TRUST BOARD AGENDA (open to members of the public and the press)
DATE: Wednesday 21 December 2016
TIME: 1300 -1400 (approx.)
VENUE: Boardroom, Chief executive’s office 2nd floor, Royal Free Hospital Royal Free Hospital
Distribution
CHAIR: Dominic Dodd Chairman of the trust board
TRUST BOARD MEMBERS: Stephen Ainger Non-executive director Mary Basterfield Non-executive director Deborah Oakley Non-executive director Jenny Owen Non-executive director Prof Anthony Schapira Non-executive director David Sloman Chief executive Caroline Clarke Chief finance officer and deputy chief executive Prof Stephen Powis Medical director Kate Slemeck Chief operating officer INVITED TO ATTEND Dr Mike Greenberg Divisional director of women’s and children’s services David Grantham Director of workforce and organisational development Prof George Hamilton Divisional director of surgery and associated services Peter Ridley Director of planning Emma Kearney Director of corporate affairs and communications Andrew Panniker Director of capital and estates Dr Steve Shaw Divisional director of urgent care Dr Robin Woolfson Divisional director of transplant and specialist services Hester Wain Deputy director of patient safety and risk Mr Joe Adams Patient representative, patient safety programme (for item 2016/218 only) Alison Macdonald Board secretary (minutes) Rebecca Longmate Deputy director of nursing (for director of nursing)
APOLOGIES Deborah Sanders Director of nursing COPY FOR Governors (agenda only) INFORMATION: Angela Attah Interim trust secretary TRUST BOARD MEETING1
The next meeting of the trust board will take place on Wednesday 21 December 2016 at 1300 in the boardroom, executive offices, 2nd floor, Royal Free Hospital.
Dominic Dodd Chairman AGENDA
ITEM LEAD PAPER ADMINISTRATIVE ITEMS 2016/213 Apologies for absence – Deborah Sanders D Dodd
2016/214 Declaration of interests D Dodd 1. 2016/215 Minutes of meeting held on 23 November 2016 D Dodd 2. 2016/216 Matters arising report D Dodd 3. 2016/217 Record of items discussed at the Part II board meeting on 23 D Dodd 4. November 2016 PATIENT SAFETY AND EXPERIENCE 2016/218 Quality improvement/patient safety S Powis Patient’s story - Joe Adams, patient representative, patient safety H Wain programme 2016/219 Patients’ voices D Oakley ORGANISATIONAL AGENDA 2016/220 Quality account 2016/17 outline process and timetable S Powis 5.
2016/221 Nursing/midwifery staff monthly report (October 2016) D Sanders 6.
2016/222 Appointment of responsible officer S Powis 7. OPERATIONAL AGENDA 2016/223 Chair’s and chief executive’s report D Dodd / 8. D Sloman 2016/224 Trust performance dashboard K Slemeck 9. 2016/225 Financial performance report C Clarke 10. Governance and regulation: reports from board committees 2016/226 Finance, investment and performance committee (15 December) D Dodd Verbal 2016/227 Shadow group board (8 December 2016) D Dodd 11. 2016/228 Patient safety committee (24 November 2016) S Ainger 12. 2016/229 Audit committee confirmed minutes (15 September 2016) D Oakley 13. 2016/230 Clinical performance committee (24 October 2016) A Schapira 14. 2016/231 Patient and staff experience committee - terms of reference J Owen 15.
1 In accordance with the Health & Social Care Act 2012, all Trust Board meetings must be held in public. All decisions which require the board’s collective approval can only be made at a Trust Board (or a Part II meeting held in closed session to discuss confidential matters). OTHER BUSINESS 2016/232 Questions from the public D Dodd 2016/233 Any other business D Dodd 2016/234 Date of next meeting – 25 January 2017 D Dodd Paper 1
Report to Date of meeting Attachment number
Trust Board 21 December 2016 Paper 1
REGISTER OF INTERESTS OF MEMBERS OF THE BOARD OF DIRECTORS
Executive summary
The trust constitution requires trust board members to declare interests which are relevant and material to the NHS board of which they are a member. The register of interests is presented at each board meeting.
The chairman has amended his declaration of interests since the last board meeting.
Action required
Board members are asked to provide an update if they have any other changes in interests not noted in the attached.
Board members are asked to declare any interests which are relevant to matters on the board agenda.
The board is asked to ratify the updated register, subject to any further changes made.
Public Patient and The register will be made available to the public. Carer involvement
Report From Dominic Dodd, chairman Author(s) Alison Macdonald, board secretary Date 9 December 2016
Register of interests – trust board December 2016 1 Version 9 Updated 14/11/16 REGISTER OF THE INTERESTS OF MEMBERS OF THE TRUST BOARD
Board Member and Directorships, Ownership or part- Majority or A position of Any connection with a Research Interests in pooled funds that are under position including non- ownership of private controlling share authority in a charity voluntary or other funding/grants that separate management (any relevant Date of latest executive directorships companies, business holdings in or voluntary organisation may be received by company included in this fund that has a amendment/confirmed held in private or consultancies likely organisations likely organisation in the contracting for NHS an individual or their potential relationship with the Trust must correct companies or PLCs or possibly seeking to or possibly seeking field of health and services department be declared) (with the exception of do business with the to do business with social care those of dormant NHS the NHS State when position State when State when interest acquired companies) State when interest State when interest State when position accepted funding/grant State when acquired acquired accepted commenced directorship commenced Dominic Dodd, Director of Nil Nil Trustee, The Nil Nil Chair UCLPartners1 King’s Fund. 8/4/16 Unpaid position Improvement Director for NHSI’s financial special measures programme, assigned to Croydon Health Services.
Member of NHSI’s Chairs’ Advisory Group. Unpaid position.
1 The Company’s constitutional documents have been drafted in accordance with charity law and Charity Commission guidance, so that the Company can apply for charitable status in the future as and when its Board of Directors considers this appropriate. Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public. Version 9 Updated 14/11/16 Board Member and Directorships, Ownership or part- Majority or A position of Any connection with a Research Interests in pooled funds that are under position including non- ownership of private controlling share authority in a charity voluntary or other funding/grants that separate management (any relevant Date of latest executive directorships companies, business holdings in or voluntary organisation may be received by company included in this fund that has a amendment/confirmed held in private or consultancies likely organisations likely organisation in the contracting for NHS an individual or their potential relationship with the Trust must correct companies or PLCs or possibly seeking to or possibly seeking field of health and services department be declared) (with the exception of do business with the to do business with social care those of dormant NHS the NHS State when position State when State when interest acquired companies) State when interest State when interest State when position accepted funding/grant acquired acquired accepted commenced State when directorship commenced Non-executive directors
Stephen Ainger Chair Downshire Nil Nil Nil Nil Nil Nil Non-executive Hill Residents’ director Association. 5/1/16
Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public. Version 9 Updated 14/11/16 Deborah Oakley, Medicines and Nil Nil Nil Medicines and Nil I work for Veritas Investment non-executive Healthcare Healthcare Management. The firm invests director Products Products money on behalf of clients. Client 13/5/16 Regulatory Regulatory portfolios are invested in various Agency Non-Exec Agency Non- healthcare companies which Director Exec Director may do business with the trust and with the NHS more broadly. These investments include but are not limited to: Sonic Healthcare; Roche; Novartis; GlaxoSmithKline, United Health, Alphabet, Oracle and others. Clients also invest in pooled funds which are managed externally and invest in a broad range of healthcare companies which may do business with the trust and the NHS. I and my family have personal holdings in pooled funds which are managed externally and invest in a broad range of healthcare companies which may do business with the trust and the NHS. I do not have any direct investments in companies which may do business with the trust or with the NHS.
Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public. Version 9 Updated 14/11/16 Board Member and Directorships, Ownership or part- Majority or A position of Any connection with a Research Interests in pooled funds that are under position including non- ownership of private controlling share authority in a charity voluntary or other funding/grants that separate management (any relevant Date of latest executive directorships companies, business holdings in or voluntary organisation may be received by company included in this fund that has a amendment/confirmed held in private or consultancies likely organisations likely organisation in the contracting for NHS an individual or their potential relationship with the Trust must correct companies or PLCs or possibly seeking to or possibly seeking field of health and services department be declared) (with the exception of do business with the to do business with social care those of dormant NHS the NHS State when position State when State when interest acquired companies) State when interest State when interest State when position accepted funding/grant acquired acquired accepted commenced State when directorship commenced Jenny Owen, Nil Nil Nil Board member Housing 21 and Nil Nil non-executive of Housing and Care 21 director Care 21 6/4/16 Alzheimer’s Trustee of Society Alzheimer’s Society Professor Upper Hampstead Nil Nil Parkinson’s Nil Medical Nil Anthony Schapira Walk Residents’ Disease Society Research Non-executive Association. Research Council, director AHV Schapira Ltd Strategy Group Wellcome Trust, 13/5/16 Parkinson’s Non-executive Disease Society director, Ministry and other of Justice charitable sources of research funding Executive directors Caroline Clarke Member, Advisory Nil Nil Trustee Nil Nil Nil Deputy chief Board to The Royal Free executive & Learning Clinic Charity (1/4/16) director of finance 11/4/16
Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public. Version 9 Updated 14/11/16 Board Member and Directorships, Ownership or part- Majority or A position of Any connection with a Research Interests in pooled funds that are under position including non- ownership of private controlling share authority in a charity voluntary or other funding/grants that separate management (any relevant Date of latest executive directorships companies, business holdings in or voluntary organisation may be received by company included in this fund that has a amendment/confirmed held in private or consultancies likely organisations likely organisation in the contracting for NHS an individual or their potential relationship with the Trust must correct companies or PLCs or possibly seeking to or possibly seeking field of health and services department be declared) (with the exception of do business with the to do business with social care those of dormant NHS the NHS State when position State when State when interest acquired companies) State when interest State when interest State when position accepted funding/grant acquired acquired accepted commenced State when directorship commenced Professor Director of HSL Nil Nil Employee of Member of Moorhead Renal Nil Stephen Powis, (appointed by UCL governing body, Trust and various medical director RFL) Merton NHS other sources of Clinical charitable funding 16/5/16 Trustee Commissioning held by Peter Samuel Group colleagues within Trust the academic Trustee renal department Trustee Healthcare Healthcare Management No individual funding but Management Trust collaborate on Trust research within academic Trustee research Moorhead Renal department Trust funded by a variety of sources Trustee eg MRC, Kidney Research UK. Royal Free Charity (1/4/16) Deborah Sanders Nil Nil Nil Board member, Nil Nil Nil Director of The Royal Free nursing Hospital Nurses’ 16/1/13 Home of Rest Trust
Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public. Version 9 Updated 14/11/16 Board Member and Directorships, Ownership or part- Majority or A position of Any connection with a Research Interests in pooled funds that are under position including non- ownership of private controlling share authority in a charity voluntary or other funding/grants that separate management (any relevant Date of latest executive directorships companies, business holdings in or voluntary organisation may be received by company included in this fund that has a amendment/confirmed held in private or consultancies likely organisations likely organisation in the contracting for NHS an individual or their potential relationship with the Trust must correct companies or PLCs or possibly seeking to or possibly seeking field of health and services department be declared) (with the exception of do business with the to do business with social care those of dormant NHS the NHS State when position State when State when interest acquired companies) State when interest State when interest State when position accepted funding/grant acquired acquired accepted commenced State when directorship commenced Kate Slemeck, Nil Nil Nil Nil Husband works Nil Nil executive director for Canon who of operations provide the 7/4/16 trust’s managed print service.
Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public. Version 9 Updated 14/11/16 David Sloman Director, Nil Nil London Nil Nil Chief executive UCLPartners2 Procurement 15/11/16 Partnership board member. Trustee/Non- executive director, Relative who Skills for Health works for Ernst & Young
Chair of North Member of HSJ’s Product Advisory Central London Board Sustainability and Transformation Member of NHS Plan Improvement CEO Advisory Group (January 2016)
Membership of Deloitte Academy
Member of international advisory board of The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC)
2 The Company’s constitutional documents have been drafted in accordance with charity law and Charity Commission guidance, so that the Company can apply for charitable status in the future as and when its Board of Directors considers this appropriate. Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public. Version 9 Updated 14/11/16
Board Member and Directorships, Ownership or part- Majority or A position of Any connection with a Research Interests in pooled funds that are under position including non- ownership of private controlling share authority in a charity voluntary or other funding/grants that separate management (any relevant Date of latest executive directorships companies, business holdings in or voluntary organisation may be received by company included in this fund that has a amendment/confirmed held in private or consultancies likely organisations likely organisation in the contracting for NHS an individual or their potential relationship with the Trust must correct companies or PLCs or possibly seeking to or possibly seeking field of health and services department be declared) (with the exception of do business with the to do business with social care those of dormant NHS the NHS State when position State when State when interest acquired companies) State when interest State when interest State when position accepted funding/grant acquired acquired accepted commenced State when directorship commenced Non-voting directors David Grantham Nil Nil Nil Board Member Board Member Nil Nil Director of and Treasurer Health Education Workforce and London North and East London OD Healthcare (HENCEL) – July 7/4/16 People 2014 Management Board Member Academy – and Treasurer March 2013 London Chair of NHS Streamlining Employers Programme(s) – March 2014 Medical Workforce Forum – August 2010
Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public. Version 9 Updated 14/11/16 Board Member and Directorships, Ownership or part- Majority or A position of Any connection with a Research Interests in pooled funds that are under position including non- ownership of private controlling share authority in a charity voluntary or other funding/grants that separate management (any relevant Date of latest executive directorships companies, business holdings in or voluntary organisation may be received by company included in this fund that has a amendment/confirmed held in private or consultancies likely organisations likely organisation in the contracting for NHS an individual or their potential relationship with the Trust must correct companies or PLCs or possibly seeking to or possibly seeking field of health and services department be declared) (with the exception of do business with the to do business with social care those of dormant NHS the NHS State when position State when State when interest acquired companies) State when interest State when interest State when position accepted funding/grant acquired acquired accepted commenced State when directorship commenced Mike Greenberg Nil Nil Nil Nil Relative of COO Nil Partner with HCA in Wellington Divisional director of Optum Labs, a Diagnostic and Outpatient women’s, subsidiary of Centre LLP since 2007 Optum children’s and imaging services 7/4/16 George Hamilton Nil Nil Nil Nil Consultant Nil Nil Divisional director shares in W.Doc surgery and which is affiliated with the associated Wellington services Hospital. Emma Kearney Director, EK Nil Nil Nil Nil Nil Nil Director of Consulting Ltd corporate affairs and communications Andrew Panniker Nil Nil Nil Nil Director, Royal Nil Nil Director of capital Free Charity and estates Development Co Peter Ridley Nil Nil Nil Nil Nil Nil Nil Director of Planning
Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public. Version 9 Updated 14/11/16 Board Member and Directorships, Ownership or part- Majority or A position of Any connection with a Research Interests in pooled funds that are under position including non- ownership of private controlling share authority in a charity voluntary or other funding/grants that separate management (any relevant Date of latest executive directorships companies, business holdings in or voluntary organisation may be received by company included in this fund that has a amendment/confirmed held in private or consultancies likely organisations likely organisation in the contracting for NHS an individual or their potential relationship with the Trust must correct companies or PLCs or possibly seeking to or possibly seeking field of health and services department be declared) (with the exception of do business with the to do business with social care those of dormant NHS the NHS State when position State when State when interest acquired companies) State when interest State when interest State when position accepted funding/grant acquired acquired accepted commenced State when directorship commenced Steve Shaw Nil Nil Nil Nil Nil Nil Nil Divisional director urgent care 7/4/16 Will Smart Nil Nil Nil Nil Nil Nil Nil Chief information officer 8/4/16
Robin Woolfson, Nil Nil Nil Nil Nil Nil Nil Divisional director transplant and specialist services
Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public. Paper 2
MINUTES OF THE TRUST BOARD HELD ON 23 NOVEMBER 2016 Present
Mr D Dodd Chairman Mr S Ainger Non-executive director Ms C Clarke Chief finance officer and deputy chief executive Ms D Oakley Non-executive director Ms J Owen Non-executive director Prof S Powis Medical director Ms D Sanders Director of nursing Ms K Slemeck Chief operating officer Mr D Sloman Chief executive
Invited to attend Mr D Grantham Director of workforce and organisational development (from 2016/158) Dr M Greenberg Divisional director for women’s, children’s and imaging services Ms E Kearney Director of corporate affairs and communications Mr A Panniker Director of capital and estates Mr P Ridley Director of planning Dr S Shaw Divisional director – urgent care Ms A Macdonald Board secretary (minutes)
Others in attendance Dr C Laing Associate medical director – patient safety (for item 2016/199) Ms MM Devaney Head of patient safety and risk (for item 2016/199) Mrs J Dewinter Lead governor and elected patient governor
2016/194 APOLOGIES FOR ABSENCE AND WELCOME Action
Apologies for absence were received from:
Prof A Schapira Non-executive director Prof G Hamilton Divisional director for surgery and associated services Dr R Woolfson Divisional director, transplant and specialist services
The chairman welcomed those present to the meeting.
2016/195 DECLARATION OF INTERESTS
The report on the register of interests was noted and entries confirmed to be correct. No director had any further interests to declare.
2016/196 MINUTES OF MEETING HELD ON 19 OCTOBER 2016
The minutes were accepted as an accurate record of the meeting.
2016/197 MATTERS ARISING REPORT
The matters arising report was noted and the following update provided.
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2016/170 falls information
The medical director confirmed that clinical quality data, including information on falls, was presented regularly to commissioners via the clinical quality review group.
2016/198 RECORD OF ITEMS DISCUSSED AT PART II BOARD MEETING ON 19 OCTOBER 2016
The report was noted.
2016/199 QUALITY IMPROVEMENT/PATIENT SAFETY – PATIENT SAFETY PROGRAMME OVERVIEW AND UPDATE
Dr Chris Laing, associate medical director – patient safety and Ms M M Devaney, head of patient safety and risk were in attendance for this item. The associate medical director updated the board on progress on the patient safety programme since the board had agreed to the ‘sign up for safety’ programme in December 2014. This had attracted funding from the NHS Litigation Authority. The initial period had been spent on putting the right framework, support and governance in place. The patient safety board was chaired by the chief finance officer and reported to the patient safety committee and ultimately to the board. The patient safety vignettes presented to each board meeting kept patient safety high on the agenda and visible. There were a number of patient safety work streams including falls, acute kidney injury, identifying the deteriorating patient, diabetes, surgical safety and VTE prevention. Achievements included:
On 16 December there would have been no surgical never events for six months There had been no cardiac arrests at Barnet Hospital since April 2016 There had been no fall with harm for 800 days on a ward where this had previously been an issue The partnership with DeepMind on the Streams acute kidney injury app
The programme had now been in place for three years and it felt like the seeds for improving patient safety had been planted in very fertile ground with an excellent central team supporting clinical colleagues at operational level.
The head of patient safety and risk added that the agreement of the quality strategy and milestones would be complementary to the patient safety programme.
Mr Ainger, non-executive director and chair of the patient safety committee, commented that the patient safety team were doing an excellent job and that a triangulated and evidence based approach was in place.
Ms Owen, non-executive director, asked whether the delirium pathway was included in the programme. The associate medical director – patient safety said that it was not at present part of the formal programme. The director of nursing added that the dementia care group was looking at enhanced care which would include the delirium pathway. The chief finance officer noted that there was a patient representative on the patient safety programme board which was extremely helpful.
The chairman asked about sharing with and learning from other organisations and
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the head of patient safety and risk responded that the team were part of a number of London wide and national patient safety fora.
The chairman asked if there was more the board could do to promote and support patient safety. The associate medical director – patient safety suggested that there was a role in influencing leadership further down the organisation and the head of patient safety and risk added that staff would like to know that their efforts in this area were appreciated. The chairman commented that the board needed to put some thought into how this could be done better.
2016/200 PATIENTS’ VOICES
The medical director read out an email received from a hepatology patient, who had not wished to make a formal complaint but wanted to know that the trust had learned from his experience. The senior matron for the service met with him and provided a response to each of his concerns. He was worried about a nurse sneezing and coughing near to him; the matron explained that the nurse in charge had assessed that the nurse was well enough to be working directly with patients. He was concerned that his portacath (device used to draw blood and give treatments) had not been flushed causing it to block. This was dealt with at the time by a specialist nurse, who took the opportunity to train the doctor and nursing staff on the shift how to deal with a portacath. The wider nursing team had also been made aware of how to escalate dealing with a portacath, if unsure. The patient also noted that there were delays in responding to call bells. The matron confirmed that the ward were not meeting the target for responding to call bells and arranged for spot checks and weekly audits until there was an improvement. Finally he was concerned about the clerking delay (history and examination of patient) on his admission. The matron had contacted the consultant who explained that the doctors were dealing with patients who required more urgent care and treatment.
The medical director then read out a compliment from the son of a patient on Rowan ward at Barnet Hospital. This stated that the overall care was excellent but the family particularly wanted to highlight the excellent care of a newly qualified nurse who was professional, pleasant, positive, approachable and hugely influential in making the mother’s stay more bearable.
The board also received a copy of a letter from an elderly patient who wanted to be discharged from hospital without further delay. The director of nursing said that it was a sobering thought that many patients in their 80’s were in the last thousand days of their lives and keeping them in hospital longer than they needed to be was taking a valuable resource from them. Ms Ms Oakley, non-executive director, would present the patients’ voices item at the Oakley next meeting. 2016/201 NORTH CENTRAL LONDON SUSTAINABILITY AND TRANSFORMATION PLAN
The director of planning presented this item. He stated that now that the STP had been published the key was to ensure that the individual organisations’ two year plans were consistent with the STP.
The chief executive stated that he had two roles in relation to the STP, as convenor of the STP and as RFL chief executive. The STP had been a
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constructive development in terms of encouraging the constituent organisations to look beyond their own interests to those of the wider health and social care system. The STP had three strands: health; social care and financial sustainability.
There were two value propositions: a real focus on productivity within institutions and across the system; and to design a health rather than sickness mode. The plan had been built from the bottom up, with strong clinical input. However public, patient and staff engagement and transparency could have been better and it was important to start tackling this now.
Mr Ainger, non-executive director, was surprised that communications around the publication of the plan had not focused on integrated care and symptom based pathways as this would have been a much more powerful message.
Ms Owen, non-executive director, commended the progress that had been made and stated that this was the way that the NHS now needed to do business. She added that it was important to set aspirational goals.
The chief executive stated that it was important to move away from planning on an annual or biannual basis and that it would also be helpful to stop the annual contract negotiation process. He added that the STP put the right people in the room, grappling with the right questions.
Ms Oakley, non-executive director, asked what the implications were for RFL and where the £70m investment would come from. The chief executive said that each institution was currently looking at what contracted activity was needed next year, but currently there was no agreement. The next step would be to look at the STP interventions and assumptions and apply them to the plans. There would be an impact on demand and capacity; cost and prices. There would still be an unanswered financial problem with a level of risk and agreement would need to be reached about how to handle these.
The board supported the North Central London sustainability and transformation plan. 2016/202 NURSING AND MIDWIFERY STAFFING MONTHLY REPORT
The director of nursing presented the report which covered September 2016 and noted planned versus actual hours was 1.5% less actual than planned across all three sites. There had been 13 shifts or part shifts out of more than 3000 where the nurse: patient ratio was below 1:8 on a day shift or 1:11, with no patient safety incidents reported.
There had been a sustained reduction in agency staff, with more substantive staff being recruited. Three years ago, 330 nurses had been recruited in a year; so far this year there had been 1000 new nurses. Currently the net position was that there were approximately 140 more joiners than leavers. New recruits were settling in well.
The Allocate e-rostering system was now in place in all areas and being used to manage rotas actively. A strong control environment was in place with all agency bookings having to be agreed by a divisional director of nursing, using a risk based approach. However the risk areas in terms of not being able to reduce agency were the emergency department, where more capacity was shortly to be opened at Barnet Hospital and ITU which was currently operating at full capacity
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and where there was a high turnover and vacancy level. The board had asked about FFT in the emergency department at the last meeting and the director of nursing commented that the patient and staff experience committee were currently reviewing FFT and how to tackle this in the emergency department would be fed into this review.
Mr Ainger, non-executive director, asked where the new nurses were coming from and whether agency had reduced in line with the levels of recruitment. The director of nursing responded that nurses were being recruited from a wide range of sources, in the UK as well as overseas. The trust had also been very successful in recruiting newly qualified nurses who had trained at RFL. It was difficult to make a direct connection between the reduction in agency and net recruitment as during this period additional capacity had been opened which required additional staff.
Ms Owen, non-executive director, noted that there had been more shifts than normal failing below the 1:8/11 ratio and asked where the trust was in relation to the NHS Improvement £29m control total for agency staff.
The chief finance officer responded that there was a realistic prospect of being able to meet the control total, depending on how winter impacted on staffing.
The chairman suggested including the following in future papers: retention levels, net recruitment and funded establishment. Director of The board agreed that the report provided sufficient assurance that the nurse nursing staffing levels were meeting the needs of patients and providing safe care.
2016/203 CHAIR AND CHIEF EXECUTIVE’S REPORT
The chief executive drew particular attention to the Chase Farm Hospital redevelopment which continued to be ahead of schedule and on budget.
Ms Owen, non-executive director, asked about follow up from the Institute for Healthcare Improvement (IHI) awayday and asked whether the board could receive a report with key elements from the day, next steps and governance. The Medical chief executive stated that governance should be at board level and there would director be a report to a future board meeting.
The board noted the report. 2016/204 TRUST PERFORMANCE DASHBOARD
The chief operating officer noted that A&E and cancer performance had deteriorated during the past month. There were particular problems with A&E performance at Barnet Hospital but it was hoped that the new facility which would be opening shortly would help. Barnet CCG were commissioning ‘discharge to assess’ which would also assist. The chief executive stated that Barnet CCG’s approach and support had been exemplary.
The chief operating officer reported that the trust continued to be non-compliant with the 62 day cancer standard, but was getting closer to compliance. The chief executive added that work on regaining cancer compliance was sustainable and would enable a return to business as usual but referrals would continue to increase, meaning that this would continue to be a challenge.
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The board noted the report.
2016/205 FINANCIAL PERFORMANCE REPORT
The chief finance officer reported the trust was £38.3m adverse to plan at the end of October 2016. The reasons for this were as reported the previous month, notably the loss of prior year income of £17m, alongside under-achievement of the private patients unit income, underperformance against activity income, pay overspends and a high level of outsourcing costs. The underlying theme was that the system could not afford the level of activity currently going through hospitals. The trust’s cash position continued to be a matter for serious concern.
The board noted the report. 2016/206 SHADOW GROUP BOARD REPORT The board noted the report.
2016/207 FINANCE INVESTMENT AND PERFORMANCE COMMITTEE REPORT The board noted the report from the committee.
2016/208 PATIENT SAFETY COMMITTEE REPORT
The board noted the report from the committee.
2016/209 AUDIT COMMITTEE
Ms Oakley, chair of the committee, reported that the audit committee had approved the external audit plan for 2016/17, together with the internal audit programme. The committee had also received an update on cyber security following the internal audit report and heard that there was a plan in place to be completed by 31 March 2017. This would be followed with testing.
Medical The chairman suggested that it would be helpful for the board to have a director discussion of cyber security in January 2017.
2016/210 QUESTIONS FROM THE PUBLIC
There were no questions from the public.
2016/211 ANY OTHER BUSINESS
Patient and staff experience committee Director Ms Owen, chair of the committee reported that there would be a report to the of January board on patient engagement and participation. nursing 2016/212 DATE OF NEXT MEETING
The next trust board meeting would be on 21 December 2016 at 1300 in the boardroom, executive offices, 2nd floor, Royal Free Hospital.
Agreed as a correct record
Signature …………………………………..date 21 December 2016……………………………. Dominic Dodd, chairman
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Trust Board Matters Arising report as at 21 December 2016 Actions completed since last meeting of the Trust Board
Minute Action Lead Complete Board date/ Outstanding No agenda item FROM TRUST BOARD HELD ON 23 NOVEMBER 2016 2016/202 NURSING AND MIDWIFERY STAFFING MONTHLY REPORT Include retention levels, net recruitment and funded D Sanders Reports will be revised accordingly establishment in future reports. 2016/203 CHAIR AND CHIEF EXECUTIVE’S REPORT Report on IHI to future board meeting. S Powis Update included in December Chair/CEO report. Agenda item for January 2017 board meeting. 2016/209 AUDIT COMMITTEE Report on Cyber security for January 2017 board S Powis Agenda item for January 2017 board meeting. meeting. 2016/211 ANY OTHER BUSINESS Report on patient engagement and participation to S Powis Agenda item for January 2017 board meeting. January board meeting.
FROM TRUST BOARD HELD ON 19 OCTOBER 2016 2016/180 NURSING AND MIDWIFERY STAFFING MONTHLY REPORT Include further information on net recruitment D Sanders Update provided – net position in the next report. recruitment of 140 positive. Consider how FFT could be captured in the emergency department. FFT was currently being reviewed at the patient and staff experience committee
Matters arising – trust board 21 December 2016 Paper 3
2016/181 DIRECTOR OF INFECTION PREVENTION AND CONTROL QUARTERLY REPORT Ms Oakley asked if more information about the D Sanders Next report due January 2017 antibiotic CQUIN could be included in the next report. Review in progress, update to be provided to Ms Owen, non-executive director, asked for more board in December 2016 information about the review of the PFI contract A Panniker FROM TRUST BOARD HELD ON 28 SEPTEMBER 2016 2016/170 Questions from the public – falls information Raise this at CQRG S Powis/ Update provided – clinical D Sanders quality data, including falls information, presented regularly to commissioners via the CQRG meeting. FROM TRUST BOARD HELD ON 27 APRIL 2016 2016/77 Patient safety committee report Board to receive training on corporate S Powis Session provided 23 manslaughter November 2016 FROM TRUST BOARD HELD ON 6 APRIL 2016 2016/54 Chairman and chief executive’s report Progress reports on pathology joint venture to the M Dinan Agreed at May shadow group board that this shadow group board and finance and performance should be programmed for July, following a committee. customer/investor annual review. Deferred to September as HSL annual accounts not received. Report discussed at finance investment and performance committee in September and further work required. Now programmed for January trust board meeting.
Matters arising – trust board 21 December 2016 Paper 4
Report to Date of meeting Attachment number Trust Board 21 December 2016 Paper 4
ITEMS DISCUSSED AT THE CONFIDENTIAL BOARD MEETING HELD ON 23 NOVEMBER 2016
Executive summary
Decisions taken at a confidential trust board are reported where appropriate at the next trust board held in public. Those issues of note and decisions taken at the trust board’s confidential meeting held on 23 November 2016 are outlined below.
• RFL digital strategy (some aspects of this are included in this month’s chair’s and chief executive’s report; there is a further report in the confidential part of the meeting (as it is commercially sensitive) which will be reported to the next public board. • Shadow group report – there is a summary report in the public board agenda • North Middlesex University Hospital partnership update – information is included in this month’s chair’s and chief executive’s report • The board approved an application to access the Department of Health’s revolving working capital facility
The board also had a detailed discussion of the trust’s financial position and discussed the trust performance report.
Action required
For the board to note.
Report From D Dodd, chairman Author(s) A Macdonald, board secretary Date 9 December 2016
Confidential trust board meeting update – trust board 21 December 2016 Paper 5
Report to Date of meeting Attachment number
Trust Board 21 December 2016 Paper 5
Development of the 2016/17 quality account
Executive summary The Trust has a legal obligation to submit an annual report covering progress made during the year to improve the quality of their services, as well as the requirement to submit a list of quality priorities for the coming year. It is the expectation that the quality priorities are developed from stakeholder engagement and consultation.
It is anticipated that the 2016/17 quality account will be developed as in previous years and in order to achieve this, a significant amount of preparation and engagement will be required.
The attached information outlines the development plan and timeline for completion of the quality account 2016/17 to meet the submission deadline.
Action required/recommendation The board is asked to approve the development plan and timeline for the 2016/17 quality account.
Trust strategic priorities and business planning objectives Board assurance risk supported by this paper number(s) 1. Excellent outcomes – to be in the top 10% of our peers on outcomes
2. Excellent user experience – to be in the top 10% of relevant peers on patient, GP and staff experience
4. Excellent compliance with our external duties – to meet our external obligations effectively and efficiently
5. A strong organisation for the future – to strengthen the organisation for the future
CQC Regulations supported by this paper Regulation 17 Good governance
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Risks attached to this project/initiative and how these will be managed (assurance) There are no identified risks attached to this project. Plans are in place to ensure that the submission deadline is met.
Equality analysis • No identified negative impact on equality and diversity
Report from Professor Stephen Powis- medical director
Author(s) Karen Gordon: Head of clinical governance and performance Dawn Atkinson: Deputy director of clinical governance and performance
Date 14 December 2016
References
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Development of the 2016/17 quality accounts
Since the introduction of the quality account in 2010, there remains a legal obligation for the Trust to submit an annual quality report outlining:
• What our trust is doing well • Where improvements in quality of our services is required • What our priorities for improvement are for the coming year; and how we have involved service users, staff and others in determining those priorities for improvement
The guidance specifically outlining the requirements for the quality account has not been published from as yet, however it is anticipated that there will not be any major changes from previous years.
The Development plan
The development of our 2016/17 quality account provides us with the opportunity to illustrate both national changes and our emerging new organisational architecture in which we will continue to operate in the future. This will be influenced from our steps to deliver on the NHS Five Year Forward View and intention to have shadow group status from April 2017.
As in previous years, the three executive leads and associated committees for patient safety, patient experience and clinical effectiveness will continue to influence the development of the quality account; especially around the review of progress in achieving the 2016/17 quality priorities and the suggestion of quality priorities for 2017/18. quality domain executive lead relevant committee
Clinical effectiveness Sonia Renwick Clinical performance Committee (CPC)
Patient experience Chandi Velodi Patient and Staff Experience (PSEC) Patient safety Chris Laing Patient Safety Committee (PSC)
Furthermore, the quality account will be the key document which incorporates the principles outlined in the quality strategy with the central theme of putting our patients and families at the heart of how we design and deliver care to improve outcomes. The account will also include a section on key successes which will be developed in partnership with our four clinical divisions.
Process of engagement
In order to set our high level quality priorities for 2016/17, a series of engagement exercises will be held with key stakeholders and key committees. The main stakeholder event is planned for the 13 January 2017 and invitees will include members of the Council of governors, Healthwatch and Commissioners.
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The event plans to showcase quality improvement initiatives as well as creating the forum for key stakeholders to feedback on what additional priorities should be considered for 2017/18. Further events will specifically be held for patients and staff in February 2017.
Timeline for quality account completion
The 2016/17 quality account must be published by 30 June 2017. Appendix A presents a detailed timetable and reporting schedule which will be followed to meet the submission deadline. An overview is presented below, highlighting specific information for the trust board.
Month What will be presented
December 2016 Signing off the development plan and delegating authority to the Trust Executive Committee (TEC)
January 2017 Stakeholder’s event showcasing quality improvement and quality account consultation.
March 2017 First draft quality account 2016/17 report for comments, prior to wider distribution for consultation with key stakeholders
April 2017 Second draft quality account 2016/17 (which includes stakeholder comments) for further comments
May 2017 Final report to be signed off by the trust board
4 Appendix A: Quality Account Development plan and reporting schedule for 2016/17
December 2016 January 2017 February 2017 Week of BHOSC 05/12/16 Report submitted to Week of RFH: 13/01/17 Stakeholders engagement Week of CFH: date TBC Stakeholders 05/12/16 the committee updating on progress 09/01/17 process including CoG, CCGs and Health 06/02/17 engagement process (staff made to address comments raised by the watch for their initial comments for and patient focus) committee in QA 2015/16. priorities for 2017/18 Week of CGCRC: 16/12/16. Report presenting an Week of CPC: 16/01/17. Progress report on Week of BH: date TBC Stakeholders 13/12/16 overview from the clinical divisions on 16/01/17 quality account priorities 2016/17 and 20/02/17 engagement process (staff progress on QA reporting suggestions for 2017/18 QA priorities and patient focus) Week of TEC: 20/12/16. Report outlining the CoG: 19/01/17. Consultation on 19/12/16 approach and development plan for the priorities for 2017/18 using members QA 2016/17 survey feedback for consideration May 2017 TB: 21/12/16. Sign of the development Week of PSEC: 25/01/17. Update report on Week of TEC: 09/05/17. Final draft plan and reporting schedule and delegate 23/01/17 progress on quality account priorities and 08/05/17 QA for approval authority to TEC suggestions for the 2017/18 priorities PSC: 26/01/17. Update report on Week of CoG: 16/03/16. Final progress on quality account priorities and 15/05/17 overview on the QA 2016/17 March 2017 suggestions for the 2017/18 priorities Week of TEC: 07/03/17. Update report on Week of TB: 23/05/17 Final 06/03/17 progress on quality account priorities and 22/05/17 ratification of the quality sign off the priorities for 2017/18 April 2017 account 2016/17 Week of CoG: 16/03/17. Feedback from Week of PSEC: 24/04/17 Review on progress AC: 23/05/17 Final 13/03/17 stakeholders event on priorities for 24/04/17 achieved from 2015/16 and agreed ratification of the quality 2017/18 and choosing an indicator for priorities for 2016/17 account 2016/17 prior to testing for 2016/17 submission to Monitor Week of PSC: 23/03/17 Feedback on agreed TEC: 25/04/17 Draft quality account for BHOSC Barnet Health Overview & Scrutiny Comm. CGCRC Clinical Governance Clinical Risk Committee 20/03/17 priorities for 2017/18 and final QA 2015/16 using Q4 data (where CoG Council of Governors 2015/16 priorities update possible)with stakeholders comments PSC Patient Safety Committee Week of TB:29/03/17 Initial draft QA report using TB: 26/04/17 Draft quality account for PSEC Patient and Staff Engagement Committee TEC Trust Executive Committee 27/03/17 Q3 data(without stakeholders feedback) 2015/16 using Q4 data (where possible) TB Trust Board with stakeholders comments
Report to Date of meeting Attachment number
Trust Board 21 December 2016 Paper 6
Monthly report of Nursing staffing levels October 2016
Executive summary – including resource implications The overall trust summary of planned versus actual hours for October was 2% less actual hours than planned:
Site specific data is as follows: • Barnet hospital 3% less actual hours than planned
• Chase Farm hospital 5% less actual hours than planned
• Royal Free hospital 1% less actual hours than planned
In October out of a minimum of 3,100 shifts there were 7 shifts reported where the nurse: patient ratio dropped below 1:8 on a day shift or 1:11 on a night shift. There were no reported patient safety incidents on these occasions.
Action required The board is requested to • consider if the report provides sufficient assurance that the nurse staffing levels are meeting the needs of patients and providing safe care
Trust strategic priorities and business planning objectives Board assurance risk supported by this paper number(s) 1. Excellent outcomes – to be in the top 10% of our peers on outcomes 2. Excellent user experience – to be in the top 10% of relevant peers on patient, GP and staff experience 3. Excellent financial performance – to be in the top 10% of relevant peers on financial performance 4. Excellent compliance with our external duties – to meet our external obligations effectively and efficiently 5. A strong organisation for the future – to strengthen the organisation for the future
CQC outcomes supported by this paper
1 Respecting and involving people who use services 4 Care and welfare of people who use services
Page 1 of 2 5 Meeting nutritional needs 7 Safeguarding people who use services from abuse 8 Cleanliness and infection control 9 Management of medicines 13 Staffing 14 Supporting staff
Risks attached to this project/initiative and how these will be managed (assurance)
Equality analysis • No identified negative impact on equality and diversity
Report from Deborah Sanders, Director of Nursing
Author(s) Deborah Sanders, Director of Nursing
Date 14 December 2016
References: Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time – Safe, sustainable and productive staffing, July 2016, https://www.england.nhs.uk/ourwork/part-rel/nqb/
Page 2 of 2 Paper 6 Introduction
This report provides information on planned versus actual nurse staffing for October 2016 and an update on progress with the reduction in use of agency nursing and midwifery staff.
Planned versus actual staffing
The overall trust summary of planned versus actual hours for October was 2% less actual hours than planned:
Site specific data is as follows: • Barnet hospital 3% less actual hours than planned • Chase Farm hospital 5% less actual hours than planned • Royal Free hospital 1% less actual hours than planned
Planned versus actual staffing
The tables below show that planned versus actual hours by ward for registered nurses and midwives and healthcare assistants.
Transplantation and Specialist Services October 2016
Registered nurse to Percent of actual vs Percent of actual vs Percent of actual vs Percent of actual vs Attributable Ward Beds patient ratio total planned shifts total planned shifts total planned shifts total planned shifts Falls FFT Score Cdiff Day Shift (RN days) (RN nights) (HCA days) (HCA nights)
9 West 33 1:4 100% 103% 153% 86% 2 0 95% 9 North 33 1:4.7 91% 94% 83% 84% 4 0 91% 11 West 22 1:4.8 96% 120% 136% 152% 5 0 93% 11 South 19 1:3.8 80% 99% 109% 94% 4 0 89% 11 East 24 1:4.8 87% 100% 96% 155% 1 1 94% 10 East 24 1:3.4 90% 97% 92% 97% 4 0 87% 10 South 25 1:6.25 94% 107% 92% 102% 4 0 86% 5 East B 24 1:5 99% 100% 102% 119% 1 0 96% Mulberry 13 1:5 105% 101% 86% 106% 2 0 84%
Urgent Care October 2016 Registered nurse to Percent of actual vs Percent of actual vs Percent of actual vs Percent of actual vs Attributable Ward Beds patient ratio total planned shifts total planned shifts total planned shifts total planned shifts Falls FFT Score Cdiff Day Shift (RN days) (RN nights) (HCA days) (HCA nights) 10 North 32 1:5.3 98% 100% 97% 100% 4 0 100% 8 West 36 1:5.1 93% 100% 95% 99% 5 1 100% 8 North 32 1:4 93% 98% 92% 100% 9 0 91% 10 West 27 1:5 98% 101% 97% 100% 1 0 100% 8 East 26 1:4.3 97% 98% 94% 100% 5 0 95% 6 South 28 1:4 98% 100% 99% 99% 2 0 83% ITU(RF) vary 1:1/1:2 99% 99% 95% 91% 1 0 n/a ED (RF) n/a n/a 102% 112% 63% 73% 2 0 83% ED(BH) n/a n/a 95% 99% 89% 98% 5 0 80% UCC (CF) n/a n/a 107% 126% 57% n/a 0 0 n/a Adelaide 25 1:6.25 86% 87% 92% 151% 0 0 50% Capetown 36 1:5.1 94% 121% 124% 170% 9 1 100% CCU 8 1:2 99% 103% n/a n/a 1 1 88% ITU (BH) vary 1:1/1:2 96% 106% 100% 81% 0 0 n/a Juniper 24 1:4.8 95% 99% 98% 152% 4 0 80% Larch 22 1:5.5 115% 97% 102% 150% 2 0 60% Olive 22 1:5.5 96% 101% 97% 91% 2 0 65% Palm 22 1:5.5 97% 99% 97% 120% 3 0 88% MSSU 48 1:4.8 92% 114% 115% 203% 8 0 90% Rowan 24 1:4.8 71% 93% 156% 148% 3 0 89% Spruce 24 1:6 75% 96% 85% 95% 1 0 88% Walnut 24 1:6 96% 100% 112% 248% 3 0 83%
1 Paper 6 Private Practice October 2016 Registered nurse to Percent of actual vs Percent of actual vs Percent of actual vs Percent of actual vs Attributable Ward Beds patient ratio total planned shifts total planned shifts total planned shifts total planned shifts Falls FFT Score Cdiff Day Shift (RN days) (RN nights) (HCA days) (HCA nights) 12 Wesr 15 vary 103% 123% 132 184% 1 0 n/a 12 South 16 1:4 95% 99% 98% 100% 2 0 100% 12 East B 12 vary 91% 84% 50% 61% 0 0 100%
Surgery and Associated Services October 2016 Registered nurse to Percent of actual vs Percent of actual vs Percent of actual vs Percent of actual vs Attributable Ward Beds patient ratio total planned shifts total planned shifts total planned shifts total planned shifts Falls FFT Score Cdiff Day Shift (RN days) (RN nights) (HCA days) (HCA nights) 5 north A 18 1:4.5 97% 100% 98% 94% 1 0 92% 7East A 20 1:5 98% 97% 128% 137% 2 0 85% 7 East B 13 1:4.3 107% 119% 100% 97% 3 0 84% 7 West 32 1:4 95% 103% 108% 122% 5 0 86% 7 North 24 1:4.7 121% 123% 98% 103% 1 0 91% Beech 24 1:6 87% 95% 95% 100% 3 0 74% Canterb'y 25 1:6.25 68% 63% 57% 85% 0 0 92% Cedar 24 1:4 60% 95% 141% 146% 4 0 80% Damson 24 1:6 82% 101% 94% 138% 2 0 89% Wel'gton 39 1:6.5 92% 98% 87% 100% 2 0 97%
Womens and Childrens October 2016 Registered nurse to Percent of actual vs Percent of actual vs Percent of actual vs Percent of actual vs Attributable Ward Beds patient ratio total planned shifts total planned shifts total planned shifts total planned shifts Falls FFT Score Cdiff Day Shift (RN days) (RN nights) (HCA days) (HCA nights) 6 North 20 1:4 99% 93% 100% n/a 0 0 n/a 5 South 31 1:8 98% 96% 94% 92% 0 0 91% Neonate RFH vary 85% 99% 70% 87% 0 0 n/a Galaxy 30 1:4 61% 80% 98% 58% 1 0 n/a Neonate BH vary 80% 80% n/a n/a 0 0 n/a Willow 16 1:5.3 102% 155% 112% 197% 3 0 86% Victoria 48 1:8 84% 85% 90% 98% 0 0 94%
Galaxy ward
The registered nurse planned versus actual for Galaxy, paediatric ward at Barnet has shown 61% for day shifts and 80% for night shift. The recommended staffing for a paediatric ward is:
• Unstable patients; mental health patients assessed as posing a risk to themselves and others: 1:1 Nursing care (or more if required) • High Dependency patients: 2:1 Nursing care • General paediatric patients: 4:1 Nursing care (RCN ) The staffing is flexed depending on the number of patients on the ward and the dependency. The tables below show the occupancy and staffing for Galaxy during October. As well as registered nurses there are also band 3 paediatric support workers who take a caseload of suitable patients under the supervision of the registered nurse. These are not shown in the numbers below. The matron reviews staffing requirements on a daily basis. During October there were shifts where nurses from Starlight (when occupancy allowed) and the matron and ward sister worked on the ward to augment the numbers below. Practice educators and specialist nurses also provided additional support to then numbers below. The head of nursing and the matron have provided assurance that there were no shifts that fell below the required staffing levels.
2 Paper 6 Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Number of patients on 16 20 18 16 19 12 12 14 17 21 11 7 13 11 12 ward at midnight
Of which were HDU 0 0 0 0 0 0 1 1 2 3 2 0 0 1 1
RN’s day shift 4 3 5 4 5 3 6 5 5 5 5 5 4 5 5
RN’s night shift 5 4 5 5 5 5 4 5 5 5 6 5 5 5 5
Date 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Number of patients 14 14 17 22 22 15 17 16 16 20 22 13 11 16 18 15 on ward at midnight
Of which were HDU 0 0 4 3 3 3 2 2 2 3 3 2 2 0 0 0
RN’s day shift 5 4 6 5 5 4 6 5 4 4 5 5 5 4 4 4
RN’s night shift 4 5 5 5 5 7 5 4 5 4 5 5 5 5 4 5
Safe staffing
In October out of a minimum of 3,100 shifts there were 7 shifts reported where the nurse: patient ratio dropped below 1:8 on a day shift or 1:11 on a night shift. On Damson there were 2 night shifts where the ratio was 1:12.5 with 3 nursing assistants. This was due to last minute sickness and it was not possible to replace the shift. On Beech there were 5 night shifts where the ratio was 1:12 with 3 nursing assistants. Again this was due to last minute sickness. There were no reported patient safety incidents associated with this.
Registered nurse agency staff
On 1 September 2015 Monitor wrote to the trust advising of the rules for nursing agency spending and setting out the spending ceiling for the trust. The rules are an annual ceiling for total nursing agency spending for each trust and a mandatory use of approved frameworks for procuring agency staff. The rules apply to all NHS trusts, NHS foundation trusts receiving interim support from the Department of Health and NHS foundation trusts in breach of their licence for financial reasons. All other NHS foundations trusts have been strongly encouraged to comply.
On 19 October 2015 Monitor wrote to the trust confirming that the agreed ceiling of nurse agency pay as a % of total nurse pay for the Royal Free London was 9.8% by March 2016 with a further reduction in April 2016. The further reduction % of nursing pay by agency has not yet been issued rather the trust has been sent an overall control total of £29 million on agency pay (all staff groups).
The divisional nurse directors, heads of nursing and matrons have further increased controls over agency usage and this combined with the new starters and the roll out of e-rostering has led to a sustained decrease in the use of agency staff.
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The financial summary for all staff groups against the control total is shown in below:
Recruitment
A key driver to reducing agency cost is recruitment to substantive posts. There are currently 322 nursing and midwifery recruits in the pipeline, 88 have agreed start dates and 234 are being processed. We continue to hold 2 assessment centres a month alongside one open day a month. Working with our recruitment partners we have recently successfully used Skype to interview and appoint 4 candidates in the Philippines and are considering this for future campaigns. The net position of starters v leavers for nursing and midwifery staff for this financial year, to November, is a positive balance of 188.91 with a breakdown shown in the table below:
Nursing and Midwifery Registered WTE
Starters WTE 447.21
Leavers WTE 338.65
Net Starters WTE 108.56
Healthcare Assistants
Starters WTE 174.35
Leavers WTE 94.00
Net Starters WTE 80.35
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Report to Date of meeting Attachment number
Trust Board 21 December 2016 Paper 7
Appointment of Responsible Officer
Executive summary
Under medical revalidation, doctors must demonstrate their fitness to practice to the General Medical Council (GMC) at least once every five years. As a designated body for medical revalidation, the Royal Free London NHS Foundation Trust is required to nominate or appoint a senior licensed doctor to act as its Responsible Officer (RO) and oversee the revalidation process.
The trust medical director Professor Stephen Powis has acted as RO since December 2010. As part of the trust’s development of its group structure, the board agreed in September 2016 that Professor Powis would step down as RO, and a new RO would be recruited.
Dr Jane Hawdon, a consultant neonatologist, has now been recruited as RO through an externally advertised, competitive process.
Action required
The board is asked to approve Dr Hawdon’s appointment as RO commencing January 9th 2017.
Trust strategic priorities and business planning Board assurance risk objectives supported by this paper number(s) 1. Excellent outcomes – to be in the top 10% of our peers X on outcomes 2. Excellent user experience – to be in the top 10% of X relevant peers on patient, GP and staff experience 3. Excellent financial performance – to be in the top 10% X of relevant peers on financial performance 4. Excellent compliance with our external duties – to meet X our external obligations effectively and efficiently 5. A strong organisation for the future – to strengthen X the organisation for the future Paper 7
Risks attached to this project/initiative and how these will be managed (assurance)
Equality analysis • No identified negative impact on equality and diversity
Report from Steve Powis, medical director Author(s) Steve Powis, medical director Date 13 December 2016 Paper 8
Report to Date of meeting Attachment number
Trust Board 21 December 2016 Paper 8
CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT
Executive summary
This is a combined chairman’s and chief executive’s report containing items of interest/relevance to the board.
Action required
The board is asked to note the report.
Report From D Dodd, chairman and D Sloman, chief executive Author(s) A Macdonald, board secretary Date December 2016
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CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT
A TRUST DEVELOPMENTS
CHASE FARM HOSPITAL REDEVELOPMENT UPDATE
The Chase Farm Redevelopment build programme continues to run on time and on budget, with a topping out ceremony planned for January 2017. The sale of Parcel A to Linden Homes has been completed, and the team are now looking at options to maximise the value of the remaining Parcel (B) which will be vacated after the new hospital is completed. Revenue savings are being tracked on a monthly basis. The activity projections in the Full Business Case are being refreshed, after which income projections and detailed workforce plans will be confirmed. Consolidation of services has continued with the closure of Maple block, which will release savings and facilitate changes to working practices.
ROYAL FREE HOSPITAL EMERGENCY DEPARTMENT UPDATE
The Royal Free Emergency Department redevelopment is being undertaken under two contracts. The first has been completed, which provided a new dedicated paediatrics' emergency department and waiting area, new staff facilities and office accommodation and a new ambulatory care unit.
Contract 2 started on 26 September 2016 and will be comprised of three phases. The first phase of the construction works will deliver Part 1 of majors, a new reception desk, and the rapid assessment and treatment area including new LAS handover facilities. Phase 2 will provide a new imaging facility including two x-ray rooms and one CT suite, and a six bedded resuscitation unit. The final phase completes the majors facility and delivers a new 30 bedded CDU, which replaces the temporary facility. Phase 1 is currently taking place, which is particularly challenging from both a build and operations perspective due to the live nature of the environment, the adjacencies of the MRI and the challenges of the infrastructure. The clinical and project teams are working closely to maintain clinical operations at all times and to ensure progression of the works.
PEARS BUILDING
Construction of the Pears Building, which will be home to the expanded UCL Institute of Immunity and Transplantation (IIT), is now due to start at the RFH in early 2017.
More than 50 local residents, members of staff, patients and local councillors attended a public consultation on the construction of the Pears Building on 30 November.
At the meeting attendees heard about the plans for the new building and how the construction project will be managed. They were also given the opportunity to ask questions about the plans.
Construction of the new building, which will be built next to the Royal Free Hospital, is expected to begin in Spring 2017. The Pears Building will be home to the expanded UCL Institute of Immunity and Transplantation (IIT), where researchers are developing new medicines for conditions such as cancer and type 1 diabetes.
At the meeting the trust responded to questions about the research taking place at the IIT, as well as access to the site during construction and parking arrangements at the hospital. A 2 X:\ Chair and CEO report 21 December 2016 Paper 8 patient at the meeting also spoke about the life-saving care she has received from clinical staff at the IIT.
The director of capital and estates chaired the meeting and Hans Stauss, head of the department of immunology, and representatives from Wilmott Dixon and Hopkins Architects responded to queries.
There is another consultation event planned for 9/10 January – this will be an exhibition with details of the basement impact report of the Pears Building. Attendees of the exhibition will be able to leave comments to which the trust will respond.
B REGULATION
NHS IMPROVEMENT/MONITOR QUARTERLY MONITORING – Q2 2016/17
The letter has not yet been received from NHS Improvement confirming the Q2 monitoring position. As reported last month, the trust’s shadow segmentation under the Single Oversight Framework is 2 (where 1 is the best rating and 4 is the worst). This means that NHSI will offer targeted support in areas where the trust is challenged.
C BOARD AND COUNCIL MATTERS
NON EXECUTIVE DIRECTOR APPOINTMENTS
As reported at the last meeting, the council of governors agreed to the appointment of two new non-executive directors, both of whom have accepted the three year appointments.
Mary Basterfield joined the trust on 1 December and is a qualified accountant. She is currently chief financial officer for the UK and Ireland at global media, digital marketing and communications group Dentsu Aegis Network, and former chief financial officer of Hotels.com.
Akta Raja, who will join the trust in January 2017, has a background as a corporate lawyer and investment banker and is currently a partner at Ansor Ventures, a firm that incubates start-ups.
D LOCAL NEWS AND DEVELOPMENTS
DEEPMIND TECHNOLOGY PARTNERSHIP
The RFL and British technology company DeepMind announced a landmark partnership on 22 November 2016. This followed discussion by the board at its meeting on 19 October 2016.
The five-year landmark agreement will see some of the best minds in healthcare and technology working together to transform care through a mobile clinical application called Streams, which will deliver improved outcomes by getting the right data to the right clinician at the right time. Like breaking news alerts on a mobile phone, the technology will notify nurses and doctors immediately when test results show a patient is at risk of becoming seriously ill, and provide all the information they need to take action.
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Following prototype testing, as well as registration with the Medicines and Healthcare products Regulatory Agency (MHRA), this first version of Streams is ready to be deployed to RFL clinicians early in 2017.
Under the new five-year partnership, additional features such as clinical task management will be added to Streams and it will be used to support clinicians in caring for patients at risk of other illnesses such as sepsis and organ failure.
The partnership will also introduce an unprecedented level of data security and audit. All data access is logged, and subject to review by the RFL as well as DeepMind Health’s nine Independent Reviewers. In addition, DeepMind’s software and data centres will undergo deep technical audits by experts commissioned by its Independent Reviewers.
Furthermore, DeepMind is developing an unprecedented new infrastructure that will enable ongoing audit by the RFL, allowing administrators to easily and continually verify exactly when, where, by whom and for what purpose patient information is accessed.
The infrastructure that powers Streams is built on state-of-the-art open and interoperable standards, allowing the RFL to have other developers build new services that integrate more easily with their systems. This will dramatically reduce the barrier to entry for developers who want to build for the NHS, opening up a wave of innovation - including the potential for the first artificial intelligence-enabled tools, whether developed by DeepMind or others.
FLU VACCINATION CAMPAIGN
Every year, the influenza vaccination is offered to NHS staff as a way to reduce the risk of staff contracting the virus and transmitting it to their family members as well as patients. Healthcare workers may transmit the illness to patients even if they are mildly or sub- clinically infected as flu is a highly transmissible infection.
The occupational health department are leading the delivery of the vaccinations across the trust.
Vaccination clinics are being held on all sites, and staff are offered the vaccination at induction days and chief executive’s briefing meetings. There is also a daily walk-in vaccination clinic at the occupational health departments at RFH and CFH. Peer vaccinators have been recruited to vaccinate colleagues Recently a 48 hour ‘jabathon’ took place resulting in over 300 members of staff having their jab in support of the event. The event was made possible by the OH nurses and peer group flu vaccinators who provided 48 hours of continuous cover to be on hand to vaccinate staff.
The ‘jabometer’ displayed on the landing page of Freenet gives the overall vaccination rate as at 12 December being 45% of staff. This is a great improvement on the level reached at the end of 2015/16 which was 28%. 4 X:\ Chair and CEO report 21 December 2016 Paper 8
ROYAL FREE LONDON LECTURE SERIES 2016/17
A series of special lectures have been confirmed to take place over the coming weeks. The lectures will be an opportunity to share, with an invited audience, the trust’s aspiration around six key themes:
• Clinical innovation • Population and whole system partnerships • Clinical standards • Developing clinical and quality leadership • Strategy for clinical support • Group structure
In addition to RFL speakers, a number of prestigious experts from across the world are being invited to take part.
The first event, which was held at the headquarters of the King’s Fund, focussed on clinical innovation and the trust’s recently announced partnership with technology company DeepMind.
LUNG CANCER TEAM WINS HSJ AWARD
The RFL lung cancer team has won a Health Service Journal award after developing a new lung biopsy method.
The biopsy team, led by Dr Sam Hare, consultant radiologist and lead for chest imaging, won the acute sector innovation award, ahead of eight other nominees. They were recognised for developing the new ambulatory lung biopsy service, based at BH, which enables the vast majority of patients to be discharged just 30 minutes after their biopsy. The method also allows biopsy patients who suffer a collapsed lung to be treated at home as out- patients.
Funding has been awarded by NHS England to support other trusts to implement this new method of lung biopsy and to improve care for lung cancer patients. The money, which will be shared among a number of trusts in north central London including the RFL, has come from the National Diagnostic Capacity Fund.
PATIENT FRIENDS AND FAMILY TEST (FFT) UPDATE
The NHS friends and family test (FFT) was introduced in 2013 to enable patients to feed back on their care and treatment to enable hospitals and other providers to improve services. It asks patients whether they would recommend hospital wards, A&E departments and maternity services to their friends and family if they needed similar care or treatment.
The FFT results are reviewed by the patient and staff experience committee and reported to every public meeting of the trust board.
The tables below show the combined scores for all sites and then the results by site for November 2016.
5 X:\ Chair and CEO report 21 December 2016 Paper 8
Royal Free London % likely/extremely likely to Number of patient responses combined data recommend November 2016 (range: 0 – 100%)
In-patient 89% 1401 A&E 82% 4689
Barnet Hospital % likely/extremely likely to Number of patient responses recommend November 2016 (range: 0 – 100%)
In-patient 88% 429 A&E 78% 2423 Antenatal care 90% 31 Labour and birth 99% 158 Postnatal hospital ward 98% 163 Postnatal community care 100% 133 Out-patients 94% 275
Chase Farm Hospital % likely/extremely likely to Number of patient responses recommend November 2016 (range: 0 – 100%)
In-patient 94% 151 Out-patients 94% 282
Royal Free Hospital % likely/extremely likely to Number of patient responses recommend – November 2016 (range: 0 – 100%)
In-patient 88% 717 A&E 86% 2266 Antenatal care 92% 13 Labour and birth 99% 72 Postnatal hospital ward 90% 72 Postnatal community care 100% 133 Out-patients 95% 229
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*The postnatal community care question is only reported as a whole trust figure and not split by site.
COMMUNICATIONS REPORT
Media coverage
Positive
During November the trust featured positively in broadcast media and national newspapers following the announcement of our partnership with technology company DeepMind. This included a story on the BBC’s website, a news item on the hour on the Today Programme, BBC News at One, the top story on BBC London 6.30pm News, second story on BBC London 10.30pm News and the BBC News Channel. Other positive coverage included, The Evening Standard, The Times and The Telegraph. Earlier in the month, Eva Ratz, volunteer at the trust, was awarded a Pride of Britain Award and celebrated in local and national press as well as on ITV News. The Barnet papers also covered a story about a retiring porter at Barnet Hospital and The Jewish Chronical covered the opening of our travel clinic.
Negative
Negative coverage about our partnership with DeepMind included stories from the Mail Online, Financial Times and some specialist/trade publications. The Mail Online and The Mirror ran a story about a patient who was left paralysed after an operation at the Royal Free Hospital.
Figure 1 shows the number of positive stories that the trust had during November. The trust was mentioned in 63 positive stories for November.
Figure 1
60 57
50
40
30
20
10 4 2 0 Royal Free Hospital Barnet Hospital Chase Farm Hospital
Royal Free Hospital Barnet7 Hospital Chase Farm Hospital X:\ Chair and CEO report 21 December 2016 Paper 8
Figure 2 shows how much this positive coverage would cost if these pieces were paid for advertorials, the total cost would be £193,739.81 for November.
Figure 2
RFL value November 2016 £250,000.00
£200,000.00 £191,526.42
£150,000.00
£100,000.00
£50,000.00
£1,677.12 £536.27 £0.00 Royal Free Hospital July Barnet Hospital July Chase Farm Hospital July
Royal Free Hospital July Barnet Hospital July Chase Farm Hospital July
Figure 3 shows the sentiment of our press mentions split as positive, neutral and negative. The sentiment of our coverage is analysed through the tone of our mentions.
Figure 3
November Royal Free Barnet Chase Farm Total Hospital Hospital Hospital Positive 57 4 2 63 Neutral 149 4 4 157 Negative 32 0 0 32 Total 238 8 6 252
Figure 4 shows how many media requests the trust received and how many statements and website stories the external and digital communications team issued during the month of November.
Figure 4
November Trust total Figure 5 shows the daily breakdown of the trust’s Statements 9 volume of news stories compared to how many Media 44 people they reached. Reach can be calculated as requests higher if the trust is mentioned in national coverage Website 17 compared to local. There is a spike for reach and stories volume on 23 November, as national, local and broadcast media reported on our partnership with DeepMind. There is also a spike on 14 8 X:\ Chair and CEO report 21 December 2016 Paper 8
November as The Guardian ran a story on Pauline Cafferkey and the trust was mentioned in a story about NHS finances in the Mail Online.
Figure 5
Figure 6 shows the number of reactions (likes) and comments our posts received, and the number of times they were shared across the month of November.
9 X:\ Chair and CEO report 21 December 2016 Paper 8
• The spike on 13 November shows the reaction to a post about pharmacy porter Harold Rollins retiring after 48 years working at Barnet Hospital. This post reached 2,896 people. • The spike on 23 November shows the reaction to a post about the Royal Free Hospital and Barnet Hospital A&E departments being extremely busy. This post reached 3,880 people. • The spike on 29 November shows the reaction to a post about the Royal Free Hospital’s first mention on BBC EastEnders in relation to the Phil Mitchell liver transplant storyline. This post reached 2,258.
Twitter activity - November • Total number of followers: 11,879 • Increase of 291 compared to October 2016 • Percentage increase YOY: 28.31% • No. of posts: 271 • Most retweeted tweet: Our medical director Prof Stephen Powis explains how our new app developed with DeepMind will work (30 retweets) • Most clicked tweet: Our medical director Prof Stephen Powis explains how our new app developed with DeepMind will work (80 clicks) • Most liked tweet: Our medical director Prof Stephen Powis explains how our new app developed with DeepMind will work (49 likes) • This tweet reached 18,572 people.
LinkedIn activity
Figure 7 shows the number of clicks our posts received over November.
Figure 7
• The spike on 23 November shows the reaction to a post about our partnership with DeepMind. This post reached 7,555 people.
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• The spike on 24 November shows the reaction to a post about the lung cancer team at the Royal Free London winning a Health Service Journal award. This post received reached 7,179 people.
Internal communications
During November, the digital and internal communications team pushed the “RFL jabathon” across the trust, to encourage staff to get their flu jab. Due to the push from the communications and the peer flu vaccinators, 332 staff members were vaccinated during the jabathon. We have vaccinated 45% of staff, this is considerably better than last year’s campaign which vaccinated 28% of staff.
The image below reveals the uptake in clinical staff across the trust and how many more clinical staff members need to be vaccinated to reach our sequin target.
Figure 8 shows a breakdown of how many items the internal communications team uploaded to our staff intranet, Freenet, during September, October and November.
Figure 8
RFL Intranet three months 50 40 30 20 10 0 Landing page news Landing page notices Freenet news Events September 38 28 46 12 October 35 19 39 17 November 36 18 30 15
11 X:\ Chair and CEO report 21 December 2016 Paper 8
Figure 9 shows how many stories and notices the internal communications team published in the monthly staff magazine, Freepress and the weekly staff e-letter Freemail.
Figure 9
November Total stories and notices Freenet 103 Freepress 18 Freemail 65 Managers’ briefing 27
Figure 10 shows how many briefings and visits the internal communications team arranged during the month of November.
Figure 10
November Total amount Chief executive 4 briefing Executive shadowing 1 Go-see visits 4
In this time the internal communications team also:
• Provided internal communication support for key trust improvement projects, the 2020 vision transformation programme and the financial improvement programme. • Promoted the 2016 NHS staff survey and the actions taken to date in response to the last two years’ feedback as part of the staff experience retention plan. • Launched the winter flu campaign to help vaccinate as many staff as possible, including organising and promoting a 48-hour jabathon. • Worked closely with the relevant staff groups to promote Healthy Living Week and launch a range of activities to celebrate Black History Month. • Continued to support the redevelopment of Chase Farm Hospital. • Provided communications advice and assistance for key IT projects due to launch in 2017, including EDSE, EPMA and critical care.
SECRETARY OF STATE
Secretary of State for Health, Jeremy Hunt, has launched a nationwide campaign to raise awareness of the symptoms of sepsis among parents and carers of children aged 0-4. The campaign, which is part of a bigger drive led by NHS England to tackle sepsis, was launched with a ministerial visit to the Royal Free London NHS Foundation Trust. Sepsis is one of the key programmes in the trust’s patient safety programme and the trust has had some success in tackling this. The Secretary of State visited the newly opened paediatric emergency department and met patients and staff.
At a national level, posters and leaflets are also being widely distributed to inform parents about the symptoms of sepsis and encouraging them to go to A&E immediately or call 999 if their children display any of the following. 12 X:\ Chair and CEO report 21 December 2016 Paper 8
E NATIONAL NEWS AND DEVELOPMENTS
CARE QUALITY COMMISSION BOARD MEETING – 16 NOVEMBER 2016
Below is a summary of the issues discussed at the CQC board meeting.
Chief executive’s report
On the 13th October the Care Quality Commission (CQC) published The state of health care and adult social care in England 2015/16. The CQC anticipates the National Audit Office’s follow up Value for Money study of the CQC to start in December with the output published in the early summer next year.
2016/17 Q2 Corporate performance and finance report
• In March the CQC finished rating all Acute Trusts (non-specialist) and in June, Acute (specialist), Mental Health, Community Health and Ambulance Trusts. • As the CQC increase their activity, there has been a corresponding increase in breaches. Locations in-breach for over a year are prioritised for inspection and if these locations receive an overall rating of inadequate they will go into special measures. • Findings from the CQC’s biannual survey show 90% of respondents from hospitals agreed or strongly agreed standards helped them to improve the quality of their services. • In Q2 there were 6 trust re-inspections; all were rated as requires improvement prior inspection. On re-inspection one trust became inadequate, one remained as requires improvement and four improved and are now good. • CQC is taking a number of measures to improve the timeliness of inspection reports. • The CQC is working with NHS Improvement to understand their proposed assessment approach and how they are going to operationalise the assessment. Until this is in place, the CQC says there is a risk over their ability to jointly consult in December at the level of detail required to allow publication of full guidance in April 2017, and begin implementation afterwards as committed. The CQC have offered NHS Improvement additional policy resources if required.
Medium term plan
• To ensure the CQC can deliver their new strategy published in May of this year within a reduced budget envelope (to reduce by £32m by 2020), the CQC is developing a medium term financial plan, an underpinning strategy implementation plan, and an annual business plan for publication in March 2017. • With the CQC’s main source of funding switching from the Department of Health to fees paid by providers, the CQC is aware of the need for them to use their resources as efficiently as possible to ensure they provide value for money. The medium term financial plan will underpin the delivery of these targets.
NHS IMPROVEMENT BOARD MEETING – 24 NOVEMBER 2016
Below is a summary of the issues discussed at the NHS Improvement board meeting.
Update on sustainability and transformation plans (STPs)
• NHS Improvement (NHSI) listed the following as the next steps for STPs: o Areas need to consider how to implement their strategies with the capital and revenue funding available. 13 X:\ Chair and CEO report 21 December 2016 Paper 8
o Operational plans need to make the first two years of STPs ‘real’. Throughout this process, it will be important to see an improvement in the capital and revenue position compared with 2016/17. o The collaborative work throughout STP preparation should support the earlier agreement of operational plans and the brought forward planning table (signing for 2017/18 to 2018/19 by the end of the calendar year). This earlier agreement will enable greater focus on the implementation of STPs in the new year. o The delivery of STPs represents a significant leadership challenge. Capacity and capability at local level are required and NHS England is currently reviewing the necessary national and regional support. o The remaining unpublished STPs are expected to be published over the coming months.
Quarterly performance of the NHS provider sector
• NHSI discussed their released quarter two (Q2) finance and operational performance figures for the provider sector: o The Q2 net deficit for the sector is £648m, compared to £461m at Q1. This is £968m better than at Q2 2015/16 and £18m worse than at the same time of 2014/15. o Including the £1.8 billion of sustainability and transformation funding (STF), the sector has forecast to end the year with a deficit of £669m, £89m worse than plan. o Against forecast, the aggregate deficit at month six is marginally over plan by £22 million. The sector was £5m ahead of plan at Q1. 71 providers reported an adverse variance against plan at Q2. The overall net adverse variance was largely driven by: . Cost Improvement Plans that were £92m under forecast delivery . Bed days lost due to delayed transfers of care rising by 35% compared to Q2 last year . Agency costs exceeding plan by almost 16% . Adverse variance of £195 million for non-pay items. In particular, costs of drugs and clinical supplies significantly exceeded plan. • 142 (60%) of 237 providers are reporting a deficit, compared to 153 (65%) at Q1 and 182 at Q2 in 2015/16. • Overall, 118 providers are forecasting a year-end deficit • At Q2, 227 providers have accepted their 2016/17 control totals, giving them access to STF. The funding has been included by 221 out of 227 trusts in their forecast outturn.
Improvement report
. NHSI and the CQC have been working together on a refreshed well-led framework which will form the basis both for the Leadership and Improvement Capability theme in NHSI’s Single Oversight Framework and well-led assessment. NHSI say they are making good progress towards agreeing a shared structure of questions, characteristics, and good practice. They plan to issue a joint consultation on the proposed well-led framework in mid-December.
14 X:\ Chair and CEO report 21 December 2016 Paper 9
Report to Date of meeting Attachment number
Trust board - public 21 December 2016 Paper 9
Monitor risk assessment framework report
Executive summary This paper summarises the trust’s performance against the metrics in the Monitor Risk Assessment framework and sets out our improvement plans, where appropriate.
Action required/recommendation For information
Trust strategic priorities and business planning objectives Board assurance risk supported by this paper number(s) 1. Excellent outcomes – to be in the top 10% of our peers on X outcomes 2. Excellent user experience – to be in the top 10% of relevant X peers on patient, GP and staff experience 4. Excellent compliance with our external duties – to meet our X external obligations effectively and efficiently 5. A strong organisation for the future – to strengthen the X organisation for the future
CQC Regulations supported by this paper
Regulation 4 Requirements where the service provider is an individual or partnership Regulation 5 ⃰ Fit and proper persons: directors Regulation 6 Requirement where the service provider is a body other than a partnership Regulation 7 Requirements relating to registered managers Regulation 8 ⃰ General Regulation 9 Person-centred care Regulation 10 Dignity and respect Regulation 11 Need for consent Regulation 12 Safe care and treatment Regulation 13 Safeguarding service users from abuse and improper treatment Regulation 14 Meeting nutritional and hydration needs Regulation 15 Premises and equipment Regulation 16 Receiving and acting on complaints Regulation 17 Good governance Regulation 18 Staffing Regulation 19 Fit and proper persons employed Regulation 20⃰ Duty of candour Regulation 20A⃰ Requirement as to display of performance assessments Care Quality Commission (Registration) Regulations 2009 (Part 4) Regulation 12 Statement of purpose Regulation 13 Financial position
Page 1 of 2 Paper 9 Regulation 14 Notice of absence Regulation 15 Notice of changes Regulation 16 Notification of death of a service user Regulation 17 Notification of death or unauthorised absence of a service user who is detained or liable to be detained under the Mental Health Act 1983 Regulation 18 Notification of other incidents Regulation 19 Fees Regulation 20⃰ Requirements relating to termination of pregnancies Regulation 22A⃰ Form of notifications to the Commission
Risks attached to this project/initiative and how these will be managed (assurance)
Equality analysis • No identified negative impact on equality and diversity
Report from Kate Slemeck, Amy Caldwell-Nichols, Temi Salami 14 December 2016 References
Page 2 of 2 Monitor Risk Assessment Dashboard Summary Month: November 2016
Risk Assessment Framework Summary A&E Performance against 95% Standard
Month Trend QTD Month Trend QTD
Royal Free London NHS FT Green 1 Green 1 Royal Free London NHS FT RR
Royal Free Hospital Green 1 Green 1 Royal Free Hospital RR
Barnet Hospital & Chase Farm Hospital Green 1 Green 1 Barnet Hospital & Chase Farm Hospital RR
C. difficile Performance against Trajectory 18-weeks RTT Performance
Month Trend QTD Month Trend QTD
Royal Free London NHS FT GG Royal Free London NHS FT GG
Royal Free Hospital GG Royal Free Hospital GG
Barnet Hospital & Chase Farm Hospital GG Barnet Hospital & Chase Farm Hospital GG
Cancer Performance against Targets 2
Month Trend QTD
Royal Free London NHS FT RR
Royal Free Hospital RR
Barnet Hospital & Chase Farm Hospital RR
1Monitor framework adjustment applies 218-weeks RTT and Cancer are reported for August 16
November 2016 Monitor Risk Assessment Scorecard October 2015 to November 2016
Royal Free London NHS Foundation Trust
2015/16 2016/17
Rolling Monitor Indicators of Governance Concerns - April 2015 - November 2016 Q3 Q4 Jun-16 Q1 Jul-16 Aug-16 Sep-16 Q2 Oct-16 Nov-16 Target Weighting Risk Assessment
*A&E - 95% of patients admitted, transferred or discharged within 4-hours 93.4% 87.8% 90.2% 91.0% 91.3% 89.99% 87.92% 89.77% 85.49% 84.99% >= 95% 1.0 High
**C difficile number of cases against plan 5 0 0 0 0 2 0 2 0 0 Q1 <= 171.0 Low
**Maximum time of 18 weeks from point of referral to treatment in 86.7% 89.6% 92.2% 92.2% 92.2% 92.0% 92.1% 92.1% 92.2% Compliant >=92% 1.0 Low aggregate for patients on an incomplete pathways
**Cancer: two week wait from referral to date first seen
All cancers 96.2% 92.9% 94.6% 93.0% 95.1% 93.8% 94.1% 94.3% 95.3% Compliant >=93% 1.0 Medium Symptomatic breast patients 96.4% 89.1% 97.3% 94.5% 92.78% 94.0% 94.7% 93.8% 94.7% Compliant >=93%
**All cancers: 31 day wait from diagnosis to first treatment 99.2% 98.1% 100.0% 97.6% 97.5% 95.8% 96.5% 96.6% 97.8% Compliant >=96% 1.0 Medium
**All Cancer 31 day second or subsequent treatment - surgery 100.0% 99.1% 100.0% 98.9% 97.1% 100.0% 100.0% 98.8% 100.0% Compliant >=94% drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98% 1.0 Low radiotherapy 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=94%
**All Cancer 62 days wait for first treatment: from urgent GP referrals: 73.3% 72.6% 85.8% 82.6% 78.9% 76.0% 78.0% 77.7% 73.7% Fail >=85% 1.0 High from a screening service 93.0% 83.3% 92.2% 94.9% 96.8% 96.7% 90.9% 94.9% 80.0% Compliant >= 90%
Compliance with requirements regarding access to healthcare for Meeting the Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 1.0 Low people with learning disabilities 6 criteria
Monitor overall governance thresholds: Trust Rating: Green 1 Green 1 Green 1 Green 1 Green 1 Green 1 Green 1 Green 1 Green 1 Green 1 Green: a service performance score of <4.0 and <3 consecutive Weighting: 2 3 2 2 3 2 quarters' breaches of a single metric
Red: a service performance score of >=4.0 and >=3 consecutive quarters' breaches of a single metric
* Denotes actual data for April 2016 **18-weeks and Cancer data is not available for April 2016 Note: C. difficile RAG rating applied on the basis of the cumulative quarterly expression of the trajectory
1The overall trust rating has been modified following application of the Monitor governance framework adjustment, refer to commentary November 2016 Monitor Risk Assessment Scorecard October 2015 to November 2016
Royal Free London Hospital
2015/16
Rolling Monitor Indicators of Governance Concerns - April 2015 - November 2016 Q3 Q4 Q1 Jul-16 Aug-16 Sep-16 Q2 Oct-16 Nov-16 Target Weighting Risk Assessment
*A&E - 95% of patients admitted, transferred or discharged within 4-hours 93.3% 89.5% 90.7% 92.1% 92.7% 84.9% 89.9% 84.1% 86.5% >= 95% 1.0 High
**C difficile number of cases against plan 4 0 0 0 0 0 0 0 0 Q1 <= 8 1.0 Low
**Cancer: two week wait from referral to date first seen All cancers 98.7% 97.4% 96.9% 96.4% 96.2% 96.7% 96.5% 96.3% Compliant >=93% 1.0 Low Symptomatic breast patients 98.8% 95.0% 98.2% 94.4% 96.3% 96.6% 95.7% 97.8% Compliant >=93%
**All cancers: 31 day wait from diagnosis to first treatment 98.5% 96.5% 95.5% 95.0% 92.8% 93.0% 93.6% 96.0% Compliant >=96% 1.0 High
**All Cancer 31 day second or subsequent treatment - surgery 100.0% 100.0% 98.1% 92.3% N/A 100.0% 96.2% 100.0% Compliant >=94% drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98% 1.0 Low radiotherapy 100.0% 99.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=94%
**All Cancer 62 days wait for first treatment: from urgent GP referrals: 72.6% 69.8% 79.7% 71.1% 68.6% 71.6% 70.4% 62.7% Fail >=85% 1.0 High from a screening service 92.6% 92.6% 91.7% 100.0% 94.1% 76.5% 89.1% 71.4% Fail >= 90%
Compliance with requirements regarding access to healthcare for people with Meeting the 6 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 1.0 Low learning disabilities criteria
Monitor overall governance thresholds: Trust Rating: Green 1 Green 1 Green 1 Red Green 1 Green 1 Green 1 Green 1 Green 1 Green: a service performance score of <4.0 and <3 consecutive quarters' Weighting: 2 3 3 4 3 breaches of a single metric
Red: a service performance score of >=4.0 and >=3 consecutive quarters' breaches of a single metric
* Denotes actual data for April 2016 **18-weeks and Cancer data is not available for April 2016 Note: C. difficile RAG rating applied on the basis of the cumulative quarterly expression of the trajectory
1The overall trust rating has been modified following application of the Monitor governance framework adjustment, refer to commentary November 2016 Monitor Risk Assessment Scorecard October 2015 to November 2016
Barnet Hospital
2015/16 2016/17
Rolling Monitor Indicators of Governance Concerns - April 2015 - November 2016 Q3 Q4 Q1 Jul-16 Aug-16 Sep-16 Q2 Oct-16 Nov-16 Target Weighting Risk Assessment
*A&E - 95% of patients admitted, transferred or discharged within 4-hours 91.5% 82.2% 91.3% 87.6% 84.5% 86.5% 86.2% 81.8% 79.1% >= 95% 1.0 High
**C difficile number of cases against plan 1 0 Compliant Compliant 2 0 2 0 0 Q1 <= 7 1.0 Low
**Cancer: two week wait from referral to date first seen
All cancers 94.5% 91.0% 91.7% 94.6% 92.2% 92.5% 93.1% 94.4% Fail >=93% 1.0 High Symptomatic breast patients 94.3% 81.5% 89.6% 91.4% 90.6% 95.7% 92.5% 92.9% Compliant >=93%
**All cancers: 31 day wait from diagnosis to first treatment 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=96% 1.0 Low
**All Cancer 31 day second or subsequent treatment - surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=94% drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98% 1.0 Low radiotherapy N/A N/A N/A N/A N/A N/A N/A N/A N/A >=94%
**All Cancer 62 days wait for first treatment: from urgent GP referrals: 76.0% 75.5% 80.0% 79.7% 80.6% 83.0% 81.0% 85.4% Fail >=85% 1.0 High from a screening service 100.0% 91.7% 100.0% 100.0% 100.0% 100.0% 100.0% 71.4% Compliant >= 90%
Compliance with requirements regarding access to healthcare for people with Meeting the 6 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 1.0 Low learning disabilities criteria
Monitor overall governance thresholds: Trust Rating: Green 1 Green 1 Red Green 1 Green 1 Green 1 Green 1 Green 1 Green 1 Green: a service performance score of <4.0 and <3 consecutive quarters' Weighting: 2 3 4 3 3 3 3 3 3 breaches of a single metric
Red: a service performance score of >=4.0 and >=3 consecutive quarters' breaches of a single metric
* Denotes actual data for April 2016 **18-weeks and Cancer data is not available for April 2016 Note: C. difficile RAG rating applied on the basis of the cumulative quarterly expression of the trajectory
1The overall trust rating has been modified following application of the Monitor governance framework adjustment, refer to commentary November 2016 Monitor Risk Assessment Scorecard October 2015 to November 2016
Chase Farm Hospital
2015/16
Rolling Monitor Indicators of Governance Concerns - April 2015 - November 2016 Q3 Q4 Q1 Jul-16 Aug-16 Sep-16 Q2 Oct-16 Nov-16 Target Weighting Risk Assessment
*A&E - 95% of patients admitted, transferred or discharged within 4-hours 99.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% >= 95% 1.0 Low
**C difficile number of cases against plan 0 0 0 0 0 0 0 0 0 Q1 <= 01.0 Low
**Cancer: two week wait from referral to date first seen
All cancers 95.5% 90.8% 89.9% 94.1% 93.9% 93.7% 93.9% 95.6% Compliant >=93% 1.0 High Symptomatic breast patients 96.6% 91.7% 92.5% 93.2% 96.2% 89.7% 93.4% 94.2% Compliant >=93%
**All cancers: 31 day wait from diagnosis to first treatment 100.0% 99.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=96% 1.0 Low
**All Cancer 31 day second or subsequent treatment - surgery 100.0% 96.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=94% drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >=98% 1.0 Low radiotherapy N/A N/A N/A N/A N/A N/A N/A N/A N/A >=94%
**All Cancer 62 days wait for first treatment: from urgent GP referrals: 69.1% 72.3% 80.4% 91.9% 83.9% 83.3% 86.9% 73.5% Fail >=85% 1.0 High from a screening service 80.0% 52.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Compliant >= 90%
Compliance with requirements regarding access to healthcare for people with Meeting the Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 1.0 Low learning disabilities 6 criteria
Monitor overall governance thresholds: Trust Rating: Green 1 Green 1 Green 1 Green 1 Green 1 Green 1 Green 1 Green 1 Green 1 Green: a service performance score of <4.0 and <3 consecutive quarters' Weighting: 1 2 2 0 2 breaches of a single metric
Red: a service performance score of >=4.0 and >=3 consecutive quarters' breaches of a single metric
* Denotes actual data for March 2016 **18-weeks and Cancer data is not available for March 2016 Note: C. difficile RAG rating applied on the basis of the cumulative quarterly expression of the trajectory
1The overall trust rating has been modified following application of the Monitor governance framework adjustment, refer to commentary November 2016 Monitor Risk Assessment Scorecard October 2015 to November 2016
Other Satellite Sites
2015/16 2016/17
Rolling Monitor Indicators of Governance Concerns - April 2015 - November 2016 Q3 Q4 Q1 Jul-16 Aug-16 Sep-16 Q2 Oct-16 Nov-16 Target Weighting Risk Assessment
*A&E - 95% of patients admitted, transferred or discharged within 4-hours >= 95% 1.0
**C difficile number of cases against plan Q1 <= 0 1.0
**Cancer: two week wait from referral to date first seen All cancers 93.4% 79.7% 82.8% 96.6% 89.3% 90.3% 92.0% 95.8% Fail >=93% 1.0 High Symptomatic breast patients 91.7% 42.9% 80.0% N/A 100.0% 100.0% 100.0% 100.0% Compliant >=93%
**All cancers: 31 day wait from diagnosis to first treatment 100.0% 100.0% 100.0% 100.0% N/A N/A 100.0% N/A Compliant >=96% 1.0 Low
**All Cancer 31 day second or subsequent treatment - surgery >=94% drug >=98% 1.0 radiotherapy >=94%
**All Cancer 62 days wait for first treatment: from urgent GP referrals: 50.0% 84.8% 100.0% 100.0% N/A 0.0% 75.0% N/A Fail >=85% 1.0 High from a screening service 94.8% 100.0% 91.4% 90.0% 96.7% 97.2% 95.3% 92.3% Compliant >= 90%
Compliance with requirements regarding access to healthcare for people with Meeting the Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant 1.0 Low learning disabilities 6 criteria
Monitor overall governance thresholds: Trust Rating: Green: a service performance score of <4.0 and <3 consecutive quarters' Weighting: 2 2 breaches of a single metric
Red: a service performance score of >=4.0 and >=3 consecutive quarters' breaches of a single metric
* Denotes actual data for April 2016 **18-weeks and Cancer data is not available for April 2016 Note: C. difficile RAG rating applied on the basis of the cumulative quarterly expression of the trajectory
1The overall trust rating has been modified following application of the Monitor governance framework adjustment, refer to commentary April 2016 Performance against Recovery Trajectory
Performance measured against trajectory The graphs presented below represent the trust's actual performance ("measure") against externally submitted trajectories ("trajectory") during the course of 2015/16 and those trajectories submitted in respect of 2016/17. For 2016/17 the data will be refreshed with each month's actual performance against trajectory. Where a negative variance (underperformance) is recorded against trajectory, or important contextual information is required, this will appear beneath each relevant chart.
Royal Free London NHS Foundation Trust Royal Free London NHS Foundation Trust Royal Free London NHS Foundation Trust A&E 95% Trajectory 92% of patients with incomplete pathways waited less than 18-weeks RTT 52 week breaches
A&E - 95% of patients admitted, transferred or discharged Patients with incomplete pathways to have waited less No of 52 week Breaches 250 100% within 4-hours 95% than 18-weeks - Percentage of Trust Compliance 200 95% 90% 150 90% 100 85% 85% 50 80% 0 80%
Measure Trajectory Measure Trajectory Measure Trajectory
The A&E trajectory delivers compliance against the 95% standard from June 16 and each month thereafter to September 16, from October 16 the trust returns to non- compliance (as a result of winter pressures) for the remainder of 2016/17. The trust's Chief Operating Officer is currently reviewing the delivery date of June 16 against the quarter 1 forecast delivery-risk, following this review the trajectory may be amended.
Royal Free London NHS Foundation Trust Royal Free London NHS Foundation Trust Cancer - 62 day wait from urgent GP referral 99% of patients on a diagnostic pathway within 6 weeks Patients with diagnostic pathways to have waited less than 6- All Cancer 62 Days Wait for First Treatment 90% weeks - Percentage of Trust Compliance Urgent GP Referrals 100% 98% 80% 96% 70% 94% 92% 60% 90% Jul-15 Jul-16 Jan-16 Jan-17 Jun-15 Jun-16 Oct-15 Oct-16 Apr-15 Apr-16 Sep-15 Feb-16 Sep-16 Feb-17 Dec-15 Dec-16 Aug-15 Aug-16 Nov-15 Nov-16 Mar-16 Mar-17 Measure Trajectory May-15 Measure TrajectoryMay-16
The Cancer 62 day trajectory delivers compliance against the 95% standard from June 16 and each month thereafter to the end of 2016/17. The trust's Chief Operating Officer is currently reviewing the delivery date of June 16 against the quarter 1 forecast delivery-risk, following this review the trajectory may be amended. April 2016 High Risk Ratings
Risk Rating - High
Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital A&E 95% Standard A&E 95% Standard A&E 95% Standard A&E 95% Standard
A&E - 95% of patients admitted, transferred or discharged A&E - 95% of patients admitted, transferred or A&E - 95% of patients admitted, transferred or A&E - 95% of patients admitted, transferred or discharged within 4-hours discharged within 4-hours discharged within 4-hours within 4-hours 100% 100% 100% 100% 95% 95% 95% 95% 90% 90% 90% 90% 85% 85% 85% 85% 80% 80% 80% 80%
Measure Target Measure Target Measure Target Measure Target
Royal Free London NHS Foundation Trust Royal Free Hospital Barnet & Chase Farm Hospital Chase Farm Hospital 92% of patients with incomplete pathways waited less than 18-weeks 92% of patients with incomplete pathways waited less than 18-weeks 92% of patients with incomplete pathways waited less than 18-weeks 92% of patients with incomplete pathways waited less than 18-weeks
Patients with incomplete pathways to have waited less than 18- Patients with incomplete pathways to have waited less than 18- Patients with incomplete pathways to have waited less than 18- 94% 94% weeks - Percentage of Trust Compliance weeks - Percentage of Trust Compliance weeks - Percentage of Trust Compliance 94%
92% 92% 92%
90% 90% 90%
88% 88% 88% 86% 86% 86% Jul-15 Jul-16 Jan-15 Jan-16 Jun-15 Jun-16 Oct-15 Oct-16 Apr-15 Apr-16 Feb-15 Sep-15 Feb-16 Sep-16 Dec-14 Dec-15 Aug-15 Aug-16 Jul-15 Jul-16 Nov-15 Mar-15 Mar-16 May-15 May-16 Jan-15 Jan-16 Jun-15 Jun-16 Oct-15 Oct-16 Apr-15 Apr-16 Feb-15 Sep-15 Feb-16 Sep-16 Dec-14 Dec-15 Aug-15 Aug-16 Nov-15 Mar-15 Mar-16 Measure Target May-15 Measure Target May-16 Measure Target
Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital All Cancer 2 week wait All Cancer 2 week wait All Cancer 2 week wait All Cancer 2 week wait
Cancer: 2 week wait (All Cancer) Cancer: 2 week wait (All Cancer) Cancer: 2 week wait (All Cancer) Cancer: 2 week wait (All Cancer) 98% 100% 98% 98% 96% 98% 96% 96% 96% 94% 94% 94% 92% 92% 94% 92% 90% 90% 92% 88% 88% 90% 90% 86% 86% 88% 88% 84% 84%
Measure Target Measure Target Measure Target Measure Target
Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital Symptomatic breast 2-week wait Symptomatic breast 2-week wait Symptomatic breast 2-week wait Symptomatic breast 2-week wait
Cancer: 2 week wait (Symptomatic Breast) Cancer: 2 week wait (Symptomatic Breast) Cancer: 2 week wait (Symptomatic Breast) Cancer: 2 week wait (Symptomatic Breast) 100% 100% 100% 100% 95% 95% 95% 95% 90% 90% 90% 90% 85% 85% 85% 85% 80% 80% 80% 80% 75% 75% 75% 75% 70% 70% 70%
Measure Target Measure Target Measure Target Measure Target April 2016 High Risk Ratings
Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital Cancer - 62 day wait from urgent GP referral Cancer - 62 day wait from urgent GP referral Cancer - 62 day wait from urgent GP referral Cancer - 62 day wait from urgent GP referral
All Cancer 62 Days Wait for First Treatment All Cancer 62 Days Wait for First Treatment All Cancer 62 Days Wait for First Treatment All Cancer 62 Days Wait for First Treatment Urgent GP Referrals 90% Urgent GP Referrals Urgent GP Referrals Urgent GP Referrals 85% 95% 100% 100% 80% 85% 90% 90% 75% 80% 75% 80% 70% 70% 65% 65% 70% 60% 60% 55% 60% 50%
Measure Target Measure Target Measure Target Measure Target
Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital Cancer 62 days from screening Cancer 62 days from screening Cancer 62 days from screening Cancer 62 days from screening
Cancer 62 Days Wait for First Treatment Cancer 62 Days Wait for First Treatment Cancer 62 Days Wait for First Treatment Cancer 62 Days Wait for First Treatment Screening Screening Screening Screening 100% 100% 100% 100% 80% 80% 90% 90% 60% 60% 80% 80% 40% 40% 70% 70% 20% 20% 60% 60% 0% 0%
Measure Target Measure Target Measure Target Measure Target April 2016 Low Risk Ratings
Risk Rating - Low Summary: The following indicators have been rated Low risk primarily on the basis that at trust level there is good headroom against the standard. However the trust requires compliance to be achieved at every hospital every month and quarter. The C. difficile charts have a black line separating the data pre and post April 15, this reflects the change in counting methodology applied by Monitor from that date. From April 15 only infections relating to "lapses in care" are included for the purposes of the Monitor risk assessment.
Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital Number of C. difficile infections against plan Number of C. difficile infections against plan Number of C. difficile infections against plan Number of C. difficile infections against plan
C-Difficile C-Difficile C-Difficile C-Difficile 7 4 6 5 2 5 4 3 4 3 2 1 3 2 2 1 1 1 0 0 0 0
Measure Target Measure Target Measure Target Measure Target
Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital All cancers: 31 day wait from diagnosis to first treatment All cancers: 31 day wait from diagnosis to first treatment All cancers: 31 day wait from diagnosis to first treatment All cancers: 31 day wait from diagnosis to first treatment All Cancers: 31 Day Wait from Diagnosis to First Treatment All Cancers: 31 Day Wait from Diagnosis to First Treatment All Cancers: 31 Day Wait from Diagnosis to First Treatment All Cancers: 31 Day Wait from Diagnosis to First Treatment 100% 100% 100% 100% 99% 98% 99% 99% 98% 96% 98% 98% 97% 94% 97% 97% 96% 92% 96% 96% 95% 94% 90% 95% 95% 93% 88% 94% 94%
Measure Target Measure Target Measure Target Measure Target
Royal Free London NHS Foundation Trust Royal Free Hospital All Cancer 31 day second or subsequent treatment for radiotherapy All Cancer 31 day second or subsequent treatment for radiotherapy All Cancer 31 Day Second or Subsequent Treatment All Cancer 31 Day Second or Subsequent Treatment Radiotherapy Radiotherapy 100% 100% 98% 98% 96% 96% 94% 94% 92% 92% 90% 90%
Measure Target Measure Target April 2016 Low Risk Ratings
Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital All Cancer 31 day second or subsequent drug treatment All Cancer 31 day second or subsequent drug treatment All Cancer 31 day second or subsequent drug treatment All Cancer 31 day second or subsequent drug treatment All Cancer 31 Day Second or Subsequent Treatment All Cancer 31 Day Second or Subsequent Treatment All Cancer 31 Day Second or Subsequent Treatment All Cancer 31 Day Second or Subsequent Treatment Drug Drug Drug Drug 100% 100% 100% 100% 80% 99% 99% 99% 60% 98% 40% 98% 98% 20% 97% 0% 97% 97%
Measure Target Measure Target Measure Target Measure Target
Royal Free London NHS Foundation Trust Royal Free Hospital Barnet Hospital Chase Farm Hospital All cancer 31 day Second or Subsequent Treatment Surgery All cancer 31 day Second or Subsequent Treatment Surgery All cancer 31 day Second or Subsequent Treatment Surgery All cancer 31 day Second or Subsequent Treatment Surgery All Cancer 31 Day Second or Subsequent Treatment All Cancer 31 Day Second or Subsequent Treatment All Cancer 31 Day Second or Subsequent Treatment All Cancer 31 Day Second or Subsequent Treatment Surgery Surgery Surgery Surgery 100% 100% 100% 100% 80% 98% 98% 95% 60% 96% 96% 90% 40% 94% 94% 20% 92% 85% 92% 0% 90% 80% 90%
Measure Target Measure Target Measure Target Measure Target High Risk Indicators Commentary and Exception Report
Month: October 2016
Risk Assessment Framework - commentary
Trust performance overview
The table below summarises the performance against standard by site and by trust. Compliance is being delivered against all standards with the exception of: • A&E • 62 day cancer from a GP referral • 62 day cancer from a screening service
Royal Chase Period Description Standard STF All Barnet Other Reported Indicator Free Farm Nov-16 AE Patients admitted, transferred or discharged 95% 90% 85.0% 86.5% 79.1% 100.0% within 4 hours Nov-16 C Difficile Lapses in care <=0 0 Compliant Compliant Compliant Compliant Compliant Cases Oct-16 RTT Patients on incomplete pathways waiting 92% 92% 92.2% less than 18weeks Oct-16 Cancer 2 week waits - All cancers 93% 95.3% 96.3% 94.4% 95.6% 95.8%
2 week waits - Symptomatic breast 93% 94.7% 97.8% 92.9% 94.2% 100.0%
31 day waits diagnosis to first treatment - All 96% 97.8% 96.0% 100.0% 100.0% cancers 31 day waits diagnosis to first treatment – 94% 100.0% 100.0% 100.0% 100.0% Surgery 31 day waits diagnosis to first treatment - 98% 100.0% 100.0% 100.0% 100.0% Drug 31 day waits diagnosis to first treatment - 94% 100.0% 100.0% Radiotherapy High Risk Indicators Commentary and Exception Report
Month: October 2016
62 day waits from GP referral to treatment 85% 78.2% 73.7% 62.7% 85.4% 73.5%
62 day waits from screening service referral 90% 80.0% 71.4% 71.4% 100.0% 92.3% to treatment
The Strategic Transformation Fund (STF) For 2016/17 NHS Improvement has allocated additional funding from the STF to trusts delivering against agreed target recovery trajectories. Our trajectories for all indicators are summarised in the table below – green indicates that we have met the trajectory, red that we have not.
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
A&E 4 hour standard 90% 92% 93% 95% 95% 95% 92% 90% 91% 91% 92% 92%
18-weeks RTT Incomplete Pathways 90% 91% 91% 92% 92% 92% 92% 92% 92% 92% 92% 92%
18-weeks RTT Volume of 52 Weeks 0 (out- Breaches 5 5 5 5 5 5 turn 2) 0 0 0 0 0
99% of Diagnostic Pathways to be 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% Seen within 6-weeks
Cancer 62 days from GP Referral 79.7% 75.2% 76.1% 77.4% 78.1% 74.4% 78.2% 83.8% 85.2% 85.3% 85.2% 85.2% High Risk Indicators Commentary and Exception Report
Month: October 2016
A&E To address our continuing performance issues, we are implementing our Safer, Faster, Better programme. Key achievements for this month include: • Surgical AEC pilot at RF site scoped and plan developed for implementation (w/c 19th Jan for Abscess pathway), • RF Navigator role scoped and pilot due to start 23rd January 2016, • SAFER bundle implemented on Rowan, 9W, 7N & 7W wards, • All discharge to assess and step down beds now open and fully utilised, • SOP for patient choice written and pending implementation, and • Communications for the programme designed and implementation has started.
The Barnet AAU development is still on schedule for opening in mid-December.
Cancer 62 day GP and Screening Cancer 62 day performance for October was below trajectory and we anticipate that November will also be below trajectory. This month we have: • Near finalised hot reporting across all our prostate cancer clinics; • Implemented a new one-stop clinic for HPB patients; and • Piloted a new tele-dermatology service for roll-out in December and January. Paper 10
Report to Date of meeting Attachment number
Trust Board 21 December 2016 Paper 10
FINANCE PERFORMANCE REPORT 2016/17 – Month 8
Executive summary The Trust delivered an actual deficit of £44.3m at end of November; this was £47.4m worse than its planned surplus of £3.1m. Key factors driving the year to date variance from plan are
1. Income adjustments relating to prior year of £18.1m 2. Income provisions relating to this financial year of £6.7m 3. Under performance in clinical activity income 4. Over spend on pay mainly relating to use of agency to cover medical pay vacancies 5. Over spend on non-pay mainly due to outsourcing. We also have increased patient transport costs due to change of supplier. 6. Under recovery of PPU income resulting in reduced contribution 7. Slippage against savings target 8. STF funding loss of £7.6m
Action required/recommendation For Discussion
Trust strategic priorities and business planning objectives Board assurance risk number(s) supported by this paper 3. Excellent financial performance – to be in the top 10% of relevant peers on financial performance
CQC Regulations supported by this paper
Regulation 13 Financial position
Risks attached to this project/initiative and how these will be managed (assurance)
Equality analysis • No identified negative impact on equality and diversity
Report from Caroline Clarke Author(s) Senior Finance Team Date 12th December 2016 Financial Performance Report November 2016
1 FINANCIAL PERFORMANCE EXECUTIVE SUMMARY November 2016 Measure Description Status Position Trend Variation 5 NHS Clinical Income: The year to date (YTD) clinical income values as at 30th Plan November shows an under performance positon of (£33.6.m) which primarily 0 relates to prior year credit notes issued. Net surplus/(deficit) in month: -5 Other Income: (£0.9m) adverse from plan in month and (£8.6m) adverse YTD. The Plan (£0.4m), Actual (£9.6m), Actual Net income and adverse variance relates primarily to private patient reduced activity and pharmacy Variance (£9.1m) adverse -10 Normalised expenditure excluding wholesaling. GR £m Net Surplus / profit from fixed asset -15 Pay excluding Integration: (£2.4m) adverse from plan in month and (£7.2m) Net surplus/(deficit) YTD: (Deficit) disposals and fixed asset adverse YTD. Overspend is mainly due to use of agency to cover medical pay Plan (£14.0m), Actual -20 impairments vacancies and unallocated CIP targets. (£61.4m), Variance (£47.4m) -25 Non-Pay excluding Integration & TEDD: (£0.1m) adverse from plan in month and deficit -30 (£7.1m) YTD. Key overspent areas are outsourcing, patient transport and
unallocated CIP targets.
Jul-16
Jan-16
Jun-16
Oct-16
Apr-16
Feb-16 Sep-16
Dec-15
Aug-16
Nov-16 Mar-16 May-16 Integration: £0.1m favourable in month and £1.6m favourable YTD. 8 CIP in month: Savings against the 6 Plan £4.3m, Actual £6.4m, recurrent CIP savings Variance £2.1m favourable 4 Plan plan. The plan includes Actual delivery of plans in M8 was of £6.4m, which is £2.1m favourable when CIP Savings A both cost efficiency or £m 2 compared to plan. CIP year to date: Actual income generation Plan £12.5m, Actual £16.9m, schemes. 0
Variance £4.4m favourable
Jul-16
Jan-16
Jun-16
Oct-16
Apr-16
Sep-16 Feb-16
Dec-15
Aug-16
Nov-16
Mar-16 May-16 12
CAPEX in month: 10 Plan £6.4m, Actual £7.5m, 8
Year to date cumulative Variance £1.1m adverse Plan Capital A 6 Capital expenditure for the month is £7.5m which is £1.1m higher than plan. expenditure in non- £m All programmes are back on track and forecast to be witin CAPEX limit. Expenditure Actual current assets. CAPEX year to date: 4 Plan £55.1m, Actual £47.9m, Variance £7.2m favourable 2
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M M 150 Cash at end of November was £12.0m against a plan of £17.0m. The cash balance Cash flow in month: was below the planned level due to lower than expected receipts of the prior year Plan £1.5m, Actual (£1.7m), Cash held with the 100 NHS over performance, debts relating to the GP Lead programme and the current
Variance £3.3m adverse Plan government banking R year deficit. On a positive note the Trust secured an advance of £10m on the Cash £m service and in commercial Actual December SLA from NHS Barnet on the 1st December which will help pay key Cash balance: 50 banks. suppliers. Plan £17.0m, Actual £12.0m, The £12m cash balance reflects the Income and Expenditure deficit position and Variance (£5.0m) adverse
0 non-recovery of NHS debts.
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M M 2015/16 2016/17 Actual 2016/17 Plan Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Monitor Monitor measures an Capital Service Cover 1 1 1 1 1 1 2 3 Financial organisations financial Monitor FSSR: Trusts with a Normalised I&E margin of less than -1% are rated as 1 Liquidity 4 4 4 4 2 2 4 4 Sustainability risk on a scale of 1-4 with R for this metric. A rating of 1 on any metric means the overall rating cannot exceed Risk Rating 4 being the lowest risk Normalised I&E Margin 1 1 1 1 1 1 1 2 2. (FSRR) and 1 the highest risk. I&E Margin Plan Variance 2 2 2 2 3 1 4 4
Overall 2 2 2 2 2 1 2 3
2 Paper 11
Report to Date of meeting Attachment number Trust Board 21 December 2016 Paper 11
SHADOW GROUP BOARD REPORT
Executive summary
The Shadow Group Board (SGB) met on 8 December 2016.
The key issues discussed were:
- an update on provider, partner and system stakeholder discussions; - the next steps for standing up the group structure; - the trust’s approach to primary care; - the Global Digital Exemplars programme; - progress of the centralisation of sterilisation and decontamination services; - an update on HSL; and - discussion of potential land sales.
Action required To note.
Trust strategic priorities and business Board assurance risk number(s) planning objectives supported by this paper 3. Excellent financial performance – to be in the top 10% of relevant peers on financial performance 5. A strong organisation for the future – to strengthen the organisation for the future
CQC Regulations supported by this paper Regulation 12 Statement of purpose Regulation 13 Financial position
Equality impact assessment No identified negative impact on equality and diversity
Report From Dominic Dodd, chairman Author(s) Tom Snowdon, planning manager Date 13 December 2016
Shadow group board report – Board December 2016 Paper 12
Report to Date of meeting Attachment number
Trust Board 21 December 2016 Paper 12
Report from patient safety committee held 24 November 2016
Executive summary The patient safety committee met on 24 November 2016. The key matters of interest were as follows:
Patient safety metrics - medical errors The committee received its summary of performance against key patient safety metrics, noting that there had been an increase in the reporting of medication errors. However, it was understood that this increase had been seen across all the trust’s hospitals and did not relate to an increase in severity and as such was not related to a decline in safety.
The chair noted that the committee had asked for granularity on medication error data for some time, adding that one of the closed serious investigations reports to be discussed later on in the meeting had been attributed to a medication error. The associate medical director for patient safety reported that a major review of such data had been undertaken recently by the pharmacist for clinical governance and a report on this (level of harm, type of error etc.) would be presented at the meeting in January, alongside a paper outlining the benefits of electronic prescribing.
Closed serious incidents investigations (SI) At each meeting, members choose which closed SI investigation reports they would like to discuss in the context of actions for improvement, lessons learned and shared learning.
A discussion was had on SIs where the trust was clearly at fault and the legal position on this, particularly in terms of fairness for the patient and the option of financial settlements / compensation outside of formal litigation. The head of legal services reported that on confirmation of an SI, the legal team would proactively report it to the NHS Litigation Authority but this was in the event that there could be a potential clinical negligence claim against the trust. The chair welcomed greater insight on this and asked the head of legal services to ascertain what the trust’s policy was in cases of an early recognition of a clear at fault SI, and to report back to the committee in due course.
Incident reporting and learning (including serious incidents and never events) policy The committee ratified the policy as it stood, noting that it would be subject to further revision once the trust’s new group structure had been established.
Care Quality Commission (CQC) The committee agreed the removal of two satellite sites from the trust’s CQC registration.
Maternity services integrated action plan The committee was pleased to see the good progress made against implementation of the action plan but noted that challenging conversations were continuing to held with IT in relation to a number of IM&T-related actions where slow progress had been made.
Page 1 of 3 Final Paper 12
The committee agreed to the formal closure of the maternity action plan in light of the good progress made to date and, going forward, the monitoring of outstanding actions through the relevant risk register / action plans and groups, and noted that Barnet CCG was in agreement. Both the director of nursing and chair noted their thanks to the staff within maternity services for all their hard work over the last year and for the many improvements made.
The medical director considered that the first wave of clinical practice groups was likely to be focused on women and children’s services, and recognised that maternity services in particular was an excellent example of where to focus initial efforts in this regards.
Action required The board is asked to note the report.
Trust strategic priorities and business planning objectives Board assurance risk supported by this paper number(s) 1. Excellent outcomes – to be in the top 10% of our peers on x outcomes 2. Excellent user experience – to be in the top 10% of relevant x peers on patient, GP and staff experience 4. Excellent compliance with our external duties – to meet our x external obligations effectively and efficiently 5. A strong organisation for the future – to strengthen the x organisation for the future
CQC Regulations supported by this paper
Regulation 4 Requirements where the service provider is an individual or partnership Regulation 5 ⃰ Fit and proper persons: directors Regulation 6 Requirement where the service provider is a body other than a partnership Regulation 7 Requirements relating to registered managers Regulation 8 ⃰ General Regulation 9 Person-centred care Regulation 10 Dignity and respect Regulation 11 Need for consent Regulation 12 Safe care and treatment Regulation 13 Safeguarding service users from abuse and improper treatment Regulation 14 Meeting nutritional and hydration needs Regulation 15 Premises and equipment Regulation 16 Receiving and acting on complaints Regulation 17 Good governance Regulation 18 Staffing Regulation 19 Fit and proper persons employed Regulation 20⃰ Duty of candour Regulation 20A⃰ Requirement as to display of performance assessments Care Quality Commission (Registration) Regulations 2009 (Part 4) Regulation 12 Statement of purpose Regulation 13 Financial position Regulation 14 Notice of absence Regulation 15 Notice of changes Regulation 16 Notification of death of a service user Regulation 17 Notification of death or unauthorised absence of a service user who is detained or liable to be detained under the Mental Health Act 1983 Regulation 18 Notification of other incidents Regulation 19 Fees
Page 2 of 3 Final Paper 12 Regulation 20⃰ Requirements relating to termination of pregnancies Regulation 22A⃰ Form of notifications to the Commission
Risks attached to this project/initiative and how these will be managed (assurance) N/A
Equality analysis • No identified negative impact on equality and diversity
Report from Stephen Ainger, non-executive director and chair of the patient safety committee Author(s) Veronica Jackson, committee secretary Date 7 December 2016
Page 3 of 3 Final Paper 13
Report to Date of meeting Attachment number
Trust Board 21 December 2016 Paper 13
Confirmed minutes of the Audit Committee
Executive summary The confirmed minutes of the audit committee held on 15 September 2016 are attached for information at Appendix 1.
Action required The board is asked to note the minutes.
Trust strategic priorities and business planning objectives Board assurance risk supported by this paper number(s) 1. Excellent outcomes – to be in the top 10% of our peers on x outcomes 2. Excellent user experience – to be in the top 10% of relevant x peers on patient, GP and staff experience 3. Excellent financial performance – to be in the top 10% of x relevant peers on financial performance 4. Excellent compliance with our external duties – to meet our x external obligations effectively and efficiently 5. A strong organisation for the future – to strengthen the x organisation for the future
CQC Regulations supported by this paper
Regulation 4 Requirements where the service provider is an individual or partnership Regulation 5 ⃰ Fit and proper persons: directors Regulation 6 Requirement where the service provider is a body other than a partnership Regulation 7 Requirements relating to registered managers Regulation 8 ⃰ General Regulation 9 Person-centred care Regulation 10 Dignity and respect Regulation 11 Need for consent Regulation 12 Safe care and treatment Regulation 13 Safeguarding service users from abuse and improper treatment Regulation 14 Meeting nutritional and hydration needs Regulation 15 Premises and equipment Regulation 16 Receiving and acting on complaints Regulation 17 Good governance Regulation 18 Staffing Regulation 19 Fit and proper persons employed Regulation 20⃰ Duty of candour Regulation 20A⃰ Requirement as to display of performance assessments
Page 1 of 2 Paper 13 Care Quality Commission (Registration) Regulations 2009 (Part 4) Regulation 12 Statement of purpose Regulation 13 Financial position Regulation 14 Notice of absence Regulation 15 Notice of changes Regulation 16 Notification of death of a service user Regulation 17 Notification of death or unauthorised absence of a service user who is detained or liable to be detained under the Mental Health Act 1983 Regulation 18 Notification of other incidents Regulation 19 Fees Regulation 20⃰ Requirements relating to termination of pregnancies Regulation 22A⃰ Form of notifications to the Commission
Risks attached to this project/initiative and how these will be managed (assurance) Any risk would be outlined in the report.
Equality analysis • No identified negative impact on equality and diversity
Report from Deborah Oakley, non-executive director and chair of the audit committee Author(s) Veronica Jackson, committee secretary Date 6 December 2016
Page 2 of 2
FINAL
Minutes of the Audit Committee 15 September 2016
Present: Ms Deborah Oakley Non-executive director (committee chair) Mr Stephen Ainger Non-executive director Ms Jenny Owen Non-executive director In attendance: Ms Caroline Clarke Chief financial officer Ms Lubna Dharssi Assistant director of finance – financial control Mr Neil Thomas Head of internal audit - KPMG Mr Dean Gibbs Senior manager, internal audit - KPMG Mr Stevan Burtenshaw Senior consultant - RSM Ms Gemma Higginson Consultant – RSM Mr Luke Price Consultant – RSM Mr Charles Martin Engagement manager - PricewaterhouseCoopers Ms Julie Dawes Interim trust secretary Mr Peter Ridley Director of planning Mr Tosh Mondal Interim chief information officer and data protection officer (for item 38-16/17 only) Mrs Emma Kearney Director of corporate affairs and communication (for item 40/16-17 only) Mr David Grantham Director of workforce and organisational development (for items 59-60/16-17 only) Ms Veronica Jackson Committee secretary (minutes)
ACTION 33/16-17 APOLOGIES FOR ABSENCE
Members: No apology
Attendees: Mike Dinan – Director of financial improvement Lynn Pamment - Engagement leader, PricewaterhouseCoopers David Foley – Head of fraud risk services, RSM
The chair noted that Dean Finch had resigned from the board and welcomed Peter Ridley and Luke Price who were new to the meeting.
34/16-17 DECLARATIONS OF INTEREST The audit committee board members confirmed no change to their declarations. 35/16-17 MINUTES OF THE AUDIT COMMITTEE MEETING HELD ON 25 MAY 2016 The minutes were agreed as a true record of the meeting. ACTION LOG AND MATTERS ARISING 36/16-17 Review open actions log (for noting) The committee reviewed the action log: 11/16-17(a) – this would be closed. 19/16-17 – would be ready for the meeting in November. 21/16-17 – would be expanded to include the gifts and hospitality register. The assistant director of finance – financial control stated that a review of the register of 1 FINAL Last update 22.11.16
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interest etc. should be undertaken on an annual basis, so the committee may wish to consider whether this needed to be done more frequently. Robust checks that all
staff were declaring, even if this was a nil return, was also needed. She agreed to bring a paper on to the meeting in January at which point the recommendations LD from the local counter fraud review would have been implemented.
26/16-17 – it was confirmed that the Royal Free Charity was still funding the patient Wi-Fi. The assistant director of finance – financial control would check whether this applied to all the trust’s hospital sites and whether there was an end date to this LD agreement. The chief finance officer declared that she was a trustee of the Royal Free Charity. 29/16-17(a) – this would be addressed at the patient and staff experience
committee and, therefore, would be closed off the audit committee action log. 120/15-16 – the assistant director of finance – financial control had updated the paper to provide additional detail. However, this was still not addressing the
committee’s concerns regarding additive work and also adding another site to an existing contract. She requested that details addressing these points and providing LD assurance as to how value for money had been obtained be added to the report.
126/15-16 – members had requested additional information; this would be included in the report when next presented to the committee in January 2017. 88/15-16(a) – the chair asked that this be addressed at the meeting in November. LCFS 45/15-16 – this was completed.
37/16-17 Matters arising There was no matter arising. 38/16-17 Information security (cyber security and national data guardian security review) The committee welcomed Mr Mondal to the meeting who was acting as the interim chief information officer following the departure of Will Smart. He updated the committee on the
outcome of two reviews; CSC’s cyber security team’s review of the trust’s information systems and a self-assessment against the the national data guardian’s (NDG) security review. The following was noted:
i. CSC’s cyber security team’s review of the trust’s information systems – the interim chief information officer explained that CSC was a consulting group that had been asked to provide an in-depth analysis of the trust’s current infrastructure and security, and to provide recommendations for improvement. He added that a copy of the full report was available on request.
An action plan was in place which was overseen by the trust’s head of infrastructure with the aim of ensuring all actions would be completed within 90 days, i.e. the end of the year. Oversight of the action plan would be provided by the information governance group. He confirmed that all actions would be completed by the end of the year, and that the committee could assume that was the case unless it heard otherwise.
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In response to a question from the chief finance officer on how the trust fared against other trusts on this issue, it was noted that CSC had found a similar picture
elsewhere.
In summing up, the committee noted
ii. NDG security review – the interim chief information officer had provided a list showing the trust’s position in relation to the NDG’s 10 security standards. The chair thanked him for this but stated that she had hoped to see greater detail and TM assurances in the report. She requested that a more comprehensive report, for example what was the proportion of the number of staff that underwent annual confidentiality training in handling PID against data security standard 1, be taken to DO the November meeting. She would speak with the interim chief information officer in advance of the meeting to ensure that the level of detail in the report met the committee’s expectations. A risk had been added to the board assurance framework (BAF) on cyber security following the audit committee’s recommendation and subsequent approval at the board. The interim chief information officer reported that good progress had been made in addressing the greatest risks, with much of the technical work completed, PR and was confident this risk had been mitigated for where possible. As such, his view was that the risk score could be reduced to 12 / 16.
39/16-17 Notice of discussion of items marked ‘for information’ (by exception) Members and attendees would decide which items they would like to discuss as the chair progressed through the agenda. OTHER ASSURANCE ITEMS 40/16-17 Well led governance review assessment process and proposal for next steps The chair had spoken with the head of internal audit in advance of the meeting and discussed whether the well led governance review could be postponed in light of the new group model governance arrangements and the assurance provided by way of the recent CQC inspection where the trust’s leadership, management and governance (are services at this trust well led?) were rated as good. The head of internal audit supported the postponement, noting that other trusts had taken the decision to postpone their well-led review on the back of positive CQC results, but added that another less intensive but probing self-assessment may be helpful in the interim and could provide a baseline for development of the group governance. Ms Owen, non-executive director considered the following needed to be factored in; capacity to undertake the review and the costs involved, including the use of external provider. Her view was that internal audit’s suggestion of a good quality self-assessment would suffice at this stage. The interim trust secretary noted that she was aware of two trusts that had undertaken the well led review and factored the group model within that.
The committee agreed that a paper outlining the alternatives was not needed. Instead a recommendation from the committee to postpone the review, given it considered that DO adequate sources of assurance were already available, would be made to the board. A review of group governance would be required once the transition was completed. The chief finance officer agreed that some form of self-assessment was needed however and JD that this should be done before the end of the year.
INTERNAL AUDIT
41/16-17 Progress report and technical update
Ms Owen, non-executive director considered the update on the principles for engaging 3 FINAL Last update 22.11.16
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people and communities to be very helpful. She added that the next patient and staff experience committee meeting in October would focus specifically on patient engagement and involvement but with the remit broadened to include membership and embedding the quality strategy. Key speakers from Northumbria Healthcare NHS Foundation Trust and East London NHS Foundation Trust would be joining the meeting to talk about their experiences and work in this area in order to help the committee understand the scale of the work needed and ambition for the trust in this regards.
The committee suggested that assurance was needed on the impact on the trust and the NHS more widely of leaving the European Union. It appreciated that any such paper would be brief as there were many unknowns at the stage but that it would be helpful to consider the strategic headline issues, e.g. staffing, access to treatment and regulation. The director of planning agreed to draft a paper for the board. PR
The director of financial operations would take a paper on the national tariff proposals for next year and the NHS Improvement price comparator tool to the finance, investment and MD performance committee.
The internal audit review into the trust’s non-emergency patient transport review had been deferred at the request of management until March 2017. Ms Owen, non-executive director would touch base with the director of facilities on the status of the new service provision and KPIs, particularly as the director of planning had recommended the closure of the patient transport risk on the BAF.
42/16-17 Follow up recommendations
The committee was pleased to note that there was no red rated recommendation that was more than six months overdue. There was, however, a total of 27 outstanding overdue recommendations, which was fewer than those reported in May. The head of internal audit suggested this could still be improved upon.
The director of planning was now the executive lead for the data quality - cancelled operations recommendation.
43/16-17 Internal audit review – electronic prescribing medicines administration (EPMA) programme management
The committee received internal audit’s review of how the trust had applied the lessons learned from the patient administration system (PAS) / patient master index lessons learned
report to the e-prescribing and medicines administration (EPMA) programme. An overall assessment of ‘Partial assurance with improvements required’ (Amber-Red) was given; this was lower than management’s expectation of Amber-Green.
It was noted that the implementation of EPMA had been postponed (now expected March 2017). In terms of the financial implications, the committee noted that this had been taken into account in the trust’s forecast. Development of the final business case had also been delayed. The director of planning noted that a revised draft was presented at the recent capital management group, and February was mooted as a potential date for the final version. It was noted that a slower testing / pilot period was needed. The committee enquired whether the knock-on effect to other projects and to CIP programs had been factored in. The chief finance officer responded that the latest financial projections took account of the delay.
KPMG confirmed that despite the postponement, the completion dates for the recommendations identified still stood and these were considered realistic. KPMG would KPMG only report back on the recommendations in the event there had been significant slippage against them.
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44/16-17 Internal audit review – serious incidents
The committee received internal audit’s review of the trust’s processes for reporting and responding to serious incidents and was pleased to note the positive rating of ‘Significant assurance with minor improvement opportunities’ (Green-Amber). Mr Ainger, non-executive director had requested that a copy of the report be taken to the patient safety committee the following week for information, adding that it would be helpful to reconcile the results of that review with the findings from the CQC inspection where the trust was rated as ‘requires improvement’ for the safety domain.
45/16-17 Internal audit review – BMI profit share / Kings Oak Hospital profit share agreement
The committee received a report outlining the work undertaken by internal audit in relation to the profit share agreement between the trust and BMI healthcare limited (BMI) for the financial years to 30 September 2014 and 30 September 2015.
The committee noted the longevity of the contract.
46/16-17 Process for the assessment of internal audit effectiveness 2015-16
A procurement exercise was underway for the trust’s internal audit provision so the committee considered whether, in light of this, there was any value in undertaking the assessment. It agreed to approve the process for the assessment pending the outcome of the procurement exercise.
EXTERNAL AUDIT
47/16-17 Progress report
It was noted that all the trust’s service level agreements were signed by the end of May 2016 which was earlier than last year. The committee was content with the quality report recommendations, and the chair stressed the need to ensure that the timescales were adhered to. It was agreed that the recommendations would be followed up on an exception PwC basis to ensure the committee did not lose sight of them.
48/16-17 Outcome of the assessment of external audit effectiveness 2015-16
The last two assessments had raised the same issue of improving external audit’s engagement with the council of governors. PwC reported that they had held a 2.5 hour governors’ development session in April but attendance had been poor, with only seven governors having attended. They would reflect on this issue in their audit plan 2016/17 which was due to presented to the committee in November, but were open to advice from trust colleagues on how engagement could be improved further. Furthermore, it was noted that PwC were due to attend the council of governors meeting in November.
LOCAL COUNTER FRAUD SPECIALIST
49/16-17 Progress report including follow up recommendations
It was noted that he committee was pleased to see the inclusion of the management action
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tracker, and following circulation of the report noted that two further actions had been completed, one was in progress, and five were awaiting status updates (which had since been received).
The committee noted there was one action which was ‘subject to negotiation’ as local counter fraud wanted to ensure that the right and sufficient in-depth checks were being undertaken.
The chair requested that the committee focus on the pre-contract procurement review RSM actions in more detail at the November meeting.
Mr Ainger, non-executive director was concerned to note that there was no standalone procurement policy, particularly in light of the financial risks associated with the redevelopment of Chase Farm Hospital, and from the view of the trust’s individual rather than shared procurement. RSM noted that the development of a procurement policy was underway and was expected to be completed by the end of the year. This would be reflected in the trust’s standing financial instructions (which required updating).
Ms Owen, non-executive director noted the frequent recovery of personal payments which were essentially small amounts and asked whether potentially the bigger issues, and therefore larger contributions, were being missed. RSM reported that when compared to other trusts, the RFL was typical in terms of the monies recovered from lower paid staff but considered this fair challenge, adding that the trust was progressive in terms of its payment recovery but that very few referrals relating to procurement and contractors were being RSM seen. RSM agreed to provide a chart in the next report showing the main areas where recovery had been made.
50/16-17 Final LCFS annual report 2015-16
The committee noted the final report and was pleased to see the inclusion of the management action tracker.
51/16-17 Process for the assessment of local counter fraud effectiveness 2015-16
A procurement exercise was underway for the trust’s local counter fraud provision so the
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committee considered whether, in light of this, there was any value in undertaking the assessment. It agreed to approve the process for the assessment pending the outcome of the procurement exercise.
Ms Owen, non-executive director noted the difficulty in rating questions 7 and 8 of the assessment because the local counter fraud fee was not shown in the counter fraud annual plan. RSM explained that the fee was omitted from the plan because it had to be shared VJ / GH with NHS Protect. Ms Higginson would send the fee details to the committee secretary dependent on the outcome of the procurement exercise.
Question 10 would be amended to read, ‘’The LCF team consider the clear and comprehensive reporting of the results of their investigations when reporting to the audit VJ committee.’’
GOVERNANCE
52/16-17 Board assurance framework
The director of planning introduced this item explaining that the BAF had been reformatted in particular to be structured around themes, and with sources of assurance, gaps and mitigations added. However, there was more work to do and he would be reviewing the sources of assurance with executive leads, followed by a more formal review with the board. The trust executive committee had reviewed the BAF earlier that week and were content with the closure of three risks (patient transport (1b/3b), general staff experience (2b), overhead coverage for specialised services (6b)), but requested that the risk around A&E targets needed to be rescored to 5 (likelihood) x 3 (impact).
Comments were sought from the committee; the general consensus was that the format was much improved. However, Mr Ainger, non-executive director was concerned about the individual elements of each risk being ranked the same and made a preference for greater granularity. The director of planning had considered this but the aim was to try and not create a framework that resembled a corporate risk register. He agreed that there were elements of the wider risks that had different risk profiles and therefore offered to reformat PR the framework so the risks were ranked at an individual level for discussion at a future PR board meeting. As part of that cycle, a decision would need to be made as to which board committee would have overall lead responsibility for the framework. Audit and counter fraud colleagues considered that the number of risks was similar to those seen on other BAFs.
Ms Owen, non-executive director stated that the patient and staff experience committee would have welcomed the opportunity to review the patient transport risk before its closure and removal from the BAF. The director of planning would check what the process for the PR review of the BAF risks by individual board committees was, and agreed not to recommend closing a risk until it had been reviewed by the relevant committee.
It was suggested that a ‘transitional risk’ should be added to that on the group model. The PR director of planning would consider how to incorporate this into the framework.
In relation to the risk on cybersecurity (8b), the committee considered that the monitoring SP/SA and review of information governance incidents should not be the responsibility of the patient safety committee (this was a legacy issue subsumed from the previous risk, governance and regulation committee). A decision needed to be made on where this responsibility should best sit in order to provide the required assurance to the board.
The chair raised the issue of future assurance items for discussion at the committee, noting that both the annual clinical audit processes update and the revised cyber security paper would be presented at the next meeting. No other assurance report was requested.
The director of planning noted the challenge in showing how the board was getting PR assurance from the BAF. He would consider taking a paper on this specifically to a future 7 FINAL Last update 22.11.16
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shadow group board meeting.
53/16-17 Patient safety committee minutes – March and May 2016
The minutes were noted.
54/16-17 Clinical performance committee minutes – April 2016
The minutes were noted.
55/16-17 Patient and staff experience committee minutes – April 2016
The minutes were noted.
FINANCIAL 56/16-17 Tender waivers: pharmacy, supplies and projects
The chair requested that an additional column be added to the report to provide assurance LD in respect of value for money.
57/16-17 Losses and special payments
The committee noted the latest losses and special payments summary. To date, total losses and special payments amounted to
AUDIT COMMITTEE
58/16-17 Outcome of the assessment of audit committee effectiveness 2015-16
The committee received the results of its self-assessment exercise and where appropriate areas for future improvement. The following was noted:
All non-executive directors (NEDs) were content with the current process for their ongoing personal development.
Mr Ainger considered that a member of the audit committee needed to be a chartered accountant. The committee appreciated that it had successfully delivered
the trust’s annual report and accounts 2015-16 without a qualified accountant, but noted the reputational risk should a financial accounting error occur in the future. The head of internal audit also supported the inclusion of a qualified accountant as
a committee member. He suggested that one possible solution would be the recruitment of an independent member with the necessary qualification.
The trust was in the process of recruiting two NEDs but it was not clear whether either of these had chartered accountancy qualifications. In the event neither had the necessary expertise, the committee were supportive of having a lay member on the committee who was an accountant and also independent from the trust. DO, VJ
The interim trust secretary agreed to circulate the NED job specification to members after the meeting. JD
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WHISTLEBLOWING 59/16-17 Incidents of whistleblowing
DG
The committee noted that more general learning in terms of whistleblowing incidents was needed, for example training staff to undertake the investigations, a clear process on how to best gather evidence, and how to ensure staff received feedback and were satisfied with the outcome of an investigation.
60/16-17 Revised speaking up policy and procedure (incorporating raising concerns and whistleblowing) The paper highlighted the changes that had been made within the trust’s existing whistleblowing / raising concerns policy. The committee was asked to note one change in particular in relation to supporting staff, namely that the trust would not tolerate harassment or victimisation of a member of staff who raised a concern, and that they would not be affected detrimentally in terms of promotion etc.
The committee was pleased to note that the national guardian’s conference had rated the trust’s policy highly.
A question was raised as to whether staff knew the process for whistleblowing. The committee’s attention was drawn to the flowchart (appendix A) which clearly outlined the number of routes staff could take to raise a concern.
Both the internal and external whistleblowing webpages would be kept under review.
The committee approved the changes.
6116-17 REFLECTIONS AND IMPROVEMENTS FOR NEXT TIME There was no comment.
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62/16-17 BOARD REPORTING Due to the close timing of the audit committee and the September trust board, the chair would provide a verbal update at the next board meeting. A written report would be provided to the board in October and would cover the following:
Recommendation to postpone the well led governance review The outcome of the cyber security review noting that the recommendations arising would be completed by the end of the year and Outcome of the internal audit reviews. Discussion on the BAF Approved the revised whistleblowing policy. Recommendation to include a lay person with chartered accountancy qualifications on the audit committee membership dependent upon the new NED recruitment.
63/16-17 PRIVATE MEETING BETWEEN AUDIT COMMITTEE MEMBERS AND AUDITORS AND COUNTER FRAUD OFFICERS A brief private meeting was held.
Date of next meeting: 10 November 2016, 0900 – 1130, boardroom, Royal Free Hospital
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Paper 14
Report to Date of meeting Attachment number
Trust Board 21 December 2016 Paper 14
Report from clinical performance committee held 24 October 2016
Executive summary The clinical performance committee met on 24 October 2016. The key matters of interest were as follows:
THE 100,000 GENOME PROJECT The committee received a presentation on the 100,000 Genomes Project, a project aiming to improve the diagnosis and increase the trust’s understanding of cancer and rare diseases. Specific reference was made to the cost of sequencing, the clinical and scientific benefits of genetic diagnosis in rare diseases, the project methodology, recruitment including data protection, long term vision and the key challenges, both current and future.
The committee welcomed the interesting presentation, noting that the trust was a major player in the 100,000 Genome Project which would bring significant benefits to patients and offered the potential to diagnose diseases more precisely in future.
Mortality and patient safety indicators report The committee received its regular performance report, noting that in terms of mortality risk, the trust’s summary hospital-level mortality indicators (SHMI) and hospital standardised mortality ratio (HSMR) performance remained good and was below the control limit.
A process of reformatting and reviewing the content of the report was underway. The chair suggested that the committee would be content to be guided by the associate medical director for clinical performance as to the revised content and format of the report. He requested a brief paper outlining the recommendations for the committee’s consideration be taken to the January 2017 meeting.
DATA DEEP DIVES ALREADY UNDERTAKEN AND PLANNED The associate medical director for clinical performance had undertaken a deep dive on the patient safety indicator on postoperative respiratory failure which had consistently signalled a high level relative risk at the Royal Free site for several years. The chair considered the report to be very helpful and reassuring.
A discussion was had on those other indicators where a deep dive of the data would be helpful to provide further assurance to the committee. The committee agreed to a deep dive on pressure ulcers with a report taken to the April 2017 meeting. The associate medical director for clinical performance also agreed to do an in-depth analysis of pneumonia cases.
The chair noted it was evident that data quality was a theme that had through many of the meetings, particularly as issues with coding had shown the trust to be outliers in many areas. He appreciated this was a complex issue but considered that the committee needed greater insight on coding and assurance on the steps for ensuring that high quality data would be Page 1 of 5
FINAL Paper 14 captured in future. It was noted that the trust’s internal auditors were conducting an external review of the trust’s data quality, albeit from a financial perspective, but there could be recommendations related to coding more generally. It was agreed that a presentation on coding, including that related to internal audit’s findings and action taken, would be provided at the April 2017 meeting.
KEY POST AND UNDERGRADUATE EDUCATION FINDINGS a. Undergraduate medical student feedback The committee received the undergraduate medical student feedback report noting that a steady improvement had been seen, and Block 3 2015-16 had the best performance with no reds which was reflective of the hard work of the sub-dean of the medical school, UCL. The committee noted that specific action plans were in place to address those red rated areas.
b. Post-graduate medical education (PGME) The committee also received an update on the 2016 GMC national trainee survey results, including the identification of priority areas for improvement in the quality of PGME. It noted the key highlights which included six patient safety concerns having been raised across the trust which had been investigated and were now closed, one bullying / undermining alert that had since been resolved with both parties happy, and an increase in green (positive) outliers (44 compared to 25 the previous year). In terms of success, it was noted that cardiology on the Royal Free site had reduced all red outliers from 2015 and achieved a green outlier for feedback. In addition, trauma and orthopaedics on both sites had fared well, having increased green outliers from zero in 2015 to 2 each in 2016.
There had, however, been an increase in red (negative) outliers (81 compared to 54 the previous year). There were a number of indicators that had been a surprise, handovers for example, but others were expected. Steps were being taken to address the quality issues that were raised. The recommendations for improvements were also noted.
The chair thanked the director of PGME for the excellent work in this area which was important in ensuring patient care and safety.
CHANGE TO THE COMMITTEE’S MEMBERSHIP The committee noted that the chief executive had stood down as a member of CPC due to commitments with his role as chair of the North Central London Sustainability and Transformation Plan programme. The chair requested that the committee formally record its thanks to him for his helpful contributions during his time as a member.
The committee’s terms of reference were updated accordingly and agreed by way of chair’s action outside of the meeting. A copy of the revised terms of reference is attached at Appendix 1.
Action required The board is asked to note the report and to ratify the revised terms of reference.
Trust strategic priorities and business planning objectives Board assurance risk supported by this paper number(s) 1. Excellent outcomes – to be in the top 10% of our peers on x outcomes
CQC Regulations supported by this paper
Regulation 4 Requirements where the service provider is an individual or partnership Regulation 5 ⃰ Fit and proper persons: directors Page 2 of 5
FINAL Paper 14 Regulation 6 Requirement where the service provider is a body other than a partnership Regulation 7 Requirements relating to registered managers Regulation 8 ⃰ General Regulation 9 Person-centred care Regulation 10 Dignity and respect Regulation 11 Need for consent Regulation 12 Safe care and treatment Regulation 13 Safeguarding service users from abuse and improper treatment Regulation 14 Meeting nutritional and hydration needs Regulation 15 Premises and equipment Regulation 16 Receiving and acting on complaints Regulation 17 Good governance Regulation 18 Staffing Regulation 19 Fit and proper persons employed Regulation 20⃰ Duty of candour Regulation 20A⃰ Requirement as to display of performance assessments Care Quality Commission (Registration) Regulations 2009 (Part 4) Regulation 12 Statement of purpose Regulation 13 Financial position Regulation 14 Notice of absence Regulation 15 Notice of changes Regulation 16 Notification of death of a service user Regulation 17 Notification of death or unauthorised absence of a service user who is detained or liable to be detained under the Mental Health Act 1983 Regulation 18 Notification of other incidents Regulation 19 Fees Regulation 20⃰ Requirements relating to termination of pregnancies Regulation 22A⃰ Form of notifications to the Commission
Risks attached to this project/initiative and how these will be managed (assurance) N/A
Equality analysis • No identified negative impact on equality and diversity
Report from Prof Anthony Schapira, non-executive director and chair of the CPC Author(s) Veronica Jackson, committee secretary Date 8 December 2016
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Appendix 1
CLINICAL PERFORMANCE COMMITTEE TERMS OF REFERENCE
Overview and purpose
The clinical performance committee is a committee of the trust board. It is responsible for seeking and securing assurance that the trust’s clinical services, research efforts and education activities achieve the high levels of performance expected of them by the board, namely “outcomes consistently in the top 10% in the UK versus relevant peers.”
Scope
• Clinical outcomes, including three trust clinical priorities - (C.difficile rates, MRSA rates and HSMR) - and clinical performance metrics for each clinical business unit. • Research productivity and educational effectiveness. • Quality Accounts. • Outcomes achieved and management approach taken (including, but not limited to, accountabilities, processes, clinical governance arrangements, audit, information, training and development, consequences).
Responsibilities
• Recommend to the board the outcome measures that should be tracked at both the overall trust and individual service line level. • Monitor those outcomes on a quarterly basis at both trust and service line level. • Determine whether there is unequal performance across patient groups and seek assurance that plans are in place to achieve greater equality of clinical outcomes. • Seek assurance that the management approach to achieving consistent high performance is robust and therefore likely to justify confidence in future performance. • Alert the board or another appropriate forum (e.g. the patient safety committee and audit committee) in a timely way to clinical, research and educational performance that falls short of the trust’s standards or to concerns about underlying management approaches. • Seek to understand lessons learned through comparison between service lines that perform well and those that perform less well.
Membership
Chair: non-executive director Members: one other non-executive director medical director director of nursing Attendees: associate medical director for clinical performance associate medical director for revalidation lead nurse for clinical performance deputy director of clinical governance and performance divisional director, or divisional director of operations or deputy director of nursing for EACH division chief information officer director of quality three governors
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Frequency
The committee will meet quarterly.
Reporting arrangements
The committee will provide a quarterly report to the trust board which will include service line performance on key outcome indicators relative to relevant external benchmarks.
Approved by
Agreed by committee: October 2016 Approved by trust board: December 2016
Terms of Reference review: Annually
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Report to Date of meeting Attachment number
Trust Board 21 December 2016 Paper 15
REPORT FROM PATIENT AND STAFF EXPERIENCE COMMITTEE - REVISED TERMS OF REFERENCE
Executive summary
At its meeting on 17 October 2016, the committee noted that the chief executive had stood down as a member of PSEC due to commitments with his role as chair of the North Central London Sustainability and Transformation Plan programme.
The committee’s terms of reference were updated accordingly and agreed by way of chair’s action outside of the meeting. A copy of the revised terms of reference is attached at Appendix 1.
Action required The board is asked to ratify the revised terms of reference.
Trust strategic priorities and business planning objectives Board assurance risk supported by this paper number(s) 2. Excellent user experience – to be in the top 10% of relevant x peers on patient, GP and staff experience
CQC Regulations supported by this paper
Regulation 9 Person-centred care Regulation 10 Dignity and respect Regulation 11 Need for consent Regulation 12 Safe care and treatment Regulation 13 Safeguarding service users from abuse and improper treatment Regulation 14 Meeting nutritional and hydration needs Regulation 16 Receiving and acting on complaints
Risks attached to this project/initiative and how these will be managed (assurance) As outlined in the report.
Equality analysis • No identified negative impact on equality and diversity
Report from Jenny Owen, non-executive director and chair of the committee Author(s) Veronica Jackson, committee secretary Date 14 December 2016 Page 1 of 3 FINAL Paper 15
Appendix 1
PATIENT AND STAFF EXPERIENCE COMMITTEE TERMS OF REFERENCE
Overview and Purpose
The trust’s corporate strategy sets out our aims to provide world class care and expertise in the form of excellent clinical care, research and teaching. By “world class” we mean to begin by being in at least the top 10% of hospitals in England for: clinical quality customer satisfaction financial performance
The patient and staff experience committee is a committee of the board. It is responsible for seeking and securing assurance on performance in relation to the experience of patients and staff, to monitor performance in relation to key outcomes set by the Care Quality Commission and to ensure that there is a clear performance and governance framework against these, which is linked to clear consequences for both good and poor performance.
Scope
• The experience of both inpatients and outpatients. • The morale, engagement and commitment of staff. • Outcomes and management approach taken (including, but not limited to, accountabilities, processes, information, training & development, consequences).
Responsibilities
• Recommend to the board the right measures of patient and staff experience that should be tracked at both the overall trust and individual service line level • Monitor patient and staff experience outcomes on a quarterly basis at both trust and service line level • Determine whether there is unequal performance across patient groups and staff groups and seek assurance that plans are in place to achieve consistent performance • Seek assurance that the management approach to achieving consistent high recommendation and staff engagement rates is robust and therefore likely to justify confidence in future performance • Alert the board or another appropriate forum (e.g. the patient safety committee) in a timely way to patient and staff experience that falls short of the trust’s standards or to concerns about underlying management approaches or to cross-cutting improvement opportunities • Seek to understand lessons learned through comparison between service lines that perform well and those that perform less well • To assume responsibility for role-modelling positive behaviours and leadership • Have oversight of the trust’s strategy for end of life care with key performance indicators for end of life care to be incorporated in patient and staff outcomes monitored by the committee
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Membership
Chair: non-executive director Members: one other non-executive director; director of nursing; chief operating officer Attendees: divisional director, divisional director of operations or deputy director of nursing for each division; director of workforce and organisational development; chief information officer; three governors; deputy director of patient experience; a representative from the Royal Free Charity; associate medical director – user experience; director of quality. Coordinator: patient affairs administrator; committee secretary (minutes) Quorum: three members, at least one non executive and one executive member
Frequency
The committee will meet quarterly
Reporting
The committee will provide a quarterly report to the trust board which will include service line performance on key indicators, relative to relevant external benchmarks.
Agreed by committee: October 2016 Approved by trust board: December 2016
Review date: Annually
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