Agenda

Group Name: Trust Board – Open Session Date of Meeting: 26 May 2016 Venue: Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH Time: 9.00am Apologies to: Sue Diduch, Corporate Affairs Administrator

9.00 1. Chair’s Welcome, Apologies and Declarations of Interest

2. Minutes of Previous Meeting held on 28 April 2016 Enclosure 1

3. Matters Arising/Summary of Agreed Actions

9.10 4. Integrated Performance Report for Month 1 including: Enclosure 2 • Access Performance • Nursing & Midwifery Staffing • Clinical Outcomes (PIF) • Infection Prevention & Control • Quarterly UHS Maternity Dashboard • Any other items of concern (Jane Hayward, Director of Transformation & Improvement/ Caroline Marshall, Chief Operating Officer)

5. Finance Discussion Items 9.45 5.1 Finance Report for Month 1 Enclosure 3 (David French, Chief Financial Officer)

6. Operational Performance Discussion Items 9.55 6.1 Informatics 6-monthly Report Enclosure 4 (Jane Hayward, Director of Transformation & Improvement/ Adrian Byrne, Director of Informatics) 10.05 6.2 Human Resources 6-monthly Report Enclosure 5 (Fiona Dalton, Chief Executive/Steve Harris, Associate Director of Human Resources)

7. Governance Decision Items 10.15 7.1 Chief Executive’s Report including items for ratification Enclosure 6 (Fiona Dalton, Chief Executive) 10.20 7.2 Briefing from Co-Chair of Audit & Assurance Committee Oral (Simon Porter, Co-Chair A&AC)

Discussion Items 10.25 7.3 Briefing from Chair of Strategy & Finance Committee Oral (David Price, Chair, S&FC) 10.30 7.4 Briefing from Chair of Quality & Performance Committee Oral (Mike Sadler, Chair, Q&PC)

10.35 7.5 Emergency Planning Response and Resilience Annual Enclosure 7 Report 2015-16 (Caroline Marshall, Chief Operating Officer/Sandra Hodgkyns, Head of Security/Emergency Planning Response and Resilience) 10.45 7.6 Security Annual Report 2015/16 Enclosure 8 (Caroline Marshall, Chief Operating Officer/Sandra Hodgkyns, Head of Security/Emergency Planning Response and Resilience)

10.55 8. Any other business

9. Comments and Questions from the public on items received or considered by the Board of Directors at the meeting

10. To note the date of the next meeting: Tuesday 28 June 2016 in Lecture Room A, Education Centre, C Level, South Academic Block, SGH

In Attendance: Adrian Byrne, Director of Informatics Steve Harris, Associate Director of Human Resources Sandra Hodgkyns, Head of Security/Emergency Planning Response and Resilience

EXCLUSION OF PRESS, PUBLIC AND OTHERS The public and representatives of the press may attend all meetings of the Trust, but shall be required to withdraw upon the Board of Directors resolving as follows “that representatives of the press, and other members of the public, be excluded from the remainder of this meeting as publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted”

UHSFT – Directors’ Actions Summary for 26 May 2016 Trust Board – Open session

______Action & Minute Reference By whom Target Date Current Status Trust Board 28 April 2016 Review of Processes for Learning from Unexpected Deaths (Minute Ref 56/16) A flowchart to be developed outlining the Trust’s process for DS/GB reviewing and reporting unexpected deaths. Equality, Diversity & Inclusivity (EDI) Action Plan Quarter Report (Minute Ref 58/16) Links to be made with local organisations to identify best GB practice and shared learning relating to EDI. UHS Clinical Strategy 2016 (Minute Ref 61/16) The Clinical Strategy to be updated to reflect the following amendments: · Diagram on page 2 to be amended to include R&D DS · Remove the duplication of people strategy Chief Executive’s Report (Minute Ref 63/16) Discussion to be held with outlets in the main entrance FD regarding Southampton Hospital/Children’s Hospital Charity collection boxes. Draft Annual Report 2015/16 (Minute Ref 64/16) The Annual Report to be amended to reflect feedback AL Complete. received.

Assurance Framework & Corporate Risk Register 2015/16 Quarter 4 Report (Minute Ref 65/16) A single page risk dashboard to be developed for inclusion AL 18/7/16 To be included in next quarter report to Audit & Risk Committee within future risk reports. 18/7/16.

as at 17/5/16

Page 1 of 1

Trust Board Minutes – Open Session

Minutes of the Open Trust Board meeting held on Thursday, 28 April 2016, in the Conference Room, Heartbeat Education Centre, North Wing, University Hospital Southampton, commencing at 0900 and concluding at 1110.

Present: Mr P Hollins, Trust Chair PH Ms F Dalton, Chief Executive FD Mr D French, Chief Financial Officer DAF Dr C Marshall, Chief Operating Officer CM Ms J Hayward, Director of Transformation & Improvement JH Mrs G Byrne, Director of Nursing & Organisational Development GB Dr D Sandeman, Medical Director DS Mr S Porter, Senior Independent Director/Deputy Chair SP Prof I Cameron, Non-Executive Director IC Ms L Lockyer, Non-Executive Director LL Dr D Price, Non-Executive Director DP Dr M Sadler, Non-Executive Director MS Ms J Douglas-Todd, Non-Executive Director JD-T

In Attendance: Ms A Lowe, Associate Director: Corporate Affairs AL Ms J Pearce, Head of Patient Safety JP Maria Dore, Head of Midwifery MD Ms V Boland, Corporate Affairs & Policy Manager (minutes) Mr L Spender, Lead Governor Mr B Bird, Governor 2 members of the public

51/16 Apologies None. Action By 52/16 Chair’s Welcome, Opening Comments and Declarations of Interest The Chair welcomed everyone to the meeting.

There were no declarations of a conflict of interest with any item on the agenda.

53/16 Minutes of Previous Meeting (Agenda item 2. Enclosure 1) The minutes of the meeting held on 31 March 2016 were AGREED as an accurate record.

54/16 Matters Arising/Summary of Agreed Actions (Agenda item 3) 54/16 a) The Board NOTED the latest position on the actions in summary of actions.

55/16 Integrated Performance Report for Month 12 (Agenda item 4. Enclosure 2) a) The Director of Transformation and Improvement provided an overview of the Executive Digest. DP questioned the Trust’s ability to compare complex discharge numbers given the change in analysis of this metric. FD confirmed that a single way of measuring complex discharge has now been agreed across the local health and social care system ensuring consistency with reporting across all organisations.

Page 1 of 6

DP queried why elective cancellations for the quarter were red rated, despite

achieving the RTT target being achieved. CM advised that there were a number of reasons for cancellations taking place, including strikes by Junior Doctors. MS provided an overview of the performance measures considered at the Quality

and Performance Committee, including: • ED performance including the increase in attendances from the working

age population • Sustainability of achieving the Referral to Treatment targets given the

continued increase in the number of referrals received • Complex discharge • The governance arrangements for investigating and reporting Serious

Incidents. Nursing and Midwifery Staffing 55/16 b) The Director of Nursing presented the report, confirming further improvement in

respect of vacancy rates. The use of agency staff increased in month, reflecting an increase in ‘specialling’ due to patient acuity, the opening of the surgical day unit for some nights and the additional support and supervision provided to new nursing

staff during their induction period. DP highlighted a number of wards showing less than 70% Registered Nurses and queried the action being taken to ensure that safety was not compromised. GB

advised that supervisory staff were not included within these numbers, enabling flexibility between roles. In addition, support is provided to Registered Nurses

through the use of Band 4 staff, however, this is subject to close monitoring to ensure this level of skill mix remains clinically appropriate. Patient Safety 55/16 c) The Director of Nursing summarised the report, highlighting that: • CQUINs for Acute Kidney Injury and Sepsis had been achieved. • 2 Never Events have been reported in this period. A Scrutiny Board has been established to ensure learning is shared and embedded. • There have been 36 avoidable grade 3 and 4 pressure ulcers; a small reduction on last year. The Trust has agreed a target of zero to be achieved in the next two years. IC queried the timescale for reporting back on the work programmes relating to Never Events. GB confirmed that the Scrutiny Board meet every 6 weeks with immediate actions already underway. LL requested further information on the actions being taken by the Trust to reduce the number of pressure ulcers. GB provided an overview of the work programmes underway. DP requested clarity regarding the medication error KPI, noting a green rating despite a 30% increase on the previous year. GB advised that the KPI is not designed to reflect the number of high harm medication errors, instead reflecting the increased reporting of medication incidents. 55/16 b) RESOLVED That the Board NOTED the content of the Integrated Performance Report.

Page 2 of 6

56/16 Quality & Safety a) Review of Processes for Learning from Unexpected Deaths (Agenda item 5.1. Enclosure 3) FD introduced the report highlighting the need for the Trust Board to be assured of the processes in place for the proactive assessment of all deaths in hospital. JP confirmed that all inpatient deaths are reviewed within 48 hours in order to identify any learning or further action required. This process of review is led by the Interim Medical Examiner Group (IMEG). In addition, the Trust has reviewed existing internal processes against the recommendations arising from the Southern Health report, with no significant gaps identified. There are areas in which the Trust continue to improve, namely in respect of the timeliness of investigation reporting. In addition, the Trust is looking to develop mechanisms for the review of unexpected outpatient deaths. DS added that the improvements made to the Trust’s internal processes have resulted in an improved relationship with the coroner with learning already identified and improvement actions instigated. SP requested clarity regarding the role of IMEG, M&M and SISG meetings within this process. It was agreed that a flowchart outlining the process and role of individual groups would be developed. Action: Develop a flowchart outlining the Trust’s process for reviewing and DS/GB reporting unexpected deaths. MS queried the point at which families are engaged within the investigation process. GB confirmed that where it is identified that a death requires further investigation, duty of candour applies and families notified at the appropriate time. JDT queried whether there are processes in place to report near misses. JP confirmed that all incidents, including near misses are reported and investigated. Lower harm incidents are managed at division and care group level. 56/16 b) RESOLVED That the Board NOTED the report.

57/16 Maternity Services Annual Report 2015 (Agenda item 5.2. Enclosure 4) a) The Director of Nursing summarised the report, highlighting that this report had been subject to detailed discussion and review at the April 2016 Trust Board Study Session. PH added that although staffing had been identified as a key issue, the Trust Board had received sufficient assurance that this issue had been assessed with appropriate mitigation taken. DP requested an update in respect of the software issue and progress made in resolving this. MD confirmed that the IT solution is now being tested with an expectation that this issue will be resolved by June 2016. FD added that the Director of Nursing had been nominated to act as the ‘Board Lead’ for maternity services. 57/16 b) RESOLVED That the Board NOTED the report.

58/16 Equality, Diversity & Inclusivity (EDI) Action Plan Quarter Report (Agenda item 5.3. Enclosure 5) a) The Director of Nursing presented the report noting two key areas of focus at present: - ensuring equitable recruitment processes and promotion opportunities for BME staff; and - ensuring a Disability Discrimination Act compliant environment and timely implementation of reasonable adjustments for those with a disability. MS queried whether comparator data for BME staff appointments was yet available? GB advised that data was now available and that this would be included within future Integrated Performance Reports.

Page 3 of 6

58/16 a) Action: BME staff short listing and appointment data to be included within cont’d future Integrated Performance Reports. MS queried whether there is a requirement for senior staff to attend each of the focus group meetings. GB confirmed that she is planning to attend future meetings. Currently members of the Divisional Management Team are in attendance. DP highlighted slippage against a number of the planned implementation dates. GB advised that the original timescales were ambitious, focus was now being given to reviewing these dates and amending these where appropriate. IC recommended liaising with other organisations such as the University to identify best practice. Action: Links to be made with local organisations to identify best practice GB and shared learning relating to EDI. 58/16 b) RESOLVED That the Board NOTED the report.

Finance 59/16 Finance Report for Month 12 (Agenda item 6.1. Enclosure 6) a) The Chief Financial Officer provided an overview of the report noting: • A pre impairment and donation deficit of £1.1m was delivered. This is £2.9m adverse to plan. • The Financial Sustainability Risk Rating (FSRR) was ‘2’, in line with forecast. • Cost Improvement Programmes totalling £31m of CIP were delivered for the year. • There are significant ‘below the line’ technical accounting adjustments in March which affect the reported deficit in the year-end financial accounts including an impairment adjustment arising from the revaluation of the Trust’s fixed assets. 59/16 b) RESOLVED That the Board NOTED the update.

60/16 2016/17 Forward Planning a) Final Operational Plan 2016/17 (NHS Improvement) (Agenda item 7.1. Enclosure 7) The Director of Transformation and Improvement presented the Operational Plan for 2016/17 outlining the Trust’s plans in terms of finance, capital, clinical quality and staffing. The plan has been submitted to NHS Improvement in accordance with national guidance. DP questioned whether the emphasis of the risk in relation to the Sustainability and Transformation Fund was sufficient. FD confirmed that the rules relating to this funding were yet to be finalised therefore, at this stage, the risk remained accurate. 60/16 b) RESOLVED That the Board NOTED the final Operational Plan for 2016/17.

Strategy 61/16 UHS Clinical Strategy 2016 (agenda item 8.1. Enclosure 8) a) The Medical Director summarised the key changes to the document following presentation of the draft strategy to the March Trust Board meeting. Following approval, the document would be circulated to clinical teams to assist them with developing local implementation strategies. DP requested clarity between hospital without walls and virtual hospital. DS outlined the purpose of each noting the key differences. IC and FD proposed two minor typographical amendments to the document which were agreed.

Page 4 of 6

61/16 a) Action: Update the Clinical Strategy to reflect the following amendments: DS cont’d - Diagram on page 2 to be amended to include R&D - Remove the duplication of people strategy. 61/16 b) RESOLVED That the Board APPROVED the Clinical Strategy subject to minor amendments.

Governance 62/16 CRN: Wessex 2015-16 Annual Report (Agenda item 9.1. Enclosure 9) a) The Medical Director provided an overview of the report highlighting: • Wessex is ranked third when recruitment is adjusted to reflect population • 22% of recruitment is attributable to one study that will close in 2016/17. The network is actively looking for studies to replace this trial. • Recruitment to commercial studies remains a challenge. Plans have been developed to support the delivery of the 80% target for 2016/17. 62/16 b) RESOLVED That the Board NOTED the Wessex Annual Report.

63/16 Chief Executive’s Report (Agenda item 9.2. Enclosure 10) a) FD provided an update on the main entrance noting that this would fully open on 4 May 2016. Staff had already provided positive feedback regarding the facilities which now include a 24 hour Costa Coffee. CM queried whether the outlets could display hospital charity collection boxes on payment counters. Action: Discussion to be held with outlets in the main entrance regarding FD Southampton Hospital/Children’s Hospital Charity collection boxes. 63/16 b) RESOLVED That the Board NOTED the report and update provided.

63/16 c) Items for Ratification Actions taken by the Chair as set out in paragraphs 5.1.1 – 5.1.5 were ratified.

64/16 Draft Annual Report 2015/16 (Agenda item 9.3. Enclosure 11) a) The Associate Director of Corporate Affairs presented the 2015/16 draft Annual Report (including Quality Account) confirming that the content of the Annual Governance Statement had been subject to review and scrutiny by the Audit & Assurance Committee. The Quality Account was out to a 30 day consultation, in line with national guidance. Requests for amendment should be provided in writing by 3 May 2016. MS proposed that the staff survey section be amended to ensure a balanced reflection of the survey outcomes. In addition, a glossary should be included. Action: Amend the Annual Report to reflect feedback received. AL 64/16 b) RESOLVED That the Board NOTED the 2015/16 draft Annual Report.

65/16 Assurance Framework & Corporate Risk Register 2015/16 Quarter 4 Report (Agenda item 9.4. Enclosure 12) a) The Associate Director of Corporate Affairs provided an overview of the report, including a summary of the significant risks. The Assurance Framework and Corporate Risk Register are subject to quarterly review at the Audit & Assurance Committee, ensuring Board level oversight of the Trust’s risk profile. The Assurance Framework identifies “top down” risks whilst the risk register is developed “bottom up” ensuring alignment of strategic and operational risks. SP requested a single page ‘dashboard’ to aid review going forward. Action: Develop a single page risk dashboard for inclusion within future risk AL reports.

Page 5 of 6

65/16 b) RESOLVED That the Board NOTED the report.

66/16 Inspections, Accreditations and Peer Reviews/Visits Quarter 4 Report (Agenda item 9.5. Enclosure 13) a) The Associate Director of Corporate Affairs provided a summary of the report, highlighting the re-design of the report format to allow for a forward facing view of up and coming inspections and/or accreditations and the escalation of any anticipated risks or issues which may arise. MS commended this clear, well structured report and requested that Executives verbalise any concerns in relation to those areas that had failed to provide a response. FD confirmed that this report had been discussed in detail at the Trust Executive Committee and confirmed that no significant issues had been identified with appropriate action being taken to address those areas with red ratings. JH requested clarity regarding how the Trust gains assurance on all other areas that do not have a formal inspection, accreditation or peer review. GB advised that internal reviews are undertaken based on the CQC quality perspective and there is also the clinical accreditation scheme for wards. 66/16 b) RESOLVED That the Board NOTED the report.

67/16 Briefing from Chair of Strategy & Finance Committee (Agenda item 9.6) a) DP provided an overview of the items considered at the April Committee meeting, including: • 2015/16 Quarter 4 Monitor return • Progress update in respect of the Sustainability and Transformation Plan. • Review of the site strategy • Contracting update • Review of the financial position including cash flow forecasts. 67/16 b) RESOLVED That the Board NOTED the update.

68/16 Briefing from Chair of Quality & Performance Committee (Agenda item 9.7) a) MS confirmed that there was nothing further to add to the summary already provided under the Integrated Performance Report item. 68/16 b) RESOLVED That the Board NOTED the update.

69/16 Any Other Business 69/16 a) None. 69/16 b) The Chair asked whether there were any comments/questions from the public. There were none.

70/16 Comments and Questions from the public 70/16 a) None.

71/16 Date and Time of Next Meeting Thursday, 26 May 2016, commencing at 9.00am in the Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH.

Page 6 of 6

May 2016

Integrated KPI Board Report Page 1

Integrated KPI Board Report for April 2016 (unless otherwise stated)

Executive Sponsors

Jane Hayward Director of Transformation [email protected]

Caroline Marshall Chief Operating Officer [email protected]

Date of Board Meeting 26 May 2016

May 2016 UHS Integrated KPI Trust Board Report – Executive Digest Page 2

The May 2016 Integrated KPI Board Report represents the first report reflecting on UHS Performance for the financial year 2016/17 and features a new design organising the performance metrics into line with the five CQC performance review domains, along with a sixth linked to financial performance and Trust resources. This new structure is in line with the new format recommended by Lord Carter and mirrors the structure given to the Executive Digest in recent months.

Are we safe?

The Trust recorded 6 SIRIs in March (the data is reported a month in arrears), 3 of which related to patients with challenging mental health or behavioural conditions. The number of patients with mental health conditions attending the Trust has been steadily increasing over recent years and, coupled with the increase in activity in general, present a challenge for the Trust. The Trust is working closely with local Community Mental Healthcare providers to strengthen the pathways and support offered to these patients, to ensure patient and staff safety, and to try to prevent incidents such as these happening in the future.

It has been confirmed that the Trust has been awarded £973k for the delivery of the Sepsis CQUIN, and £1.2m for the Acute Kidney Injury CQUIN which is not only a significant result but also represents a notable improvement in our patient safety.

Are we effective?

The Trust’s Hospital Standardised Mortality Ratios (HSMR), as measured by Dr Foster, reduced significantly in 2015/16 and the Trust is targeting further improvement through 2016/17. At the end of 2014/15 UHS HSMR was 108.15 and in April 2016 (covering Feb 15 to Jan 16) this had reduced to 97.94. Performance of 100 is the national baseline and anything under this considered very good.

The Trust’s Medical Director is leading a piece of work to improve clinical coding which should have an additional positive impact on the Trust’s HSMR position.

The Trust has made good progress against the Patient Reported Outcome Measures (PROMs) for knee and hip replacements. These measures assess the health gain patients achieve post-operation and the Trust is now in line with national averages with a trajectory of improvement over the past year.

Are we caring?

The Friends & Family Test continues to give us positive real time feedback on patients’ views. The standard is for fewer than 5% of respondents to rate the Trust negatively and the Trust is exceeded this performance throughout 2015/16 for the three areas monitored; inpatients (1.09%), the Emergency Department (2.06%), and Maternity Services (0.00%). However, while inpatient and maternity services have achieved high response rates, the response rate in the Emergency Department is significantly below expected levels.

Are we responsive?

The number of patients attending Main ED was again significantly above the levels experienced in the same month in 2015, with a 5.2% rise. However, this is closer to the expected levels, having experience more than 10% year on year growth in January to March. Performance against the 4hr target also improved year on year to 87.8%, above the Trust’s agreed performance trajectory of 86.1%, despite the increase in activity.

The volume of total inpatient activity rose by over 500 spells year on year, a 4.7% increase, while rolling 12- month length of stay (LoS) has reduced, particularly for non-elective patients. The reduction of 0.5 days for

May 2016 UHS Integrated KPI Trust Board Report – Executive Digest Page 3

adult medical patients across the year equates to an efficiency saving of approximately 1,200 bed days per month, or 40 beds. A significant factor in this improvement are the improved flows for patients requiring a complex discharge package of care and is testament to the hard work carried out in conjunction with local authorities and commissioners.

Referral data is reported one month in arrears and the final position for 2015/16 saw a 4.9% increase in the number of referrals received by the Trust compared to the previous year, including an 11.3% rise in the number of urgent suspected cancer referrals. This increase in demand is reflected in both the total number of patients with an open 18-week pathway (up 3,122 in April 2016 compared to April 2015) and the number of new and follow-up outpatient appointments carried out (up 22,909 for May 15 to April 16 over the previous year). The risk to the Trust in 2016/17 is that this generates an increased demand for inpatient and day case activity. Despite these increases, the Trust met the 18-week performance target, achieving 92.61%, the highest performance since September 2015. The Trust is continuing to work on building robust capacity plans to accommodate this potential increase in demand.

Cancer performance data is also reported a month in arrears and the final position at the end of March was that the Trust met all of the statutory targets for the month, for quarter 4 and for the year as a whole. This is an excellent achievement, especially in light of the significant rises in activity seen in the Trust’s cancer services. The increases in activity are expected to continue as GPs rightly refer more patients in order to identify the disease earlier and improve outcomes. The Trust is always working to improve these pathways anticipates meeting these targets on a quarterly basis throughout 2016/17.

Finally, the Trust met the diagnostics target for less than 1% of patients waiting over 6 weeks for diagnostics testing. This is a target the Trust has never failed. However, for the third time in the last 6 months performance reached 0.99%. This is a concern to the Trust and focused work is ongoing to ensure the Trust continues to meet this target.

Are we well-led?

The Trust maintained performance against the Staff Friends and Family Test measure which asks staff whether they would recommend the Trust as a place to work to friends and family, with 76% of respondents saying yes, they would recommend the Trust. The last available publically published data shows the national average performance at 62% so this is an excellent result for the Trust.

We remain focused on achieving safe staffing standards to ensure that our nursing hours are closely matched to each patient’s dependency and care needs. The vacancy level for ward staffing (registered and unregistered) was maintained in April at 367 (12.2%) with vacancy levels being at the lowest they have been since September 2014.

Levels of temporary staffing for April have reduced following the sharp increase noted in March 2016. The use of non-framework agencies for ‘break-glass’ safety issues was also kept to a minimum during April with the lowest spend recorded. Usage was generally isolated to critical care areas. This position is explored further in the Ward Staff Commentary later in this document.

How effective are our enabling services?

The Trust has delivered a net deficit in April of £0.3m which is £2.3m better than plan. Whilst estimated clinical income was very close to plan the majority of this positive financial result is as a result of the timing of expenditure held in earmarked reserves. Agency levels in April reduced by £0.3m compared to March. May 2016 Trust Overview Page 4

Page Ref. KPI Target Target Source Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16

6 1.1.4 Clostridium Difficile Reduction (confirmed lapse in care) <=3 National 5 4 3 2 2 4 3 2 5 0 1 4 3 6 1.1.2 MRSA Bacteraemia Reduction 0 National 0 0 0 0 0 0 0 0 0 1 2 0 0 6 1.1.1 Never Events 0 National 0 0 0 0 2 0 0 0 0 0 2 0 0 6 1.1.7 SIRIs (month in arrears) <=2 Internal 3 3 2 4 2 5 6 5 4 2 2 6 N/A 1. Safe N/A N/A Safety Express Thermometer =>97.0% Internal 99% 98% 98% 98% 97% 97% 98% 98% 98% 98% 98% 98% 98% 7 Focus: Infection Prevention Annual Summary Notes: None 8 2.1.8 HSMR - UHS (reported 3 months in arrears) <100 Internal N/A N/A 100.22 99.60 99.08 98.44 98.58 98.85 98.05 97.94 N/A N/A N/A 8 2.1.9 HSMR - SGH (reported 3 months in arrears) <100 Internal N/A N/A N/A N/A 90.03 89.43 89.66 89.92 89.18 88.95 N/A N/A N/A 2. 8 2.1.4 Readmissions (month in arrears) =<10% National 9.8% 10.0% 10.2% 9.2% 10.3% 9.8% 9.9% 10.2% 10.6% 10.8% 10.0% 10.2% N/A

Effective 9-16 Focus: Clinical Effectiveness & Outcomes Quarterly Report, and Maternity Dashboard Notes: None 17 3.1.2 FFT Negative Score - Inpatients <5% National 1.35% 1.20% 1.42% 1.04% 1.00% 1.40% 1.10% 1.85% 1.31% 1.50% 0.88% 0.86% 1.09% 17 3.1.4 FFT Negative Score - ED <5% National 3.07% 3.42% 3.67% 2.87% 2.54% 2.73% 2.25% 4.29% 2.77% 3.06% 2.66% 3.16% 2.06% 17 3.1.6 FFT Negative Score - Maternity <5% National 0.00% 0.82% 0.83% 1.43% 2.36% 0.00% 0.45% 0.74% 3.41% 1.90% 0.00% 0.77% 0.00% 17 3.1.10 Complaints Received N/A N/A 30 38 41 47 40 34 53 39 28 28 42 23 N/A

3. Caring3. 17 3.1.9 Nutrition >=95% National 90.63% 82.05% 84.62% 82.86% 83.93% 88.07% 73.21% 81.25% 77.23% 74.53% 88.89% 81.90% 83.50% N/A Focus: None this month Notes: None 5 N/A Rolling 12-Month Total Inpatients (Elective, Non-Elective & Day Case combined) N/A N/A 144,984 144,678 144,945 144,843 144,351 144,190 144,183 144,907 145,340 145,283 145,905 146,060 146,611 5 N/A Rolling 12-Month Total Outpatients (New & Follow-up combined) N/A N/A 540,569 541,968 547,112 548,957 551,979 554,491 552,606 556,461 557,261 559,041 562,902 562,972 563,478 5 N/A Rolling 12-Month Total ED Attendances (All types combined) N/A N/A 111,055 110,811 110,390 109,945 109,971 109,792 109,827 110,175 110,407 111,374 112,681 113,568 113,989 18 4.1.3 A&E: % patients spending less than 4 hours in ED (Type 1) =>95.0% National 85.2% 89.4% 93.4% 91.0% 82.8% 91.3% 86.3% 84.5% 86.3% 80.0% 79.2% 85.2% 85.5% 18 4.1.8 A&E: % patients spending less than 4 hours in ED (Types 1, 2 & 3) =>95.0% National 87.6% 91.0% 94.5% 92.5% 85.6% 92.7% 88.5% 86.9% 88.4% 82.8% 82.5% 87.5% 87.8% 19 4.2.1 RTT: % Incomplete Pathways Within 18 Weeks in Month =>92.00% National 94.99% 95.01% 94.85% 94.43% 94.08% 93.17% 92.15% 93.02% 92.11% 92.04% 92.14% 92.26% 92.61% 19 4.2.5 RTT: Total Patients in Backlog <1200 Internal 1209 1244 1297 1463 1615 1825 2110 1859 2098 2118 2093 2040 2015 20 4.3.1 Cancer: Urgent GP referrals seen in 2 weeks (month in arrears) =>93.0% National 96.6% 97.9% 96.4% 96.4% 96.1% 95.8% 95.6% 96.4% 95.0% 95.9% 98.9% 96.5% N/A 20 4.3.3 Cancer: Treatment started within 62 days of urgent GP referral (month in arrears) =>85.0% National 84.6% 90.2% 87.4% 84.9% 91.9% 83.5% 85.3% 85.7% 88.4% 82.4% 84.0% 89.6% N/A

4. Responsive4. 21 4.5.2 Complex Discharge Census (monthly average) <=75 Local N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 105.4 120.8 119.2 21 4.5.6 Red Alerts (monthly total) N/A N/A 43 13 8 16 29 39 43 23 13 47 48 40 38 21 4.5.7 Black Alerts (monthly total) N/A N/A 0 2 0 0 3 0 0 0 0 0 0 2 4 21 4.5.9 % Elective Operations Cancelled at the Last Minute <=1.0% Local 1.14% 1.37% 0.89% 1.00% 1.12% 1.39% 1.00% 0.81% 0.82% 2.03% 1.37% 1.19% 1.16% N/A Focus: None this month Notes: New complex discharge methodology implemented from February 2016 N/A - Trust completes National 22 5.1.6 Staff FFT - % of Staff Likely or Extremely Likely to Recommend UHS as a Place to Work =>76% Internal 75% 73% 76% 76% Staff Survey instead 22 5.1.1 Turnover - Rolling 12-months <=10.00% Internal 12.40% 13.10% 13.06% 13.01% 13.26% 13.26% 13.30% 13.28% 13.52% 13.66% 13.75% 13.56% 13.54% 22 5.1.2 Sickness Absence - Rolling 12-months <=3.00% Internal 3.50% 3.48% 3.46% 3.44% 3.45% 3.48% 3.47% 3.47% 3.42% 3.38% 3.37% 3.41% 3.40% 22 5.1.4 Nursing Vacancies <=8.00% Internal 16.2% 16.6% 16.4% 17.2% 17.6% 15.4% 13.7% 13.2% 14.0% 14.0% 12.2% 12.2% 12.2% N/A N/A Statutory & Mandatory Training (composite measure) =>90% Internal N/A N/A N/A 84% 85% 84% 85% 84% 84% N/A N/A 76% N/A 5. Well-Led 5. 28 5.3.3 NiHR Patients Recruited (month in arrears) Variable Internal 1685 1317 1554 1647 1399 1433 1985 2219 1789 1881 1983 1853 N/A 23-26 Focus: Ward Staffing Report (+ detailed analysis in Appendix 1, pages 31-36) Notes: None 29 6.1.1 Clinical Income (£000s) Variable Internal 44,621 47,894 47,440 51,223 46,085 48,708 50,979 50,255 48,566 50,086 48,856 51,557 50,958 29 6.1.4 Operating Expenses (£000s) Variable Internal 53,354 54,109 55,486 55,333 53,721 55,859 54,952 57,366 54,868 55,242 56,252 61,142 56,291 29 6.1.5 EBITDA (£000) pre-donations Variable Internal 1,284 -2,033 -16 -4,273 -1,352 -1,371 -4,704 -2,510 -2,443 -3,154 -73 -1,204 -2,153 29 6.1.11 Financial Sustainability Risk Rating (CoSRR to July 2015) Variable Internal 2 2 2 2 2 2 2 2 2 3 2 2 3 29 6.1.16 CIP Delivered (£000s) - Cumulative YTD Variable Internal 767 1,867 3,690 5,833 8,294 11,354 14,292 17,476 20,678 24,864 27,934 31,046 549 Resources

6. Money & 6. 29 6.1.17 Cash (£000s) Variable Internal 22,139 19,838 11,063 6,123 16,097 14,463 11,323 19,262 20,644 16,271 11,255 21,856 18,061 N/A Focus: See separate Finance Board Report Notes: None May 2016 Latest Position Page 5

Compared to last year To Target Month QTD YTD R-12 Month QTD YTD R-12 We received… New referrals Mar N/A 16,383 48,802 191,313 191,313 -2.2% 6.6% 4.9% 4.9% Urgent cancer referrals Mar N/A 1,319 3,693 15,362 15,362 -0.8% 8.0% 11.3% 11.3%

We treated…. Main ED attendances Apr N/A 7,873 7,873 7,873 95,603 5.2% 5.2% 5.2% 1.6% Eye ED attendances Apr N/A 1,559 1,559 1,559 18,386 2.3% 2.3% 2.3% 8.4% Non-elective spells Apr N/A 5,733 5,733 5,733 68,529 5.3% 5.3% 5.3% 2.4% Elective spells Apr N/A 1,681 1,681 1,681 21,608 -4.1% -4.1% -4.1% 2.1% Day cases Apr N/A 4,760 4,760 4,760 56,474 7.6% 7.6% 7.6% -0.8% New outpatient appointments Apr N/A 15,860 15,860 15,860 197,916 0.4% 0.4% 0.4% 3.8% Follow-up outpatient appointments Apr N/A 30,162 30,162 30,162 365,562 1.5% 1.5% 1.5% 4.5%

Our efficiency… Elective Length of Stay Apr N/A N/A N/A N/A 3.50 N/A N/A N/A -0.05 Non-Elective Length of Stay Apr N/A N/A N/A N/A 5.54 N/A N/A N/A -0.22 Adult Medical Length of Stay Apr N/A N/A N/A N/A 4.72 N/A N/A N/A -0.50 Outpatient DNAs Apr N/A 3,655 3,655 3,655 49,402 - 777 - 777 - 777 - 668 Outpatient DNA Rate Apr N/A 7.94% 7.94% 7.94% 8.77% -1.80% -1.80% -1.80% -0.50% Adult Midday Bed Occupancy Mar 95% 95.88% 95.90% 94.65% 94.65% -4.27% -5.48% -5.80% -5.80% Paediatric Midday Bed Occupancy Mar 80-85% 85.45% 81.49% 82.34% 82.34% 7.78% 4.44% 8.89% 8.89% May 16 1. Safe Patient Safety Page 6

This Year Last Year Theme Ref. Indicator Target Source Feb Mar Apr QTD YTD Month YTD Detail 1.1.1 Never Events 0 National 2 0 0 0 0 0 0 1.1.2 MRSA bacteraemia reduction 0 National 2 0 0 0 0 0 0 1.1.3 MRSA bacteraemia contaminant 0 National 0 0 0 0 0 0 0 Clostridium difficile reduction (Confirmed lapse 1.1.4 <=3 National 1 4 3 3 3 5 5 in care) 15/16 + 1.1.5 Medication Errors Internal 211 225 215 215 215 189 189 10% 1.1.6 Medication Errors (Severe/Moderate) <=1 Internal 3 3 1 1 1 3 3 Below This Year Last Year Jan Feb Mar QTD YTD Month YTD 1.1 Patient Safety 1.1.7 Serious Incidents Requiring Investigation 2 Internal 2 2 6 10 54 2 34 Below 1.1.8 Grade 2 Pressure Ulcers 13 Internal 12 19 19 50 195 10 193 Avoidable Hospital Acquired Grade 3 and 4 1.1.9 2-3 Internal 2 4 1 7 36 5 40 Pressure Ulcers 1.1.10 Avoidable High Harm Falls 1 Internal 0 0 0 0 3 3 18 1.1.11 % Thromboprophylaxis Patients Assessed >=95 National 94.92% 95.28% 95.02% 95.07% 95.18% 95.43% 95.34% 2015/16 2014/15 Q1 Q2 Q3 Q4 N/A Q3 Q4 Diabetes: Insulin-related medication errors (high 1.1.12 <8 a year 0 3 0 0 N/A 0 0 harm)

1.1.6 - Medication Errors. Three moderate errors reported in March, two are still under investigation. One relates to the prescribing of the wrong dose of lorazepam for agitation, subsequently requiring reversal, the second relates to a patient who came off the end of life pathway but was not prescribed any VTE prophylaxis and subsequently developed a PE and DVT. The third incident relates to the connection of a local aneasthetic infusion to an IV cannula, this has been fully reviewed and a subsequent alert issued. 1.1.7 SIRIs. There were three SIRIs relating to patients with challenging mental health or behavioural conditions in this period. In one of these cases the patient came to moderate physical harm from potentially inappropriate restraint. In the other 2 cases there was no harm to the patient but staff injuries and significant potential media interest. These cases are complex cross organisational investigations involving poilice, community mental health and UHS.

May 2016 Annual Infection Prevention Summary 1. Safe Report – 2015/16 Page 7

Report from Graeme Jones, Director of Infection Prevention Unit Julie Brooks, Head of Infection Prevention Kieran Hand, Consultant Pharmacist in Anti-infectives Executive Sponsor Gail Byrne, Director of Nursing and Patient Services

Key Items for Noting • Continued need for attention to basic infection prevention practice to reduce risk of transmission of alert organisms including MRSA and prevent avoidable healthcare-acquired infection. • Deterioration in ward accreditation scores as a marker of basic infection prevention practice and processes to improve. • Good performance to prevent C difficile infection in 2015-16. • Improvement in bed days lost to Norovirus infection as a result of trust-wide measures to improve patient flow. • Rise in carbapenem-resistance seen in blood stream infections and the need for enhanced antimicrobial stewardship. • 2015-16 antimicrobial prescribing data and implications for achieving the 2016-17 CQUIN to improve antimicrobial use.

Summary of Progress

Category Qrt 4 YTD Action /Comment RAG RAG MRSA 3 attributable MRSA BSI attributable to UHS in bacteraemia R R 2015-16 including 2 cases in Q4 against a reduction performance limit of zero. MRSA 65 patients acquired MRSA colonisation in UHS in Targets: screening and G G 2015-16 including 15 in Q4. acquisition Clostridium 37 attributable C difficile cases in 2015-16. 30 cases difficile with lapses in care against a performance limit of 43 G G infection cases. reduction 7 cases in Q4. Overall compliance with CQC outcome 8. The Trust CQC assurance G G continues to implement actions to improve framework performance relating to cleanliness and isolation. Hand hygiene Full ward accreditation was achieved by 67% of Provide and Saving clinical areas for September-April 2016 compared to 84% to March 2015. Constituent data are assurance of Lives high N/A G impact reviewed monthly and supportive actions initiated basic infection interventions at that time. prevention Continued risk from multidrug resistant Gram- : practice Prudent negative infections. These form a small proportion antibiotic G G of infections but represent a concerning trend. An prescribing active antimicrobial stewardship programme is in place.

May 16 2. Effective Clinical Effectiveness Page 8

This Year Last Year Theme Ref. Indicator Target Source Jan Feb Mar QTD YTD Month YTD Detail Stroke: 90% of people with stroke spend at least 2.1.1 90% National 81.7% 89.8% 80.6% 83.6% 84.6% 81.9% 89.6% 90% of their time on a stroke unit Stroke: Door to needle time <60mins (National 2.1.2 55% National 42.9% 87.5% 53.8% 60.7% 56.6% 75.0% 54.5% Target: 55%) 2.1.4 Readmission Rate =<10% National 10.8% 10.0% 10.2% 10.3% 10.1% 9.4% 10.3% 2015/16 2014/15 Q1 Q2 Q3 Q4 N/A Q3 Q4

Management of Fragility Fractures - All patients 2.1.6 admitted with a fragility fracture should have a =>96% Internal N/A 40% 84% 75% N/A N/A N/A falls and bone health assessment undertaken 2.1 Clinical Fractured Neck of Femur Best Practice Tariff Effectiveness 2.1.7 Performance (Quarterly only, one month in =>90% Internal 78% 65% 78% 77% N/A 82% 75% arrears) Rolling 12-Months Last Year to Sep 15 to Oct 15 to Nov 15 to Dec 15 to Jan 16 to Jan 15 N/A

2.1.8 HSMR - UHS <=100 Internal 98.44 98.58 98.85 98.05 97.94 107.66 N/A 2.1.9 HSMR - SGH <=100 Internal 89.43 89.66 89.92 89.18 88.95 99.36 N/A Latest Data Last Year 2014/15 N/A N/A N/A N/A 2013/14 N/A

2.1.10 PROMS Health Gain - Hip replacements <=National Average 21.444 N/A N/A N/A N/A 21.671 N/A 2.1.11 PROMS Health Gain - Knee replacements Performance 16.148 N/A N/A N/A N/A 14.975 N/A

May 2016 2. Effective Quarterly Clinical Effectiveness and Outcomes Report Page 9

Period January to March 2016 (Q4 2015-2016) Report From Sharon Garrigos, Clinical Effectiveness Manager Simon Corbett, Director of Clinical Effectiveness Executive Sponsor Derek Sandeman, Medical Director

Purpose of the report To provide members of Trust Board with an update on: • Planned key performance indicators (KPIs) and work streams for clinical effectiveness and outcomes for 2015/16 • Progress against the agreed KPIs and a summary of progress against related clinical effectiveness and outcomes work streams • To highlight areas of good progress and any areas that require further focused improvement, with proposed actions to be taken to address any areas of non-compliance.

Recommendation(s) • Note progress against the work streams and performance for Quarter 4. • Note areas for improvement and for future focus.

Summary 1 This is the Clinical Effectiveness and Outcomes Report for Q4, January to March 2016. This report reflects the Clinical Effectiveness and Outcomes PIF priorities and Contract requirements for 2015-2016 and also includes local outcomes. These can be identified within the table below. Some areas of the PIF (e.g. supporting recruitment to an NIHR portfolio research study) as well as some of those works are reported via other methods and therefore are not included in this report.

2 Points to note are: • Provisional February PROMs data for 2014/15 (latest available published data) show a slight increase in Participation and Knee Health Gain figures since the last report. Hip Average Adjusted Health Gain has decreased slightly since the last report. Targets are set in comparison to England average results. HSCIC have confirmed that UHS are not statistically different from the national average. • The target for patients with a stroke spending at least 90% of their time on a stroke unit has increased from 80% to 90% • The target for stroke patients to receive Thrombolysis within 60 minutes of arrival to hospital (Door to Needle target) has decreased from 95% to 55% in agreement with commissioners for the 2015-16 contracting year. • Trevor Smith is now leading on the speciality local outcomes programme and further updates will be given in future reports • Fractured neck of femur compliance has dropped by 2% (draft report) since Q3. 76% of inpatient spells met the Best Practice Tariff criteria for Q4 2015/16 (draft report). • Funding approved for band 4 to provide bereavement care and IMEG support. • Retrospective review of annual IMEG activity and outcomes submitted for publication to national journal. • 3 other hospitals are now adopting the IMEG process.

3 Areas for improvement and for future focus in 2016/17 are: • The current HSMR (Feb 15 – Jan 16) is 97.94 ‘within expected’. Diagnosis groups that are statistical outliers are subject to further investigation by conducting either a clinical validation audit or clinical standards of care audit. HSMR Care Group level reports are updated and shared on a monthly basis.

May 2016 2. Effective Quarterly Clinical Effectiveness and Outcomes Report Page 10

• Speciality local outcomes, to continue in 16-17, with each clinical specialty working towards identifying 3 outcomes in total. • For PROMS, work is ongoing to ensure data completeness and greater clinical engagement and an audit has been started to investigate patients reporting no health gains following surgery. A new report detailing responses to specific PROMS questions will be sent to consultants on a monthly basis. • Improve facility for completion of hospital death certification and HMC referral at IMEG. • Address issue of co-location of IMEG, patient safety, patient support services and bereavement care to increase efficiency and improve responsiveness to complaints and adverse events • RCA process is in place for stroke Thrombolysis performance. Targets for CT scans need to be developed with Division D.

May 2016 2. Effective Quarterly Clinical Effectiveness and Outcomes Report Page 11

Progress End of Work- Clinical Target 2015/16 For Current from last Action /Comment yr/ Out stream Lead RAG report turn . Each speciality will identify 1-3 outcomes that are specific to their clinical work Speciality . Each speciality will monitor and Identification of clinical outcomes is still in progress across the specialities. local Trevor report on the outcome progress PIF  Trevor Smith leading on this work stream and it will continue into 16-17 A outcomes Smith A . Each care group will publish an Development of a platform for gathering and reporting outcomes in progress.

outcome review at the end of the year demonstrating progress against the identified outcomes. HSMR Claire Contract Current UHS HSMR = HSMR 97.94 ( Feb 15 – Jan 16) (3 months in . Target 100 in-line with benchmark  G Hayward PIF G Further details are available in the Monthly Monitored HSMR Data Report. arrears) . Explore funding streams to secure Band 4 approved  and develop the service A Co-location of IMEG, bereavement care, patient safety and patient support services A Promote essential to streamline services, reduce costs and provide a coordinated response to . Enhance E-Discharge and patient learning  bereavement, AERs and complaints from reviews HMRs Neil A A PIF of hospital Pearce HMC agrees in principle to electronic referral document, based on the E-Discharge death . Include maternal, peri-natal, and HMR. Lack of space and hardware in IMEG office prevents implementation. certification paediatric and hospice deaths A  A during 15-16 Paediatric, neonatal and hospice deaths now actively reviewed by IMEG or C-DAD. Currently exploring maternity. . Deliver CQUIN for dementia Risk  UHS has consistently exceeded the 90% threshold G assessments (90%) G

. Deliver CQUIN for diagnostic Gayle Dementia PIF assessment of dementia patients Strike /  UHS maintains 100% performance against this CQUIN G Contract G (90%) Jeni Bell . Deliver carer cafe twice a week and Currently delivering the carer cafe once a week  measure carer satisfaction A Planning to start carer satisfaction survey A

. 90% of people with stroke spend at Nic Weir PIF Jan and Feb data for 90% stay on unit shows improvement compared to Q3. Stroke least 90% of their time on a stroke  A Provisional data for March is showing 73% performance for the month. A unit (month in arrears)

May 2016 2. Effective Quarterly Clinical Effectiveness and Outcomes Report Page 12

Progress End of Work- Clinical Target 2015/16 For Current from last Action /Comment yr/ Out stream Lead RAG report turn

Provisional results from the Stroke National audit programme (SSNAP) for Q4 shows . Door to needle time <60mins  that the Trust achieved 64% of patients with a door to needle time of under one G G hour and a median door to needle time of 53 minutes.

. CT within one hour Accelerated Service is maintaining CT within 1 hour of arrival position at around 45% at the Stroke Indicator (ASI) CT target moment. Provisional Q4 results from the National stroke audit will be 46% achieved A  A within the hour is 50%. against a target of 50%. . Insulin-related medication errors Mayank Contract Diabetes 0 incidents in Q4, making a total of 3 incidents since April 15. G (high harm) Target is 8 for 15-16 Patel PIF G  HSCIC figures suggest that in 14/15 the UHS average adjusted health gain had . Average Adjusted Health Gain – Hip decreased since 13/14 and was less than the England average. Replacements Primary: Target: David Contract  96.3% of UHS patients reported an improvement after their operation, an increase of 21.444 (England Average Adjusted Warwick A A 1.4% from 13/14 however 1% less than the national % improving. Health Gain) UHS is not outlying for primary hip replacements. HSCIC figures suggest in 14/15 the UHS average adjusted Health Gain had increased . Average Adjusted Health Gain – Chris since 13/14 but was less than England average. PROMS Knee Replacements Primary: Target: Jack/ Contract  93.3% of UHS patients reported an improvement after their operation, an increase of 16.148 (England Average Adjusted A A Will Tice 1.5% from 13/14 although 0.6% less than the national % improving. Health Gain) UHS is not outlying for primary knee replacements. David UHS Participation rate in the pre-operative questionnaire was 85.9% for the 14/15. . Participation Rate – All Procedures: Warwick  This is an increase of 2.9% since 13/14 and is 10.5% higher than the national Target: 80% /Chris Internal G G participation rate. Jack . Best Practice Tariff Performance Fractured (Quarterly only, one month in Simon An estimated 76% percent of eligible operations will receive the Best Practice Tariff Neck of Contract  A arrears) Tilley A uplift for Quarter 4 2015/16. This is a decrease of 2% over Q3 2015/16 Femur . Target : 90% Management . All patients admitted with a non hip Mark Q4 data shows that we are now assessing 75% (across the quarter) of those patients of Fragility fragility fracture, should have a falls Baxter/ Contract R  admitted with a non hip fragility fracture, which is down from Q3 data of 84% but up R Fractures and bone health assessment Jeanette Internal by 35% since Q2 (when data first collected). (2.6) undertaken Robson

May 2016 2. Effective UHS Maternity Dashboard January to March 2016 Page 13

Key to RAG Impacting adversely on: patient and staff experience or management of activity Red Immediate escalation required or income and expenditure Early alert Escalation required with action plan to Amber Potential for adverse impact – diversionary management required mitigate risk of Red flag Green No adverse impact No action required

Current Reporting Indicator Description Expected Amber Red flag Comparator / comment Indicator Frequency >1500 500 or >500 per Women birthed - 467 per Monthly See Forecast below. fewer month quarter Statutory and Number of sessions mandatory training None None Any Monthly Impacts on service ability to meet training KPIs. cancelled sessions cancelled 26.5% = NHS Maternity Statistics, England: 2014-15. Available from Total rate (planned Jan to Mar 16 Less than 24% or

C-Section 23% Quarterly http://www.hscic.gov.uk & unscheduled) 23.6% 23% more Ref: Agreed local rates (measured against comparable services within South Central SHA)

CTIVITY 59.7% = NHS Maternity Statistics, England: 2014-15. Available from A 63% and 55 to Less than Normal Birth rate % of babies born 66.2% Monthly http:// www.ic.nhs.uk over 62% 55% Ref: Agreed local rates Apr-Jun 16 More Number of women . Manager on call rota for out of hours concerns re peaks in activity, capacity, staffing and acuity. (g) 1425 Fewer than 1500 than Forecast of women expected to birth . Discussions within South Central Heads of Midwifery on how to work together to support a ‘no 1500 in the in the 1500 in Monthly birthing within foreseeable closure’ protocol with all services having joined up escalation processes. Jul-Sept 16 quarter quarter the quarters . This forecast is based on reports run 12th April 2016. (g) 1479 quarter Weekly hours of LW cover by senior Jan to Mar 16 60 to less Fewer National recommended standards for safe staffing as laid down by professional bodies within ‘Safer medical staff 72 hours per 72 o 98 than 72 than 60 Quarterly Childbirth’ (2008). Hours refer to Consultant hours of direct LW cover carrying acute bleep (consultant or week hours pw hours pw hours pw (additional hours of post CST qualified Dr providing direct LW cover and carrying acute bleep). qualified CST (+28)

holder) Midwife/birth ratio End of MARCH figures: Staffing levels for whole time 1:27.5 ORKFORCE funded Number of midwife vacancies 18.04

W funded establishment 1:32 but Less than 1:34 or Number of midwife sickness overall – long 9.40 less than Monthly 1:32 more Midwife/birth ratio 1:34 Number of midwife sickness overall – short 3.00 1:35 with inclusive of sickness, sickness etc Number of midwife maternity leave 16.59 maternity leave and vacancies Total 47.03

May 2016 2. Effective UHS Maternity Dashboard January to March 2016 Page 14

Reporting Indicator Description Current Indicator Expected Amber Red flag Comparator / comment Frequency Q1 2015-16 90% = National and local target for access by 12 weeks + 6 days when measured SCCCG women (g) 94.8% according to DH methodology whereby numerator = number of women booked by 12+6 booked by 12 Less than Access 90% or more N/A Quarterly in Qn; denominator = number of women birthed in Qn+2. SCCCG rates given (most completed weeks of 90% Q2 2015-16 representative of service activity) for most recent two quarters with known results. pregnancy (g) 93.0% Please see also bottom page 4. Number of mothers Jan to Mar 16 HDU Quarterly New item June 2015 by request needing 87 Jan to Mar 16 ITU transfers Number of mothers Quarterly New item June 2015 by request 1 PPH 2000ml+ and Massive maternal requiring either of: Jan to Mar 16 An event of this nature is rigorously investigated to ensure processes were followed and 0 N/A 1 or more Quarterly haemorrhage • Hysterectomy 2 to enable lessons, if any, to be learned. • Transfer ITU

Babies known to be Intrapartum alive at onset of Jan to Mar 16 5 or fewer per More than 5 An event of this nature is rigorously investigated to ensure processes were followed and stillbirths N/A Quarterly labour who die before 0 annum per annum to enable lessons, if any, to be learned. (unexpected) birth during labour

Low Birth Weight at Jan to Mar 16 2.9% 2014 CCG Outcomes Indicator Set published December 2015 % of term live births tbc tbc tbc Quarterly ELLBEING INDICATORS term (<2500g) 2.5% http://www.hscic.gov.uk/catalogue/PUB19278

W 74.0% 2013-14; 74.3% 2014-15; 73.8% Q1 2015-16 NHS England Breastfeeding % of mothers whose Jan to Mar 16 Less than http://www.england.nhs.uk/statistics/statistical-work-areas/maternity-and- 80% or more 75 to 79% Quarterly initiation feeding status known 78.1% 75% breastfeeding/ See bottom page 4 for UHS rates by this measure. Update Jan16: no longer being reported by HSCIC Recent UHS rate has varied 5 to 7.5% [at time of this summary from RI]. Best evidence available (see below) demonstrates this sits within national range. This suggests local Unanticipated rate is good in view of our status as a tertiary referral centre importing high risk cases admission to NNU at from elsewhere in the region. Oct to Dec 15 birth and later of % of term live births 5% or less 6% 7% or more Quarterly National info on PCT based admissions: www.Rightcare.nhs.uk 4.5% term babies (37+0 Individual service or local population data: and over) Rohininath et al J. Maternal, Fetal & Neonatal Med. 2005 17 139 -43 S. Tracy et al Birth 2007 34 301-307 Hubbard M J. of neonatal nursing 2006 12 172 – 176

Reporting Indicator Description Current Indicator Expected Amber Red flag Comparator / comment Frequency

May 2016 2. Effective UHS Maternity Dashboard January to March 2016 Page 15

Evidence from SitReps produced by neonatal service. In utero transfers out …. .... crosschecked against LW log book. The number of Transfers in In utero transfers in = 1 women refused expected Transfers in January to March 2016 admission or In utero transfers out = 7 Destination In Utero Transfers Out x 23 transferred in or No transfers Transfers out (NNU capacity) Sitreps has 6 1 or 2 3 or more Basingstoke x 4 out of the service out Monthly Salisbury x 8 due to maternity or Refused Refused in utero admissions = Winchester x 1 neonatal capacity, No refused admissions 0 Dorchester x 1 staffing and / or admissions (LW capacity or complexity) 1 or 2 3 or more Portsmouth x 3 other reasons. from network Poole x 3 Chichester x 3 • Home Birth

CAPACITY Service Jan to Mar 16 • New Forest Birth Potential for compromised safety and quality of service for women and 3 x escalations to black alert Closure of one or Centre staff. (closure of LW plus one or more birthing (standalone) more BCs) environment but Closure of Closure of January to March 2016 • Broadlands Birth 10 x escalations to red alert No closures NOT the Princess Princess Quarterly Ward/Unit Women diverted because of service closure x 7 Centre (co- (variously closure of Anne Unit; Anne Unit 5 x women diverted to Portsmouth located) Broadlands BC, closure of IOL community 2 x women diverted to Winchester • Princess Anne service, closure of LW to activity cancelled

Unit potential NNU candidates) • Community Activity Maternity spend within financial Break even or Forecast risk of Any over

OST Budget RED Monthly Weekly tracker kept of excess hours, overtime etc.

C envelope set as the surplus overspend spending Budget Responders as % of Key FFT challenges are: eligible populations Less than 24.8% 30% or more Monthly • Feedback from women on postnatal community experience No longer any 30% FFT response rate national target Key feedback themes are: and performance Recommenders as Less than • Communication FEEDBACK

rating 95.7% 90% or more Monthly % of responders 90% • Staff attitude Trust targets only • Service capacity

USER NOT recommending as 0.5% Less than 5% 5% or more Monthly • Food % of responders • Inconsistent advice

May 2016 2. Effective UHS Maternity Dashboard January to March 2016 Page 16

2015 2016 JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR Women 536 455 423 479 524 515 502 478 460 470 460 476 445 456 467 Babies born 545 461 429 489 532 520 507 484 468 483 465 483 449 461 473 Normal births 61.8 58.8 62.5 58.3 59.0 60.2 56.8 55.4 57.3 53.4 59.4 59.8 56.1 61.8 66.2

2016 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jan-Mar Apr-Jun Jul-Sep Oct-Dec Total Rates per Women 4817 4947 5094 5220 5603 5887 5811 6098 6225 6195 5815 5933 5778 1368

Babies born 4880 5005 5172 5296 5703 5977 5905 6187 6336 6301 5910 6014 5866 1383

Normal births 64.8% 66.0% 64.6% 63.1% 60.9% 63.2% 61.4% 60.9% 60.8% 60.4% 60.0% 59.0% 58.6% 61.5 100 babies born

Caesareans 21.9% 20.6% 22.0% 21.7% 23.4% 20.5% 21.3% 21.9% 23.0% 23.5% 23.0% 24.0% 24.4% 23.6 100 women birthed

Stillbirths 20 24 35 29 22 27 35 27 38 39 28 28 36 6 AN/prior to admission 15 21 30 23 20 23 31 25 31 33 28 25 29 5 Intrapartum (inevitable) 5 3 5 6 2 4 2 0 4 5 0 3 5 1 Intrapartum (unexpected) To be reclassified 2 2 3 1 0 0 2 0 Reported on previous page Massive maternal 1 3 3 4 2 7 3 5 3 6 7 4 1 Conditions as described haemorrhage 2 In-utero transfers out 46 103 88 14 14 27 50 51 41 42 87 54 83 23 LBW at term (<2500g) ------2.4% 2.8% 2.3% 2.3% 2.5% 100 babies liveborn at term Unanticipated admission to NNU at birth and later of ------5.1% 4.2% 3.8% 4.0% 4.5% 100 babies liveborn at term term babies (37+0 and over) Days on RED alert 2015 6 months data only 35 11 Days on BLACK alert 2015 9 months data only 32 3

2015-16

04 05 06 07 08 09 10 11 12 13 14 15 03 - 04 - 05 - 06 - 07 - 08 - 09 - 10 - 11 - 12 - 13 - 14 - Apr-Jun Jul-Sep Oct-Dec Jan-Mar UHS Maternity rates per

No longer being reported UHS rates as reported HSCIC above using different 75.8 76.4 by HSCIC denominator Breastfeeding 100 mothers whose feeding status known. [2015-16, 75.6 76.3 76.4 76.6 77.5 78.7 77.6 77.7 78.6 79.1 79.1 77.6 78.2 77.0 77.0 78.1 initiation 97.1% of women birthed had first feed status recorded] SCCCG 100 SCCCG women birthed this quarter [report on recent booked women will women be incomplete and scan EDD not on HICSS until birthing]. NB Numerator derived from this denominator population in contrast to NHSic methodology. booked by 12 55.1 58.3 56.9 64.2 72.3 73.5 79.8 79.3 80.5 81.7 81.3 80.7 83.7 88.7 81.5 82.4 90% target does not apply to this measure. 75.9% = average England. weeks (up to Ref: NHS Maternity Statistics, England: 2014-15 12+6) http://www.hscic.gov.uk/catalogue/PUB19127

May 16 3. Caring Patient Experience Page 17

This Year Last Year Theme Ref. Indicator Target Source Feb-16 Mar-16 Apr-16 QTD YTD Month YTD Detail 3.1.1 FFT response rate - Inpatients >=20% National 22.96% 22.19% 22.93% 22.93% 22.93% 21.85% 21.85% 3.1.2 FFT Negative Score - Inpatients <=5% National 0.88% 0.86% 1.09% 1.09% 1.09% 1.35% 1.35% 3.1.3 FFT response rate - ED >=20% National 5.14% 3.92% 3.25% 3.25% 3.25% 22.04% 22.04% 3.1.4 FFT Negative Score - ED <=5% National 2.66% 3.16% 2.06% 2.06% 2.06% 3.57% 3.57% 3.1.5 Maternity FFT response rate >=20% National 30.92% 27.90% 33.61% 33.61% 33.61% 27.50% 27.50% 3.1.6 Maternity FFT Negative Score <=5% National 0.00% 0.77% 0.00% 0.00% 0.00% 0.00% 0.00% Have you ever shared a sleeping area with 3.1 Patient 3.1.7 patients of the opposite sex during this stay in 15% National 10.06% 7.08% 7.89% 7.89% 7.89% 13.73% 13.73% Experience hospital? (Those who gave an answer) Same Sex Accommodation (Non Clinically 3.1.8 0 National 0 0 0 0 0 0 0 Justified Breaches) 3.1.9 Nutrition: % Patients with a care plan in place >=95% National 88.89% 81.90% 83.50% 83.50% 83.50% 90.63% 90.63%

This Year Last Year Jan-16 Feb-16 Mar-16 QTD YTD Month YTD

3.1.10 Total Complaints Received N/A N/A 28 42 23 93 443 52 556 May 16 4. Responsive ED Performance Page 18

This Year Last Year Theme Ref. Indicator Target Source Feb Mar Apr YTD R-12 Month YTD Detail 4.1.1 Main ED (type 1) attendances N/A N/A 7,795 8,697 7,873 7,873 95,603 7,487 7,487 4.1.2 Main ED (type 1) breaches N/A N/A 1,625 1,287 1,139 1,139 13,183 1,107 1,107 % patients spending less than 4 hours in ED 4.1.3 >95% National 79.2% 85.2% 85.5% 85.5% 86.2% 85.2% 85.2% (Type 1) 4.1.4 ED Conversion (Type 1) N/A N/A 27.6% 26.8% 27.2% 27.2% 27.3% 26.3% 26.3% 4.1.5 Emergency reattendance within 7 days (Type 1) <5% National 6.5% 6.8% 6.0% 6.0% 6.4% 6.0% 6.0% 4.1.6 All ED (types 1, 2 & 3) attendances N/A N/A 9,313 10,326 9,432 9,432 113,989 9,011 9,011 4.1.7 All ED (types 1, 2 & 3) breaches N/A N/A 1,628 1,292 1,148 1,148 13,238 1,115 1,115 % patients spending less than 4 hours in ED 4.1 ED 4.1.8 >95% National 82.5% 87.5% 87.8% 87.8% 88.4% 87.6% 87.6% (Types 1, 2 & 3) Performance 4.1.9 Time to initial assessment (Types 1, 2 & 3) 00:15 National 01:04 01:12 00:55 00:55 00:45 00:28 00:19 4.1.10 Time to treatment - Median (Types 1, 2 & 3) 01:00 National 01:24 01:25 01:10 01:10 01:16 01:01 01:06 Total time spent in ED - 95th Centile (Types 1, 2 4.1.11 04:00 National 07:35 06:29 06:45 06:45 06:08 06:54 06:48 & 3) % patients who left the department before 4.1.12 <5% National 4.0% 3.7% 2.8% 2.8% 3.8% 3.3% 4.1% being seen (Types 1, 2 & 3) This Year Last Year Jan Feb Mar YTD R-12 Month YTD

4.1.13 Ambulance handover delays fines N/A N/A £ 1,000 £ 1,800 £ 1,400 £21,600 £21,600 £ 4,400 £67,000 May 16 4. Responsive RTT Performance Page 19

This Year Last Year Theme Ref. Indicator Target Source Feb Mar Apr YTD R-12 Month R-12 Detail % incomplete pathways within 18 weeks in 4.2.1 =>92% National 92.14% 92.26% 92.61% N/A N/A 94.99% N/A month % admitted patients within 18 weeks in month 4.2.2 N/A N/A 85.06% 84.01% 83.69% N/A N/A 90.03% N/A (adjusted for patient choice) % non-admitted patients within 18 weeks in 4.2.3 N/A N/A 89.78% 92.26% 90.65% N/A N/A 95.50% N/A month Total number of patients on an incomplete 4.2.4 N/A N/A 26,622 26,367 27,273 N/A N/A 24,151 N/A Below 4.2 RTT pathway Performance 4.2.5 Total patients in backlog N/A N/A 2,093 2,040 2,015 N/A N/A 1,209 N/A Below 4.2.6 Weeks waited for first outpatient appointment N/A N/A 7.63 7.23 7.48 N/A 7.32 6.78 7.37 %of Patients waiting over 6 weeks for 4.2.7 <=1% National 0.85% 0.97% 0.99% 0.99% 0.80% 0.38% 0.40% diagnostics This Year Last Year Jan Feb Mar YTD R-12 Month YTD

4.2.8 New referrals received N/A N/A 15,486 16,933 16,383 191,313 191,313 16,755 182,402 Below

Total Incompletes Total Backlog Rolling 12-Month Referrals 30000 3000 200000 2500 190000 25000 2000 180000 1500 170000 20000 1000 500 160000 15000 0 150000 Jul-13 Jul-13 Jul-13 Jul-14 Jul-15 Jan-16 Jan-16 Oct-14 Apr-12 Sep-12 Feb-13 Oct-14 Apr-12 Dec-13 Sep-12 Feb-13 Aug-15 Dec-13 Aug-15 Mar-15 Nov-13 Nov-14 Nov-15 Mar-15 Mar-13 Mar-14 Mar-15 Mar-16 May-14 May-14 May 16 4. Responsive Cancer Performance - Whole Trust Page 20

This Year Last Year Theme Ref. Indicator Target Source Jan Feb Mar QTD YTD Month QTD Detail 4.3.1 Urgent GP referrals seen in 2 weeks =>93% National 95.9% 98.9% 96.5% 97.1% 96.5% 96.5% 96.3% 4.3.2 Breast symptoms referral seen in 2 weeks =>93% National 95.6% 97.6% 95.7% 96.3% 93.6% 98.9% 97.4% Treatment started within 62 days of urgent GP 4.3.3 =>85% National 82.4% 84.0% 89.6% 85.5% 86.6% 88.4% 80.7% referral Treatment started within 62 days of referral 4.3.4 =>90% National 96.6% 95.7% 100.0% 97.2% 95.7% 91.3% 93.8% (Breast, Cervical & Bowel) 4.3.5 62 Day - Consultant Upgrades =>86% National 100.0% 82.6% 88.2% 90.2% 91.9% 97.0% 93.8% 4.3 Cancer Rare Cancers - 31 Day N/A Performance 4.3.6 N/A N/A 100.0% 100.0% 100.0% 87.9% N/A 100.0% Treatment started within 31 days of decision to - Whole 4.3.7 =>96% National 95.9% 99.1% 98.2% 97.7% 97.1% 96.1% 97.0% Trust treat Second or subsequent treatment (surgery) 4.3.8 =>94% National 96.1% 94.0% 97.3% 95.8% 95.9% 97.6% 98.2% started within 31 days of decision to treat Second or subsequent treatment (anti cancer 4.3.9 drugs) started within 31 days of decision to =>98% National 98.5% 99.2% 100.0% 99.2% 99.6% 100.0% 99.4% treat Second or subsequent treatment (radiotherapy) 4.3.10 =>94% National 98.5% 99.1% 100.0% 99.2% 99.1% 96.4% 97.4% started within 31 days of decision to treat May 16 4. Responsive Flow Page 21

This Year Last Year Theme Ref. Indicator Target Source Feb Mar Apr YTD R-12 Month YTD Detail 4.5.1 Delayed transfers of care (CQC Calculation) <=3.50% National 8.79% 10.07% 9.58% 9.58% 12.10% 6.14% 6.14% 4.5.2 Complex Discharge Census (average) <=75 Local 105.5 120.77 119.23 119.23 N/A N/A N/A Average Number of Complex Discharges per 4.5.3 =>26 Local N/A 23.6 20.9 20.9 N/A N/A N/A Working Day 4.5.4 Early discharge on day (pre-midday) =>35% Internal 17.90% 16.61% 18.41% 18.41% 17.26% 15.32% 15.32% 4.5.5 Weekend Discharge =>80% Internal 59.3% 63.02% 59.57% 59.57% 58.37% 57.63% 57.63% 4.5.6 Red Alerts N/A N/A 48 40 38 38 357 43 43 4.5 Flow 4.5.7 Black Alerts N/A N/A 0 2 4 4 11 0 0 4.5.8 Last minute cancelled operations N/A N/A 72 65 62 62 750 58 58 % elective operations cancelled at the last 4.5.9 <=1% National 1.37% 1.19% 1.16% 1.16% 1.17% 1.14% 1.14% minute Number of patients who are not readmitted 4.5.10 N/A N/A 10 3 4 4 46 8 8 within 28 days % elective operations cancelled and not 4.5.11 <=5% National 13.89% 4.62% 6.45% 6.45% 6.13% 13.79% 13.79% readmitted within 28 days May 16 5. Well Led Human Resources Page 22

This Year Last Year Theme Ref. Indicator Target Source Feb Mar Apr YTD R-12 Month YTD Detail 5.1.1 HR - Turnover - Rolling 12-months <=12% ESR 13.75% 13.56% 13.54% N/A N/A 12.40% N/A 5.1.2 HR - Sickness absence - Rolling 12-months <=3.2% ESR 3.37% 3.41% 3.40% N/A N/A 3.50% N/A HR - Appraisals completed (non-medical) - 5.1.3 =>92% ESR 87.46% 86.98% 87.79% N/A N/A 87.26% N/A Rolling 12-months 5.1 Human 5.1.4 Nursing Vacancies <=8.00% Internal 12.2% 12.2% 12.2% N/A N/A 16.20% N/A resources 2015/16 2016/17 2014/15 Q1 Q2 Q3 Q4 Q1 Q3 Q4

5.1.5 Staff FFT response rate 25% Picker 26% 27% N/A 24% 22% N/A 28% Staff FFT - % of staff likely or extremely likely to 5.1.6 76% Picker 75% 73% N/A 76% 76% N/A 72% recommend UHS as a place to work.

The Workforce Project Management Office (WFPMO) continues to core focus on driving up permanent recruitment, and reducing agency. There is also a key focus on retention.

Paper accepted by TEC for recruitment focus in 2016/17 including plans to develop a careers website, launch our Think UHS brand, and focus on hotspot areas in the staff attitude survey. Plans also include continued overseas recruitment.

Sickness Absence

• Reductions in sickness absence during Q3 and Q4 to an outurn position for 2016/17 of 3.4%. • UHS has been selected to be part of Simon Stevens (CEO NHS) national wellbeing project which will provide greater opportunity to tap into national thinking, including piloting new ideas to improve the health of the workforce.

Appraisals • Continued focus on Appraisal performance through Divisions with regular monitoring at Divisional level. • Refreshed appraisal documentation and process has been shared with Senior Divisional Management representatives on 13 October who were broadly supportive. Further consultation to take place before launch.

May 2016 5. Well Led Ward Staffing Report – April 2016 Page 23

The following highlight report (in fulfilment of the National Quality Board expectations on trust board awareness of safe staffing) focuses on any ‘hotspot’ areas in April 2016 which the board needs to be aware of in each Division after review of the overall staffing figures, daily staffing reports and staffing incident reports.

The table below represents the high level summary of the planned and actual ward staffing levels reported for April 2016. This is the information which has been uploaded and will be for public display on NHS choices from early June 2016.

From May 2016, NHS Improvement has requested additional information in order to calculate Care Hours Per Patient Day (CHPPD) as recommended in the Carter report. Processes are currently being put in place to collect this additional information.

April 2016 Day Night

Average fill rate - Average fill Average fill rate - Average fill registered rate - care registered rate - care Site Name nurses/midwives (%) staff (%) nurses/midwives (%) staff (%) Southampton General 84.8% ↑ 110% ↑ 92.7% ↔ 131.3% ↓ Hospital Countess Mountbatten 88.4% ↓ 125.1% ↔ 97.8% ↑ 139.4% ↓ House Princess Anne Hospital 85% ↑ 83% ↑ 87.6% ↔ 81.6% ↑ NB: Arrows indicate changes against the previous month and do not represent either a positive or negative performance position.

A detailed breakdown of ward by ward information is available for review and is included as part of this KPI pack as Appendix 1.

‘Hotspot’ areas for nursing/midwifery staffing in April 2016

Key metrics show that April was a more settled month in terms of both staffing and capacity challenges. The high level of sickness, specialling and leave noted in March reduced significantly and more staff completed periods of supervision and became active on the rosters.

Exceptions by Division are detailed below:

Division A Critical Care Areas – Acuity levels fluctuated throughout the month across all of the units and staffs were moved between units to support. Skill mix also continued to pose a significant challenge whilst new starters were supernumerary within the units and the skill mix of agency and substantive staff was balanced for safety across the units. Joint roster management across all units continued to maximise staff utilisation. Cancer Care - Increased special-ling requirements continued throughout the month leading to a higher use of additional shifts. Vacancy hotspot for cancer care remains C6 which was also compounded by high sickness in April. A key challenge with the additional chemotherapy skills required in some areas has led to the continued use of non-framework agency. Work is ongoing to develop more skills internally to address this. Surgery – Increased specialling requirements were experienced throughout the month. F5 and F6 remain the hotspot areas for the care group.

May 2016 5. Well Led Ward Staffing Report – April 2016 Page 24

Division B Emergency medicine wards, ED, and AMU - Emergency Care continues to have the highest percentage of registered nurse vacancies overall at 27.8% and this has risen in the month. Medicine for Older People - Remains a hotspot for the Division with RN vacancy rates currently at 32.7%. This is however offset by a stable supply of consistent temporary staff with a good fill-rate across the wards. The care group has over recruited with HCA’s and appointed band 4 assistant practitioners. It has also been agreed to include MOP in the Retention payments for the next 3 months.

Recruitment activity in the Division during April included: • Focus on recruiting into senior nursing leadership roles (DHN, DDHN, ED Matron, Ophthalmology Matron) • Focus on staffing in RHDU, improvement plan developed and trajectory for an improved vacancy position set

Staffing shortages across the division were mitigated by the daily review of staffing and movement of staff across the care group, division and trust to maintain safe levels: • Non ward based staff redeployed to ward areas • Supervisory ward leaders utilised in numbers to support the underlying vacancy position. Despite mitigation actions, areas worked on minimum numbers for patient safety on a number of occasions which could have impacted at times on the timeliness of patient care.

Division C Child Health - The position for registered nurses in Child Health has remained stable during April and 33 offers have been made to newly qualified children’s nurses who will commence in September. Midwifery- Peaks in activity for 1:1 care in labour and complex postnatal/HDU exceeded the available midwifery staffing on a few occasions in the month. Midwifery escalation processes were put into place, utilising non-ward based midwives to maintain safe levels. Neonates- High activity in the month (driven by the activity in midwifery and external transfers in) required the staffing of additional cots not yet supported by substantive recruitment in the expansion plan. The internal bank was used to support where possible however non-framework agency were required on a number of occasions to safely staff these cots.

Division D The overall Divisional registered nurse vacancy position has further decreased to 15.4%. Unregistered nurse vacancies also continued to fall in line with plan. Overall turnover of staff has reduced with a 50% reduction in external turnover. T & O and Neurosciences - Continue to carry a higher level of total vacancy and a higher level of vacancy in registered staff – 23.6% and 23.5% respectively but these have reduced in the month. ------Staff continue to reference the ‘red flags’ identified in the NICE guidance on safe staffing when completing adverse event reports (AER) linked to staffing. These red flags highlight when patient care has potentially been impacted due to staffing shortfalls. These AER are reviewed, actioned and mitigated in real-time to reduce the risks. They are also themed monthly and identified actions taken forward linked to the reporting on safe staffing and the trust risk register. From January 2016 care group and divisional reports have been available to enable focus on trends in incidents being reported from each clinical area.

In April there were 87 staffing incident reports in total across all staff groups (a significant fall on the previously reported levels of 162 in March, 137 in February and 111 in January). These incidents have been rated from near miss to moderate (7) impact.

May 2016 5. Well Led Ward Staffing Report – April 2016 Page 25

Of these incidents, 42 were relating to nurse staffing (a significant fall on the previously reported levels of 106 in March, 79 in February and 68 in January) which reverses the rising trend which was being closely monitored. Midwifery incidents accounted for 2 reports (down from 5 in March and 15 in February). Hotspot areas identified through the reporting are being closely reviewed by the divisions.

Graph 1 below provides the latest trajectory for the staffing position within the Trust extended to March 2017 taking account of all known capacity changes and recruitment activity currently planned. Two further EU overseas campaigns take place in Q1 and further campaigns are currently being negotiated as well as contracts to broaden the overseas campaigns to non EU. An estimate of the planned recruitment numbers from this route is included in the trajectory

Interviews are currently taking place for the new qualifiers exiting from the Universities in September 2016. To date 102 (Adult and Child) posts have been accepted.

The vacancy level for ward staffing (registered and unregistered) was maintained in April at 367 (12.2%) with vacancy levels being at the lowest they have been since September 2014. A number of these staff are currently on supervisory induction periods so are not fully impacting the clinical numbers.

Graph 2 details the breakdown of temporary staffing cover across the year. Levels for April have reduced following the sharp increase noted in March 2016. The use of non-framework agencies for ‘break-glass’ safety issues was also kept to a minimum during April with the lowest spend recorded. Usage was generally isolated to critical care areas.

Daily escalation processes continue to support the most effective deployment of staff.

NHS Improvement agency controls

Our framework nursing agency partners revised their charge rates in line with the rate caps for November and in most cases for February. Some key suppliers had not complied with the April capped rates for unregistered nurses and these have now either been removed from the cascade or have adjusted their rates and are now compliant. Some key players remain non-compliant for registered nurses and actions are being taken to negotiate further and put in measures over the next couple of months to reduce reliance on these agencies and remove them if they remain non-compliant. Key risk areas for the trust are around supply of nurses for Critical Care areas, Cancer Care (chemotherapy skills), Neonates and Midwifery.

May 2016 5. Well Led Ward Staffing Report – April 2016 Page 26

Graph 1

Graph 2 May 16 5. Well Led Education & Training Page 27

This Year Last Year Theme Ref. Indicator Target Source Feb Mar Apr YTD R-12 Month YTD Detail 5.2.1 Safeguarding Adults 90% Internal 84% 84% 84% N/A N/A 83.0% N/A 5.2.2 Child Protection (L3 only) 90% Internal 64% 65% 64% N/A N/A 68.0% N/A 5.2.3 Infection Prevention 90% Internal 84% 84% 83% N/A N/A 87.0% N/A 5.2.4 Moving and Handling - Practical Only 90% Internal 62% 58% 60% N/A N/A 64.0% N/A 5.2.5 Fire Safety 90% Internal 76% 75% 76% N/A N/A 81.0% N/A 5.2.6 Basic Life Support 90% Internal 73% 73% 72% N/A N/A 76.0% N/A 5.2.7 Local Induction 90% Internal 84% 84% 84% N/A N/A 90.0% N/A 5.2.8 Information Governance 90% Internal 80% 84% 83% N/A N/A 88.0% N/A 2015/16 2014/15 Q1 Q2 Q3 Q4 N/A Q3 Q4 5.2 Participant perception of the impact of a course 5.2.9 3.0 Internal 2.9 2.9 N/A 3.0 Education & (Q1 & Q3 only) Training Quality of practice experience for doctors in Minor Minor Minor Minor Minor Minor 5.2.10 training (annual report with quarterly No risk Internal N/A Risk Risk Risk Risk Risk Risk qualitative updates) Utilisation of funding (CPD/Salary Support) Minor 5.2.11 received from Health Education Wessex No risk Internal No Risk No Risk No Risk No Risk N/A No Risk Risk (quarterly only) National Learning and Development Agreement Minor Minor Minor 5.2.12 No Risk Internal N/A Compliance (Q2 & Q4 only) Risk Risk Risk Minor Minor Minor Minor 5.2.13 Recruitment to Apprenticeship No Risk Internal No Risk No Risk N/A Risk Risk Risk Risk Minor Major Major Major 5.2.14 Completion of Care Certificates No Risk Internal N/A N/A N/A Risk Risk Risk Risk

A quarterly report is presented at Education Strategy Group and discussed in detail - this report includes the activity over the course of the preceding quarter and an update on the action related to specific topics plus a detailed action plan from each division and for THQ against each topic. An Annual Report is also available. May 16 5. Well Led Research & Development Page 28

This Year Last Year Theme Ref. Indicator Target Source Feb Mar Apr QTD YTD Month YTD Detail Income from contract commercial studies 5.3.1 £0.29 Internal £ 0.22 £ 0.04 £ 0.25 £ 0.25 £ 0.25 £ 0.26 £ 0.26 (portfolio and non portfolio) £m Income from non commercial activity (including 5.3.2 £0.26 Internal £ 0.52 £ 0.37 £ 0.19 £ 0.19 £ 0.19 £ 0.18 £ 0.18 grants and funded non-commercial studies) £m This Year Last Year Jan Feb Mar QTD YTD Month YTD Total number of patients recruited to NIHR 5.3.3 Portfolio studies (commercial and non 1,725 Internal 1,881 1,983 1,853 5,717 20,745 2,049 20,766 commercial) Total number of patients recruited to 5.3.4 90 Internal 43 107 50 200 584 69 676 5.3 Research commercial studies & 2015/16 2014/15 Development Q1 Q2 Q3 Q4 N/A Q3 Q4 % of interventional studies recruiting first 5.3.5 patient within 70 days of valid application date =>85% Internal 98% 100% 100% N/A N/A 98% 98% (reported approx 3 months in arrears) Risk of financial penalties due to comparative poor performance in attaining 70 day 5.3.6 No Risk Internal No Risk No Risk No Risk N/A N/A No Risk No Risk benchmark (reported approx 3 months in arrears) % of commercial interventional studies Increasing 5.3.7 recruited to target within specified timelines quarterly Internal 58% 56% 52% N/A N/A 57% 57% (reported approx 3 months in arrears) targets

Targets in place are currently the same as for 2015/16 but are under review and will be updated in the June 2016 report. May 16 6. Money & Resources Finance Page 29

This Year Last Year Theme Ref. Indicator Target Source Feb Mar Apr YTD R-12 Month YTD Detail 6.1.1 NHS Clinical Income (£000) 51224 Finance 48,856 51,557 50,958 50,958 49,384 46,042 46,042 6.1.2 Total Income (£000) 59446 Finance 56,324 62,346 58,444 58,444 57,992 52,070 52,070 6.1.3 Employee Benefits Expense (£000) 36596 Finance 34,017 34,857 34,970 34,970 34,115 33,813 33,813 6.1.4 Total Operating Expenses (£000) 59362 Finance 56,252 61,142 56,291 56,291 55,885 53,354 53,354 6.1.5 EBITDA (£000) pre-donations -84 Finance -73 -1,204 -2,153 -2,153 -2,137 1,284 1,284 (Net Surplus)/Deficit pre impairments, 6.1.6 2627 Finance 2,509 1,102 345 345 448 3,917 3,917 exceptionals & donations 6.1.7 Capital Service Cover Rating 1 Finance 1 1 2 2 1 1 1 6.1.8 Liquidity rating 2 Finance 2 2 2 2 2 2 2 6.1 Finance 6.1.9 I&E Margin Rating 1 Finance 1 1 2 2 1 N/A N/A 6.1.10 I&E Margin Variance Rating 4 Finance 3 3 4 4 4 N/A N/A 6.1.11 Financial Sustainability Risk Rating 2 Finance 2 2 3 3 2 N/A N/A 6.1.12 Net Capital Investment (UHS) (£000) 870 Finance 1,821 3,593 627 627 1,139 316 316 6.1.13 Capital Leases (Excl IISS) (£000) 0 Finance 0 410 0 0 2,811 45 45 6.1.14 Capital Leases (IISS) (£000) 0 Finance 210 2,434 0 0 385 0 0 6.1.15 CIP Indentified (£000) 29000 Finance 31,230 31,048 27,257 27,257 32,633 30,199 30,199 6.1.16 CIP Delivered (£000) 664 Finance 3,070 3,112 549 549 2,569 767 767 6.1.17 Cash (£000) 15459 Finance 11,255 21,856 18,061 18,061 15,517 22,139 22,139

Full detail of financial performance can be found in the separate Finance Report. May 16 6. Money & Resources Estates Page 30

This Year Last Year Theme Ref. Indicator Target Source Feb Mar Apr QTD YTD Month YTD Detail

6.3.1 Estates - Total Completed Maintenance Jobs N/A N/A 1922 1919 1181 1181 1181 1797 1797

Estates - % Maintenance completed within 6.3.2 80% Internal 67.2% 67.2% 66.5% 66.5% 66.5% 86.9% 86.9% planned time Estates - Statutory Completed Maintenance 6.3.3 N/A N/A 188 108 100 100 100 255 255 Jobs Estates - % Planned Maintenance Completed - 6.3.4 90% Internal 94.7% 84.3% 83.0% 83.0% 83.0% 69.0% 69.0% Statutory 6.3 Estates Estates - Mandatory Completed Maintenance 6.3.5 N/A N/A 435 367 305 305 305 586 586 Jobs Estates - % Planned Maintenance Completed - 6.3.6 90% Internal 85.5% 89.1% 90.8% 90.8% 90.8% 83.6% 83.6% Mandatory Estates - Good Practice Completed Maintenance 6.3.7 N/A N/A 161 167 138 138 138 204 204 Jobs Estates - % Planned Maintenance Completed - 6.3.8 80% Internal 91.3% 94.6% 93.5% 93.5% 93.5% 77.5% 77.5% Good Practice Page 31

Integrated KPI Board Report - Appendix 1 - Nursing and Midwifery Staffing Hours - April 2016 Report notes Our staffing levels are monitored daily and we will risk assess and fill any gaps to ensure that safe staffing levels are always maintained

The total hours planned is our planned staffing levels to deliver care across all of our areas but does not represent a baseline safe staffing level. We plan for an average of one registered nurse to every five or seven patients in most of our areas but this can change as we regularly review the care requirements of our patients and adjust our staffing accordingly.

Staffing on intensive care and high dependency units is always adjusted depending on the number of patients being cared for and the level of support they require. Therefore the numbers will fluctuate considerably across the month when compared against our planned numbers.

Specialling occurs when patients in an area require more focused care than we would normally expect. In these cases extra, unplanned staff are assigned to support a ward. If specialling is required the ward may show as being over filled.

If a ward has an unplanned increase or decrease in bed availability the ward may show as being under or over filled, even though it remains safely and appropriately staffed.

The maternity workforce consists of teams of midwives who work both within the hospital and in the community and are able to respond to women wherever they choose to give birth. This means that our ward staffing and hospital birth environments have a core group of staff but the numbers of actual midwives caring for women increases responsively during a 24 hour period depending on the number of women requiring care. Registered Registered nurses nurses Unregistered staff Total hours Total hours Unregistered staff Total hours Registered nurses Unregistered staff WARD planned worked Total hours planned worked % Filled % Filled Comments C4 (Solent ward) Day 1469.7 1366.9 1008.3 1160.5 93.0% 115.1% Additional staff used for specialling - Support workers. C4 (Solent ward) Night 1046.5 1035.3 655.5 736.0 98.9% 112.3% Additional staff used for specialling - Support workers. C6 Day 2816.1 2748.7 201.0 83.2 97.6% 41.4% Safe staffing levels maintained.

C6 Night 2058.0 1985.8 0.0 11.0 96.5% Shift N/A Safe staffing levels maintained; No requirement for Support workers. C6 (Teenage Cancer Trust unit) Day 685.7 705.5 317.0 146.6 102.9% 46.2% Safe staffing levels maintained.

C6 (Teenage Cancer Trust unit) Night 673.6 668.0 0.0 90.0 99.2% Shift N/A Safe staffing levels maintained; No requirement for Support workers. Staffing appropriate for number of patients; Additional staff used for Countess Mountbatten House Day 2088.5 1846.8 1143.5 1430.0 88.4% 125.1% specialling - Support workers. Staffing appropriate for number of patients; Additional staff used for Countess Mountbatten House Night 989.3 967.3 654.8 913.0 97.8% 139.4% specialling - Support workers. Band 4 staff working to support registered nurse numbers; Additional D2 Day 1919.4 1541.4 765.3 1052.8 80.3% 137.6% staff used for specialling - RNs. Band 4 staff working to support registered nurse numbers; Additional D2 Night 1380.0 931.5 345.0 875.0 67.5% 253.6% staff used for specialling - Support workers. D3 Day 1364.4 1377.1 876.7 832.5 100.9% 95.0% Safe staffing levels maintained. D3 Night 1012.1 1002.6 675.0 675.0 99.1% 100.0% Safe staffing levels maintained. Safe staffing levels maintained; Nurse practitioners not in numbers but CAOS Day 2450.2 1824.6 7.5 0.0 74.5% 0.0% support area. CAOS Night 689.8 643.8 11.5 11.5 93.3% 100.0% Safe staffing levels maintained. Page 32

Registered Registered nurses nurses Unregistered staff Total hours Total hours Unregistered staff Total hours Registered nurses Unregistered staff WARD planned worked Total hours planned worked % Filled % Filled Comments Safe staffing levels maintained by sharing staff resource; HCA's not Surgical high dependency unit Day 1694.5 1585.2 377.9 207.5 93.6% 54.9% backfilled. Surgical high dependency unit Night 1449.8 1335.8 196.8 31.0 92.1% 15.8% Safe staffing levels maintained by sharing staff resource. Staffing appropriate for number of patients; Safe staffing levels Cardiac intensive care unit Day 4675.6 3967.0 1051.3 789.3 84.8% 75.1% maintained by sharing staff resource. Staffing appropriate for number of patients; Safe staffing levels Cardiac intensive care unit Night 4695.5 3962.0 322.0 138.0 84.4% 42.9% maintained by sharing staff resource. Staffing appropriate for number of patients; Safe staffing levels General intensive care unit Day 8281.6 7151.5 1098.6 753.1 86.4% 68.5% maintained by sharing staff resource. Staffing appropriate for number of patients; Safe staffing levels General intensive care unit Night 7948.5 7076.8 898.8 689.5 89.0% 76.7% maintained by sharing staff resource.

Staffing appropriate for number of patients; Safe staffing levels Neuro intensive care unit Day 4369.4 4118.4 535.7 255.0 94.3% 47.6% maintained by sharing staff resource; ; HCA's not backfilled.

Staffing appropriate for number of patients; Safe staffing levels Neuro intensive care unit Night 3789.0 3571.8 315.0 231.0 94.3% 73.3% maintained by sharing staff resource; HCA's not backfilled. E5A Day 1073.4 1015.5 732.0 997.4 94.6% 136.3% Additional staff used for specialling - Support workers. E5A Night 690.0 679.5 345.0 690.0 98.5% 200.0% Additional staff used for specialling - Support workers. E5B Day 1199.5 1119.2 812.9 701.9 93.3% 86.4% Safe staffing levels maintained. E5B Night 690.0 678.5 345.0 437.0 98.3% 126.7% Additional staff used for specialling - Support workers. E8 Day 2559.0 2176.4 1356.9 1590.4 85.0% 117.2% Additional staff used for specialling - Support workers. E8 Night 1380.3 1345.8 678.3 1068.8 97.5% 157.6% Additional staff used for specialling - Support workers. F11 Day 1597.9 1323.7 796.6 683.6 82.8% 85.8% Safe staffing levels maintained by sharing staff resource. F11 Night 1029.3 1068.5 345.0 345.0 103.8% 100.0% Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Additional F6 Day 2145.9 1743.5 631.7 916.0 81.2% 145.0% staff used for specialling - Support workers. F6 Night 1034.0 1004.0 690.0 779.5 97.1% 113.0% Additional staff used for specialling - Support workers. Band 4 staff working to support registered nurse numbers; Additional F5 Day 1916.2 1501.5 1057.3 1223.1 78.4% 115.7% staff used for specialling - Support workers. F5 Night 1035.0 1035.0 345.0 494.5 100.0% 143.3% Additional staff used for specialling - Support workers.

Safe staffing levels maintained by sharing staff resource; Band 4 staff working to support registered nurse numbers; Skill mix swaps Acute medical unit Day 5441.0 4507.3 2141.0 2779.1 82.8% 129.8% undertaken to support safe staffing across the Unit. Acute medical unit Night 3450.0 3459.7 1455.5 1962.5 100.3% 134.8% Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; Safe staffing levels maintained; Band 4 staff working to support D5 Day 1776.5 1452.3 1189.0 1266.5 81.8% 106.5% registered nurse numbers. Skill mix swaps undertaken to support safe staffing across the Unit; D5 Night 1035.0 1007.5 570.0 672.5 97.3% 118.0% Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; Safe staffing levels maintained; Band 4 staff working to support D6 Day 2205.5 1720.6 1555.0 1875.5 78.0% 120.6% registered nurse numbers. Page 33

Registered Registered nurses nurses Unregistered staff Total hours Total hours Unregistered staff Total hours Registered nurses Unregistered staff WARD planned worked Total hours planned worked % Filled % Filled Comments Skill mix swaps undertaken to support safe staffing across the Unit; D6 Night 1380.0 1319.5 690.0 1002.5 95.6% 145.3% Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; Safe staffing levels maintained; Band 4 staff working to support D7 Day 2033.0 1289.5 1119.0 1524.1 63.4% 136.2% registered nurse numbers. Skill mix swaps undertaken to support safe staffing across the Unit; D7 Night 1035.0 1016.3 570.0 984.0 98.2% 172.6% Additional staff used for specialling - Support workers. Skill mix swaps undertaken to support safe staffing across the Unit; D8 Day 1678.5 1450.0 1126.0 1212.7 86.4% 107.7% Safe staffing levels maintained. Additional staff used for specialling - Support workers; Safe staffing D8 Night 1035.0 1052.5 570.0 828.0 101.7% 145.3% levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; E7 Day 1602.5 1106.0 1024.0 1076.3 69.0% 105.1% Safe staffing levels maintained. E7 Night 690.0 730.5 690.0 811.5 105.9% 117.6% Safe staffing levels maintained. Respiratory high dependency unit Day 2379.8 1389.3 418.5 456.0 58.4% 109.0% Beds flexed to match staffing; Safe staffing levels maintained. Respiratory high dependency unit Night 2070.0 1651.5 225.0 238.0 79.8% 105.8% Beds flexed to match staffing; Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; C5 Day 1020.0 914.5 807.0 773.7 89.7% 95.9% Safe staffing levels maintained. C5 Night 690.0 692.0 345.0 485.0 100.3% 140.6% Safe staffing levels maintained. D10 Day 1404.5 826.5 796.5 864.3 58.8% 108.5% Band 4 staff working to support registered nurse numbers. D10 Night 805.0 699.5 483.0 514.0 86.9% 106.4% Safe staffing levels maintained.

Band 4 staff working to support registered nurse numbers; Skill mix F4M Day 1351.5 1074.7 1222.2 1181.6 79.5% 96.7% swaps undertaken to support safe staffing across the Unit. F4M Night 690.0 701.5 690.0 754.5 101.7% 109.3% Safe staffing levels maintained.

Band 4 staff working to support registered nurse numbers; Skill mix G5 Day 1580.0 1127.8 1354.5 1602.8 71.4% 118.3% swaps undertaken to support safe staffing across the Unit. Skill mix swaps undertaken to support safe staffing across the Unit; G5 Night 1035.0 701.5 690.0 1011.1 67.8% 146.5% Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Safe G6 Day 1569.0 1315.3 1396.5 1449.1 83.8% 103.8% staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; G6 Night 1035.0 714.0 690.0 1282.8 69.0% 185.9% Safe staffing levels maintained. Safe staffing levels maintained; Skill mix swaps undertaken to support G7 Day 760.0 723.0 984.0 774.9 95.1% 78.8% safe staffing across the Unit. G7 Night 690.0 692.0 345.0 368.0 100.3% 106.7% Safe staffing levels maintained. G8 Day 1531.3 1377.8 1428.0 1386.0 90.0% 97.1% Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; G8 Night 1035.0 709.0 690.0 1195.5 68.5% 173.3% Safe staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; Band 4 staff working to support registered nurse numbers; Safe G9 Day 1455.5 1230.5 1202.5 1413.8 84.5% 117.6% staffing levels maintained. Skill mix swaps undertaken to support safe staffing across the Unit; G9 Night 1023.5 691.0 690.0 1062.0 67.5% 153.9% Safe staffing levels maintained. Page 34

Registered Registered nurses nurses Unregistered staff Total hours Total hours Unregistered staff Total hours Registered nurses Unregistered staff WARD planned worked Total hours planned worked % Filled % Filled Comments Eye short stay unit Day 1062.0 981.0 690.5 630.7 92.4% 91.3% Safe staffing levels maintained. Eye short stay unit Night 330.0 341.0 330.0 319.0 103.3% 96.7% Safe staffing levels maintained. Bursledon House Day 780.0 857.3 352.5 357.5 109.9% 101.4% Staffing appropriate for number of patients. Bursledon House Night 152.0 155.5 152.0 152.0 102.3% 100.0% Staffing appropriate for number of patients. Paediatric high dependency unit Day 1192.5 1153.0 0.0 0.0 96.7% Shift N/A Safe staffing levels maintained. Paediatric high dependency unit Night 1035.0 1035.0 0.0 0.0 100.0% Shift N/A Safe staffing levels maintained. Paediatric medical unit Day 1857.0 2033.0 342.0 444.0 109.5% 129.8% Beds flexed to match staffing. Paediatric medical unit Night 1650.0 1788.0 330.0 484.0 108.4% 146.7% Beds flexed to match staffing.

Paediatric assessment unit Day 1302.5 1168.5 511.5 368.5 89.7% 72.0% Skill mix swaps undertaken to support safe staffing across the Unit.

Paediatric assessment unit Night 1120.5 847.5 130.5 234.5 75.6% 179.7% Skill mix swaps undertaken to support safe staffing across the Unit. Paediatric intensive care unit Day 5847.0 5354.0 393.0 371.5 91.6% 94.5% Patient requiring 24 hour 1:1 nursing in the month. Paediatric intensive care unit Night 5531.5 5303.8 264.5 218.5 95.9% 82.6% Patient requiring 24 hour 1:1 nursing in the month. Piam Brown ward Day 2973.0 2491.0 105.0 0.0 83.8% 0.0% Staffing appropriate for number of patients. Piam Brown ward Night 1035.0 1006.5 0.0 0.0 97.2% Shift N/A Staffing appropriate for number of patients. E1 Day 2026.0 2050.3 614.5 502.5 101.2% 81.8% Beds flexed to match staffing. E1 Night 1368.5 1368.3 253.0 287.0 100.0% 113.4% Beds flexed to match staffing.

G2 Day 771.0 751.5 0.0 20.8 97.5% Shift N/A Skill mix swaps undertaken to support safe staffing across the Unit.

G2 Night 720.0 694.3 0.0 11.0 96.4% Shift N/A Skill mix swaps undertaken to support safe staffing across the Unit. G3 Day 2304.0 1778.0 793.5 627.8 77.2% 79.1% Beds flexed to match staffing. G3 Night 1650.0 1409.0 330.0 341.0 85.4% 103.3% Beds flexed to match staffing.

G4 (nephrology) Day 1063.5 1352.8 440.5 313.8 127.2% 71.2% Skill mix swaps undertaken to support safe staffing across the Unit.

G4 (nephrology) Night 759.0 815.0 231.0 220.0 107.4% 95.2% Skill mix swaps undertaken to support safe staffing across the Unit. G4 (surgery) Day 1449.0 1089.5 696.0 399.0 75.2% 57.3% Beds flexed to match staffing. G4 (surgery) Night 988.8 838.3 330.0 385.0 84.8% 116.7% Beds flexed to match staffing. Bramshaw women's unit Day 1556.5 1518.7 1150.5 710.5 97.6% 61.8% Beds flexed to match staffing. Bramshaw women's unit Night 690.0 701.0 1035.0 761.0 101.6% 73.5% Beds flexed to match staffing. Neonatal unit Day 5697.0 4223.0 2010.5 1788.0 74.1% 88.9% Beds flexed to match staffing. Neonatal unit Night 4620.0 3797.0 1650.0 1485.0 82.2% 90.0% Beds flexed to match staffing. Maternity service Day 9521.0 8509.0 3688.5 3184.5 89.4% 86.3% Safe staffing levels maintained. Maternity service Night 6019.0 5430.0 2625.0 2086.5 90.2% 79.5% Safe staffing levels maintained.

Non-ward based staff supporting areas; Safe staffing levels Cardiac high dependency unit Day 5217.0 4370.0 1209.0 1046.0 83.8% 86.5% maintained; Support workers used to maintain staffing numbers. Safe staffing levels maintained; Support workers used to maintain Cardiac high dependency unit Night 3949.0 3458.0 561.0 515.5 87.6% 91.9% staffing numbers. Page 35

Registered Registered nurses nurses Unregistered staff Total hours Total hours Unregistered staff Total hours Registered nurses Unregistered staff WARD planned worked Total hours planned worked % Filled % Filled Comments Coronary care unit Day 1204.5 1148.5 375.8 372.5 95.3% 99.1% Safe staffing levels maintained. Coronary care unit Night 990.0 990.3 90.0 81.0 100.0% 90.0% Safe staffing levels maintained. Band 4 staff working to support registered nurse numbers; Support workers used to maintain staffing numbers; Safe staffing levels Cardiac short stay unit Day 944.0 700.5 249.0 445.3 74.2% 178.8% maintained. Band 4 staff working to support registered nurse numbers; Safe Cardiac short stay unit Night 420.0 346.8 0.0 0.0 82.6% Shift N/A staffing levels maintained. Band 4 staff working to support registered nurse numbers; Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels D4 Day 1807.5 1327.3 916.5 1024.8 73.4% 111.8% maintained. Band 4 staff working to support registered nurse numbers; Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels D4 Night 765.0 622.5 660.0 763.0 81.4% 115.6% maintained.

Band 4 staff working to support registered nurse numbers; Non-ward E2 Day 1542.0 1187.0 816.0 689.3 77.0% 84.5% based staff supporting areas; Safe staffing levels maintained. Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels E2 Night 671.0 673.0 330.0 399.0 100.3% 120.9% maintained. Band 4 staff working to support registered nurse numbers; Skill mix swaps undertaken to support safe staffing across the Unit; Patient E3 Day 2782.3 1886.3 915.0 1417.9 67.8% 155.0% requiring 24 hour 1:1 nursing in the month. Band 4 staff working to support registered nurse numbers; Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels E3 Night 1320.0 1141.0 660.0 937.0 86.4% 142.0% maintained. Band 4 staff working to support registered nurse numbers; Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels E4 Day 2184.0 1792.0 825.0 960.9 82.1% 116.5% maintained. Band 4 staff working to support registered nurse numbers; Patient requiring 24 hour 1:1 nursing in the month; Safe staffing levels E4 Night 1035.0 966.3 690.0 918.8 93.4% 133.2% maintained. Support workers used to maintain staffing numbers; Skill mix swaps undertaken to support safe staffing across the Unit; Additional staff Acute stroke unit Day 1777.5 1417.3 1457.0 2459.9 79.7% 168.8% used for specialling - Support workers. Additional staff used for specialling - Support workers; Increased night Acute stroke unit Night 990.0 937.5 990.0 1897.0 94.7% 191.6% staffing to support raised acuity. Skill mix swaps undertaken to support safe staffing across the Unit; Regional transfer unit Day 1197.0 860.5 400.0 526.2 71.9% 131.6% Staff moved to support other wards. Regional transfer unit Night 660.0 627.0 330.0 496.0 95.0% 150.3% Additional staff used for specialling - Support workers. Support workers used to maintain staffing numbers; Additional staff used for specialling - Support workers; Band 4 staff working to support E Neuro Day 1929.0 1489.5 534.0 995.5 77.2% 186.4% registered nurse numbers. Additional staff used for specialling - Support workers; Support workers used to maintain staffing numbers; Band 4 staff working to E Neuro Night 1320.0 1146.0 660.0 906.5 86.8% 137.3% support registered nurse numbers. Skill mix swaps undertaken to support safe staffing across the Unit; Band 4 staff working to support registered nurse numbers; Support Hasu Day 1221.0 819.5 399.5 734.6 67.1% 183.9% workers used to maintain staffing numbers. Page 36

Registered Registered nurses nurses Unregistered staff Total hours Total hours Unregistered staff Total hours Registered nurses Unregistered staff WARD planned worked Total hours planned worked % Filled % Filled Comments Hasu Night 660.0 615.5 660.0 706.0 93.3% 107.0% Band 4 staff working to support registered nurse numbers. Support workers used to maintain staffing numbers; Additional staff used for specialling - Support workers; Band 4 staff working to support D neuro Day 1997.0 1332.5 543.0 1428.5 66.7% 263.1% registered nurse numbers. D neuro Night 1320.0 1254.2 660.0 1059.0 95.0% 160.5% Additional staff used for specialling - Support workers. F7 Neuro Day 1419.0 1139.8 612.0 590.5 80.3% 96.5% Safe staffing levels maintained. F7 Neuro Night 660.0 627.0 660.0 772.0 95.0% 117.0% Increased night staffing to support raised acuity. Skill mix swaps undertaken to support safe staffing across the Unit; Safe staffing levels maintained; Safe staffing levels maintained by Brooke ward (trauma and orthopaedics) Day 960.5 1102.5 858.0 560.0 114.8% 65.3% sharing staff resource. Skill mix swaps undertaken to support safe staffing across the Unit; Safe staffing levels maintained; Safe staffing levels maintained by Brooke ward (trauma and orthopaedics) Night 690.0 712.5 690.0 662.0 103.3% 95.9% sharing staff resource.

Additional staff used for specialling - Support workers; Safe staffing levels maintained by sharing staff resource; Staff moved to support F1 Day 2501.7 2260.5 1917.0 2277.8 90.4% 118.8% other wards; Patient requiring 24 hour 1:1 nursing in the month.

Additional staff used for specialling - Support workers; Safe staffing levels maintained by sharing staff resource; Additional staff used for F1 Night 1725.0 1727.5 1380.0 1738.8 100.1% 126.0% specialling - RNs; Patient requiring 24 hour 1:1 nursing in the month. F2 Day 1788.0 1948.4 1665.0 1534.5 109.0% 92.2% Safe staffing levels maintained by sharing staff resource. Additional staff used for specialling - Support workers; Safe staffing F2 Night 990.0 1388.8 990.0 1113.5 140.3% 112.5% levels maintained by sharing staff resource. Safe staffing levels maintained by sharing staff resource; Staff moved F3 Day 1560.4 1591.9 796.5 1453.8 102.0% 182.5% to support other wards. Safe staffing levels maintained by sharing staff resource; Staff moved F3 Night 1001.0 969.3 330.0 1041.3 96.8% 315.5% to support other wards. Safe staffing levels maintained by sharing staff resource; Staff moved F4 Day 1533.0 1128.0 862.5 1040.7 73.6% 120.7% to support other wards. Safe staffing levels maintained by sharing staff resource; Staff moved F4 Night 990.0 943.3 319.0 375.0 95.3% 117.6% to support other wards.

Trust Board Meeting 26 May 2016

Report to: Finance Report Month 1 2016-17

Report from: Paul Goddard, Director of Finance/ Gavin Hawkins, Head of Management Accounts

Sponsoring David French, Chief Finance Officer Executive:

Purpose of Report: To update Trust Board on the financial, activity and savings performance of the Trust for April 2016.

Review History to The Trust Board has previously agreed income and expenditure budgets for 2016/17 Date: with a full year planned pre-donation surplus of £14.6m (£16.2m surplus post donations).

Recommendation: The Board are asked to note the report and the proposed actions highlighted at the end of this report.

Summary: (1) In April the Trust has delivered a pre-impairment deficit of £0.3m excluding donations. This was £2.3m better than plan. EBITDA was £2.1m favourable against plan.

(2) The Financial Sustainability Risk Rating (FSRR) resulting from this month-end position holds the Trust at a ‘3’ against a plan of ‘2’.

(3) The in month clinical income position is estimated to be £0.3m adverse to plan, with other operating income being £0.7m behind plan.

(4) Although the finer detail of how the Sustainability and Transformation (S&T) fund will operate is still to be confirmed, the current financial position and performance against the key access targets has provided sufficient assurance to account for the full S&T funding in April (£1.4m).

(5) Cost Improvement Programmes (CIPs) of £0.6m have been delivered to date, which is £0.1m (14%) behind plan. In total £27.3m of CIPs have been identified against the annual target of £29m (94%) although at this stage £2.1m of the identified schemes are red rated. Non-recurrent schemes total £5.2m of the £27.2m identified (19%), which is partially offset by the full year effect of identified schemes of £2.2m.

Income: Achieving the agreed volumes of activity to deliver the income plan

NHS clinical income for month 1 is estimated to be £0.3m (1%) below plan including a deficit from first cut of actual income data for the previous month of £0.3m. Elective activity is above expectations for the month; non-elective activity is also higher than the anticipated level. Outpatient activity is slightly lower than expected.

The income reported for month 1 reflects actual activity for spells and outpatients with estimated average tariff applied as fully coded data is not available at this stage. The remainder of the income is based on contract plan values with an adjustment made for any planned activity not expected to affect income in the first month. Further provisions have been made, where appropriate, for likely impacts, based on early estimates, from penalties and fines under the National Tariff guidelines for non- achievement of clinical targets (where they are not contained within the S&T funding regime) and for performance against CQUIN targets. Adjustments have also been made for Spells and Critical Care work-in-progress.

Page 1 of 11 CCGs have been invoiced on a block basis and over or underperformance will result in additional invoices/credit notes once the full monthly income data is available and agreed (as per the standard NHS contract this is just over 2 months after the activity month).

Other income is £0.7m adverse in month, of which £0.4m relates to Education & Training income which is still to be confirmed by Health Education Wessex. In addition the in month variance can also be attributed to lower R&D activity matched by lower costs (£0.1m) and private patients (£0.2m).

Costs: Controlling expenditure within budgets

In overall terms the Trust was £3.1m under plan on operating expenditure in April. Divisions and Trust Headquarters were £0.2m under spent against expenditure budgets in month, and corporate and reserve budgets under spent by £2.8m. This reserves position is a product of the timing of spend to date.

Worked whole time equivalents (wte) including agency, excess and overtime fell by 39 in April to 9,160 when compared to March. This is driven by lower agency use of some 31wtes across the Divisions. Locum and agency spend has fallen by £0.3m since March and is within the nursing staff groups in the main. This underspend is mainly a result of usage rather than price, although there is an expectation that some of the agency rates are to fall during in May.

NHS Improvement has set the Trust an agency expenditure ceiling for all staff for 2016/17 of £15.3m. This compares to the 2015/16 outturn of £19.3m and with the success of reducing agency spend over the last few months, there is a lower exit run-rate of £17.1m. Therefore the minimum further reduction required to meet the ceiling is £1.8m / 10%. This is planned to be achieved by initiatives for both price and usage reductions and is profiled in the plan from October 2016 i.e. the agency expenditure plan has been profiled at current rate for the first six months and the lower run-rate for the latter six months.

The staff groups with increased spend are being followed up with the relevant areas to identify reasons and agree actions.

Division A: £0.1m favourable

Expenditure within Division A was £0.1m less than budget in April. The position in April is a result of favourable variances for medical staff, drugs and clinical supplies, with no significant adverse variances.

The Division has delivered £0.1m in April against a target of £0.2m. Currently the Division have identified 92% of its £7.3m target.

Division B: £0.1m favourable

Division B was underspent in the month by £0.1m, largely due to £0.1m over- delivered CIPs. Drugs and MSSE spend combined to overspend by £0.1m (thought to be activity related) this has been offset by other non-pay overspends.

The Division has identified 87% of its £6.5m CIP target for the 2016/17 financial year and has delivered £0.2m to date. Work is being undertaken to fully identified the CIP target by the end of May.

Division C: £0.1m favourable

Division C was £0.1m underspent against budget in month 1. The variances are largely due to an under-spend on pay costs.

At the end of April the Division has identified £5.4m 91% of its £5.9m CIP target for

Page 2 of 11 2016/17 and delivered £0.1m 102% to date.

Division D: £0.2m adverse

Division D was £0.2m over spent in the month. The main variances were CIP (£0.1m), sub-contracting (£0.1m) and nursing (£0.1m) offset by other staff (£0.1m).

At the end of April, the Division has identified 83% of its CIP target.

Trust Head Quarters: £0.1m favourable

At an aggregate level Trust Headquarters (THQ) expenditure was £0.1m favourable against budget for April, mainly relating to pay spend.

THQ has identified £2.2m of CIP schemes against a target of £2.4m (91%). Delivery was down against April’s target with only 51% of the target being delivered.

CIPs: Delivering an in-year financial saving of £29m

By the end of April, the Trust has identified £27.3m (94%) of the CIP target for 2016/17 (2015/16 = 92%). £5.2m of the identified schemes are non-recurrent, however the full year effect of schemes identified will offset this by £2.2m.

Savings of £0.5m were delivered in month, leading to an adverse variance against plan of £0.1m. The year to date delivery equates to 2% of the annual target (2014/15 & 2015/16 delivery was 2% year to date also).

Whilst good progress is being made concerted action is still required to improve identification and delivery of recurrent CIPs. The plan is for 100% identification by the end of May so delivery can then be the main focus going into 16/17. At present roll-forward (current identification less non-recurrent add full year effect) delivery stands at £24.3m.

Cash & Liquidity The period end cash balance at 30 April 2016 of £18.1m is £2.6m above plan due to higher cash generated from operations of £2.1, lower working capital movements of £1.9m and lower financing costs of £0.1m, offset by higher investing activities of £1.6m.

Net Capital expenditure in month was £0.6m which is £0.3m less than Plan.

Proposed Actions Whilst performance against the overall plan is favourable, underlying pressures within some Divisions, largely due to CIP delivery, are a minor concern. CIP identification and delivery need to improve particularly given the phasing ramp up of delivery in the second 6 months of the financial year. The Trust needs to continue to reinforce the corrective actions it began last year.

The key actions are as follows:

1. To identify and deliver recurrent CIP schemes as well as controlling expenditure closely, with ongoing monthly detailed review with any division that is materially adverse to plan.

2. Continue the focus on reducing agency spend across all staff groups as part of the WPMO work and also to constantly review recruitment and retention performance.

3. Maintain tight controls on non-clinical and discretionary expenditure.

4. Continue to meet monthly with Divisional Management Teams to monitor and support improvement in performance of identifying and delivering CIPs.

Page 3 of 11 Schedule 1 Month 1 FINANCIAL SUMMARY 1 Financial Sustainability Risk Rating: 2016/17 CONDITION : Green Summary Performance Amber Month 1 2016/17 Q1 • The Trust delivered a pre-impairment and donations deficit of £0.4m which is £2.3m better Risk Ratings 2016/17 Plan Performance than plan. YTD Full Year YTD Last Mth Forecast • EBITDA is £2.1m better than plan excluding donations. Capital service cover rating 1 3 2 A 1 1 R • Financial Sustainability Risk Rating is a 3 - which is ahead of Plan. Liquidity rating 2 2 2 A 2 2 A • NHS clinical income is £0.3m below Plan in month. I&E Margin Rating 1 4 2 A 1 1 R • CIPs of £0.5m have been delivered to date (£0.1m behind Plan) (94% identified to date). I&E Margin Variance Rating 4 3 4 G 3 4 G FSRR Final Risk Rating 2 3 3 G 2 2 R 2 0

Total income in month is Current Month Year to Date Forecast to Year End adverse to plan. Plan Actual Variance Plan Actual Variance Plan Forecast Variance Total expenditure to date £m £m £m £m £m £m £m £m £m is £3.1m under plan NHS Income: CCGs 22.4 22.4 0.0 G 22.4 22.4 0.0 G M15 largely due to timing of 645.9 645.9 - G NHS England 24.1 22.3 -1.8 R 24.1 22.3 -1.8 R reserves spend. M16 9,160 wte vs 9,199 last Other clinical 4.7 6.3 1.5 G 4.7 6.3 1.5 G month (-0.4%). Other income 8.2 7.5 -0.7 R 8.2 7.5 -0.7 R 98.7 98.7 - G Total income 59.4 58.4 -1.0 A 59.4 58.4 -1.0 A 744.5 744.5 -G

Costs Pay -36.6 -35.0 1.6 G -36.6 -35.0 1.6 G -428.5 -428.5 - G Drugs -7.8 -7.1 0.6 G -7.8 -7.1 0.6 G -96.3 -96.3 - G Drugs spend is £0.6m Clinical supplies -5.2 -6.8 -1.6 R -5.2 -6.8 -1.6 R -60.5 -60.5 - G under Plan YTD . Other non pay -9.8 -7.4 2.4 G -9.8 -7.4 2.4 G -112.1 -112.1 - G Total expenditure -59.4 -56.3 3.1 G -59.4 -56.3 3.1 G -697.4 -697.4 -G Divs A/B/C/D identification A15 levels: 92%/87%/91%/83% EBITDA 0.1 2.2 2.1 G 0.1 2.2 2.1 G 47.1 47.1 - G respectively, with THQ at 91%.A16 Depreciation -1.9 -1.7 0.2 G -1.9 -1.7 0.2 G -22.6 -22.6 - G S15 EBITDA £2.1m above PDC and interest -0.8 -0.8 0.1 G -0.8 -0.8 0.1 G -9.9 -9.9 - G YTD Plan (excl. Surplus / (Deficit) pre-donations -2.6 -0.4 2.3 G -2.6 -0.4 2.3 G 14.6 14.6 - G donations) Donations 0.1 0.2 0.0 G 0.1 0.2 0.0 G 1.6 1.6 - G

Surplus after donations -2.5 -0.1 2.3 G -2.5 -0.1 2.3 G 16.2 16.2 - G

CIPs (delivered) 0.7 0.5 -0.1 R 0.7 0.5 -0.1 R 29.0 29.0 - G Liquid days are 2.7 days Locum, agency and bank spend -1.7 -2.1 -0.4 R -1.7 -2.1 -0.4 R -18.9 -18.9 - G Finance leases £2.4m O16 short of a "3" (£5.1m) higher than plan . Sub-contracted services -1.3 -1.4 -0.1 R -1.3 -1.4 -0.1 R -15.4 -15.4 - G Net capital expenditure -0.9 -0.6 0.2 G -0.9 -0.6 0.2 G -24.5 -24.5 - G Net cash flow -6.3 -3.8 2.6 G -6.3 -3.8 2.6 G -2.6 -2.8 -0.2 R Cash and cash equivalents 15.5 18.1 2.6 G 15.5 18.1 2.6 G 19.2 19.0 -0.2 A Capital service cover Liquidity days -10.6 -9.7 0.9 G -7.8 -7.8 -G I&E margin £0.9m short of a "3"; Borrowings and finance leases -55.7 -58.3 -2.6 A -70.1 -70.4 -0.3 A £0.2m short of a "3"; D16 £2.2m short of "4" £0.7m short of "4" I&E Margin -4.19% -0.26% 3.93% G 2.17% 2.17% 0.00% G Capital service cover metric 0.1 1.3 1.2 G 2.3 2.3 -G

Page 4 of 11 Schedule 2 Month 1

DIVISIONAL/HEADQUARTERS PERFORMANCE: 2016/17 (Cumulative)

Net Expenditue WTEs CIPs - Identified CIPs - Delivered Plan Actual Var. Worked Agency Total Target Identified Var. Plan Actual Var. £000's £000's £000's WTE WTE WTE £000's £000's £000's £000's £000's £000's Fav/(Adv) 0 Fav/(Adv) Fav/(Adv)

Divisions

Surgery 2,683 2,729 (46) 453.2 22.1 475.3 1,850 1,231 (619) 42 30 (12) Cancer Care 4,717 4,634 82 533.0 13.1 546.1 2,787 2,557 (230) 64 84 20 Critical Care 2,057 2,037 21 446.1 11.3 457.4 1,026 884 (142) 23 13 (10) Theatres 3,594 3,501 93 687.0 4.3 691.3 1,550 1,521 (29) 35 4 (32) Division A Management 118 131 (13) 40.0 1.0 41.0 76 500 424 2 0 (2) Sub Total Division A 13,169 13,032 137 2,159.3 51.8 2,211.1 7,289 6,693 (596) 167 131 (36)

Specialist Medicine 4,433 4,230 203 404.1 4.1 408.2 2,184 1,966 (218) 50 120 70 Ophthalmology 1,464 1,625 (161) 200.2 4.4 204.5 724 706 (18) 17 16 (1) Emergency Medicine 2,800 2,906 (106) 622.5 49.5 672.0 1,828 1,310 (518) 42 21 (21) Medicine for Older People 1,088 1,076 12 243.8 12.7 256.5 675 586 (89) 15 25 9 Pathology 1,446 1,369 77 236.0 0.9 236.8 1,111 1,074 (37) 25 43 18 Division B Management 185 154 31 41.8 0.0 41.8 0 0 (0) 0 0 0 Sub Total Division B 11,416 11,360 56 1,748.4 71.5 1,820.0 6,522 5,642 (880) 149 225 76

Women and Newborn 3,234 3,215 19 730.8 10.2 741.1 1,611 1,425 (186) 37 21 (16) Child Health 4,153 4,129 24 666.2 10.1 676.3 2,517 2,341 (176) 58 38 (20) Clinical Support 1,916 1,835 81 636.6 8.4 645.1 1,014 1,069 55 23 60 37 Non Clinical Support 1,555 1,598 (43) 152.4 0.0 152.4 749 533 (216) 17 19 2 Division C Management 47 46 1 7.5 0.0 7.5 0 0 0 0 0 0 Sub Total Division C 10,906 10,823 83 2,193.5 28.8 2,222.3 5,891 5,368 (523) 135 138 3

Trauma & Orthopaedics 2,660 2,802 (141) 339.0 19.0 358.1 1,600 1,405 (195) 37 2 (35) Cardiothoracic 4,046 4,076 (30) 557.4 11.4 568.8 2,337 1,870 (467) 54 4 (50) Neurosciences 2,943 2,959 (17) 380.8 15.5 396.3 1,745 1,143 (602) 40 9 (31) Radiology 2,218 2,223 (5) 349.2 6.6 355.8 1,161 1,326 165 27 12 (15) Division D Management 91 97 (6) 19.8 1.0 20.8 72 0 (72) 2 0 (2) Sub Total Division D 11,959 12,157 (199) 1,646.3 53.6 1,699.8 6,915 5,744 (1,171) 158 26 (132)

Miscellaneous

Page 5 of 11 Net Expenditue WTEs CIPs - Identified CIPs - Delivered Plan Actual Var. Worked Agency Total Target Identified Var. Plan Actual Var. £000's £000's £000's WTE WTE WTE £000's £000's £000's £000's £000's £000's Fav/(Adv) 0 Fav/(Adv) Fav/(Adv) TOTAL DIVISIONS 47,450 47,372 78 7,747.5 205.6 7,953.1 26,617 23,447 (3,170) 610 520 (89)

Headquarters

Chief Financial Officer 346 303 43 129.1 13.4 142.5 307 482 175 7 8 1 Estates 1,262 1,286 (24) 120.6 7.3 127.8 785 687 (98) 18 10 (8) Clinical Governance 271 253 18 57.0 0.1 57.1 293 100 (193) 7 0 (7) Medical Director 51 39 12 7.9 0.0 7.9 Training and Development 350 337 12 78.9 0.0 78.9 Chief Executive Office 39 29 11 12.2 0.0 12.2 23 23 0 1 1 1 Chief Operating Officer 489 450 39 160.8 3.8 164.7 274 220 (54) 6 2 (5) Director of Transformation 175 146 30 30.3 0.0 30.3 111 104 (7) 3 5 3 Research & Development (0) 1 (1) 239.5 1.5 241.0 Human Resources 241 196 45 104.0 4.4 108.4 242 230 (12) 6 2 (4) Informatics 592 554 38 159.4 3.5 162.9 348 315 (33) 8 0 (8) Other Services (743) (685) (57) 1.0 0.0 1.0 0 0 0 0 0 0 Capital Revenue Programme 11 26 (15) 16.5 1.0 17.5 Corporate Costs (2) (5) 3 CLRN (0) (0) 0 23.1 0.0 23.1 Hosted Services 0 (0) 0 24.3 0.0 24.3 OPA's 0 0 (0) Corporate Affairs 934 926 8 7.3 0.0 7.3 UHS Pharmacy Ltd 0 (3) 3 UHS Estates Ltd 0 36 (36)

Headquarters Total 4,017 3,889 128 1,171.7 35.0 1,206.8 2,383 2,161 (222) 55 28 (26)

Div/HQ Income Adjustment 5,044 5,028 16

Division/Headquarters Total 56,511 56,289 222 8,919.2 240.7 9,159.9 29,000 25,608 (3,392) 664 549 (116)

Central Reserves / Schemes 2,723 0 2,723 0 1,649 1,649 0 0 (0) Corporate Income Removal 128 0 128 Miscellaneous other 0 2 (2)

Total Operating Expenses 59,362 56,291 3,071 8,919.2 240.7 9,159.9 29,000 27,257 (1,743) 664 549 (116)

R u Expenditure variance > 4% Agency as proportion >= 10% Proportion of CIP > -10% Proportion of > -10% A • against plan <= 4% of total workforce >= 2% target not yet <= -10% planned CIPs not <= -10% G l <= 0% < 2% identified <= 0% delivered in month <= 0%

Page 6 of 11 Schedule 3 Financial Sustainability Risk Rating: 2016/17 Forecast Position at Month 1 Actuals

2016/17 Plan3.0 Capital Service Cover

2.5

2.0 CSC Actual CSC Plan

1.5 0

1.0 4 rating 3 rating Cover (no. of of (no. times) Cover EBITDA would need to be £0.9m higher to 0.5 have been a 3 and £2.2m to have been a 4. 0.0 2 rating

16 16 17 17 16 17 16 16 16 16 16 16 ------Jul - Jan Jun Oct Apr - Feb Sep Dec Aug Nov Mar - May

Liquidity Rating 2

0

-2 Liquidity would need to improve by LR Actual LR Plan -4 £5.1m (2.7 days) to have been a 3.

-6

-8

Liquid Days Liquid 4 rating 3 rating -10

-12

-14

2 rating -16

31 16 16 17 17 17 16 16 16 16 16 16 16 ------Jul - Jan Jun Oct Apr - Feb Sep Dec Aug Nov Mar - May

Page 7 of 11 I&EForecast Margin Position at Month 1 Actuals 3%

2%

1% I&E Margin Actual

0% I&E Margin Plan -1%

Margin Month 12 Cumulative -2% 4 rating

-3% YTD deficit would need to be £0.2m lower to have been a 3 and £0.7m lower## to have115449 3 rating -4% been a 4. ## 155095

-5% 2 rating

17 16 16 16 16 16 16 16 16 17 17 16 ------Jul - Jan Jun Oct Apr - Feb Sep Dec Aug Nov Mar - May

UHS Estates Ltd I&E Margin - Variance 5.0%

4.0% YTD deficit could have fallen by £2.3m before falling to a 3. 3.0% I&E Margin Variance Actual

2.0% I&E Variance Plan 1.0%

0.0% 4 rating Margin Variance Margin -1.0%

3 rating -2.0%

-3.0%

2 rating 17 16 16 16 16 16 16 16 17 16 17 16 ------Jul - Jan Jun Oct Apr - Feb Sep Dec Aug Nov Mar - May

Page 8 of 11 Schedule 4 Month 1

Bedstate 2015/16 - 2016/17

120.0% Current Month 0 100.0% B B B B B B B B B B B B B R R R R 80.0% R

A R R R R A R 60.0% R R A R A 40.0% A

G A G 20.0% A G A A A A G A G G G A G 0.0% G G G G G A15 A16 M15 M16 J15 J16 J15 J16 A15 A16 S15 S16 O15 O16 N15 N16 D15 D16 J16 J17 F16 F17 M16 M17

Elective and Non-Elective 2015/16 25

31 20 12.399 12.437 13.374 12.881 12.698 12.977 13.092 15 12.516 12.582 12.814 12.17

11.883 12.719 13.142 12.385 12.897 13.143 12.871 12.197 11.901 12.161 12.099 11.431

12.541 Non-Elective £m

£ Million Elective £m 10

5 9.96 10.909 10.837 9.916 9.867 9.819 10.368 9.726 10.244 9.650 10.173 9.584 9.387 9.362 9.237 9.222 9.138 9.078 9.049 9.047 8.915 8.845 8.742 8.576

0 A14 A15 M14 M15 J14 J15 J14 J15 A14 A15 S14 S15 O14 O15 N14 N15 D14 D15 J15 J16 F15 F16 M15 M16

Summary Income (Production Plan) Month 12 Cumulative Plan Actual Variance % Split £000s £000s £000s Elective Inpatients 120,925 115,449 (5,476) 43% Non-Elective Inpatients 150,226 155,095 4,869 57%

Page 9 of 11 Schedule 5 Month 1 Key Financial Risks

Risks Identified Description Potential Likelihood Weighted Mitigation Value £m risk value 1 2016/17 Plan The Trust is anticipating £38m L – 10% £3.8m Ensure that payments for clinical income in excess overperformance are secured. of contracted levels Seek to ensure hospital flow is maximised in order to facilitate delivery of forecast income. This is assured by daily actions by COO team to maximise flow.

2 CIPs Non-delivery of CIPs in £3m M – 50% £1.5m Strong performance excess of forecast management through the established detailed monthly review with individual divisions with Executive Directors.

3 Agency In excess of planned £2m L – 25% £0.5m Tight control. Trust wide expenditure levels initiatives to reduce reliance on very high premium agencies.

Page 10 of 11 Schedule 6 List of Supporting Annexes within the TEC Report

The following supporting Annexes form part of the more detailed report to TEC, and are available electronically to Trust Board members should they require them.

Annex 1 Key Metrics Annex 2 Consolidated Statement of Comprehensive Income Annex 3 Consolidated Statement of Comprehensive Income Forecast Annex 4 Graphs Annex 5 Central and Divisional Revenue Performance Annex 6 Operating Expenses Annex 7 Divisional/Headquarters Performance Annex 8 CIPs - Identification Levels and RAG Rating Annex 9 CIP Delivery - Scheme Analysis Annex 10 CIP Delivery - Divisional Analysis Annex 11 Consolidated Cashflow Annex 12 Non-Operating Income and Expenditure Annex 13 Divisional/Headquarters Income Annex 14 UHS Pharmacy LTD Statement of Comprehensive Income Annex 14a UHS Estates LTD Statement of Comprehensive Income Annex 15 Consolidated Statement of Financial Position Annex 16 UHS Pharmacy LTD Statement of Financial Position Annex 16a UHS Estates LTD Statement of Financial Position Annex 17 Capital Expenditure Annex 18 Financial Sustainability Risk Rating

Page 11 of 11

Trust Board meeting 26 May 2016

Title Informatics 6-monthly Report

Sponsoring Executive Jane Hayward, Director of Transformation & Improvement

Authors’ names & Job Adrian Byrne, Director of Informatics titles

Purpose of the paper For To note ☑ Formal For decision o information o approval o

History This is a regular update to the Trust Board, this paper has been reviewed by Trust Executive Committee and Informatics strategy group (ISSG)

Main issues / Executive This paper sets out progress made on the key informatics Summary systems

Action Required The Trust Board is asked to note this report

Next Steps This report will be updated in 6 months time

1. Purpose 1.1. The informatics strategy to 2020 was presented to the Board in June 2015. The objective laid down in the Personalised Health and Care 2020 is for a paperless environment by 2020. The strategy will deliver better: · Information for clinicians · Information for patients · Information for managers 1.2. The strategy aims to deliver: · High quality patient care by improving decision making and increasing patient safety. · A reduction in the cost of creating, handling and storing data.

Page 1 of 5 2. Strategy Highlights 2.1. The continuation of a very ambitious programme for UHS Informatics will see some significant developments during 2016/17 and completion of projects that started through national funding over the past year or so: · Roll out of ePAMS vital signs monitoring by the end of 2016 · Completion of the Critical Care system roll out by the end of 2016 · The Electronic Document Management System (EDMS) live by end of 2016 · Roll out of nurses handover in CHARTS · Electronic nursing documents · An eWhiteboard function driven by the CHARTS worklists · Electronic signature (iSign) for documents allowing electronic send · The My Medical Record patient on line programme will become much more mainstream, and continue to grow to support others nationally 2.2. There is a large emphasis in nursing engagement within the Informatics programme and with this in mind discussions are ongoing between the Director Of Nursing, Director of Informatics and Derek Waller as Chief Clinical Information Officer as to how this is progressed. 2.3. Note that in line with NHS England and a more general understanding of the term Informatics the IM&T department has re-branded itself Informatics. It is felt this will be easier for people to grasp what we do in future, though the IM&T name will clearly linger. 2.4. Emis, known mainly as a supplier to primary care, took over the trust main EPR supplier Ascribe just over two years ago. The informatics management team have met again with Emis to ascertain the future prospects of key clinical systems (the CHARTS worklist, eQuest [electronic orders] eDocs and Bed management). The future of the products has been uncertain since the takeover. Board may recall Ascribe in turn purchased the set of products (HICSS) from a Hampshire company Scorpio Information Systems. EMIS is clearly not pursuing the Ascribe strategy and has moved bed management back within CaMIS PAS, which UHS broadly agrees with. It is too early to judge success. There are no plans to move to a different local strategy but there should be some further discussion on the risk, aligned with the possibility of some national money – see next para 2.5. £4Bn has been announced by Jeremy Hunt to support the national strategy (5YFV and Personalised H&C 2020). Half of this will go to the electronic interoperable record but a bidding process has not yet been designed. It is likely this will not happen until 2017. 2.6. The interoperability programme is developing plans for Hampshire. This aligns to the footprint of the digital roadmaps due to be submitted [by the CSU] June 2016. There is no immediate plan to replace the whole Hampshire Health Record (HHR) but to improve the integration in the short term and possibly align with other local programmes such as the SWASH PACS [imaging] domain and national work within NHSE. The work is now within the Sustainability and Transformation Programme (STP) 2.7. Note an audit on the technical infrastructure by PWC has recommended more investment in resilience and cyber security monitoring. 2.8. This is a period of significant underlying change. Upgrades to the EPR and ED systems went live during April. Apart from some new functionality including ability for all documents to be digitally signed for electronic release, a major part of the work relates to a desktop upgrade of Internet Explorer (application readiness for this). The nature of this and the various desktop components affected has created some localized problems that will take a while to work through. In addition, a database platform change was implemented on 5th May which took the whole EPR across from Windows servers which had been slow and troublesome to Linux servers which will better support the Oracle database. These projects represent a large infrastructure shift and put the environment on a sound footing for the next few years.

Page 2 of 5 2.9. The Electronic Document Management System project has started with discovery and design sessions for the various workflows. Negotiations continue on Nursling library lease for a one year extension (the landlord wants three). The plan will be finalized during May following the supplier feedback, but a live service is expected around the end of the calendar year. 2.10. The on-line My Medical Record (MyMR) platform has some interesting developments around whole cancer module and possible collaboration with others is emerging. A business case is forthcoming (c.July 2016). It has also received some national exposure where UHS is seen as a leader in this. 2.11. The critical care project stalled at the end of the financial year due to estates priorities, and the need to upgrade and merge to accommodate the ePAMS vital signs acuity system. In the interim period a bid has come forward to include respiratory high care which has none of the asbestos or power issues experienced elsewhere. 2.12. In genomics the UHS work has received good feedback as the phenotype data is being successfully joined with sample test data for the Genomics England programme. 2.13. The bleep system, previously recorded as a risk, is being replaced by a new Multitone system 2.14. A number of technology projects are progressing but need accelerating in 2016 · Audit recommendations with asset management, security and data centre work · Decision on NHS mail (switch from local mail) · Completion of XP to Win 7 almost done but now need to deploy the newer IE11 web browser · Wireless network extension of coverage for ePAMS will be difficult due to building access issues and asbestos · A new messaging system to supplement the bleep system and link to the EPR

3. Risks There is no significant change:

ID1806 Ageing IT hardware - delaying care delivery – Risk Score 20 ID1739 EMIS Health product strategy - operational impact - Risk Score 16 20 ID1795 IT systems unavailability in paperless environment - Risk Score 16 ID1972 COSD cancer XML – Pathology system – Risk Score 16 – Discussed with Clinisys Account Manager 18/2/16 – he is tasked with progressing au UHS pilot.

4. Reliability Clinicals – (previously – “Still vulnerable, awaiting go-live of new database platform on 20th April.”) The move has just been carried out as at 5th May. Early reporting indicates improvement in performance.

The work to upgrade all desktops to Windows 7 is ongoing. There have been no reported security issues specific to XP PCs this period.

We have suffered some performance problems on our N3 network connection, in particular affecting PACS cross-platform working and GP requesting via ICE. We carried out an upgrade to the Trust firewall to help alleviate this although the underlying cause, which is down to the amount of data being pulled across the link in real-time (for PACS), still requires further investigation.

Page 3 of 5 5. PC Age Report

Page 4 of 5 Page 5 of 5

Trust Board Meeting 26 May 2016

Title Human Resources 6-month Report for Q3 & Q4 2015/16 Objectives for 2016/17 for HR

Sponsoring Fiona Dalton – Chief Executive Office Executive

Authors’ names & Steve Harris – Associate Director of HR Job titles

Purpose of the paper For information o To note ☑ Formal For decision o approval ☑ The purpose of the report is to provide a summary of performance in HR over Q3 &Q4 of 2015/16.

It is also to set out 2016/17 objectives for approval.

History Report presented to Trust Executive Committee (TEC) during May and draft HR Objectives were approved.

Main issues / Key highlights of Q3/Q4 2015/16: Executive Summary · HR has broadly delivered all of its key objectives for 2015/16 as set out in Appendix A.

· A new model of Employee Relations has been agreed, and is in implementation including recruitment for new positions.

· UHS has continued to robustly plan for mitigation of strike action by Junior Doctors thanks to the hard work of the operational teams. Positive local working relationships have been maintained with Junior Doctor Representatives throughout.

· HR has delivered performance against operational KPI targets including recruitment speed. There are no investigations or suspensions of employees exceeding 6 months at present. Occupational Health has delivered all main KPIs. This is set out in Appendix E.

Key performance against strategic KPIs:

· Turnover has increased from 12.4% to 13.56% during 2015/16 for all staff groups, but has started to fall in February and March 2016. Turnover for nursing staff has fallen during Q3 & Q4 2015/16 to 12.15%. This was rising sharply during Q1 & Q2, so a reduction is encouraging news.

· Rolling sickness absence has decreased from 3.5% to 3.46%. This remains favourable compared to national averages for NHS Trusts.

· Appraisal performance has not met the target of 92% with the exception of some THQ departments and Division B. The outturn position for Q4 was 87%.

1 of 9

Action Required Trust Board is asked to:

· Note the performance of HR during the last 6 months against its objectives.

· To agree the key objectives for HR for 2016/17, and provide any comments that may support the development of these objectives further.

Next Steps For the HR Team to drive the implementation of these objectives reporting progress to TEC and Trust Board at 6 month progress intervals.

Introduction and Purpose

1.1 This report is a 6 month summary account of performance within the HR department.

1.2 The report will provide updates on the following areas:

· To provide key successes and challenges over the last 6 months against the core 15/16 objectives. · To provide an account on operational HR performance. · To set out the objectives for agreement for 2016/17.

2 Core performance against HR objectives:

2.1 The full objectives for 2015/16 set for the HR function are set out in Appendix A.

2.2 By exception the following should be noted:

Successes Challenges · CIP+ delivered £2.45m savings through · Appraisal levels at year end have fallen organisational change and restructure in short of 92% target at 87%, although management and administration. Division B performance is noted as very · UHS remained in the top 20% for staff positive at 92%. engagement from recent staff survey results. · Management of annual leave carry over Highest Friends and Family score of 76% (Bank holiday sickness issue), caused recommended UHS as a place to work. challenges to both unions and line · Decision made on employee relations model managers. following Capsticks pilot. New internal model · Staff turnover, whilst decreasing marginally in the implementation of posts in recruitment. in Feb and March, is still at 13.56%. Nursing · Achievement of status as a pilot site for the staff turnover has fallen during Q3 and Q4 to NHS Healthy Workplace project. Investment 12.15%. of £192k secured. · Agency compliance breaches have risen in · £2,312k savings in medical locums compared Nursing staff groups (both qualified and to 2014/15 spend. unqualified) as the capped price has fallen in · Increased focus on areas of continued breach February and April 2016. in monitor agency caps. · Some AHP areas have still been unable to · New senior manager appraisal process reach the price stipulated set against agreed and launch planned for May 2016. agencies refusing to meet the cap. Action · Creation of a Junior Doctor steering group for plans are in place for each area of breach. new contract. · Positive partnership engagement with local Junior Doctors to establish areas where work can be improved. · Continued close partnership working with staff side on completion of CIP+ and regular Wednesday meetings now set up with HR to review ongoing organisational issues affecting UHS employees. · Continued overall positive operational performance of HR against KPIs. · Recruitment of a new Non Executive Director with a focus on equality and diversity.

2 of 9

3 Key operational performance account of HR:

3.1 Operational HR service performance is reviewed monthly at the HR Performance Board. The key summary of overall position for 2015/16 is outlined below;

· Recruitment timescales remain in line with our target and customer satisfaction remains positive. · Occupational health KPIs have been hit during the period. · No investigations in employee relations currently longer than 6 months. · No suspensions of staff in excess of 6 months. · UHS Nursery satisfaction from users remains positive. · Consultant recruitment process under review to assess the levels of delegation and composition of panels.

Details are provided in Appendix C.

3.2 The Trust has an ongoing responsibility to report on any whistle-blowing cases. A detailed dashboard is shared with the Trust Executive Committee (TEC) and also with the Lead Non Executive Director for whistle blowing

4 HR Objectives for 2016/17:

4.1 The HR objectives are detailed in Appendix B. The key areas of focus will be as follows;

· To deliver the Recruitment, Retention and Agency control plans as set out to TEC in April 2016. · To respond to the hotspots in the Staff Attitude Survey to continue the improvement of UHS performance. · To implement the new Junior Doctor contract and new Consultant contract once agreed. · To implement a new model for Employee Relations Services and streamline policies and procedures and management development. · Delivering the NHS Healthy Workplace project including continued focus on absence and wellbeing.

5 Next Steps:

5.1 Trust Board is asked to;

· Note the performance of HR during the last 6 months against its objectives.

· To note the operational performance for HR.

· To agree the key objectives for HR for 2016/17, and provide any comments that may support the development of these objectives further.

3 of 9

Appendix A: HR Core Objectives Performance

The following details the key priorities for HR for 2015/16 and progress to date: Objective Outrun Comments position To continue to drive down agency spend through Achieved A total of £2m saved on locum agency in 2015/16 through implementation of a range of improved recruitment and retention initiatives. controls and initiatives, including implementation of the monitor price caps.

To review the success of the 6 month R&R premia for Achieved R&R premia reviewed with Divisions in partnership with trade unions. Premia to continue ward areas. until July 2017, although areas included have been refocused to include MOP. To develop and implement a new service model for Achieved New Service Model for ER agreed in partnership with Divisions following the Capstick Pilot. employee relations through the task and finish group. Service agreed to be retained in house. Advertisement underway for new roles. Interims in place for current service at present to fill vacancies.

Long standing challenge areas within team addressed and resolved. New service model to be launched from a position of strength. To support Divisions to respond to the implementation Ongoing WPMO has worked with finance, procurement, central nursing and the Divisions to advise on phases 2 and 3 of the monitor agency price cap in and plan for the impact of the reductions in February and April 2016 price caps. February and April 2016.

To complete the re-fresh of the Trust appraisal Achieved The refresh of the Senior Manager appraisal paperwork is complete with a launch planned for documentation for senior managers, and to focus on May 2016. supporting improvements in performance. This will be for managers at band 8C and above.

To continue to support the completion of the Trust Achieved £2.45m saved on workforce costs in management and administration posts through HR CIP+ programme to deliver further workforce savings support to organisational changes. in management infrastructure. Redundancy costs of £1.12m to achieve savings. Over 50 WTE reduced.

Unions fully engaged and consulted through the process. Regular updates on progress against project milestones provided to staff side. To set up a project steering group chaired by the Achieved First two meetings held. Project structure organised. Medical Director, to implement the revised consultant and junior doctor contracts. Implementation schedule agreed for UHS. Ongoing discussion with the Juniors about improving morale and motivation.

4 of 9

To continue to focus on reducing staff absences within Ongoing The rolling sickness absence level has decreased marginally during 2015/16 to a final the Trust, target of 3.2%. position of 3.39%.

To support Occupational Health in the delivery of the Achieved Investment of £192k secured. First steering group has taken place, chaired by CEO. Sir Simon Stevens Healthy Workforce Pilot site work. To secure funding and agree an action plan for Action plan set out for 2016/17. 2016/17. To respond to the National Staff Survey results in Achieved UHS remained in the Top 20% for staff engagement. Top level priorities have been decided February 2016, and continue to find ways to increase at TEC and Trust Board. Task and finish groups are being formed. employee engagement. To work with the Director of Education, Training and Achieved Overarching objectives agreed between Director of Education and Associate Director of HR. Workforce to agree key joint corporate priorities for the people agenda.

5 of 9

Appendix B- Draft HR Objectives for 2016/17

Corporate People Lead function Objective Deadline Objective Recruiting and Workforce Project To increase permanent registered Nurse recruits by 129 WTE by 31 March 2017, through 31 March 2017 Retaining Talent Management Office plans agreed at TEC to increase recruitment and reduce turnover in nursing to 10%. This and Recruitment includes, branding, career website, overseas recruitment and focus on retention hot spots.

To deliver reductions in agency spend to ensure a maximum ceiling of £15.2m by 31 March 31 March 2017 2017, including specific actions to address locum medical and nursing, AHP, A&C agency spend.

To deliver compliance against the NHS Improvement agency cap rules by 1 November 2016. 1 November 2016 Nursery Team To deliver improvements in the childcare provision to raise UHS nursery OFSTED rating to 31 March 2017 excellent, improve nursery income by £30k, and to review nursery opening hours to ensure the best offering to our parents.

HR Best Practice To implement the requirements of the national pension auto enrolment refresh. 1 November Team 2016

Increasing levels of Best Practice Team To design and deliver a plan to improve the Trust performance in the 2016 annual staff attitude 31 March 2017 staff engagement survey with specific focus on bullying, violence, discrimination, and disability. and wellbeing To deliver improved performance in our annually published WRES data by 31 March 2017.

HR Employee To deliver improvements in sickness absence management to reduce our Trust rolling average 31 March 2017 Relations Team performance to 3.2% by 31 March 2017.

Occupational Health

Occupational Heath To design and implement a plan to deliver the objectives of the NHS Healthy Workforce 31 March 2017 Spearhead project by 31 March 2017.

Occupation health To deliver improvements in staff health and wellbeing to achieve the CQUIN objectives of 31 March 2017 improved staff health, improved catering offerings, and to achieve a minimum flu take up of 75% for clinical staff.

6 of 9

Improving medical Medical HR Team & To deliver the implementation of the 2016 new Junior Doctor contract in line with agreed 1 August 2016 deployment and Workforce Systems transitional phasing. productivity October 2017 Medical HR To make improvements in Junior Doctor morale by implementing changes to increase 1 August 2016 HR Best Practice satisfaction with working lives at the Trust.

Medical HR Team To deliver the implementation of the 2016 new consultant contract in line with agreed national TBC and Workforce timescales once confirmed. systems

Building people HR Best Practice Roll out the new agreed process for senior manager appraisal for bands 8C,8D and Band 9 by 1 June 2016 leadership and Team 1 June 2016. management capability HR Best Practice Roll out a refreshed version of the new appraisal process for all staff ensuring a clear link to 31 March 2017 Team values, behaviours, and performance. To increase the number of staff reporting a well structured appraisal.

Employee Relations To deliver a revised model of our employee relations function, focusing on speed, efficiency, 1st Nov 2016 Team simplified processes and partnership working.

To ensure a clear published set of KPI’s to reduce time of cases, and drive up quality of advice.

HR Best Practice To deliver a range of new policies for management of core HR issues including organisational 31 March 2017 Team change, disciplinary, grievance, attendance management and performance. To ensure that these are simple, clear and effective.

HR Best Practice To refresh a suite of training for line managers on core HR processes including appraisal and 31 March 2017 Team performance, absence and disciplinary and grievance management Employee Relations team

7 of 9

Appendix E - Operational HR Service Account:

Outline of key performance at the end of 2015/16

HR Service Performance Target Current Notes Area Performance at 1 April Recruitment Non Medical Recruitment process 9.9 weeks Achieved. Outliers are duration less than 10 weeks from reviewed where this is advert to start date. not achieved. Management customer service at 80% Where poor service is greater than 80% good or excellent. identified this is followed up individually.

Medical recruitment process duration 15 weeks Further reviews taking less than 16 weeks from advert to place of composition of start date. Consultant Recruitment panels including scheme of delegation. Management customer service at N/A No data. greater than 90% good or excellent.

Occupational Pre-employment checks processed 99% Currently meeting all key Health by OH in 3 days. KPIs for both UHS and Pre-employment checks cleared in 3 92% UoS. days.

Management referral appointments 94% offer within 3 days of request. Nurseries Nurseries by OFSTED as good or Both rated as Continued focus on customer better. good plans for 2016/17 to satisfaction achieve Excellent OFSTED rating. Employee No investigations (from start time to Achieved Further KPIs will be Relations submit of report) taking longer than 6 delivered once new months. software system is No individual suspended for more Achieved purchased as part of than 6 months at present. new model development.

Appraisal Performance by Division end of2015/16

It is noted appraisal performance has fallen below the expected level of 92%. Division B performance is noted as very positive and they have achieved and maintained 92% for a series of months.

Reviewed

Not Reviewed Reviewed Grand Total 188 Division A 297 1611 1908 84.43% 188 Division B 112 1422 1534 92.70% 188 Division C 317 2005 2322 86.35% 188 Division D 190 1320 1510 87.42% 188 Trust Headquarters - Division 187 1011 1198 84.39% Grand Total 1103 7369 8472 86.98%

8 of 9

Sickness absence rolling average performance for 2015/16

Turnover by Trust and by Nursing for 2015/16

9 of 9

Trust Board Meeting 26 May 2016

Title Chief Executive’s Report on Current Issues

Sponsoring Executive Fiona Dalton, Chief Executive

Authors’ names & Job Amanda Lowe, Associate Director of Corporate Affairs titles Purpose of the paper For To note o Formal For decision o information ☑ approval ☑

1. To alert Board to current news items available on the website. 2. To update Board on actions undertaken by TEC and not referred to Board. 3. To inform Board of the signing and sealing undertaken in accordance with SFIs. 4. To seek ratification of the Chair’s actions undertaken with regard to contracts in accordance with SFIs. History Monthly report.

Action Required 1. Ratify the action undertaken by the Chair (paragraph 5.1.1) 2. Note this report.

1. Current News Current news is available on the Trust website at http://www.uhs.nhs.uk/Home.aspx and CEO blog at http://www.uhs.nhs.uk/AboutTheTrust/Newsandpublications/Chief-executives-blog/Chief- executives-blog-28-April-2016.aspx

2. Recent Press Stories 2.1 In April/May 2016 the Trust received significant press coverage. A selection of stories is listed below. The full press releases can be found on the Trust’s website. 2.1.1 The Daily Echo ran an item on our specialist regional service for patients with neuroendocrine tumours being named a centre of excellence by the European Neuroendocrine Tumour Society. The service is made up of clinicians at Southampton General Hospital, the Queen Alexandra Hospital in Portsmouth and the Dorset Cancer Centre who form the Wessex NET Group. 2.1.2 The Daily Echo, The Engineer and Medical News Today reported on a new advanced 3D X-ray imaging technology, known as Microfocus CT, which is being used at Southampton General Hospital to give new insight into the way idiopathic pulmonary fibrosis develops in the body. 2.1.3 The Mail on Sunday, The Sun and The New Day ran items on a revolutionary weight loss operation developed in the US called bariatric arterial embolisation, which involves using tiny beads to block arteries and prevent the release of a hormone linked to food intake. Surgeon James Byrne is now preparing the first UK trial at UHS. 2.1.4 The Guardian, the Daily Echo, BBC South, Wave 105 FM, ITV Meridian, the Jersey Evening Post and a number of other regional online media highlighted the Trust’s contingency plans for the two-day junior strike. 2.1.5 Surgeon Robert Wheeler and former UHS medical director Dr Michael Marsh penned an article for the Health Service Journal on the development of the UK’s first department of clinical law and legal advice in hospital.

Page 1 of 3

2.1.6 Emergency Nurse magazine ran a brief item on plans for a new children’s emergency and trauma department at Southampton Children’s Hospital. 2.1.7 The Daily Echo, ITV Meridian, BBC South Today and Wave 105 FM covered the release of a new national report which rated the heart unit at Southampton Children's Hospital one of the best-performing in the UK. 2.1.8 The Echo ran a feature on emergency department nurse Arlene Brady following 50 years of service in the NHS. 2.1.9 Players and staff from Southampton Football Club made their annual trip to hospital meet young patients on the wards. This was covered by saintsfc.co.uk and the Daily Echo. 2.1.10 The Daily Echo, BBC South Today, BBC Radio Solent, ITV Meridian, That’s Solent TV, Wave 105, Heart and Capital South Coast covered the first major incident simulation exercise to be held at UHS involving clinicians, the fire brigade, ambulance service and casualties played by actors. This was also followed-up by the Echo the next day. 2.1.11 The Daily Echo featured the story of 71-year-old Allan Glass, who life was saved by clinicians at Southampton General Hospital. He underwent a combination of pioneering targeted radiotherapy and a bone marrow transplant after developing acute myeloid leukaemia ten years ago. 2.1.12 Emma Munro, head of nursing in research and development, talked to the Nursing Times about how a better understanding of the research nurse role is needed in hospitals. 2.1.13 The Daily Echo and Portsmouth News highlighted public listening events being hosted by NHS England to showcase the vision for world class vascular services in the south. 2.1.14 The Daily Echo ran an article on the Trust’s review of 24 Southern Health NHS Foundation Trust patients who died at UHS as a result of medical conditions or illnesses. 2.1.15 The Daily Echo and a number of other local and regional newspapers covered the story of Southampton breast cancer patient Nicola Hensser, who is the star of Cancer Research UK’s new TV awareness campaign. 2.1.16 The Daily Echo and That’s Solent TV covered the Trust’s celebrations for international nurses’ day. 2.1.17 ITV Meridian interviewed interventional radiologist Dr Jason Macdonald about the use of cutting-edge intra-arterial thrombolysis which was used to clear a blot clot in the brain and save the life of 18-year-old Ben Gray at SGH. 2.1.18 BBC South Today featured a road safety awareness event organised by paediatrician Clarissa Chase which took place in Southampton’s Guildhall Square and involved representatives of all the emergency services.

3. Actions from Trust Executive Committee (TEC) 3.1 The Trust Executive Committee (TEC) is a formal standing committee of the Trust, which executes actions from the Board and supports the operational management of the Trust. Business from the May 2016 period which was not passed on to Board include: 3.1.1 Staffing Status Report – the monthly report updated on the Trust vacancy position for ward, theatre and Allied Health Professionals - staff and doctors and provides assurance through TEC of staffing risks, and the actions taken to mitigate. The report also informs and improves decision support about recruitment and safe staffing alongside financial and activity plans. 3.1.2 Minutes from Division B Board Meetings February and March 2016 were received.

Page 2 of 3

4. Signing & Sealing 4.1 The Seal of the Trust is required to be fixed to some documents. There were 7 seals fixed between 21 April and 18 May 2016: 4.1.1 Managed Facility Contract for Business Support Offices between University Hospital Southampton NHS Foundation Trust (Customer) and UHS Estates Limited (Supplier) for the design and construction of fully equipped business support offices. Seal number 110. 4.1.2 Deed of Novation relating to the contract for the design and construction of a four-storey office building at Southampton General Hospital between Portakabin Limited (Continuing Party) and University Hospital Southampton NHS Foundation Trust (Outgoing Party) and UHS Estates Ltd (Incoming Party). Seal number 111. 4.1.3 Supplemental Agreement between Prime Infrastructure Management Services Limited and University Hospital Southampton NHS Foundation Trust to vary plans previously agreed under the Project Agreement relating to the Main Entrance Retail Area, Southampton General Hospital. Seal number 112. 4.1.4 Deed of Rectification and Variation of Headlease between University Hospital Southampton NHS Foundation Trust and Prime Infrastructure Management Services Limited relating to the Main Entrance Retail Area, Southampton General Hospital. Seal number 113. 4.1.5 Peppercorn Underlease between Prime Infrastructure Management Services Limited (Landlord) and University Hospital Southampton NHS Foundation Trust (Tenant) relating to areas of the Main Entrance Retail Area, Southampton General Hospital. Seal number 114. 4.1.6 Underlease between Prime Infrastructure Management Services Limited (Landlord) and University Hospital Southampton NHS Foundation Trust (Tenant) relating to Charities Unit (League of Friends) located within the Main Entrance Retail Area, Southampton General Hospital. Seal number 115. 4.1.7 Licence to Carry Out Works between University Hospital Southampton NHS Foundation Trust (Head Landlord), Prime Infrastructure Management Services Limited (Landlord), University Hospital Southampton NHS Foundation Trust (Tenant) and League of Friends of University Hospital Southampton NHS Foundation Trust (Undertenant) relating to Retail Unit 2 located within the Main Entrance Retail Area, Southampton General Hospital. Seal number 116.

5. Chair’s Actions 5.1 The Board has agreed that the Chair may undertake some actions on its behalf. The following action has been undertaken by the Chair: 5.1.1 Single Tender Action for annual maintenance contract for 6 Linacs (linear accelerators) and associated peripheral systems, for Radiotherapy Physics, from Elekta Limited at a cost of £868,074 including vat.

6. Recommendations 6.1 To ratify the action undertaken by the Chair (paragraph 5.1.1). 6.2 To note this report.

Page 3 of 3

Trust Board Meeting 26 May 2016

Title Annual Report Emergency Planning Response and Resilience

Sponsoring Executive Dr Caroline Marshall Chief Operating Officer AO

Authors’ names & Job Sandra Hodgkyns, Head of Security / Emergency Planning titles Response and Resilience.

Purpose of the paper For To note o Formal For decision o information ☑ approval o

History The Emergency Planning and Business Continuity met the required standard of Substantial in the national EPRR Standard 2015.

Main issues / Executive Our focus from the previous year had been to improve the Summary Business Continuity Plans within the Divisions. As part of the assurance process an improvement plan is required. This was submitted to the CCG in late 2015 and Trust Board in January 2016.

Improvements to Training. The Head of Security/ Emergency Planner (Hos/EPRR) will make some changes during 2016 to the delivery of the training for Tactical (Silver) Commanders and improve engagement within this field.

Prevent Training Prevent is part of the Government’s strategy for counter terrorism (CONTEST) and seeks to reduce the risks and impact of terrorism on the UK. CONTEST focuses on all forms of terrorism. The aim of Prevent is to ensure that there are preventative strategies in place across all agencies to support and divert people who may be susceptible to radicalisation, before they become directly involved in any illegal activity relating to acts of violence or terrorism. Health is a key partner in the Prevent agenda and raising awareness of Prevent among front line staff providing health care is crucial (NHS England 2014). Prevent training within the Trust is split into Level 1 –for those staff who have no patient interaction at anytime in their role, level 1 is an on line e- learning package. Level 2 is for all other staff and is a challenge to achieve, given the numbers affected. We have had some success in improving the numbers of staff that have attended the face to face training.

General Training As with previous years we have carried out Major Incident Training: ü April 2015 we were invited to participate in a Multiagency event in Fareham with the Cruise liner Industry reviewing what might occur in a major incident. ü June 2015 Exec and DDO’s and the Emergency Planning Team were invited by the LHRP to hear

1 of 2

Mark Scoggins, Solicitor Advocate, Fisher Scoggins Waters LLP , speak on Emergency Preparedness, Liability and Self-Defence, Leadership, Defensible decision-making and Learning from previous incidents. ü November 2015 we held a Silver Command LIVEEX. This was a multiagency response to Chemical Incident at Fawley refinery. ü November 2015 Missing Child Exercise – testing the plan ü November 2015 COMMEX ( Communication Exercise) ü January 2016 The Emergency Planning Team were trained by PHE to provide Loggist Training ü March 2016 Head of Security/ EPRR Completed Dip HEPEP ( awaiting final result) ü Major Incident Training has been provided to various groups including Duty Managers and some Divisional Groups

Policies All EPRR Policies are in date.

Major Incident Planning Group (MIPG) The MIPG is currently reviewing how UHS would manage in the event of a Paris style attack.

Joint working We continue to work with the Police and attend the Sub Group of the Local Health Resilience Forums (LHRF). Additionally we attend the City Council Public Health Meeting and also the PREVENT working group. Recently we have been working with the Southampton City Council on Mortuary Capacity and Mass Casualty. For 6 months the HoS/EP supported Salisbury Hospital with their EPRR assurance.

Implications Resource implication for Major Incident Exercise, staffing time.

Action Required For Board to note the importance of training and emergency preparedness at UHS, given the current heightened possibility of a major terrorist incident within the UK.

Next Steps Completion of the EPRR action plan Improving Major Incident Training Delivery Providing Major Incident Loggist Training for Duty Managers and Tactical Commanders Testing Divisional Business Continuity Plans Provide (Silver) Tactical and Gold (Strategic) Commanders with a focused training event.

2 of 2

Trust Board Meeting 26 May 2016

Title Annual Security Report 2016

Sponsoring Executive Dr Caroline Marshall, Chief Operating Officer (Security Management Director)

Authors’ names & Job Sandra Hodgkyns Head of Security/Emergency Planning titles Response and Resilience (Local Security Management Specialist) LSMS

Purpose of the paper For information To note o Formal For decision o ☑ approval o

History In May 2016 a report was provided to Trust Executive Committee on the work that had been undertaken over the last financial year relating to Security. The outline detail of that report is being provided to Trust Board for information and supporting the requirements from NHS Protect to update Trust Board annually on Security.

Main issues / Executive The key issue affecting security is the violence and Summary aggression exhibited to staff working within the Emergency Department, including the Security Team and also staff working within Medicine for Older People.

Hampshire Police are encouraging staff to report incidents of violence or aggression and where appropriate patients or relatives/visitors will be pursued by the police.

In March of this year there was a serious incident within the Emergency Department which lasted for 8 hours. From this 5/7 Security Officers were injured in one shift resulting in 3 of them being off sick with injuries, one is still off sick now. This had a wide range on impacts on the Security Team and others involved in the incident. The incident is being investigated under the Trusts SIRI Process.

Working relations The LSMS meets regularly with the police and in turn this has helped to support appropriate information sharing when there have been large police investigations within the community or within the Trust. The Trust also has a Police Engagement Officer covering the hospital and surrounding area. This works well as the LSMS and Engagement Officer meet and discuss incidents share information and feedback on outcomes. There are also a number of Police Officers who visit the Security Control Room on a regular basis which is excellent for proactive working. Work on reducing the amount of cycle thefts has also worked to due this partnership.

1 of 3

The LSMS has good links with the University Security Manager. Communication is also maintained by email and phone with NHS Protects Area Security Manager and other LSMS’s for support and advice, information sharing and bench marking; this information flows both ways. The LSMS continues to attend all regional meetings as required by the Secretary of State’s Directions. Once again we were compliant with the NHS Protect Self Assessment Standards rated as Green by NHS Protect.

The LSMS continues to be supported by the SMD (Dr Caroline Marshall) and meets with the SMD as required and also at 1:1.

Contract Monitoring The KPI’s for the Security Contract have been high during 2015 and the early part of 2016 apart from March when a serious incident affected their KPI’s following a Security Officer being reported to the police. Compliments however have remained high on a monthly basis which reflects the excellent work that the team do. Once again the team were nominated for Hospital Heroes and attended the Award Ceremony.

We are currently working with the Security contractor to try and improve the T&C for the Security Officers and also bring in Velcro restraints following the incident in March in line with the review process. We are also reviewing the possible use of body cameras.

Violence towards staff – Physical Assaults

51 60 45 40 44 45 36 33 37 36 34 37 40 27 20 0 15 15 15 16 16 15 15 15 15 15 16 15 ------Jul Jan Jun Oct Apr- Sep Feb Dec Aug- Nov Mar- May- Total number of physical assaults by Month ( Report from Lauren Woodley)

Security – Time security spend directly with patients

Service stats Accompaniment requirements include: Car Park Cash Runs 3.10 13.25 Car Park Issues Include: • Sectioned Patients • DOLS Coin/Note Jams • Patient Escort • Escrow Jams • Managing Aggressive Patients • • Ticket Jams Calculation based on 2 x Officer • Barrier Re-Set/Breaks in attendance requirement • Visitor Assists • Manual Machine Re-Sets Patient accompaniment • Machine Short Changes Monthly Comparison • Machine Ticket, Receipt or Ribbon 821.40 Hours Replenishment Feb 168.00 Hrs Sep 401.00 Hrs General Faults Mar 176.30 Hrs Oct 563.30 Hrs • Apr 396.00 Hrs Nov 459.10 Hrs (Calculation based on avg 10 min May 499.30 Hrs Dec 478.30 Hrs resolution time ) June 512.00 Hrs Jan 579.10 Hrs July 474.50 Hrs Feb 579.20 Hrs Aug 422.20 Hrs

25

2 of 3

Polices All polices are in date apart from one, (Lone worker Policy) which is currently under review at the moment.

CCTV The LSMS is continuing to upgrade the CCTV which is an old system and starting to fail. Our new contractors are working well with us and understand the financial constraints.

Implications The cost of our security contract has increased for a period of six months (March 2016- August 2016) to assist with capacity and increased resources in staffing. This is already budgeted and funded.

Action Required To consider and approve this annual report

Next Steps In late 2015 some staff from ED, MOP and QA hospital were able to trial breakaway techniques to help them in the work place if a patient or visitor were to attack them. This is not defensive training and could be used in any circumstances including with a frail patient. It also provides the staff with safe holding techniques again that could be used with any patient. The trial was so successful that staff from both Trusts asked if we would be rolling out the training. Both Security and H&S would like to support this in 2016.

Some very early work is being put into exploring alternative models of contracting for our security needs, including visiting other similar sized NHS Trusts to understand how they managed security problems and provisions.

3 of 3