any increases in Committee signed. activity above contracted levels. Cash and Liquidity report monthly to F&I Q1 Sustainability and committee Transformation Fund trajectory achieved.

DoF Failure to deliver efficiency programme 4 4 16 Programme Management Office in place. 3 4 12 3 x 4 = 12 QIA's reviewed at Board's Quality Efficiency Programme Steering group meets and Risk Committee - majority Fortnightly Executive led Steering Group to review delivery of plans and development now approved. embedded. of pipeline schemes to mitigate risk Dividional Efficiency programme Weekly programme assurance meetings boards in place and operational. forms key part of governance arrangments. Q1 achieved circa 90% of efficiency programme target.

True North : People TARGET : To achieve a Staff Engagement Score –Top 20% in DODL Operational pressures and available capacity 3 4 12 Management and Leadership Development Leadership Strategy and 3 3 9 3 x3 =9 Management and Leadership country (3.82 currently) impact on staff availability to engage. Inability Programmes Development Plan to support Patient plan to be developed by end of of staff to be able to take advantage of First Programme Q2. engagement opportunities could impact on achieving True North objective. Mentorship and new Consultant programme continues. Senior leaders invited to be part of Lean yellow belt training.

Broader range of Health and Well-being initiatives underway.

True North : Quality Improvement : Preventable Mortality

Page 1 of 3 MD We fail to implement care pathways 3 4 12 Care bundle progress monitored at monthly Feedback data from Enhancing Quality (EQ) HSMR Monitoring tracks 3 3 9 3 x3 =9 On-going monitoring and adequately in order to improve mortality Divisional Integrated Performance Review programme to Board improvement through Board. enhancement of plans through Panel meetings. Quality Board Reporting of site specific care pathway data Mortality Steering Group reviews in Development of site-specific metrics to to Board place. Significant improvement New Mortality Steering Group in demonstrate processes in place and working demonstrated. place. TARGET: HSMR Top 20% in the country Monthly diagnosis group-specific mortality Reporting of care bundle process metrics to reporting to Board Performance continues to Board. improve and be sustained. Quality Board to monitor Quality Strategy

True North : Quality Improvement : Avoid Harm MD Non compliance with agreed standards and 4 4 16 Regular reporting to Board. Inquests (+/-) Triangulation of vacancy rates v 3 4 12 2 x4 =8 Executive led Agency panel to benchmarks results in avoidable harm. SIRIM weekly Root cause analysis findings (=/-) harm events by ward scrutinise requests for non- Divisional Governance meetins quarterly M monthly reporting of harms ie falls / framework agency and ensure Divisional monthly meetings pressure in juries/MRSA/C Diff (+) safety maintained. Escalation of Reporting of incidents by staff. RCA meetings for C Diff and Grade 3/4 concerns to Quality Board TARGET : Patient Safety Thermometer 99% Harm free Care Triangulation Metting pressure ulcers identify through Triangulation Committee. avoidable/unavoidable harm (+/-) Whistleblowing by staff. Triangulation of vacancy rates v harm events by ward report to Trust Board. True North : Systems and Partnership TARGET : RTT – 92% incomplete < 18 wks COO Increased volumes, reduced flow, and non- 4 4 16 Agreed activity and referral demand contract Trust Board Performance Report (+ Monthly) Control Gap - Implementation of 3 4 12 2x4=8 RTT incomplete position to be delivery of activity volumes required lead to a with CCG and internal activity plan to deliver enhanced 'end of month' reporting discussed through newly poor patient experience / extended waiting agreggate compliance. Weekly Operative Theatre activity vs plan and validation process to confirm implemented Strategy times for elective treatement and failure to reporting for Surgery Division (+ Weekly) and update non-admitted outcomes Deployment Room achieve the National RTT 18wk Target - a Weekly COO/DoF Surgery Division Activity condition of the constitution and Sustainability review and planning meeting. Weekly incomplete position reported through A3s and structured improvement and Transformation Fund. to COO/DDO performance board meeting (+ plans to be agreed for RTT, Activity and Delivery Plan reviewed at F&I Weekly) including development of and Board and monitored monthly through enhanced reporting and validation Board reporting. process/programme

RTT Incomplete position reported monthly to Performance to Q1 ahead of Trust Board. improvement trajectory. STF requuirement achieved.

COO Increased volumes and reduced flow within 3 4 12 Daily 2hrly SITREP reporting through to exec Trust Board Performance Report (+ Monthly) Control Gap - Development of 2 4 8 2x4=8 A&E 4hr position to be discussed A&E - 95% < 4 hrs wait the A&E units lead to a poor patient / senior operational / on-call directors. improvement plan and monitoring through newly implemented experience and failure to achieve the National Daily SITREP on performance and MTD / associated with 'Minors' sustainability Strategy Deployment Room A&E 4hr Target - a condition of the consitution Weekly COO/DDO/DoP review of QTD / YTD (+ Daily) and Sustainability and Transformation Fund. performance, activity, and trends. A3s and structured improvement Weekly A&E position reported through to plans to be agreed for A&E COO/DDO performance board meeting (+ including development of Weekly) enhanced reporting and validation process/programme

Q1 targets achieved. STF requirement acheived.

Page 2 of 3 Breakthrough Objectives

Breakthrough Objective : Sustainability Reduce the amount of agency Spend DoF Failure to comply with agency capped-rates 3 4 12 Executive Agency Panel meets daily to Executive led Agency panel in place. 3 4 12 3 x 3 = 9 Remain above cap-compliance requirements. review requests for agnecy above cap or from trajectory for Q1 non-framework. Executive bi-lateral meetings with Divisions to focus on Agency spend.

Reduce the amount of agency Spend DoF Failure to achieve Agency ceiling as required 3 4 12 Weekly reporting at Executive Agency 3 4 12 3 x 3 = 9 Achieved Q1 trajectory for as a condiction of the Sustainability and Review Meeting. Agency ceiling. Transformation Fund. Weekly scrutiny of agency spend against overall ceiling trajectory plan. Breakthrough Objective : People Staff feel they are able to contribute to make improvements Staff do not feel that they are able to 3 4 12 weekly data collection through mandatory 3 3 9 3 x 3 = 9 in there are of work. contribute to making improveemnts in training days. there are of work. Improvement is an output from the Patient First Improveemnt System work.

Communication around expectation underway.

Capability and capacity building through green/yellow DODL belt training well underway. Breakthrough Objectives : Quality Improvement : Avoid Harm Reduce the number of falls by 30% from a baseline of 237. MD Interventions do not result in a reduction of 3 4 12 Development of Ward accreditation. Board reporting monthly through Quality 3 4 12 3 x 3 = 9 tracking of data via safety Falls. Report huddles at ward level PFIS Wards embedded in parctice on 'PFIS' Wards. Breakthrough Objective : Systems and Partnership Reduce the number of patients medically fit for discharge COO Failure to reduce MFFD patients occupying 3 4 12 Daily MFFD multi agency meetings on both Board performance report (+ Monthly) Control Gap - Detailed MFFD 3 4 12 2x4=8 A3 refreshed and issued. acute hospital beds and adversely impact acute sites. improvement plan to be developed delivery of services and achieving elective and SITREP reporting on both MFFD and DTOC through developing A3 process non-elective targets. Daily Board Round collection of delay and patients (- Daily) (commenced) next step information as part of Discharge Team support.

Daily SITREP reporting of Formal DTOC patient numbers and reasons

Strategic Initiatives

Patient First Development of Kaizen Office Strategy Deployment Development of Patient First Improvement System Capacity and Capability Lean Projects Sustainability and Transformation Plan Coastal Care (Development of Accountable Care Organisation) Front Door (A&E) Stroke Reconfiguration Outpatient Transformation Time taken to process referrals Demand and Capacity Patient on-site waiting times Workforce Transformation Closing the Skills / Capacity gap in some professional staff groups

Corporate Projects

Western Sussex Eye Care - Southlands CWS MSK Integrated Service Junior Doctor Contract Clinical Portal

Page 3 of 3

To: Trust Board Date of Meeting: 28 July 2016 Agenda Item: 15

Title NHS Improvement Self-Assessment Submission Report – Quarter 1 Responsible Executive Director Marianne Griffiths, Chief Executive Prepared by Andy Gray, Company Secretary Status Disclosable Summary of Proposal The Board is required to approve the Quarterly Self-Assessment prior to submitting to NHS Improvement. NHS Improvement will assess the trust’s performance for the last quarter and will discuss any issues in a review meeting the date of which is to be confirmed. The Board should note that there is currently a NHS Improvement consultation underway regarding a ‘Single Oversight Framework’ for both foundation trusts and NHS trusts which may alter the certificate in due course. Implications for Quality of Care No direct implications – the report seeks assurance that quality of care standards are maintained. Link to Strategic Objectives/Board Assurance Framework Links to key objectives of (i) Maintain an acceptable financial risk rating; (ii) Maintain a Monitor Governance rating of no worse than Amber Green throughout the year. Financial Implications No direct implications – the report seeks assurance that the financial plan is maintained going forward. Human Resource Implications N/A Recommendation The Board is asked to APPROVE the submission. Communication and Consultation To public Board meeting. Appendices 1: Internal checklist 2: Governance submission

This report can be made available in other formats and in other languages. To discuss your requirements please contact the Company Secretary on 01903 285288.

To: Board of Directors Date: 28 July 2016

From: Andy Gray, Company Secretary Agenda Item: 15

FOR DECISION

QUARTER 1 2016-17 – NHS IMPROVEMENT QUARTERLY SELF ASSESSMENT

1. INTRODUCTION

1.1 The Board of Directors is asked to review the Trust’s performance as presented and the attached self-certification checklist attached at Appendix 1. The Board is asked to note the statement at Appendix 2 which is required to be signed by the Chair and Chief Executive.

1.2 The Board should note that following the Quarter 4 2015-16 submission Monitor rated the Trust as having (i) a Financial Sustainability Rating of 2 and (ii) A Governance Risk Rating of ‘Under Review’ ; Requesting further information”.

1.3 The Board should also note that NHS Improvement is currently holding consultation on a Single Oversight Framework to cover both foundation trusts and NHS trusts. A paper briefing on the consultation has been presented to the Finance and Investment Committee.

2 SUMMARY OF SUBMISSION

2.1 The return covers the period 01 April 2016 to 30 June 2016. In making this return, the Board of Directors is considering performance against the Annual Plan for 2016-17, derived from the Operational Plan submitted. The Board should note that the Trust is declaring non- compliance against the Referral to Treatment Target although above trajectory for the recovery plan.

2.2 In signing the financial declaration the Board isconfirming that it anticipates that the trust will continue to maintain a Financial Sustainability Risk Rating (“FSRR”) of at least 3 over the next 12 months.

3 RECOMMENDATION

3.1 The Board is asked to APPROVE the submission to Monitor.

Appendix 1 NHS Improvement Quarterly Reporting Exception Checklist

The following checklist is taken from the Compliance Framework and covers the period 1 April 2016 to 30 June 2016

Lead Quarter 1 2016/17 Finance / KG  Unplanned significant reductions in No income or significant increases in costs Finance / KG  Requirement for additional working No capital facilities Finance / KG  Failure to comply with the NHS No Foundation Trust Annual Reporting Manual Finance / KG  Discussions with external auditors Unqualified Audit Report which may lead to a qualified audit issued. report Finance / KG  Transactions potentially affecting the STF Trajectory for Q1 financial risk rating and/or resulting in achieved. an ‘investment adjustment’ Governance/AG  Removal of director(s) for significant No contractual or non-contractual dispute with another NHS body Finance / KG  Adverse report from internal auditors No Governance/AP  Risk of failure to maintain registration CQC comprehensive with the Care Quality Commission Inspection during December 2015. Quality Summit held 19 April 2016 – Outstanding Rating. Governance  Significant third party investigations that No /AP/AG suggest material issues with governance e.g. fraud or Care Quality Commission reports of ‘significant failings’ Governance/AP Care Quality Commission responsive or No planned reviews Governance/AP  Outcomes or findings of Care Quality Quality Summit held 19 April Commission responsive or planned 2016 – Outstanding Rating. reviews Follow up action plan in place. Governance/No  Other patient safety issues which reflect CQC comprehensive quality governance issues (e.g. serious Inspection during December incidents) 2015. Quality Summit to be held 19 April 2016 Finance / KG  Performance penalties to No commissioners All  Enforcement notices from other bodies implying potential or actual breach of any other requirement of the licence, e.g.: o Health and Safety Executive or No fire authority notices o Material issues impacting on No the trust’s reputation o Adverse reports from overview No and scrutiny committees o Patient group and Healthwatch No concerns

In Year Governance Statement from the Board of Western Sussex Hospitals NHS Foundation Trust

The board are required to respond "Confirmed" or "Not confirmed" to the following statements (see notes below) Board Response

For finance, that: The board anticipates that the trust will continue to maintain a financial sustainability risk rating of at least 3 over the next 12 months. Confirmed

The Board anticipates that the trust's capital expenditure for the remainder of the financial year will not materially differ from the amended forecast in this financial return. Confirmed

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) Not Confirmed as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.

Otherwise:

The board confirms that there are no matters arising in the quarter requiring an exception report to NHS Improvement (per the Risk Assessment Confirmed Framework, Table 3) which have not already been reported.

Consolidated subsidiaries:

Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable funds. 0

Signed on behalf of the board of directors

Signature Signature

Name Mike Viggers Name Marianne Griffiths

Capacity Chair Capacity Chief Executive

Date 28-Jul-16 Date 28-Jul-16

The board is unable to make one of more of the confirmations in the section above on this page and accordingly responds:

RTT: Performance dipped in March 2016, following a sustained improvement from September 2015 – through to February 2016, to 86.5% March 2016. Since March, RTT incomplete compliance has improved month on month to 88.3% end June 2016. The Trust, with LHE partners, submitted a recovery trajectory for RTT as part of the contractual requirements associated with the strategic transformation fund (STF). The Trust has consistently delivered ahead of the STF trajectory in each month of 2016/17 to date. Sustained improvement is contingent on the success of QIPP based demand management mitigation and redirection of demand via CCG programmes, and increases in completed pathways at the Trust to meet recurrent demand and reduce waiting list backlog.