Board of Directors - Central London Community Healthcare NHS Trust

Transcription

Board of Directors
Time: 1300-1430 hours
Date: Tuesday, 31 March 2015
Venue: Board Room, level 7, 64 Victoria Street,
London SW1E 6QP
Presenters are reminded to provide a succinct and focused introduction, highlighting the key questions and
only things which have changed since the preparation of the report
1
Administrative items
Time
1.1
Welcome, introduction and apologies:
P Chesters
Verbal
1.2
Patient story
Laura Holt
Verbal
1
1.3
Written questions from the public
Pamela Chesters To be tabled 2
1.4
Interests to declare
Pamela Chesters Verbal
1.5
Minutes of meeting held 25.02.15
Pamela Chesters Pages 3-8
1.6
Matters arising and action log
1.7
Chairman’s report
Pages 15-23
1.8
Chief Executive’s report
James Reilly
2
Operational items
Pages 24- 44
2.1
Integrated finance and performance report
Ian Millar
2.1.1 FRIC report to Board
Pages 45-70
2.2
Monthly staffing report
Louise Ashley
Pages 71-82
2.3
Draft key performance indicators 2015/16
Ian Millar
3
Governance / assurance items
Pages 83-94
3.1
Patient Safety – serious incident report summary
Louise Ashley
Pages 95-124
3.2
People strategy
I Millar
Pages 125-130
3.3
Information governance – annual report to Board
Ian Millar
Pages 131-144
3.4
Board self-certifications
James Reilly
3.5
Board committee reports
Committee chairs
Pages 145-146
Pages 147-149
3.5.1 Quality Committee report 16.03.15
3.5.2 Charitable Funds Committee report 09.03.15
3.6
Committee terms of reference
Anne Barnard
3.6.1 Finance, Resources and Investment Committee
3.6.2 Charitable Funds Committee
3.7
3.8
4
4.1
Risks identified during meeting
Issues/items for which further assurance is
required
Items to agree/note without discussion3
Committee Minutes
4.1.1 Quality Committee
4.1.2 Charitable Funds Committee
4.2
Pages 150-154
Pages 155-159
Pamela Chesters
Pamela Chesters
16.02.15
17.12.15
Verbal
Verbal
Pages 160-165
Pages 166-170
Date of next meeting in public:
Thursday, 30 April 2015, Board Room, Victoria Street SW1E 6QP
Attached – list of commonly used abbreviations pages 171-172 and key performance indicator
definitions pages 173-174
1
Written questions that are relevant to the agenda must be submitted in advance (at least two clear days) before the meeting to the Trust Secretary
Routinely if any questions are received
3
Unless notified in advance
2
In the interests of transparency, at the end of the meeting, ten minutes will be allowed for members of staff / public in attendance to
have an opportunity to ask questions relevant to the agenda or the work of the Trust. Questions will be accepted at the discretion
of the chairman; it will not be possible to answer any questions which refer to named staff or patients.
RESOLUTION
“That representatives of the press, and other members of the public, be excluded from part of the meeting
having regard to the confidential nature of the business to be transacted, publicity on which would be
prejudicial to the public interest”, section 1 (2), Public Bodies (Admission to Meetings) Act 1960.
Circulation: Board members, Trust Secretary, Committee Administrator, attendees
Agreed with Chairman 09.03.15
Board of Directors 1
Minutes of the meeting held on Wednesday, 25 February 2015
Education Centre, Edgware Community Hospital, Burnt Oak Broadway, Edgware HA8 0AD
Present
Pamela Chesters
Louise Ashley
Anne Barnard
Julia Bond
Tony Brown
Carol Cole
Joanne Medhurst
Ian Millar
James Reilly
David Sines
In attendance 2
Clare Gallagher
Ged Timson
Jayne Walbridge
Trust Chairman
Chief Nurse and Director of Quality Governance
Vice Chairman, Non-Executive Director
Non-Executive Director
Medical Director
Executive Director of Finance, Performance and Corporate Resources
Chief Executive
Care Navigator, Central London
Divisional Director, Networked Community Nursing and Rehabilitation
for R Milner
Trust Secretary
BoD/29/15
29.1
Welcome, introduction and apologies 3
Apologies had been received from:
Richard Milner, Deputy Chief Executive
BoD/30/15
30.1
Patient story
Clare Gallagher read a story from an elderly patient who has sustained a fracture in her
home. With the exception of the ambulance driver who had declined to assist her in walking
from her home to the vehicle, the patient was extremely complimentary about the
“remarkable” NHS services received. These included: rapid referral and physiotherapy
treatment, occupational therapy and receipt of equipment.
30.2
Members discussed the patients’ experience, noting the valuable service provided by the
care navigators and the benefit of practice multidisciplinary meetings in providing high
quality, coordinated care.
30.3
In response to questions, C Gallagher explained that while the patient had declined to make
a complaint regarding the ambulance driver, it would be possible to raise the issue informally
at the multidisciplinary team meeting with a view to determining the service’s policy on
assisting patients with impaired mobility.
30.4
Resolved
The Board thanked the team and the patient for the interesting story.
BoD/31/15
31.1
Written questions from the public
No written questions had been received.
BoD/32/15
32.1
There were no interests declared.
1
T
Sentences marked include an action for ELT members that does not require report back to the Board.
The meeting was observed by Mark Brice and Sean Overett from the TDA and Charles Martin from PWC.
3
Quorum = one third the membership including one officer and one NED member.
1
2
3
BoD/33/15
33.1
Minutes of the Board of Directors meetings held on 29 January 2015
The minutes of the Board of Directors meeting held on 29 January were agreed subject to
correction of paragraph 10.6 to read “… however the FRIC planned to continue to focus on
debtors and to emphasise the need to resolve long-standing issues.
BoD/34/15
34.1
The action log was reviewed and it was agreed that completed actions could be closed.
34.2
ABoD/02/15 Nurse staffing escalation policy
At the suggestion of the Chairman, it was agreed that while it was acceptable for actions to
be marked as complete when added to the programme of Board Committees, the Trust
Secretary must ensure that such actions are monitored to closure and reported back to the
Board if planned action by the Committee is postponed to ensure processes are robust.
34.3
ABoD/04/15 Health and safety policy
I Millar reported that the policy was being updated in line with the Board’s comments.
It was agreed that final sign off would be delegated to the NED lead for health and safety
and the Chairman. Action to remain open.
34.4
ABoD/05/15 Health and safety risks
Further to the email circulated to Board members, the full list of health and safety risks would
be considered by the Board later the same day - therefore Board action closed.
34.5
ABoD/07/15 Influenza campaign 2014/15
The scope of the peer review was being considered. A report to the Quality Committee
would be made later in the year – therefore Board action closed.
34.6
ABoD/010/15 Board self-assessment
Eight returns had been received to date, three outstanding returns to be provided as soon as
possible for collation. Action to remain open.
BoD/35/15
35.1
Chairman’s report
Fit and proper person test
Non-executive directors were advised to check their details as requested by the TDA, the
CLCH self-declarations signed in December 2014 had been shared, therefore there was no
need to repeat this exercise and this had been agreed with the TDA.
35.2
Resolved
The Chairman’s report providing an update on external, internal and membership events
was noted.
35.3
It was agreed that the current composition of the Council of Governors would be maintained
– for review when Governors are in situ.
BoD/36/15
36.1
Chief Executive’s report
Freedom to speak up
The recommendations would be considered together with review of the existing
whistleblowing policy for report to the Board in April 2015.
36.2
In response to P Chesters’ questions regarding how staff are identified / offered
opportunities to study, L Ashley confirmed that there were processes in place to identify and
support ‘rising stars’.
36.3
Resolved
The Chief Executive’s report was noted, including the Information Commissioner’s Office
statement following the voluntary audit and participation in the “hello my name is” campaign.
2
4
BoD/37/15
37.1
Integrated performance and finance report
The report had been discussed in detail by the Finance, Resources and Investment
Committee (FRIC) the previous day. A Barnard highlighted matters discussed in relation to
KPIs, including an increase in the number of KPIs rated red and focusing on clinical
outcomes, pressure ulcers, complaints, cancelled appointments, appraisals and vacancies.
An exception report in relation to cancelled appointments and clinical outcomes (if there was
no improvement in February) had been requested.
37.2
I Millar and S Graham had been asked to review the accuracy of data in relation to
vacancies.
37.3
The proportion of staff satisfied with care given had reportedly improved in Q3. This was
discussed and it was noted that due to anonymity was it was not possible to differentiate
between permanent and temporary staff.
37.4
J Medhurst was confident that the trajectory for clinical outcomes would be achieved in
March. It was confirmed that safeguarding was no longer included in the project but was
closely monitored through the local safeguarding board.
37.5
In response to C Cole’s questions regarding continuous improvement, J Medhurst reported
that an external review had been arranged to identify how to increase the uptake of training,
given the poor response from divisions to date.
37.6
L Ashley confirmed that action had now been taken to strengthen performance management
arrangements for complaints and that members could expect to see the Trust’s target (90%
resolved within 25 days) met in March and thereafter.
37.7
Financial performance
A Barnard reported that the value of recurrent QIPP identified (£10.5m) was, disappointingly,
£0.5m less than in M9, leaving a shortfall of £1.5m to be identified in the 2015/16 planning
round. The cash balance remained significantly above plan due to delayed payments to
NHS Property Services. The FRIC had been assured that, while capital expenditure was
behind plan, the capital resource limit would be met at year-end (for further report to FRIC in
March).
37.8
Resolved
The Board noted the Integrated Finance and Performance Report, including action agreed to
closely monitor and improve performance where required.
BoD/38/15
38.1
Monthly staffing report
L Ashley confirmed that minimum staffing levels had been achieved in January, explaining
that usage of staff (for example Marjory Warren) is adjusted as required in response to the
needs of specific patients and the balance between registered nurses and health care
assistants.
38.2
To date, there did not appear to be any correlation between staffing levels and individual
patient incidents (reference appendix 2 of the report), however this position was sensitive to
the level of agency usage.
38.3
Garside House, Princess Louise Kensington and Athlone House continuing care homes
continued to have high vacancy rates resulting from the divestment process and all three
units remain closed to admissions and under close review. A programme of supervision and
action learning had been instituted for non-permanent HCAs at the homes in support of
patient safety. L Ashley had discussed the issues with J Webster, Director of Nursing at
Central London, CCG, and it was acknowledged that urgent action would need to be taken if
the vacancy rate increased to 60%.
38.4
L Ashley confirmed that the Quality Committee would be considering the nurse staffing
3
5
escalation policy in April.
38.5
In response to J Bond’s questions regarding quality action team (QAT) involvement on
wards, L Ashley confirmed that a significant improvement had been achieved on both wards;
however, the QAT would not be withdrawn until there was evidence of sustained
improvement.
38.6
Resolved
The issues in relation to the nursing homes were well understood and members expressed
their appreciation for action taken to minimise the risks and ensure the safety of patients and
the work being undertaken by frontline staff under difficult circumstances.
38.7
It was agreed that it would be helpful for future reports to highlight that shift fill rates are
aligned to bed occupancyT.
38.8
The Board noted the monthly staffing report and that the requirement for care contact time
information would be included in staffing reports once the appropriate guidelines on this had
been issued.
BoD/39/15
39.1
Serious incident report
L Ashley confirmed that there had been a worrying increase in pressure ulcers across
London. A significant amount of work had been undertaken with the Trust’s own
bedded units with a demonstrable improvement seen; however pressure ulcer
management of patients in their own homes remained a concern. This would be
discussed at the ‘pressure ulcer nurse summit’ the following week and, further to the
suggestion of an external review at the Quality Committee, a review by Professor Jane
Nixon, Head of Nursing Research, University of Leeds, was being arranged. It was
suggested that it would be helpful to share the findings and any subsequent action plan
with commissioners.
39.2
It was confirmed that SI investigations were being completed on time but that there had been
a recent system error on STEISS which had incorrectly identified the Trust as having 11% of
overdue reports.
39.3
A Board briefing had been arranged later the same day to discuss the duty of candour.
39.4
Resolved
The Board noted the serious incident report and action taken to better understand the issues
in relation to pressure ulcer management in the community.
39.5
It was agreed that L Ashley would review the newly reported SIs (table 1) and confirm, by
email whether the category of “patient’s home” included residential units.
Action ABoD/12/15 (L Ashley)
BoD/40/15
40.1
IM&T strategy
The strategy had been considered in detail by the FRIC; progress in implementing the
strategy would be considered by the Committee in March 2015.
40.2
The following comments were made by Board members for inclusion:
• How progress against the strategy will be measured
• Greater emphasis on clinical aspects, including the Caldicott function
• Assistive technology – to emphasise what and how this will be used for the benefit of
patients
• How cultural challenges will be addressed, including training, education and pilot studies
• Mapping potential developments over the next five years, for example electronic
prescriptions
• Reference to the people strategy and workforce enablers, for example ESR and the
appraisal system
4
6
•
40.3
BoD/41/15
41.1
Business intelligence and how the needs of ‘customers’ can be met
Resolved
The Board approved the policy in principle subject to inclusion of comments from the FRIC
and Board, for final sign off by the FRIC Chair and Director of Finance, Information and
Corporate Resources.
Action ABoD/13/15 (I Millar)
External stakeholder strategy
P Chesters reported that the strategy had been discussed at the NEDs’ meeting. It had
been concluded that the document was overly focused on the FT application rather than the
benefits and need to secure high level relationships with key people in commissioning
organisations. NEDs were also disappointed that issues identified in the original BGAF
(2012) had not been adequately addressed and that this now required urgent attention. This
highlighted the importance of ensuring that in focusing on near term deadlines, the Trust did
not lose sight of longer term “slow burn” priorities.
41.2
Members offered the following comments for the final draft:
• To be clear on the direction and purpose of the strategy
• To be clear how stakeholder engagement will be embedded in the organisation,
including the roles and responsibilities of the Board and other officers
• To consider assigning named leads for specific audiences
• To reference how the CLCH brand will be promoted and championed
• To reference engagement with Health Education North West London and planning teams
across the sector
• Removal of reference to tiers of engagement
• A section on quality and clinical engagement including:
 CLCH links to professional groups in relation to clinical care
 Clinical engagement through the Medical Director, for example community education
and networks
 Working with the universities, including research
 More focus on GP liaison and the need to engage with and influence the integrated
management group.
41.3
Resolved
It was agreed that the engagement strategy must be progressed rapidly for consideration by
the Board, together with a separate engagement plan, in March.
Action ABoD/14/15 (I Millar)
41.4
It was agreed that the Board must give more attention to issues which may not have near
term deadlines, but which must be addressed to secure the longer term future of the Trust.
BoD/42/15
42.1
Membership strategy
The strategy had been refreshed in line with the production of the IBP. J Walbridge
highlighted that, at the Board’s request, targeted recruitment had led to an increase in the
number of members in the inner boroughs, however more work was required to achieve a
better balance of male and white British members to ensure this reflected the local
population.
42.3
Resolved
The refreshed membership strategy was approved. The Board thanked S Rush for her work
in progressing the Trust’s membership plans.
BoD/43/15
43.1
Engagement plan - update
The comprehensive update on the engagement plan was considered, members welcomed
the development of CBU plans, noting that these would be supported by the patient
experience facilitators.
5
7
43.2
It was suggested consideration could be given to engagement with relevant charitable
bodes, for example Age UK and Diabetes UK.
43.3
Resolved
The Board noted the report and thanked A Pritchard for his effort in implementing the Trust’s
engagement plans.
BoD/44/15
44.1
Resolved
The self-certifications for January 2015 were approved, for submission to the TDA.
BoD/45/15
45.1
Board Committee reports
Quality Committee report from 16.02.15
J Bond reported that the Committee had agreed for the Quality Account 2014/15 to be
audited by KPMG.
45.2
Workforce Committee report from 19.02.15
The Committee report was tabled following the meeting of 19.02.15. D Sines reported that
the focus of the meeting had been on the development of the ‘people strategy’ for Board
approval in March.
45.3
Resolved
The Board noted the Committee reports.
BoD/46/15
46.1
Risks identified during meeting
The risk in relation to stakeholder engagement was noted together with the action that had
been agreed.
BoD/47/15
47.1
Issues / items for which further assurance is required
No issues identified.
BoD/48/15
48.1
Confirmed Committee minutes received
Quality Committee 19.01.15
BoD/49/15
49.1
Code of governance comparison
Resolved
The comparison with Monitor’s code of governance was noted.
BoD/50/15
50.1
Date of next meeting in public
Tuesday, 31 March 2015, 64 Victoria Street, London SW1E 6QP
The meeting closed at 1050 hours
RESOLUTION
“That representatives of the press, and other members of the public, be excluded from part of the meeting having regard to the
confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”, section 1 (2),
Public Bodies (Admission to Meetings) Act 1960.
Signature …………………………………………………………….. Pamela Chesters, Chairman
Date ………………………………………………
6
8
Board of Directors Public Action Log
Action number
Date of meeting
Subject
Action
ABoD/04/15
29.01.15
Health and Safety policy
ABoD/06/15
29.01.15
ABoD/08/15
ABoD/10/15
Responsible officer
Due date
Comments
The Board approved the policy in principle, subject to
I Millar
comments and reformatting in line with the CLCH corporate
template, for final sign off by I Millar.The following comments
for inclusion were made: Accountability structure to be added
at appendix I, citing national guidance; Reference to roles and
responsibilities relating to the Board , as a whole and individual
Board members to be clarified and consistent throughout,
citing the HSE publication ‘leading health and safety at work’;
Inclusion of personal evacuation plans for disabled persons
(section 6.15); To determine the position for the children of
staff (for which CLCH should not be responsible); To consider
whether listing paragraphs in alphabetical order by heading is
logical as this may be more confusing that useful; To consider
how the policy would be implemented throughout the
organisation. To clarify the policy is signed off by the Board
and not ELT.
20.03.15
Some actions complete,
31.03.15
structure included and
reformatting planned. On
25.02.15, it was agreed that final
sign off of the policy would be
delegated to D Sines and P
Chesters.
open
Clinical Framework
Members welcomed the update framework with the following J Medhurst
comments: To include a description of the types of healthcare
professionals adults and children would meet; To consider how
the outcomes (ref table 4) will be applied at every level across
the organisation; Correction of the reference on page 7 to
table 2; To capture the sentiment of ‘no care without me’ in
the clinical principles; To ensure pages 4 and 13 of the
document are consistent in order; To review the positioning of
the research section, currently in the conclusion; Correction of
typographical errors in the ‘easy read’ version.
20.03.15
Framework updated noting
comments.
31.03.15
Complete
29.01.15
Influenza campaign
It was agreed that the Trust’s flu vaccination performance C Johnstone for J
in comparison to other Trusts, including those in London, Medhurst
should be circulated.
28.02.15
Completed.
31.03.15
Complete
29.01.15
Board self-assessment
Board members would be asked to complete and return the
annual self-assessment during February.
25.02.15
All received.
31.03.15
Complete
All members
Last reviewed / to be reviewed
Status - completed is defined as
confirmation received from ELT
responsible lead that the proposed
action is complete as described in the
comments column. Completed actions
will not be closed until the committee
has confirmed that action taken is
satisfactory.
9
Board of Directors Public Action Log
ABoD/12/15
25.02.15
Serious incident report
It was agreed that L Ashley would review the newly reported
SIs (table 1) and confirm, by email whether the category of
patient’s home included residential units.
ABoD/13/15
25.02.15
IM&T strategy
The following comments were made by Board members for
B Wheatley for I Millar
inclusion:
• How progress against the strategy will be measured
• Greater emphasis on clinical aspects, including the Caldicott
function
• Assistive technology – to emphasise what and how this will
be used for the benefit of patients
• How cultural challenges will be addressed, including training,
education and pilot studies
• To map potential developments over the next five years, for
example electronic prescriptions
• Reference to the people strategy and workforce enablers, for
example ESR and the appraisal system
• Business intelligence and how the needs of ‘customers’ can
be met
for final sign off by the FRIC Chair and Director of Finance,
Information and Corporate Resources
ABoD/14/15
25.02.15
External Stakeholder
Engagement Strategy
L Ashley
I McMillan for I Millar
Members offered the following comments for the final draft:
• To be clear on the direction and purpose of the strategy
• To be clear how stakeholder engagement will be embedded
in the organisation, including the roles and responsibilities of
the Board and other officers
• To consider assigning named leads for specific audiences
• To reference how the CLCH brand will be promoted and
championed
• To reference engagement with Health Education North West
London and planning teams across the sector
• Removal of reference to tiers of engagement
• A section on quality and clinical engagement including:
15.03.15
email sent 11.03.15 - 12 of the
14 incidents were in patient's
own homes, 2 were in
residential homes
31.03.15
31.03.115
Complete
31.03.15
Complete
Strategy updated accordingly
and sent for final approval to
FRIC Chair and Director of FPCR
24.03.15
16.03.15
send to Iain McMillan 26.02.15
for inclusion.
31.03.15
Open
example community education and networks
influence the integrated management group.
10
BOARD OF DIRECTORS
31 March 2015
Report title:
Chairman’s report to Board of Directors
Agenda item number:
1.7
Report of:
Chairman
Contact Officer:
Trust Secretary
Relevant CLCH 14/15 Goal(s)
1. Embody the best of the NHS for our patients: delivering great
results with compassion and thoughtfulness
2. Support people safely out of hospital: providing safe, high quality
value for money alternatives to hospital admissions
3. Deliver better value than competitors in our selected markets:
securing our sustainability by providing effective and efficient
services
4. Be responsive to our patients and partners’ needs: promoting
integration and partnership by demonstrating our capacity,
character and competence
5. Employ only the best staff: selecting staff who care and
supporting them to go the extra mile for our patients
6. Be innovation and technology pioneers: leading transformation
of out of hospital services to empower staff and improve patient
health
Freedom of Information
Status
Report can be made public
Executive Summary: An update on external and internal events, membership and engagement and
draft constitution and governance rationale.
Report for: Decision
Discussion
Information
11
1.0
External events
1.1
As part of our FT journey, the Chief Executive and I have continued our visits to three key
stakeholders to discuss our strategy and its alignment with commissioner intentions. We have
been well received by the Westminster HOSC, Hammersmith & Fulham HOSC and Barnet Local
Authority/Public Health.
1.2
I have been approached by Dr Ruth O’Hare concerning recent issues relating to data assurance and
have asked executives to bring this matter to the next FRIC meeting for further consideration.
1.3
I was pleased to represent the Trust at the 50th anniversary celebrations of Local Government in
London held at Westminster Abbey.
1.3
I have continued to support the TDA Leadership Academy in their work to increase the pool of
candidates ready to apply for Chief Nurse posts. Mock Chief Nurse interviews were held at CLCH
to provide training for this part of the application process.
1.4
Along with the Chief Executive, I have attended the FTN Providers Chairs and Chief Executives
conference. Speakers included the CEOs of both Monitor and CQC. It is clear the system is already
under severe strain and 2015/6 is anticipated to be even more challenging. We also attended the
FTN Providers Annual Conference on Quality which provided useful insights which we will consider
further in the context of CLCH.
2.0
Internal events
I had a very useful visit to Marjory Warren ward and was pleased to hear about the progress
being made by the team to improve patient care.
3.0
Non-executive director (NED) re-appointments
I am pleased to confirm that the NHS TDA’s Appointments Committee have agreed the
recommendation for the re-appointments of Anne Barnard, Julia Bond, Anthony Brown and the
extension of Carol Cole’s term, each as non-executive directors to the Trust Board, as follows.
•
•
•
•
3.1
Anne Barnard – term end 31/03/2018
Julia Bond – term end 31/03/2017
Tony Brown – term end 31/03/2016
Carol Cole – term end 31/07/2018
Associate NED
Anne Barnard and I have successfully concluded the interviews for the post of Associate Non
Executive Director, a one year pilot initiative. An offer has been made and verbally accepted and
the appropriate paperwork is being prepared.
3.2
Whistleblowing
Carol Cole has agreed to act as the designated NED should a whistleblower wish to contact a
non-executive director. A dedicated confidential email account is being established for her and
will be publicised in due course.
4.0
Membership update
4.1
Membership numbers (monthly target 70 new members).
12
As set out in the membership strategy recently updated and approved by the Board, public
membership will be increased by 1,000 new members this year. To assist in achieving this target
communications agency MES, who also host the membership database, undertook a recruitment
campaign to recruit 500 public members from our Trust walk-in centres, urgent care centres and
other community settings (libraries, leisure centres, colleges) across our four main boroughs.
February
Total as at 31 January 2015
New public members February 2015
Total as at 28 February 2015
Public
6,019
143
6,162
Clinical
staff
Non-clinical
staff
Total
2,196
731
8,946
2,183
715
9,060
12 members deleted
4.2
Membership engagement
4.3
Sign up to safety listening event
As many as 69 patients and members took part in Sign up to Safety listening events held in each of
our four principal boroughs in February and early March, led by the PPE team and supported by
the membership and communications teams.
The format for each two hour session included an introduction to the Trust and the sign up to
safety campaign, a short film of Charlie Sheldon, deputy chief nurse explaining the aims of the
campaign, followed by staff facilitated table discussions about the film and posing the question
‘What more could be done to improve patient safety when patients and clinicians work together?’
NED Carol Cole hosted the Barnet event.
Two of the events were filmed to capture table feedback on thoughts and ideas raised through
discussion and individual feedback on what people learnt, their experience of the event and what
improvements could be made to events for the future. These films will be used as evidence of
engagement on the Trust website. The films are also hosted on a ‘collaborative space’ that allows
the public to comments and share their views further. This is to allow people who were unable to
attend the event to participate.
http://www.clchlistening.citizenscape.net/core/portal/home
Engagement and discussions were lively and rich with similar themes coming from each session
such as, the importance of good communication, integrated care, utilising technology more and
sign-posting. Initial feedback has been shared with the staff group who also recently met to share
their thoughts and views on the campaign. The PPE team will draft a report for the Quality
Committee and we have committed to sharing progress with everyone who attended the events.
Work is under-way to plan the next round of listening event scheduled for May.
4.4
PLACE (patient-led assessment of the care environment)
There were two PLACE briefing sessions involving members held in February. There is now a list of
over 30 members who have been trained to undertake PLACE and will be called upon to do so in
late April and May, to avoid clashing with the CQC preparation and inspection timetable.
4.5
Parson’s Green signage way-finding
Two members volunteered to participate in a signage way-finding exercise at Parson Green to
assess and advice on improving signage for patients visiting the site.
13
4.6
15 Steps at Marjory Warren at Finchley Memorial Hospital also involved members this month.
4.7
One of our most active members Anthea de Barton Watson attended the Quality Stakeholder
Reference Group to provide independent feedback on a 15 steps challenge visit to Athlone House
Rehab Unit, that she took part in in December. This was part of a wider presentation given by the
CBU manager and clinical lead in response to concerns raised by one of the members of the group.
Anthea has now been invited to join the group on a regular basis.
14
BOARD OF DIRECTORS
31 March 2015
Report title:
Chief Executive’s Report
Agenda item number:
1.8
Report of:
Chief Executive
Contact Officer:
Trust Secretary
Relevant CLCH 14/15
Goal(s)
1. Embody the best of the NHS for our patients:
delivering great results with compassion and
thoughtfulness
Freedom of
Information Status
2. Employ only the best staff: selecting staff who care
and supporting them to go the extra mile for our
patients
Executive Summary: The CEO’s Report provides to the Board a summary of key
issues and developments that impact upon the trust which emanate from regulators,
national, regional and local arenas and which are occurring within the Trust itself.
Discussion
Information
15
1.
REGULATION
1.1
Care Quality Commission (CQC)
From 01 April 2015 all providers that have been inspected under CQC’s new
inspection regime (as we will be in early April) and issued with a formal rating
(anticipated in June / July) will be legally required to display that rating at the
premises where the service is being provided and on the website.
A guide for care providers on how to display ratings has been issued
The Fundamental Standards will also come into force on 01 April 2015. The
finalised Regulations Guidance provides direction for providers on meeting two
groups of regulations:
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which
encompass the new Fundamental Standards including the Fit and Proper
Persons Test (Regulation 5); the Statutory Duty of Candour (Regulation 20), and
the Display of CQC ratings (‘Performance Assessments’) (Regulation 20a).
Further guidance about Regulations 5, 20 and 20A will be published in March.
Care Quality Commission (Registration) Regulations 2009 (Part 4)
These will replace in its entirety CQC's Guidance about Compliance: Essential
standards of quality and safety and its 28 outcomes. The Regulations guidance
is available online.
The Trust’s preparations for the CQC comprehensive inspection commencing on
7 April 2015 are well advanced.
An unannounced inspection was made by the CQC at Princess Louise Nursing
Home on 16 March. The Trust is expecting a draft report to be received in early
April.
2.
CLCH DEVELOPMENTS
2.1
Our consultation with staff on a proposed updated vision and mission for CLCH
has now concluded and we will update our vision and mission.
From:
Our vision: To lead out of hospital community healthcare
Our Mission: To give children a better start and adults greater independence
To:
Our vision: Great care closer to home
Our Mission: Working together to give children a better start and adults greater
independence
This will better align with the strategic priorities of both the local and national
NHS as set out in the Five Year Forward View and rightly places the emphasis
16
on achieving high quality and integrated working in the delivery of community
healthcare services.
2.2
Foundation Trust (FT) Timeline – we have agreed a new timeline with the Trust
Development Agency (TDA). This means that the Higher Due Diligence
Assessment by Price Waterhouse Coopers will be in June 2015. The TDA
readiness review will occur in early September rather than late June and TDA
Board sign off to instigate the Monitor assessment will be in November. In effect
this extends the process by two months.
2.2
At the quarterly meeting of the Executive Leadership team with inner London
Clinical Commissioning Group (CCG) Chairs we discussed an agreement for the
sharing of information to enable better planning, the actions we are taking
following recent correspondence to improve data quality in relation to
performance, the progress in rolling out SystmOne (our new clinical record
system), the alignment of community nursing teams with GP practices and the
need to consider together the new models of care set out in the Five Year
Forward View.
2.2
We will be implementing the Care Certificate for all new employees in clinical
bands 1 – 4 from April 2015, following the recommendation from the Cavendish
Review. This will be undertaken in collaboration with Central and North West
London NHS Foundation Trust (CNWL) and Hounslow and Richmond
Community Healthcare NHS Trust to deliver the Care Certificate.
The Care Certificate is considered best practice for the induction and initial
training of this staff group. Achievement of the Care Certificate will ensure that
the healthcare support worker (HCSW) has the required values, behaviours,
competencies and skills to provide high quality compassionate care. The Care
Quality Commission will also be assessing the ability of organisations to provide
this enhanced induction/training to this staff group within their inspection criteria
as part of regulations 18 and 19 in April 2015.
2.3
Similar to the CLCH Board decision in February, the majority of all NHS
providers (88%) have chosen the new voluntary tariff option (the ‘Enhanced
Tariff Option’) for 2015/16. Those who opted to stay on 2014/15 prices will not
be eligible for CQUIN payments.
2.4
As part of CLCH’s investment in Information Technology, from 2 March 2015
CLCH’s adult community services will be using the innovative new SystmOne
technology to improve patient care.
2.5
SENIOR STAFF CHANGES: The Board will join me in thanking Louisa
McGeehan, head of communications, for her valued contribution to the work of
the Trust. Louisa is leaving at the end of March and will be taking on the new
role of the aspirant community foundation trust network facilitator.
We would also like to thank the following colleagues for their contribution and
support in the following roles over the last year. Iain McMillan, interim
commercial director, strategy and business development, who is leaving at the
end of March, Bruce Wheatley, interim chief information officer and Steve
17
Graham, interim head of human resources (HR) and organisational development
(OD) who are both leaving in May.
2.6
I am pleased to welcome the following new colleagues who will be joining CLCH
in the coming weeks. Tom Stevenson as the new head of communications and
external relations who will start on 1 April, he is currently the director of
communications at the North West London Collaboration of Clinical
Commissioning Groups
Emily Boynton, new divisional director of HR and OD, she is currently working at
Surrey County Council, Andrew Chronis as our new chief information officer and
Tom Wright our new divisional commercial director all commence employment in
May 2015.
2.7
In the run up to the national election, our Trust will follow official guidance
relating to the “Purdah” period from the 30 March. From that time to the election
we will not support any visits or provide any interviews by parliamentary
candidates. We have advised staff who are actively campaigning in the election
that this must be in their own time and without any involvement of the Trust.
3
REGIONAL DEVELOPMENTS
3.1
Attached is the Imperial College Health Partners briefing for March 2015
providing an update on projects and partnership events.
3.2
The Shaping a Healthier Future Programme Board has approved the submission
to the Treasury of a business case for Capital expenditure to progress the plans
for developing services across North West London.
3.3
North Central London convened a regional meeting of all providers and
commissioners to progress system changes required in the region. Carnell
Farrar has been commissioned to work with partners on developing this
programme.
3.4
Work is progressing to mobilise the Community Independence Service led by
Imperial College Hospitals NHS Trust and in which our Trust is a significant
contributor of services.
4
NATIONAL DEVELOPMENTS AND REPORTS
4.1
Recommendations following the Jimmy Savile investigation have been
considered and we are mapping our position with a view to developing and
implementing, rapidly, any action required to provide assurance to the Board
and the TDA, no later than 31 May 2015.
4.2
Sir Robert Francis’ report ‘freedom to speak up’ has been published,
recommending a wide-ranging reform of culture in healthcare, to ensure that
healthcare staff feel safe to raise concerns over patient care and treatment
without fear of reprisal.
18
Sir Robert’s stated priority is that “above all, behaviour by anyone which is
designed to bully staff into silence, or to subject them to retribution by speaking
up, must not be tolerated.”
To reinforce the concept of raising concerns as a safety issue, the report
recommends that responsibility for policy and practice should rest with the
executive board member who has responsibility for safety and quality rather than
human resources. It is also recommended that the Board should nominate a
non-executive director to receive reports of concerns directly from employees –
Carol Cole, NED has kindly agreed to undertake this role from mid April 2015.
In the meantime, the chief nurse and head of human resources have agreed to
review the Trust’s raising concerns policy in the light of these and other report
recommendations.
4.3
NHS England has announced the 29 ‘vanguard’ areas to develop new models of
integrated services which then can be replicated across the country. The
vanguard areas will be expected to spend the next year establishing three of the
new models of care set out in the NHS Five Year Forward View. These are:
multispecialty community providers (MCPs), primary and acute care systems
(PACS), and enhanced health in care homes. The expectation is that the MCPs
and PACS areas will be ready to run on a single capitated budget to pay for
health services for a defined population by the end of 2015/16. The vanguard
announced yesterday consists of 14 MCPs, 9 PACS and 6 sites trialling
enhanced health in care homes. In London an MCP Bid from Tower Hamlets
was successful as was a bid from Sutton to deliver enhanced care in care
homes. The successful bidders will still have to go through a “gateway process”
to assure that they are capable of implementing new care models quickly. The
vanguard programme will be supported by a £200m transformation fund.
It has been estimated that more than five million patients will benefit, just from
this first wave. For example, this could mean: fewer trips to hospitals as cancer
and dementia specialists and GPs work in new teams; a single point of access
for family doctors, community nurses, social and mental health services; and
access to tests, dialysis or chemotherapy much closer to home.
4.4
Kent Community Health NHS Trust is the third community trust to become a
foundation trust, and is the second largest community trust in England.
There are now 150 NHS foundation trusts in total, almost two-thirds of all trusts
in England’s NHS
4.5
It is reported that David Flory will step down as the chief executive of the NHS
Trust Development Authority in May. Mr Flory will retire on 7 May after running
the organisation responsible for managing NHS trusts since it was founded in
June 2012. Finance director Bob Alexander will be interim chief executive until a
new appointment is made, and Elizabeth O’Mahony will be the interim finance
director in Mr Alexander’s absence.
4.6
Greater Manchester and NHS England have announced groundbreaking plans
around the future of health and social care with a signed memorandum agreeing
19
to bring together health and social care budgets – a combined sum of £6bn. This
sees NHS England, 12 NHS Clinical Commissioning Groups, 15 NHS providers
and 10 local authorities agree a framework for health and social care – with
plans for joint decision-making on integrated care to support physical, mental
and social wellbeing.
4.7
Staff engagement – six building blocks for harnessing the creativity and
enthusiasm of staff. This recent King’s Fund publication encourages NHS
boards and other leaders to focus on staff engagement and suggests six
building blocks for ensuring a highly engaged workforce – a priority for our Trust.
4.8
The false or misleading information offence: guidance for providers has been
issued. The offence applies to commissioning and other data sets and other
specified information including information in quality accounts. A full schedule of
the data sets and other information is set out in The False or Misleading
Information (Specified Care Providers and Specified Information) Regulations
2015. These can be found at:
http://www.legislation.gov.uk/ukdsi/2015/9780111129234/schedule and covers
data set in relation to the collection of complaints collection and quality account
information.
4.9
The Chancellor presented his Budget Statement on the 18th March and included
within it was a commitment to £1.25bn extra funding for Mental Health Services.
National forecasts are indicating that the deficit for the provider sector of the
NHS will be between £800m and £1bn at the end of this financial year and
concerns are being expressed that the position will deteriorate further over the
coming financial year.
4.10
National Guidance was issued on the 10th March relating to the transfer of
commissioning responsibility for Health Visiting and other 0-5 children’s services
on the 1st October 2015 from NHS England to Local Authority Public Health
Services.
4.11 NHS England and Public Health England launched a national initiative on the 12
March to reduce the incidence of Type 2 Diabetes and thereby reduce the 4
million people projected to have this illness by 2025.
5
SUMMARY OF KEY DECISIONS FROM RECENT CONFIDENTIAL BOARD
MEETINGS
5.1
At the confidential meeting on 25th February 2015, the Board received the
contracts and new business report and discussed the draft annual plan, capital
plan and budget for 2015/16. The revised estates strategy and draft workforce
strategy were also considered. (The latter being in an early stage of
development and will come back to the public board meeting for final
consideration in due course.)
6
REPORT ON THE USE OF THE TRUST SEAL
6.1
The Trust seal has been applied in the following circumstances:
20
Date of Use Reason for use
Signatory
Witness
18 February
2015
Contract extension and
variation agreement between
the Mayor and Burgesses of
the London Borough of Barnet
and CLCH for the provision of
Mental Health and Learning
Disability Services.
Seal 56
Ian Millar
Jayne
Walbridge
10 March
2015
Contract for School Nursing
between Barnet Council and
CLCH, contract term
01/04/2015 – 01/03/2017
Seal 57
James Reilly
Jayne
Walbridge
James A Reilly
Chief Executive
March 2015
21
PARTNER BRIEFING
MAR 2015
PROJECT UPDATES
Patient safety
 Our patient safety collaborative – one of 15 nationally – is forging ahead and making great progress
with a number of initiatives underway. These include:
-
Foundations of Safety – a forum comprising of leaders and patients from across NWL who will be
part of a two year programme being developed in partnership with Ashridge Business School. The
programme will promote and foster best practice from within the NHS and other industries, and will
be an opportunity to share learnings and develop new initiatives across NWL. The programme has
over 45 members and will launch officially on 24 March.
-
Patient Safety Champion Network – a network of service users, carers and citizens from across
NWL who want to get involved in improving patient safety across NWL. In addition to champions
supporting ICHP work, we are keen to identify opportunities within our partners for champions to
get involved in safety improvement projects. ICHP will provide central training, development and
support for champions. More information can be found here. Please get in touch if you have local
opportunities for our champions to get involved in.
-
Measuring and monitoring safety – We are working with West London Mental Health NHS Trust
and West Middlesex Hospitals NHS Trust, to test a measuring and monitoring framework that aims
to answer the question: How safe is your organisation? The first workshop for clinicians, managers
and service users will be held on 20 March.
 For more information about ICHP’s patient safety work please see our project plan on a page
For more information please contact [email protected]
Medicines Optimisation
 On 3 March we launched a national programme of events on medicines optimisation, working in
partnership with NHS England and the Association of the British Pharmaceutical Industry (ABPI).
 Over 100 pharmacists, clinicians and patients from NWL attended the event where Bruce Keogh was
amongst the speakers. Various improvement initiatives across NWL were showcased with discussions
on enablers and barriers to scale up best practice interventions. Presentations and photos from the day
can be accessed here.
 We are now - engaging with key stakeholders on developing a detailed strategy that will incorporate
locally identified priorities for improving medicines optimisation including:
-
Visibility of patient journey to all staff
-
Staff capability development
-
Funding and resource
IMPERIAL COLLEGE HEALTH PARTNERS
PARTNER BRIEFING • MARCH 2015
22
PARTNER BRIEFING
MAR 2015
PROJECT UPDATES
Mental Health
 ICHP hosted a successful partnership event last month – over 90 clinicians, patients, local and national
stakeholders attended. The event launched the next phase of our Mental Health Programme and
celebrated the success of the first phase. Presentations from the event can be accessed here.
 In partnership with our CCGs, we have secured £550k additional funding from NHS England to support
the next phase of the programme which will focus on improving the early intervention pathway for
people with psychosis in NWL.
 Our work will support the access and waiting standards for first episode psychosis that were recently
published by NHS England which can be accessed here. For more information about our Mental Health
programme please see our project plan on a page
Neurorehabilitation
 We recently held a co-design workshop with patients and clinicians to review the care pathway and
develop a proposal for a new role to support best practice care in neurorehabilitation across NWL – the
neuro navigator. The role will help facilitate patients through the complex neurorehabilitation
pathway, working with teams to speed up access to specialist and community services. We plan to pilot
the role with two posts for a term of one year.
 We are also launching a pilot to test a new web-based referral tool in bedded and non-bedded sites
across NWL. The sites will include acute, inpatient rehabilitation and community rehabilitation
services. The tool is intended to improve patient access to all levels of services to ensure they receive
the right care at the right time and enable healthcare professionals to identify system bottlenecks along
the care pathway for service improvement opportunities.
 In October 2014, an interim report on the initial project findings was provided to commissioners
recommending additional capacity across the system. This is available here. We await the decision from
commissioners on this recommendation. Final recommendations to achieve long-term sustainable
change will be made to commissioners in Autumn this year.
UPCOMING MEETINGS AND EVENTS
Date
Event/meeting
Relevant for
Time
22 April
Partnership Board / Expert
Advisory Board dinner
Partnership Board directors, 1730 EAB members
2100
Athenaeum Club, Pall Mall,
London
12 June
Partnership Board meeting
Partnership Board directors
or alternates
ICHP offices,
10 Greycoat Place, London
0900 –
1200
Location
For more information about any of the above meetings or to register your interest please email
[email protected]
IMPERIAL COLLEGE HEALTH PARTNERS
PARTNER BRIEFING • MARCH 2015
23
BOARD OF DIRECTORS
31 March 2015
Report title: Integrated Finance and Performance Report
Agenda item number: 2.1
Report of: Director of Finance, Performance and Corporate Resources
Contact Officer: Divisional Director – Resources and Performance
Relevant CLCH 14/15 Goal: Embody the best of the NHS for our patients
Executive Summary:
Key points to note from the report are:
Performance:
All Trust KPIs are now RAG rated with 10 Trust KPIs rated as red during February (14 in January).
During February 2 KPIs achieved a Green rating which we previously Red (percentage of incidents
affecting patients that did not cause harm and percentage of staff which were satisfied with the
care they have provided) and 2 KPIs achieved and Amber rating which were previously Red ( staff
appraisal rate and percentage of clinical services capturing clinical outcomes).
Improvements were also seen in the Trust sickness rate and vacancy rate although these indicators
are still rated as Red however the Trust did experience lower performance relating to cancelled
appointments (although Trust performance is good compared to external benchmarks of similar
organisations) and complaints resolved within the Trust target of 25 days.
Pressure ulcers were lower in February but continue to be Red rated.
Quality:
During 3 out of 29 indicators were rated as red on the Trust quality scorecard during February (down
from 6 in January).
I&E Performance:
Trust surplus £1.8m YTD, favourable variance against plan by £16k. Forecasting £1.8m surplus
requiring £1.5m surplus on reserves, all of which is identified. The key issue impacting on the
unadjusted YTD position is unachieved / unidentified QIPP (causing a £1.6m adverse variance).
Usage of temporary staffing, remains a concern due to it representing the main variable element of
Trust cost.
•
Cash: Cash balances are above plan to date due to delayed payments to NHSPS offsetting
delays in collection of some debts including PACE, WIC/UCC and LA income.
•
Working Capital: Receivables >90 days 12% (11% Month 10), Payables >90 days 37% (25%
Month 10). The deterioration on the receivables performance is linked to delay in SLA
payments by CCGs, Trusts and local authorities as well as timing delays in payments to the
24
Trust which led to payments expected by the month end not being made till working day 2
of mth12. Payables continues to reflect the disputes with NHSPS but payments to other
suppliers such as RFL, Imperial and Chel West have now been authorised due to progress on
receiving payments from these organisation.
Assurance provided:
The report represents the aggregate results of the Trust performance.
Discussion
Information
25
Central London Community Healthcare NHS Trust
Contents
Page
• Overview
2
• Trust KPIs
3
• Finance
17
• Key Financial Issues
INTEGRATED FINANCE &
PERFORMANCE REPORT
TO
28th February 2015
18
• Corporate and Service Transformation Summary 19
26
1
Overview – The Must Knows
Quality
Finance
I&E Performance: Trust surplus £1.8m YTD; favourable variance against plan of
£16k. Forecasting £1.8m surplus requiring an underspend of just £1.5m on
reserves broadly consistent with £1.4m last month. The key issue impacting
on the unadjusted YTD position is unachieved / unidentified QIPP (causing a
£1.9m adverse variance); usage of agency staffing has remained at the Month
10 level reflecting the impact of controls on booking of interims.
QIPP: Trust is currently under-performing against YTD and year end plans, and
the forecast level of QIPP achieved during 2014/15 is consistent with Month
10. P21 shows the significant efforts being made to develop the pipeline of
alternative ideas for bridging the gap in year. The residual challenge of non
recurring solutions for 15/16 and beyond is being worked on.
Cash: Cash balances are above plan to date due to delayed payments to NHSPS
offsetting delays in collection of some debts relating to PACE, WIC/UCC and LA
income.
Working Capital: Receivables >90 days 12%, Payables >90 days 37%.
Workforce
Grade 2-4 Pressure Ulcer Incidents: The incidence of Pressure Ulcers this month
is 45 (58 in January). The pressure ulcer group is reviewing this by area to note
any issues relating to performance and the focus on training compliance
continues, backed up by the Pressure Ulcer Policy in place across the Trust.
Complaints Resolved within 25 days of Receipt: The level of complaints
resolved within 25 days of receipt was 3 out of 7 complaints resolved within the
target.
Percentage of Appointments Cancelled by CLCH: Performance has been
maintained at 2.7% or 4,013 appointments. Performance is green in two
divisions and red in two.
Performance
Ratio of Bank to Agency Staff: the %age of temporary staff provided via bank
has remained stable at C50:50 during February. further details are contained in
the exception report on page 11.
–
Friends & Family Test: Trust performance was stable during February however
it is still within the Amber threshold. Two divisions were amber in month with
two Red.
Staff from BME backgrounds at Band 7 and Above: a slight increase in Mth11
compared to Mth10 however this is still within Amber tolerance.
CQUIN performance is forecast to be £270k under achieved and there is risk
around SDIP income of £265k
Cancelled appointments has deteriorated during February with 4,000
cancellations in month
Staff Appraisal Rate: level of appraisal has increased in month to 82% (78% Mth
10) .
Vacancy Rate: while this measure is still red the vacancy rate has reduced in
month to 17.3% (18.7% Mth9).
Note:
= Trust KPI
= Other Must Know
27
2
Trust KPIs
28
3
February 2015 – Strategic KPIs (1)
NB. RAG ratings are shown against Trajectory targets, not End of Year targets
Embody the best of the NHS for our patients
Friends and Family test - Net Promoter Score (National
Methodology)
Amber
Friends and Family test - Net Promoter Score (CLCH Methodology)
Amber
60
Patients agreeing they were treated with dignity and respect
Amber
88
100%
86
56
80%
84
82
52
60%
80
48
40%
78
76
44
20%
74
72
40
April
May
June
Actual 2014-15
APCS
July
August
Sept
Actual 2013-14
NCNR
Oct
Nov
Dec
Jan
Target Trajectory
BCSS
Feb
March
100
90
80
70
60
50
40
30
20
10
0
APCS
May
June
Actual 2014-15
Amber Threshold
APCS
CHD
Lead Director: Louise Ashley
The record count for this month is 1592. Performance has remained stable during February,
and the Trust is still within amber threshold for the KPI. There is still some way to go to
fully achieving the target, which is unlikely to be met during this financial year. CHD was
the only division to meet the target this month. None of the Divisions met the target this
month, although two were within amber threshold.
Green
April
July
August
Sept
Oct
Actual 2013-14
Nov
Dec
Jan
Target Trajectory
BCSS
NCNR
Feb
0%
March
Amber Threshold
Actual 2014-15
CHD
APCS
The record count for this month is 1592. Performance has improved considerably during
February, and the Trust is still within amber threshold. There is still some way to go to
fully achieving this target, which is unlikely to be met during this financial year. BCSS met
the target this month, while two further divisions were within amber threshold.
Staff agreeing with the statement "I am satisfied with the care I give to
patients/services users" (quarterly)
Actual 2013-14
CLCH 2014 Target
NCNR
Amber Threshold
BCSS
CHD
The record count for this month is 1480. Performance has improved again this month, and
the Trust was just short of achieving the target during February. BCSS Division achieved the
monthly trajectory target again during February, and two further divisions were within
amber threshold.
Ratio of Bank to Agency Staff (Hours Based)
Red
70
60
50
40
30
20
10
Q1
Actual 2013-14
BCSS
Q2
Actual 2014-15
NCNR
Q3
Target
CHD
Q4
Amber Threshold
Finance &
Corporate
Quality &
Learning
Sample size: Q1 - 251, Q2 - 246, Q3 - 650
There has been a huge improvement in performance this quarter against Q2, and the Trust is fully
achieving the trajectory target as at Q3 14-15. Three operational Divisions and the Finance/
Corporate Division fully achieved the target, while CHD Division was borderline, with a score of 84.5%
against a target of 85%. Quality & Learning failed to achieve the target this quarter (73% agreed).
0
Apr-14
May-14
Jun-14
Jul-14
Bank Actual
APCS
NCNR
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Agency Actual
BCSS
Jan-15
Feb-15
Mar-15
Bank Target
Corporate
Departments
CHD
Lead Director: Steve Graham
Performance against target has remained stable during February. The Trust is therefore still failing to achieve this
target on a monthly basis, and is unlikely to meet the target during this financial year. None of the Divisions
achieved the target this month, although BCSS achieved amber status for the KPI. Please see attached exception
report from the HR Department for further information.
29
4
NB. RAG ratings are shown against Trajectory targets, not End of Year targets except where stated
Support people safely out of hospital
Amber
Proportion of Patients with No New Harms Recorded
99%
98%
97%
96%
95%
Amber Threshold
= 88.2%
94%
5
100%
4.5
90%
4
80%
3.5
70%
3
60%
2.5
50%
2
40%
1.5
30%
1
20%
0.5
10%
0
Actual 2014-15
CLCH target 2014-15
APCS
NCNR
BCSS
CHD
The Trust continues to achieve the national target for this metric of 96% but has not been
able to achieve our internal stretch target of 98%.
Green
Percentage of time bedded units achieving
minimum staffing each month
0%
Q1
Actual 2013-14
National Target 2014-15
Q2
Actual
Q3
Trajectory Target
Statutory & Mandatory Training
60.0%
300
50.0%
40.0%
200
30.0%
20.0%
20%
0%
Grade 2-4 Pressure Ulcer Incidents - Monthly & Annual Targets
400
70.0%
40%
Amber Threshold
500
80.0%
60%
Q4
Q3
Target
Lead Director: Dr Jo Medhurst
This KPI is measured on a quarterly basis only. Results for Q4 14-15 should be
available in April 2015.
Red
90.0%
80%
Q2
Actual
Amber Threshold
100.0%
100%
Q1
Q4
The QGAF has been subsumed into the CQC well-led programme. This KPI is therefore no longer being
monitored.
Green
120%
Hand Hygiene Audits
Green
QGAF Score
Green
100
10.0%
0.0%
Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
Monthly Value
APCS
NCNR
0
Trajectory Target
BCSS
Actual 2014-15
CHD
APCS
NCNR
Actual 2013-14
BCSS
CHD
Corporate
Departments
May
June
July
Aug
Monthly Actual 2014-15
Linear (Cumulative 2014-15)
Trajectory Target
Figures for February include the Winter Ward
Overall performance has remained stable during February, and the Trust continues to
Trust-wide performance has remained stable over the last month, and the Trust is still
achieving, and exceeding, the 100% monthly and end of year targets for this KPI. Both relevant meet the monthly trajectory target for this KPI. All Divisions met the target this month.
Divisions continue to meet the monhtly targets.
Trust-wide performance is currently 90.2%. The split across all courses for February is:
Clinical 91%, Non-Clinical 86%.
April
APCS
NCNR
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Cumulative 2014-15
Trajectory Target
BCSS
CHD
The Trust had 45 Pressures Ulcers in February, and the breakdown for this month
is as follows:
Grade 2 = 32, Grade 3 = 3, Grade 4 = 10
For further information, please see attached Exception Report.
30
5
NB. RAG ratings are shown against Trajectory targets, not End of Year targets
Deliver better value than competitors in our selected markets
Net New Business Won
Red
Proportion of Services capturing
Patients' Clinical Outcomes
Amber
65%
4.0
70.00%
2.0
60.00%
0.0
50.00%
-2.0
40.00%
-4.0
30.00%
-6.0
20.00%
35%
10.00%
30%
0.00%
25%
-8.0
YTD Value
-10.0
60%
55%
50%
45%
40%
20%
-12.0
End of Year
Target
-14.0
Lead Director: Iain McMillan
There has been a further deterioration in performance during February, and it is unlikely
that this target will be fully achieved during this financial year. Please see the attached
exception report for a full breakdown of gains and losses during 2014-15.
Percentage of incidents affecting patients that did not cause harm
Green
YTD Value (Actual)
Trajectory Target
Amber Threshold
April
May
June
July August
Monthly Value 2014-15
Sept
Oct
Nov
Trajectory Target
APCS
NCNR
BCSS
Dec
Jan
Feb
Mar
Amber Threshold
CHD
APCS
NCNR
BCSS
CHD
As at February 2015, 60.6% of services have identified a minimum of 3 outcome
This performance figure relates to a total of 354 incidents, 181 of which were harm free.
measures with electronic data collection. This is on track to deliver against the KPI
Performance has improved considerably during February, possibly due to a decrease in the
target for 2014/15. During February, a Clinical Outcomes Business Analyst has been
number of pressure ulcers recorded. The Trust fully achieved the trajectory target this
recruited to accelerate progress against this metric, as well as to develop the
specification for reporting mechanisms which will enable monthly reporting of all clinical month, although the YTD figure is slighly under the year end target. Two Divisions continue
to meet the monthly target, while NCNR has improved, and is now within amber threshold.
outcomes.
Lead Director: Jo Medhurst
Be responsive to our patients and partners needs
Complex complaints resolved within 60 days
Green
Complaints resolved within 25 days of receipt
Red
Red
120%
120%
3.0%
100%
100%
2.5%
80%
80%
2.0%
60%
1.5%
60%
40%
1.0%
40%
20%
0%
0.5%
20%
April
May
June
July
August
Sept
Oct
Nov
Dec
Target
Jan
Feb
March
Amber Threshold
0.0%
0%
April
May
June
July
NCNR
BCSS
CHD
APCS
These figures relate to 7 complaints received during February, 3 of which were resolved within the 25
day time period specified. Overall Trust-wide performance deteriorated again last month, with neither
of the relevant Divisions achieving the monthly trajectory target. Please see the exception report for
furthe information.
Percentage of Appointments cancelled by CLCH
August Sept
Oct
Nov
Dec
Jan
Feb
Mar
Target
APCS
NCNR
BCSS
CHD
All divisions, and therefore the Trust as a whole, continued to achieve the target for this KPI
during February. The figures relate to 3 complaints, all of which were responded to within the
given deadline.
Monthly Value
APCS
NCNR
Lead Director: Richard Milner
Trajectory Target
Amber Threshold
BCSS
CHD
4013 cancellations out of 146,789 appointments .
Two divis ions continue to meet the monthly trajectory target, however there has generally
been a deterioration in performance during February, and the Trus t as a whole is s till underachieving agains t this target. It is unlikely that the target will be met this financial year.
31
6
Employ only the best staff
Percentage of Staff that recommend CLCH as a place to work
Amber
6.00%
100.00%
70%
90.00%
60%
80.00%
50%
70.00%
5.00%
4.00%
60.00%
40%
Monthly Value
2014-15
Trajectory
Target
Amber
Threshold
30%
20%
10%
0%
Q1
APCS
BCSS
Q2
NCNR
Q3
40.00%
2.00%
30.00%
1.00%
20.00%
10.00%
Q4
CHD
Finance & Corporate Quality & Learning
Lead Director: Steve Graham Sample size for February was: 732.
The performance figure is taken from the Pulse survey on a quarterly basis. There was a
further small improvement in performance during Q3, and the KPI is currently within
amber threshold against the trajectory target. Three Divisions are still failing to achieving
the target, while the remaining three Divisons were within amber threshold for this target.
3.00%
50.00%
0.00%
0.00%
Apr-14 May-14 Jun-14
Actual 2014-15
Jul-14 Aug-14 Sep-14
Actual 2013-14
Oct-14 Nov-14 Dec-14
Trajectory Target
Jan-15 Feb-15 Mar-15
Amber Threshold
APCS
NCNR
BCSS
CHD
The Trust has continued to show an improvement against achievement of this target during February 2015, and is
now within amber threshold for this KPI. BCSS and CHD Divisions have achieved the trajectory target this month,
while the other three Divisions are just falling short of the amber threshold. The Corporate Departments
performance is borderline amber at 80.18% against the trajectory of 81%.
Jul-14
Aug-14
Sep-14
Oct-14
Actual 2014-15
Nov-14 Dec-14
Jan-15
Feb-15
Trajectory Target
Mar-15
Amber Threshold
Corporate
Departments
CHD
APCS
NCNR
BCSS
Performance has improved slightly during February, but the Trust is still under-achieving on this target. The
Corporate Departments met the trajectory target this month, and NCNR achieved amber threshold status. CHD
Division is also borderline amber at 3.88% against the target of 3.85%. For further information on this KPI, please
see the attached exception report from the HR department.
Staff from BME Backgrounds at bands 7 and above
Amber
20.0%
Actual 2013-14
Corporate
Departments
Vacancy Rates
Red
Sickness absence rate
Red
Staff Appraisal Rates
Amber
35.00%
18.0%
16.0%
14.0%
30.00%
12.0%
10.0%
8.0%
25.00%
6.0%
4.0%
2.0%
0.0%
Apr-14
May-14
Jun-14
Actual 2013-14
APCS
Jul-14
Aug-14
Sep-14
Actual 2014-15
NCNR
Oct-14
Nov-14
Dec-14
Trajectory Target
BCSS
CHD
Jan-15
Feb-15
Mar-15
20.00%
Amber Threshold
Corporate
Departments
There has been a considerable improvement in performance during February, however the Trust continues to underachieve against this target, and is not yet within amber threshold. None of the Divisions achieved the target this
month, although APCS and CHD Divisions are borderline amber. For further information, please see the attached
exception report from the HR department.
Apr-14
May-14
Jun-14
Actual 2014-15
APCS
NCNR
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Trajectory Target
BCSS
Jan-15
Feb-15
Mar-15
Amber Threshold
Corpora te
Depa rtments
CHD
Lead Director:
Steve Graham
Performance against this KPI has improved slightly during February, and is still within amber threshold for the
Trust as a whole. Two clinical divisions met the trajectory target this month, while NCNR Division is within amber
threshold. CHD and Corporate departments continue to under-achieve against the target.
32
7
Be innovation and technology pioneers
Percentage of QIPP plans achieving the planned level of savings in-year
Red
Recurrent QIPPS achieved % of total for the year
Red
The Innovation committee will see a number of projects each
year, some of which will be taken forward as pilots
35
100.00%
100.00%
Red
30
90.00%
25
90.00%
20
80.00%
15
80.00%
70.00%
70.00%
60.00%
Apr-14
May-14
Jun-14
YTD Value
APCS
NCNR
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Trajectory Target
BCSS
Jan-15
Feb-15
Mar-15
Amber Threshold
CHD
10
5
Jul-14
YTD Value
CORPORATE
DEPARTMENTS
Lead Director: Richard Milner
APCS
NCNR
Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
Amber Threshold
Trajectory Target
BCSS
CHD
CORPORATE
DEPARTMENTS
Lead Director: Ian Millar
Trust-wide performance has deteriorated again during February, and the Trust is still failing to meet the monthly
Trust-wide performance has continued deteriorated marginally during February, and the Trust is still underachieving against target. Performance within CHD Division has improved during February, and the division met the and annual trajectory targets. Three Divisions continue to meet the target on a monthly basis. Please see Finance
section for further details.
target this month. Please see the Finance section for further information.
GREEN
KPIs that are RAG rated GREEN on overall data quality confidence level.
100%
80%
6%
41%
20%
Target = 85%
29%
59%
60%
40%
7%
24%
64%
35%
35%
0%
Q1
AMBER
Q2
Q3
Borderline GREEN
GREEN
Q4
Trajectory Target
Lead Director: Mike Fox
The updates for 3 of the KPIs for Q3 have not yet been received, and the ratings for Q3 are
not therefore based on a complete dataset. However, the indications are that good progress
has been made, and that the target for Q3 (60%)has been met, or exceeded. 82% of a cti on
pl a ns from Q3 ha ve be e n compl e te d, a nd the re ma i ni ng a cti ons a re e xpe cte d to be
compl e te d by the e nd of Fe brua ry/Ma rch thi s ye a r.
0
Projects Reviewed
Actual
Projects taken forward
End of Year Target
Lead: Jo Medhurst, Medical Director
There have been no further improvements in performance against this target during
February. The Trust is not yet within amber threshold, it is therefore unlikely that the
target will be met during this financial year. The Trust hboard has discussed an
improved metric for Trust Innovation for next financial year which should better
reflect the level of innovation taking place in the Trust.
Number of Staff successfully completing the Continuous Improvement
Programme in 2014/15
As at 28th February 2015 there are currently 11 people who have successfully completed the
programme in 2014/15. The current cohort will run until 5th March 2015, which will
provide an additional 11 graduates. This will bring the year end total to 22 successful
completions, which is 10 short of the KPI target. A review of the programme is currently
underway, and the report will be presented at the March Quality Committee for initial
discussion. This will subsequently be subject to a Board discussion, although a date is yet
to be set for this.
Amber
33
8
Exception Report: Pressure Ulcer Incidence – February 2014
Review of Performance
Monthly Performance 2014-15 v.2013-14
The breakdown of the number of Grade 2,3 and 4 ulcers per month during 2014-15 is as
follows:
70
60
50
40
30
20
10
0
Actual 2014-15
Actual 2013-14
Monthly Threshold
Cumulative Performance 2014-15
500
Proposed remedial actions
Status
400
300
200
100
0
April
May
June
July
Aug
Sept
Cumulative 2014-15
Annual Threshold
Monthly Threshold
Cumulative 2014-15
Cumulative Threshold
Annual Threshold
Oct
Nov
Dec
Jan
Feb
Mar
Cumulative Threshold
Linear (Cumulative 2014-15)
Timescale
Pressure Ulcer competency & training remains a focus for the
quality team. New e learning refresher courses are in
development.
On-going
The quality committee are now receiving a quarterly deep dive
into pressure ulcers
On-going
It is hoped that the Sign Up To Safety Campaign will create
new initiatives to decrease pressure ulcer incidence.
On-going
A Pressure Ulcer Policy is now in place across the Trust.
New
New
Complete
On Target
Direction
of Travel
35
X
↔
381.26
416
34
9
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
41
46
35
46
31.90
416
44
45
35
91
34.66
416
42
48
35
139
69.32
416
31
46
35
185
103.98
416
49
38
35
223
138.64
416
45
52
35
275
173.30
416
46
46
35
321
207.96
416
35
48
35
369
242.62
416
34
43
35
412
277.28
416
35
58
35
470
311.94
416
32
45
35
515
346.60
416
28
Exception Report: Bank to Agency Ratio – February 2015
Ratio of Bank to Agency Staff (Hours Based)
Red
The 75:35 ratio has proven impossible to deliver as a target for this year, however
benchmarking has indicated that the average performance across London is 50:50.
Outside of London high performance is at the 60:40 ratio.
70
60
We have hovered around 50:50 all year and so have been performing as per our peers.
50
The KPI for 2015/16 will be a trajectory to 60:40 so work will have to continue to achieve
that and move away from agency to bank.
We continue to scope ways of make the bank more attractive with the move to provide
weekly payments to bank staff working in Barnet in order to increase and maintain the
size of the bank and a review of rates of pay using a recent benchmarking report
40
30
20
We will campaign to move agency workers onto the bank and increase the number of
clinical workers registered on the bank, success was achieved with the move of Agency
workers from No 1 recruitment to the bank, to reduce the reliance on clinical agency
workers
We will introduce tighter control of the Agency spend through a control panel as part of
the Trust wide QIPP programme from April 2015
10
0
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Bank Actual
APCS
Oct-14
NCNR
BCSS
51.7
51
48.3
52.3
52.5
47.7
Jul-14
52.7
54
47.3
Severity
M
54.1
55.5
45.9
52.4
57
47.6
Mar-15
Oct-14
51.6
58.5
48.4
49
61.5
51
Temp staff team
developing plans
to increase
numbers
Introduce Agency Control Panel to source and control length
of stay of agency workers
March 2015
Review bank payment rates using LPP benchmarking data
March 2015
New starters on
weekly, migration
to move monthly
underway
Introduce weekly pay for new starters
March 2015
Migrate existing monthly paid bank workers to weekly
On going
Review use of agency in light of staff flow to identify more
workers that can go through that system
Ongoing
Increased recruitment via international recruitment and over
hire of roles
Ongoing
Nov-14 Dec-14 Jan-15
50.9
60
49.1
We will increase substantive recruitment to reduce the reliance on temporary staffing by
utilising overseas recruitment and over hiring to clinical roles
We will focus on retaining staff through exit interviews and staff engagement activities
Mitigated
H
Aug-14 Sep-14
Feb-15
Corporate
Departments
CHD
Incentives to work on the bank
Jan-15
Bank Target
Number of staff registered to work with
bank
51
51
49
Dec-14
Agency Actual
Risk to achieving target
Bank Actual
Bank Target
Agency Actual
Nov-14
50
63
50
Feb-15 Mar-15 On Target Travel
50
64.5
50
65
X
↔
35 10
Exception Report: Vacancy Rates – February 2015
Vacancy Rates
Red
The target of 11% has proved difficult to achieve this year, however the last 3 months
have seen a significant drop in the vacancy rate to a level of around 15%. This
movement is due to a mixture of the increased rate of fill and the movement of staff out
of the organisation via TUPE reducing establishment.
20.0%
18.0%
16.0%
14.0%
The KPI target for 2015/16 will be 14% , which is the London average reported by the
RCN.
12.0%
10.0%
8.0%
To deliver this target we will continue to
6.0%
4.0%
2.0%
0.0%
Jul-14
Actual 2013-14
APCS
Aug-14
Sep-14
Oct-14
Actual 2014-15
NCNR
Nov-14 Dec-14
Jan-15
Trajectory Target
BCSS
CHD
Feb-15
Mar-15
Amber Threshold
Corporate
Departments
There has been a considerable improvement in performance during February, however the Trust continues to underachieve against this target, and is not yet within amber threshold. None of the Divisions achieved the target this
month, although APCS and CHD Divisions are borderline amber. For further information, please see the attached
exception report from the HR department.
Review opportunity for overseas recruitment
Timescales
Ongoing
Robust exit interview process
April
Resource plans for divisions and CBUs
April
Continue to recruit high numbers of new starters
On going
Review use of Overseas recruitment to bulk posts.
Talent bank model for clerical roles
Over hire to clinical roles
Continue high level of recruitment of new starters.
Use networks to increase attractiveness of CLCH
Status
The vacancy rate is also impacted by the number of leavers and the consequent
turnover.
Work has started to increase the take up of exit interviews, with some of the divisions
already providing analysis of the reasons for leaving.
This will continue to be promoted by HR BPs and Advisors and the data used to identify
potential trends on reasons for leaving. Most recent analysis have shown no single
major reason but reflect
a mobile workforce looking for opportunities in other locations or
Staff leaving for further education
In addition we will run focus groups through Q1 2015/16 with staff to find out why they
stay, and publicise the positive reasons for that.
DDOs will continue to be supported to produce resource plans for their divisions for
2015/16 to focus recruitment activity, this will support the development of a more robust
vacancy metric for 2015/16, which will look at vacancy rates per staff group recognising
the labour market
All of this work will be monitored at the Workforce Group and reported to the Workforce
Committee.
36
11
Exception Report: Sickness absence rate – February 2015
Red
6.00%
The sickness absence rate has been stable at 4% for several months. Whilst this is
declared red on the Trust 2014/15 KPI we have performed well against the NHS as a
whole and Community Trust in particular.
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
Apr-14
May-14
Actual 2013-14
Jun-14
Jul-14
Aug-14
Sep-14
Actual 2014-15
Oct-14
Nov-14
Dec-14
Trajectory Target
Jan-15
Feb-15
Mar-15
Amber Threshold
Corporate
Departments
NCNR
APCS
BCSS
CHD
Performance has remained stable during February, and the Trust is still under-achieving on this target. The
Corporate Division met the trajectory target this month, and NCNR achieved amber threshold status. CHD Division
is also borderline amber at 3.88% against the target of 3.85%. For further information on this KPI, please see the
attached exception report from the HR department.
Severity
The average sickness absence rate for the NHS as reported by the HSCIC during 2014
was 4.07%
The average sickness absence rate for Community Trust as reported in the Community
Trust Aspirant FT benchmarking was 4.5%
The average long term sickness absence rate for Community Trusts was 2.77%, we were
reported as 2.60%
The average short term sickness absence rate for Community Trusts was 2.32%, we were
reported as 1.6%
Mitigated
For 2015/16 this KPI will be amended to a sickness absence rate of 4% and will be green
from April
Work will continue with managers to support them with return to work interviews and
managing all absence to make sure the current grip on sickness absence is not lost .
Activity will continue to include
Reports sent to managers on monthly basis identifying staff who have hit trigger point for
short and long term absence.
Advisors cross reference absence report with returns to work and chase absent ones
Current grip on absence
management will ensure that the
target of 4% is maintained
M
Advisors and
managers have
delivered
absence at this
rate for past 6
months
HR advisors regularly meet with managers to ensure return to work interviews are done
and long term sickness absence episodes are met in line with policy
HR BPs oversee absence work for their division and report outliers at Divisional
management teams
Employee Health process referrals in timely fashion to support management of short term
and long term absence
Status
HR advisors regularly meet with managers to ensure
return to work interviews are done
Timescale
On-going
37 12
Exception Report: Net New Business Won – February 2015
Net New Business Won
Red
The main changes during February relate to termination notices or their values agreed,
these being:
4.0
2.0
Continence inner £1.1m (linked to the notice re Gynaecology and Urology, confirmed by
commissioners to now include continence).
0.0
-2.0
Smoking Cessation Barnet (£0.4m) previously omitted from my figures although notice
reported to FRIC and Board.
-4.0
Chlamydia Screening inner boroughs (£0.3m).
-6.0
Further detail Is provided in the Contracts and New Business Paper.
-8.0
YTD Value
-10.0
-12.0
End of Year
Target
-14.0
Net New Business won
Severity
Mitigated
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
YTD Value
-8.8
-8.2
-11.1
-7.9
-11.5
-5.0
-3.2
-3.2
-3.5
-3.7
-5.6
End of Year Target
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Mar-15
3.1
On Target
Travel
X
↓
38 13
Exception Report: Complaints Resolved within 25 Days – February 2015
Red
Performance has remained below target for February. Currently we have not achieved the
90% target in any month this year, and thus the annual target will not be met.
120%
100%
A review of processes has been undertaken. A key issue influencing performance has been
related to delays in returning draft responses to the complaints team. Changes have now
been made to ensure that a draft response is received from the service with time to address
any further investigation required, and Associate Directors of Quality (ADQ’s) are monitoring
this with their respective CBU managers.
80%
60%
40%
The Chief Nurse meets with the ADQ’s along with the Complaints and PALS team on a
weekly basis to review any delays in the response process, and weekly reporting on the
status of all complaints is in place.
20%
0%
April
May
June
July
August Sept
Oct
APCS
NCNR
Nov
Dec
Target
Jan
Feb
Amber Threshold
BCSS
Severity
March
CHD
Mitigated
Status
Timescale
Introduce new process and timescales for receiving draft
responses.
From 23rd
Feb 2015
April
May
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
March
100%
50%
90%
38%
14%
0%
13%
13%
14%
0%
29%
0%
43%
83%
57%
75%
75%
62%
79%
50%
71%
50%
43%
0%
Target
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
81%
81%
81%
81%
81%
81%
81%
81%
81%
81%
81%
81%
Amber Threshold
New
On Target
Travel
X
↓
39 14
Exception Report: Appointments Cancelled by CLCH – February 2015
Red
Overall performance has been above the amber threshold since August, at between 2.5% - 2.7%. Work
is underway to compare last year’s performance evolution month-by-month to understand whether
the September and February “surges” fit with the pattern of previous years and if December/January
holiday period drives additional cancellations.
3.0%
2.5%
2.0%
Consideration of other metropolitan community providers shows that cancellation rates are closer to
5%-7% and so the Trust needs to consider going forward whether the 14/15 target is realistic within
the operating environment. It is not clear from either the Barnet or inner London contract that the
2.0% figure is a contractual ‘must-do’.
1.5%
1.0%
Between Barnet and inner London services, it is by far the Barnet services where the higher numbers
of service cancellations occur. In BCSS this is driven by MSK, urology and community nursing and APCS
it is dental services. In inner London, BCSS is diabetes, continence and MSK. APCS is again dental.
0.5%
0.0%
Monthly Value
APCS
Trajectory Target
NCNR
Amber Threshold
BCSS
Severity
In addition to reviewing processes within specific services, teams will be encouraged to agree with the
BIPA experts a set of standard operating procedures to ensure that all relevant staff are working to a
common reporting definition of “cancellation by service”.
CHD
Mitigated
Absence of SOPs
Ongoing discussions with
ops and BIPA
Clinical staff not fully aware of S1
functionality and their ability to
reschedule
None
Define remit of “quick to resolve”
clinical admin vs “open-ended
and/or complex” SPA-type admin
Will be a function of above
re: knowledge of S1
functionality
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Monthly Value
2.3%
2.3%
2.2%
2.1%
Trajectory Target
2.1%
2.1%
2.1%
2.1%
Amber Threshold
2.30%
2.30%
2.30%
2.30%
Timescale
CBU managers to check datasets distributed by BIPA team and
advise if any amendments need to be made to the teams and
services included in the construction for this target.
March 2015
CBU managers to request historical trend analysis for each team or
service from BIPA to determine where specific problems lie, and to
action accordingly.
April 2015
2.3%
Sep-14
2.6%
Oct-14
2.6%
Nov-14
2.5%
Dec-14
2.6%
Jan-15
2.6%
Feb-15
2.7%
2.1%
2.1%
2.1%
2.1%
2.1%
2.1%
2.1%
2.1%
2.30%
2.30%
2.30%
2.30%
2.30%
2.30%
2.30%
2.30%
Status
Mar-15 On Target
X
Travel
↓
40 15
Quality Scorecard – February 2015
41 16
Finance
42 17
Key Financial Issues
Income
Expenditure
Year to Date
I&E Forecast
At Month 11, CLCH has achieved a £1,785k surplus (£1,753k Month 10);
this represents a £16k favourable variance against plan.
The Trust achieved an EBITDA margin of 3.4% as at the end of Month 11
which is broadly in line with plan.
The Trust is forecasting a surplus of £1.8m which is in line with the annual
plan. The forecast assumes an underspend of £1.5m (£1.4m Month 10) on
reserves (all of which is identified).
The Trust has identified several risks to achieving its financial plan include:
achieving CQUIN and SDIP related income in full and costs relating to
pathology services.
Income and Expenditure Summary
Year-to-Date (£'000)
Income & Expenditure
Income
179,558
180,482
924
1,446
Pay Expenditure
126,200
126,893
-693
-753
47,094
47,521
-427
-849
EBITDA
6,264
6,068
-196
-155
Depreciation
3,778
3,673
104
27
765
679
86
106
Interest Received
47
69
23
23
Surplus/(Deficit)
1,769
1,785
16
0
EBITDA Margin
3.5%
3.4%
Non-Pay Expenditure
Dividend
Quality,
Innovation,
Productivity
and
Prevention
(QIPP)
Balance
Sheet,
Capital and
Cash
The QIPP target for 2014/15 is £12m. As at Month 11 the Trust has
identified QIPP schemes with the value of £12.7m and is reporting underachievement of £1,898k against a year to date plan of £9,971k (£1,565k at
Month 10).
The Trust is currently forecasting achievement of £10.4m of QIPP by the
end of the financial year (£10.5m Month 10) resulting in a £1.6m forecast
adverse variance against plan; but after factoring in the £1.4m contingency
reserve for QIPP achievement this is reduced to £0.2m. During 2014/15
£9.0m of the forecast QIPP will be achieved in year through recurrent
schemes. The forecast achieved recurrent QIPP is £10.4m meaning there
is at present a £1.5m recurrent gap (£1.4m Month 10) which is being
addressed in business planning for 2015/16.
As at the end of Month 11 CLCH had a cash balance of £22.2m (19.2m at
Month 10). This is £10.8m higher than plan primarily due to outstanding
rent payments to NHS Property Services as they are yet to fully resolve
queries relating to their current and prior year billing. The cash balance is
forecast to reduce to £10.3m by the end of 2014/15 but this is dependent on
payments to NHSPS being authorised.
Capital Resource Limit for 2014/15 is £7.1m. As at Month 11, the Trust had
capitalised £4.4m (£3.9m at Month 10) of expenditure, this is £1.5m behind
plan due to Estates Backlog maintenance of £1.1m being back ended. This
will be subject to weekly monitoring through the Financial Controls team.
Statement of Financial Position
Opening as
at 01/04/14
£'000
Property, Plant and Equipment
Cash
Debtors
Total Assets
Total Liabilities
Net Assets
Surplus(Deficit)
General Fund b/f
Revaluation Reserve
Public Dividend Capital
Total Reserves
The Trust would achieve a CSRR of 4 out of 4 under the Monitor Risk
Assessment Framework.
Month 11
£'000
Forecast
Year end
£'000
39,444
13,968
15,107
68,519
40,095
22,201
18,327
80,623
42,440
10,307
7,721
60,468
-28,624
39,895
1,915
29,785
7,993
202
39,895
-38,943
41,680
1,785
31,700
7,993
202
41,680
-18,740
41,728
1,833
31,700
7,993
202
41,728
QIPP Plan Summary
CIP Target Identified RAG Adj YTD Plan YTD Act
Identified
The %age of Trust payables over 90 days was 37% and receivables 12%
compared to a target of 5%.
CSRR
Forecast
Variance
YTD Plan YTD Actual Variance
Total CIPs 2013/14
£'000
11,958
£'000
12,662
£'000
11,062
£'000
11,284
YTD Var FOT Var
against against
Plan
Target
£'000
£'000
£'000
9,385
-1,898
-1,428
43
18
Corporate and Service Transformation Summary
M11 CIP/QIPP position: Operational Divisions
Plan
Forecast
Variation
Change
FY Target M10 YE M11YE
in-month
£'000
£'000 £'000
£'000
Comments re: in month changes
Plan vs.
YE £'000
Corp
Servs
£3,834
£3,186
£3,149
-£37
Slight deterioration in forecast
£685
NNCR
£1,511
£873
£851
-£22
There is a reduction in the Phase 2 neuro transformation CIP as previously
identified CIP posts are now required for staff in post
£660
BCSS
£2,473
£2,382
£2,436
£54
In month improvement of £54k relates to the delivery of longstanding
pipeline scheme relating to 2 vacant posts (which will remain vacant for the
remainder of the year).
£37
CHD
£2,182
£2,137
£2,137
£0
No Changes in month
£45
All CIPS schemes have been identified and forecasted to achieve full year
target.
Within the month of October two schemes progressed from Amber to
Green:
9. Sexual Health re-design of administration and business management
function
29. Interpreting Services (reprofiled)
£1
APCS
£1,958
£1,957
£0
Total
£11,958 £10,535 £10,530
-£5
% gap
12%
£1,957
12%
£ gap to plan (excluding pipeline potential)
Plan vs. YE
including
pipeline
£'000
Comments re: gap to YE target
Pipeline schemes have an in-year value of £240k (£154k of which relate to
Estates - primarily linked to Barnet NHSPS and CHP management charges).
Additional schemes to meet this gap are currently being explored, including
freezing vacant posts and savings from Bedded Rehab schemes. The gap
includes pipeline schemes which have a total value of £29k.
The division previously reported a gap £90k from month 8 through to month
10. This has now been reduced to a gap of £37k after the delivery of a
pipeline scheme
The Division is working through the recurrent CIP plans for 15/16, which also
addresses the recurrent gap on the 14/15 CIP target (£165k) the in year gap
does not pose a risk to the 14/15 financial position.
The £1,000 deficit is due to rounding.
£444
£631
£37
£45
£1
£1,428 £ gap to plan if current pipeline potential is included
£916
Positive movement/position
Negative movement/position
No change in movement/position
44
19
BOARD OF DIRECTORS
31 March 2015
Report title:
Monthly Staffing Report (February Data)
Agenda item number:
2.2
Report of:
Contact officer:
Director of Patient Safety
Relevant CLCH goal(s)
1. Embody the best of the NHS for our patients: delivering great results
with compassion and thoughtfulness
securing our sustainability by providing effective and efficient services
integration and partnership by demonstrating our capacity, character
and competence
5. Employ only the best staff: selecting staff who care and supporting
them to go the extra mile for our patients
6. Be innovation and technology pioneers: leading transformation of out
of hospital services to empower staff and improve patient health
Can be made public
status
Executive summary:
This report provides the monthly performance against our set staffing numbers for in-patient beds, as per
the joint guidance to Trusts on the delivery of the ‘Hard Truths’ commitments associated with publishing
staffing data regarding nursing, midwifery and care staff levels.
The report also considers our quality indicators alongside the staffing of these wards and units.
Appendix 1 shows the day by day staffing.
Appendix 2 shows individual staffing and its relationship to individual incidents.
Appendix 3 is to be tabled in confidential Board.
Assurance provided: Continued monitoring of staffing in line with national guidance. Continued six-monthly
reviews considering our staffing against the most up to date guidance.
Report provenance: NA
Report for:
Decision
Discussion X
Information
45
Recommendation: To note the report
1. Introduction
This paper informs the Trust Board of the monthly staffing levels. The paper also seeks to provide assurance
both for the Trust Board and the public that any issues related to ward staffing are taken very seriously both
by front line staff and the organisation as a whole.
Assurance is also provided within this paper that the Trust has met all of its commitments as outlined in
the the guidance issued by Jane Cummings, Chief Nursing Officer for England, and Professor Sir Mike
Richards, Chief Inspector of Hospitals, Care Quality Commission and our staffing information submitted
to NHS Choices and displayed on our website.
http://www.clch.nhs.uk/health-professionals/providing-quality-services/staffing-levels.aspx
2. February Performance
Monthly Summary of Staffing Levels and Associated Quality Indicators
100% of the Trust’s in-patient units submitted complete data on time, which has been reported to the
national database via UNIFY.
Monthly Fill Rate
Athlone House
Ahlone Rehab
Garside
Princess Louise
Alexandra Rehab (PLK)
Jade
Marjory Warren
Pembridge
Winter Ward (CXH)
Whole Trust
Day
RN
80%
84%
89%
85%
67%
96%
95%
95%
114%
91%
HCA
114%
130%
101%
105%
124%
100%
171%
113%
181%
120%
Night
RN
HCA
100%
100%
100%
100%
67%
95%
100%
100%
96%
46%
104%
104%
123%
204%
100%
100%
96%
204%
98%
109%
46
3. Garside House, PLK & Athlone House Nursing Homes
The continuing care homes are running with a high level of vacancies mitigated by a high percentage of bank
and agency. This is due to the recruitment and retention issues largely resulting from the divestment
process, the SMART Bank is at times unable to fill a shift. If a RN is not available HCAs are over booked in an
attempt to compensate. There are also additional nurses who provide 1-1 care as agreed with
commissioners and the continuing care assessment team due to the complexity of the resident’s needs.
Regular recruitment drives are in place, the CLCH recruitment team have been asked to approach Nurse
Agencies regarding fixed term contracts for Band 5 and Band 6 nurses.
Beds have been closed on the ground floor at Garside (8 beds); PLK reduced to 18 beds on each floor i.e.
from a total of 45 beds to 36 beds across both the Dementia Unit and the Frail Elderly Unit; Athlone House
admissions are accepted on a one-out: one-in basis subject to staffing levels at the time.
47
48
49
4. Bedded Rehabilitation Units
A review of staffing is currently being undertaken for bedded rehabilitation in inner and Barnet Boroughs. In
inner boroughs this relates to the requirement to increase staffing as the trust will no longer be able to
provide RN cover between Nursing Homes and Rehabilitation when the NH service moves. In Barnet the
Associate Director for Quality is reviewing skill mix with the ward team.
50
51
52
53
5. Pembridge Unit
Currently there are no issues to report on Pembridge.
54
7. Winter Ward (Marjory Warren - Charing Cross)
The usage of staff related to this ward is due to the acuity of patients and cognitively impaired patients at
risk of falling.
8. New Guidance
As part of the new guidance on national monitoring (reported February paper) the Trust has been issued
with our initial performance on the draft performance indicator. This is currently embargoed so is
reported in confidential board papers.
9. Conclusion
The Trust has adjusted its staffing establishments to meet the required numbers and has a clear
policy of approving all staffing requests related to minimum numbers of staff or quality of care.
Inevitably at times it will be difficult to staff to the full levels particularly to cover short term sickness
but this is quickly highlighted and risk assessed.
55
Unit:
Athlone House
Month:
February
Early:
Late
Night
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
Reason Codes
Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat
1
2
3
4
5
6
7
8
9
10
11
12 13 14 15 16 17
18
19 20 21 22 23 24
25
26 27 28
19 19 19
20
21 19 19 19 19 19
19
19 20 20 20 20 20
19
20 20 20 20 20 20
20
19 19 19
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
1
2
2
1
2
2
2
2
2
2
1
1
1
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
4
3
1
4
2
2
4
4
4
3
1
4
4
4
4
4
4
4
4
4
3
1
4
3
1
4
2
2
4
2
2
4
3
1
4
2
2
4
2
2
4
2
2
4
4
4
3
1
4
3
1
4
3
1
4
3
1
4
4
4
3
1
4
2
2
4
3
1
4
4
4
3
1
4
2
2
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
19
2
2
19
2
2
19
2
2
20
2
2
21
2
2
19 19
2
2
2
2
19
2
2
19
2
2
19
2
1
1
19
2
2
19
2
2
20 20
2
2
1
2
1
20
2
2
20
2
2
20
2
1
1
19
2
2
20
2
1
1
20 20
2
2
2
2
20
2
2
20
2
2
20
2
2
20
2
2
19
2
2
19 19
2
2
2
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
3
3
1
3
3
1
3
3
1
3
4
3
4
3
2
2
3
3
1
3
3
1
3
2
2
3
2
2
3
3
1
3
3
1
3
3
1
3
2
2
3
4
3
3
1
3
4
3
4
3
3
1
3
3
1
3
2
2
3
3
1
3
2
2
3
2
2
3
3
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
3
2
1
1
4
1
3
2
2
4
1
3
2
1
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
4
1
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
19
2
2
19
2
2
19
2
2
20
2
2
21
2
2
19 19
2
2
2
2
19
2
2
19
2
2
19
2
1
1
19
2
1
1
19
2
2
20 20
2
2
1
2
1
20
2
2
20
2
2
20
2
2
19
2
2
20
2
2
20 20
2
2
2
2
20
2
2
20
2
2
20
2
2
20
2
2
19
2
1
1
19 19
2
2
1
2
1
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
2
1
1
2
2
2
1
1
2
2
2
2
2
1
1
2
1
1
2
1
1
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
1
2
3
4
5
6
7
8
Sickness
Unfilled bank shift
Escort
Special
Unauthorised absence
Vacancies
Annual Leave
Mandatory Training
56
Unit:
Athlone Rehab
Month:
February
Early:
Late
Night
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
1
2
3
4
5
6
7
8
9
10
11
12 13 14 15 16 17
18
19 20 21 22 23 24
25
26 27 28
19 19 19
19
18 16 18 18 18 19
19
19 19 20 20 20 20
21
21 22 23 23 23 22
21
21 21 21
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
2
2
2
2
2
3
2
2
2
2
2
3
3
3
2
1
1
1
2
1
2
2
2
1
2
1
1
1
1
1
2
-1
6
3
0
3
0
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
3
0
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
3
0
3
0
3
0
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
4
4
2
4
4
2
4
4
2
4
4
2
4
4
2
4
4
2
4
3
2
4
3
2
4
4
2
4
4
2
4
4
2
4
4
2
4
4
2
4
3
2
4
3
2
4
4
2
4
4
2
4
4
2
4
4
2
4
4
2
4
3
2
4
3
2
4
4
2
4
4
2
4
4
2
4
4
2
4
4
2
4
3
2
6
2
6
2
6
2
6
2
6
2
6
2
5
1
5
1
6
2
6
2
6
2
6
2
6
2
5
1
5
1
6
2
6
2
6
2
6
2
6
2
5
1
5
1
6
2
6
2
6
2
6
2
6
2
5
1
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
19
2
2
19
2
2
19
2
2
19
2
2
18
2
2
16
2
2
18
2
2
18
2
2
18
2
2
19
2
1
1
19
2
1
1
19
2
2
19 20
2
2
2
2
20
2
1
1
20
2
2
20
2
2
21
2
2
21
2
2
22 23
2
2
2
2
23
2
2
23
2
2
22
2
2
21
2
2
21
2
2
21
2
2
21
2
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
4
2
2
4
4
1
4
3
2
4
3
2
4
3
2
4
2
2
4
3
1
4
3
1
4
5
4
5
4
5
4
5
4
4
4
4
4
5
4
5
4
5
4
5
4
5
4
5
4
4
4
4
4
5
4
5
4
5
4
5
4
5
4
4
4
0
5
1
5
1
5
1
5
1
4
0
4
0
4
0
5
1
5
1
5
1
5
1
4
0
4
0
5
1
5
1
5
1
5
1
5
1
5
1
4
0
4
0
5
1
5
1
5
1
5
1
5
1
4
0
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
19
2
1
1
19
2
1
1
19
2
1
1
19
2
1
1
18
2
1
1
16
2
1
1
18
2
2
18
2
1
1
18
2
1
1
19
2
1
1
19
2
2
19
2
2
20 20
2
2
2
2
20
2
2
20
2
2
21
2
2
21
2
2
22
2
2
23 23
2
2
2
2
23
2
2
22
2
2
21
2
2
21
2
2
21
2
2
21
2
2
21
2
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
57
Unit:
Garside House
Month:
February
Early:
Late
Night
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
1
2
3
4
5
6
7
8
9
10
11
12 13 14 15 16 17
18
19 20 21 22 23 24
25
26 27 28
28 28 28
28
28 28 28 28 28 28
28
28 29 29 29 29 29
29
29 29 29 29 29 29
29
29 29 29
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
2
3
4
2
3
1
3
3
2
2
3
4
3
1
3
3
2
3
3
2
2
3
3
3
4
3
1
1
2
1
1
1
1
1
2
1
1
1
1
2
1
1
1
1
1
1
1
3
2
4
4
2
4
3
3
4
3
4
4
4
4
2
3
4
4
4
4
3
3
4
4
4
4
3
2
-1
-2
0
0
-2 0 -1 -1
0
-1
0
0
0
0
-2
-1
0
0
0
0 -1 -1
0
0
0
0 -1 -2
2
2
2
2
2
2
2
2
2
2
2
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
6
2
6
5
6
6
6
6
6
6
6
4
6
3
4
6
0
1
6
0
6
0
6
0
1
7
1
4
2
6
0
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
28
3
1
28
3
3
28
3
2
28
3
3
28
3
2
2
3
0
3
0
1
3
0
3
0
2
-1
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
6
3
6
4
2
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
28
3
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
4
1
3
4
0
4
7
1
4
1
1
2
-1
6
6
5
6
5
6
4
6
6
4
7
1
4
6
3
1
3
7
1
4
1
6
0
2
7
1
4
2
6
0
6
5
1
6
0
6
2
3
2
7
1
4
6
3
2
1
6
0
6
4
2
6
0
6
3
2
2
7
1
4
6
3
6
3
6
0
3
6
0
3
6
0
28
3
2
28
3
1
28
3
3
28
3
2
28
3
2
28
3
2
1
28
3
3
29 29
3
3
3
1
29
3
2
29
3
2
29
3
2
29
3
2
29
3
2
1
3
0
2
3
0
3
0
1
3
0
1
3
0
3
0
3
0
3
0
2
3
0
1
3
0
1
3
0
1
3
0
1
3
0
6
4
6
2
6
2
2
6
0
6
3
1
2
6
0
6
3
6
0
6
3
2
1
6
0
6
5
1
6
5
6
2
6
0
6
2
3
1
6
0
6
5
4
6
0
6
4
2
6
4
1
6
0
6
1
2
3
6
0
3
6
0
4
6
0
4
6
0
2
6
0
28
3
1
1
28
3
2
29 29
3
3
1
2
1
29
3
2
29
3
2
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
4
1
2
1
4
0
6
2
2
2
6
0
6
5
28
3
1
28
3
2
28
3
2
28
3
1
28
3
1
28
3
1
28
3
1
28
3
1
28
3
1
1
2
-1
6
2
-1
6
2
-1
6
1
2
-1
6
1
2
-1
6
1
2
-1
6
1
2
-1
6
1
2
-1
6
1
2
-1
6
4
1
3
4
4
4
4
4
4
4
4
4
3
1
4
3
4
2
2
4
2
2
4
1
3
4
2
2
4
1
3
4
1
3
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
1
6
0
1
4
0
6
0
6
3
2
1
6
0
6
5
6
3
2
1
6
0
6
2
2
2
6
0
6
4
2
6
0
6
1
1
4
6
0
6
2
2
1
5
-1
2
5
-1
1
1
3
0
29 29
3
3
1
1
1
2
1
3
3
0
0
29
3
1
2
29
3
1
29
3
1
29
3
1
29
3
1
29
3
1
29
3
3
1
2
-1
6
1
2
-1
6
1
2
-1
6
1
2
-1
6
1
2
-1
6
3
0
6
2
3
1
6
0
6
1
3
2
6
0
6
4
1
6
0
6
2
3
1
6
0
6
2
1
3
6
0
6
1
2
3
6
0
6
2
2
2
6
0
6
2
2
6
0
6
1
3
2
6
0
4
6
0
6
2
2
2
6
0
29
3
1
1
29
3
2
29
3
2
29 29
3
3
1
2
1
29
3
1
29
3
2
29
3
2
29
3
2
29
3
2
29
3
2
29
3
2
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
1
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
4
3
1
4
2
2
4
3
1
4
2
2
4
3
1
4
2
2
4
2
2
4
2
2
4
1
1
4
2
1
4
2
1
4
3
4
3
4
0
4
0
4
0
4
0
4
0
4
0
4
0
4
0
2
-2
6
3
-1
6
3
-1
6
3
-1
6
3
-1
6
1
6
0
3
0
6
4
1
6
4
1
1
6
0
58
Unit:
Princess Louise
Month:
February
Early:
Late
Night
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
Sun Mon Tue Wed Thu Fri Sat Sun Mon
1
2
3
4
5
6
7
8
9
42 42 42
42
42 41 41 41 41
5
5
5
5
5
5
5
5
5
3
3
3
2
2
2
3
3
3
1
2
2
2
1
1
1
1
1
4
5
5
4 3
3
4
4
4
-1
0
0
-1 -2 -2 -1 -1
-1
6
6
6
6
6
6
6
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
8
5
3
8
5
3
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
42
4
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
8
4
6
8
4
3
10
2
4
7
-1
2
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
42
2
1
1
42
2
1
1
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
6
5
1
8
0
3
8
5
3
42
4
2
2
3
-1
2
8
3
5
8
2
6
8
4
5
8
4
5
8
4
5
8
5
5
8
5
4
8
2
6
8
2
6
9 10
1 2
4
4
7
-1
2
8
0
8
0
9
1
4
9
1
4
9
1
4
10
2
9
1
4
8
0
8
0
42
4
1
2
42
4
2
1
41
4
41
4
1
3
41
4
1
1
41
4
2
4
0
4
0
2
-2
2
2
4
0
2
4
0
41 41
4
4
1
3
3
3
4
-1 0
2
41
4
1
3
3
-1
2
41
4
1
1
1
3
-1
2
41
4
2
3
-1
2
2
1
3
-1
2
41
4
2
2
8
4
3
3
10
2
8
5
4
8
2
6
8
1
5
8
2
6
8
3
5
8
4
4
8
5
4
8
5
3
8
4
4
8
4
4
8
0
6
-2
2
8
0
8
0
8
0
9
1
4
8
0
8
0
8
0
42
2
1
1
42
2
1
1
42
2
1
41
2
41
2
41
2
2
1
1
2
0
41
2
1
1
41
2
1
1
41
2
1
1
2
0
1
1
2
0
41
2
1
2
0
2
0
6
4
2
6
3
3
6
4
2
6
2
4
6
4
2
6
5
1
6
0
6
0
6
0
6
0
6
0
6
0
8
0
42
4
2
2
4
0
2
0
6
3
3
6
0
8
3
4
4
0
2
0
4
2
0
6
3
3
6
0
Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat
11
12 13 14 15 16 17
18
19 20 21 22 23 24
25
26 27 28
41
41 41 41 41 41 41
40
40 40 40 40 40 40
40
40 40 40
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
2
3
2
2
2
2
3
2
2
2
3
2
1
2
2
2
2
1
1
2
2
1
1
4
2
1
3
3
1
2
1
2
1
1
2
1
1
2
2
1
4
5
4
4
4
3
5
4
4
3
4
4
5
5
4
4
4
4
-1
0 -1 -1 -1
-2
0
-1
-1 -2 -1 -1
0
0
-1
-1 -1 -1
5
6
6
6
6
6
6
6
6
6
6
6
6
5
8
5
5
8
0
8
5
4
Tue
10
41
5
3
1
1
5
0
9
1
2
0
6
3
3
6
0
6
0
1
2
0
1
2
0
8
2
2
5
9
1
4
8
6
3
8
8
1
8
5
3
8
4
5
8
4
4
8
2
6
8
3
5
8
3
6
8
7
2
8
5
4
8
5
3
8
5
4
9
1
4
9
1
4
8
0
9
1
4
8
0
8
0
8
0
9
1
9
1
4
9
1
4
8
0
9
1
41
4
2
41
4
40
4
1
40
4
40 40
4
4
1
2
1
2
1
3
4
-1 0
2
40
4
1
3
40
4
1
3
40
4
2
40
4
1
40
4
4
0
2
4
0
2
3
-1
2
40
4
1
3
4
0
40
4
1
2
1
4
0
8
3
6
8
5
3
8
4
4
8
1
7
8
5
3
8
2
5
8
3
5
8
5
3
8
4
4
9
1
4
8
0
8
0
8
0
8
0
7
-1
2
8
0
8
0
8
0
40
2
40
2
2
40
2
40
2
2
40
2
40
2
2
40
2
1
1
2
0
2
0
2
0
2
0
1
1
2
0
1
1
2
0
4
0
1
3
-1
2
1
2
3
-1
2
8
3
5
8
4
4
8
5
4
8
2
7
8
5
3
8
0
8
0
9
1
4
9
1
4
8
0
8
4
1
3
8
0
41 41
2
2
1
41
2
41
2
2
41
2
2
40
2
1
1
40
2
1
1
2
0
2
0
2
0
2
0
40 40
2
2
1
1
2
1
3
2
1
0
1
1
2
0
3
4
0
4
4
0
1
1
2
0
3
1
4
0
4
0
2
0
1
2
0
1
1
-1
2
6
4
2
6
4
2
6
3
3
6
5
1
6
4
2
6
1
5
6
2
4
6
3
3
6
2
4
6
3
3
6
2
4
6
5
1
6
2
4
6
2
4
6
4
2
6
5
1
6
4
2
6
6
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
59
Unit:
Alexandra (PLK)
Month:
February
Early:
Late
Night
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
1
2
3
4
5
6
7
8
9
10
11
12 13 14 15 16 17
18
19 20 21 22 23 24
25
26 27 28
9
9
9
10
11 11 11 11 11 10
11
11 11 11 11 11
9
9
8
8
9
9
9
9
9
10 11 11
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
2
2
2
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
-1
6
1
-1
6
2
0
2
0
2
0
1
-1
6
1
-1
6
1
-1
6
1
-1
6
2
0
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
1
-1
6
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
2
2
1
1
2
1
1
2
2
2
2
1
1
2
2
2
2
2
2
2
2
2
1
1
2
2
2
1
1
2
2
2
1
1
2
2
2
2
2
2
2
1
1
2
2
2
1
1
2
2
2
1
1
2
1
1
2
0
2
1
1
2
2
1
1
2
1
1
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
0
-2
2
0
2
0
2
0
2
0
0
-2
2
0
2
0
2
0
2
0
2
0
2
0
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
9
1
1
9
1
1
9
1
1
10
1
1
10
1
1
11 11
1
1
1
1
11
1
1
10
1
1
11
1
1
11
1
1
11
1
1
11 11
1
1
1
1
11
1
1
11
1
1
1
8
1
1
8
1
1
8
1
1
9
1
1
1
9
1
1
9
1
1
9
1
1
10
1
1
11 11
1
1
1
1
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
0
-1
1
0
1
0
1
0
1
0
0
-1
1
0
1
0
1
0
1
0
1
0
1
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
2
1
2
2
1
1
1
1
2
1
1
1
1
2
1
1
1
1
2
1
1
1
1
2
1
1
1
1
2
1
1
1
1
2
1
1
1
1
2
1
1
1
2
1
1
1
1
1
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
0
-1
6
2
1
2
1
2
1
2
1
0
-1
6
2
1
2
1
2
1
2
1
2
1
2
1
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
9
1
1
9
1
1
9
1
1
11
1
1
10
1
1
11 11
1
1
1
1
11
1
1
10
1
11
1
11
1
11
1
8
1
1
1
1
9
1
1
11
1
1
9
1
1
9
1
1
8
1
1
9
1
1
11
1
1
9
1
1
11
1
1
1
1
11 11
1
1
1
1
1
1
11 11
1
1
1
1
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
0
-1
1
0
2
1
1
0
1
0
0
-1
1
0
1
0
1
0
1
0
1
0
1
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
2
2
2
1
2
1
2
1
2
2
1
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
0
-2
1
-1
1
-1
1
-1
1
-1
0
-2
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
1
60
Unit:
Jade Ward
Month:
February
Early:
Late
Night
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
1
2
3
4
5
6
7
8
9
10
11
12 13 14 15 16 17
18
19 20 21 22 23 24
25
26 27 28
20 20 21
20
20 20 20 20 20 20
20
20 20 20 20 20 20
20
20 20 20 20 20 20
20
20 20 20
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
4
4
3
4
3
3
4
3
4
3
3
2
4
3
3
4
3
3
3
3
3
4
4
4
2
1
2
1
1
1
2
2
1
1
1
1
1
1
2
1
1
1
3
4
4
4
4
4
4
4
4
4
4
4
4
4
3
4
3
3
4
4
4
4
3
4
4
4
4
3
-1
0
0
0
0
0
0
0
0
0
0
0
0
0
-1
0
-1
-1
0
0
0
0
-1
0
0
0
0 -1
2
1
1
1
2
1
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
3
1
1
1
3
0
3
1
3
1
1
1
3
0
3
2
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
20
3
1
2
20
3
2
1
20
3
3
20
3
3
3
0
3
0
3
0
3
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
3
2
3
3
1
3
0
2
1
3
0
3
1
1
1
3
0
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
20
3
20
3
20
3
20
3
1
2
3
0
1
2
3
0
3
3
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
2
1
2
1
1
3
1
4
2
0
4
2
3
0
2
2
1
1
4
2
4
3
1
1
1
3
0
3
2
1
1
4
1
4
3
2
20
3
2
20
3
2
3
0
1
3
0
1
3
0
3
1
1
1
3
0
3
1
1
1
3
0
3
1
2
1
2
3
0
20
3
1
1
1
3
0
20
3
1
1
1
3
0
2
1
1
2
1
1
2
0
2
0
1
3
0
3
3
0
3
1
1
1
3
0
3
1
3
2
2
4
1
4
3
1
1
2
4
1
4
20
3
2
1
20
3
2
20
3
3
20
3
3
20
3
4
2
-1
2
3
0
3
0
4
1
4
3
1
1
1
3
0
3
1
1
1
3
0
3
1
1
1
3
0
3
20
3
1
1
1
3
0
20
3
20
3
1
2
3
0
20
3
1
1
1
3
0
20
3
1
2
2
1
2
2
2
2
2
2
2
2
2
3
1
4
2
0
2
0
2
0
2
0
3
4
1
3
3
0
2
1
3
0
1
3
0
3
3
3
0
3
2
1
3
0
3
1
2
3
0
3
1
2
3
0
3
1
1
2
4
1
3
3
1
20
3
1
20
3
3
2
3
0
3
0
20 20
3
3
3
1
2
20
3
1
1
20
3
3
20
3
2
1
3
0
3
0
2
-1
2
3
0
3
0
3
1
1
1
3
0
3
1
2
3
1
1
1
3
0
3
3
20
3
1
1
1
3
0
2
3
1
20
3
1
2
3
0
2
3
0
2
1
3
0
2
2
2
1
1
2
2
2
2
0
1
1
2
0
2
2
0
1
1
2
0
2
1
1
2
0
2
0
2
2
-1
2
3
0
20
3
3
1
1
1
3
0
2
1
3
0
3
2
1
3
0
3
0
20
3
2
2
-1
1
20
3
1
2
3
0
2
1
3
0
2
3
0
3
1
2
3
0
3
1
1
3
1
1
1
3
0
3
1
2
3
0
3
1
1
1
3
0
20
3
2
1
20
3
3
20
3
3
3
0
3
0
3
3
0
3
1
1
1
3
0
20
3
1
1
1
3
0
20 20
3
3
2
2
1
1
2
4
4
1
1
4
4
2
-1
2
3
1
2
3
0
3
3
1
2
3
3
0
2
-1
1
20 20
3
3
2
2
1
1
3
3
0
0
20
3
2
3
1
1
1
3
0
2
2
4
1
3
3
2
1
3
1
1
1
3
0
3
2
20
3
3
20
3
2
20
3
2
3
0
3
0
1
3
0
1
3
0
3
3
3
2
1
3
0
2
1
3
0
1
1
2
-1
2
2
1
3
0
3
2
3
3
20
3
1
1
2
4
1
4
20
3
2
1
20
3
2
1
20
3
2
1
20
3
2
1
20
3
2
1
20
3
2
1
3
0
3
0
3
0
3
0
3
0
3
0
2
1
3
0
3
1
1
2
-1
3
1
3
0
1
3
0
4
3
0
4
20
3
1
1
1
3
0
20
3
1
2
1
2
2
2
1
1
2
1
1
2
2
2
2
2
2
2
1
2
0
2
1
1
2
1
1
2
1
1
2
1
1
2
0
2
0
2
0
2
0
0
-2
2
0
2
0
2
0
2
0
2
0
2
0
2
3
0
61
Unit:
Marjory Warren
Month:
February
Early:
Late
Night
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
1
2
3
4
5
6
7
8
9
10
11
12 13 14 15 16 17
18
19 20 21 22 23 24
25
26 27 28
34 34 32
32
33 34 34 34 33 34
34
34 34 34 33 32 33
33
31 34 34 34 32 30
31
31 31 31
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
2
5
6
6
4
5
4
4
4
4
4
3
3
4
4
4
4
3
3
4
4
3
5
5
5
4
4
2
1
3
-2
2
5
0
6
1
4
6
1
4
2
6
1
4
1
5
0
1
5
0
1
5
0
1
5
0
1
5
0
2
5
0
1
4
-1
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
3
2
2
1
5
2
4
3
2
2
2
6
3
4
3
2
1
2
5
2
4
3
3
3
3
3
3
3
4
3
2
2
2
6
3
4
3
3
1
3
3
1
4
1
4
3
2
1
2
5
2
4
4
1
4
4
1
4
3
3
1
1
5
2
4
3
2
1
1
4
1
4
3
2
2
2
6
3
4
3
1
1
1
3
0
6
3
4
6
3
4
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
34
4
2
34
4
3
32
4
4
33
4
3
34
4
1
34
4
2
34
4
3
34
4
3
31
4
3
34
4
2
34
4
3
34
4
3
2
4
0
1
4
0
4
0
1
4
0
2
3
-1
2
2
4
0
1
4
0
1
4
0
1
4
0
2
4
0
1
4
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
3
2
3
3
3
2
5
2
4
3
3
1
2
6
3
4
3
3
1
3
3
2
1
6
3
4
3
3
1
1
5
2
4
3
4
1
3
2
3
1
6
3
4
3
3
1
4
1
4
3
2
2
1
5
2
4
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
34
3
2
34
3
1
4
32
3
1
2
33
3
1
3
34
3
1
3
34
3
34
3
1
2
31
3
2
2
5
2
4
3
0
4
1
4
34
3
1
1
2
4
1
4
3
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
1
3
2
1
3
2
2
2
2
2
2
2
2
2
2
3
1
2
2
2
4
2
4
4
2
4
4
2
4
4
2
4
4
2
4
4
2
4
4
2
4
5
2
4
1
3
0
4
1
4
5
0
4
1
4
5
2
4
2
1
3
0
4
-1
2
4
-1
2
1
4
-1
1
1
4
-1
2
3
3
3
3
3
1
6
3
4
4
1
4
3
2
1
1
4
1
4
3
4
1
1
6
3
4
32
4
2
1
1
4
0
33
4
3
1
4
0
34 33
4
4
2
2
2
2
4
4
0
0
33
4
3
1
3
3
1
1
5
2
4
3
3
1
1
5
2
4
3
2
1
2
5
2
4
3
2
2
1
5
2
4
3
2
3
3
3
1
5
2
4
4
1
4
34
3
2
2
34
3
2
2
34
3
2
2
32
3
2
33
3
2
4
1
4
4
1
4
4
1
4
4
1
4
34 33
3
3
1
1
2
2
1
3
4
0
1
4
1
3
0
1
3
0
2
1
3
2
1
3
2
2
2
1
5
3
4
2
2
2
2
2
2
4
2
4
2
2
2
1
5
3
4
2
2
2
4
2
4
2
2
2
1
5
3
4
4
2
4
4
2
4
4
2
4
4
-1
1
2
1
2
1
4
2
4
1
5
0
1
4
0
4
-1
1
4
-1
2
1
4
-1
2
5
0
5
0
5
0
4
-1
2
3
1
1
3
5
2
4
3
3
3
2
2
2
6
3
4
3
2
3
2
7
4
4
3
3
1
3
7
4
4
3
2
2
4
1
4
3
3
1
1
5
2
4
31
4
3
33
4
3
34 34
4
4
3
4
34
4
2
32
4
2
30
4
3
4
0
2
5
1
4
1
4
0
3
-1
2
4
0
1
3
-1
2
2
4
0
3
-1
2
3
2
3
1
6
3
4
3
2
2
1
5
2
4
3
1
1
3
5
2
4
3
1
1
3
5
2
3
3
2
3
3
3
2
3
3
5
2
4
5
2
4
33
3
2
2
31
3
1
1
1
3
0
33
3
2
1
1
4
1
4
34 34
3
3
1
1
2
3
1
4
4
1
1
4
4
34
3
3
1
2
2
2
2
2
2
2
4
2
2
2
4
2
4
4
2
4
4
2
4
4
2
4
4
1
4
3
6
3
3
2
5
2
4
3
3
2
5
2
4
30
3
2
4
1
4
32
3
2
1
1
4
1
4
2
2
2
2
2
2
2
2
2
4
2
4
4
2
4
4
2
4
2
1
2
1
4
2
4
2
4
1
4
1
5
0
3
5
0
3
3
2
1
6
3
4
3
2
3
3
2
31
4
3
31
4
3
31
4
3
31
4
1
1
4
0
2
3
-1
2
1
4
0
3
4
0
3
2
2
2
6
3
4
3
3
2
1
6
3
4
3
3
3
2
3
31
3
2
1
31
3
2
1
31
3
1
3
31
3
2
2
3
0
3
0
4
1
4
4
1
4
2
1
2
2
2
2
2
2
2
2
1
3
3
1
4
4
2
4
4
2
4
4
2
4
3
5
2
4
2
5
2
4
5
2
4
5
2
4
62
Unit:
Month:
Winter Ward CXH
February
Early:
Late
Night
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
1
18
2
2
2
18
3
1
1
1
3
0
3
16
3
1
1
1
3
0
4
16
3
1
1
1
3
0
5
18
3
1
1
1
3
0
6
7
20 19
3
2
2
1
1
1
3
2
0
0
8
19
2
1
2
1
2
2
1
3
2
2
2
2
2
2
2
1
2
2
4
2
3
1
2
0
1
2
0
9
19
3
1
1
1
3
0
10
15
3
11
16
3
1
2
3
0
2
1
3
0
2
2
2
2
1
3
1
2
1
3
1
19
2
12
17
3
1
15
20
2
1
16
19
3
2
2
3
0
13 14
20 20
3
2
1
1
1
1
1
3
2
0
0
17
20
3
1
1
1
3
0
18
20
3
1
1
1
3
0
19
20
3
1
2
3
0
20 21
20 19
3
2
1
2
2
3
2
0
0
22
19
2
1
1
1
2
0
1
3
0
2
1
3
2
3
2
1
2
3
1
3
1
4
2
4
2
2
1
2
1
4
2
15
2
16
2
1
2
3
1
1
2
3
1
1
1
2
0
17
2
2
20 20
2
2
2
2
1
3
2
1
0
2
2
2
2
2
2
4
2
2
2
1
3
2
0
4
2
2
2
1
1
4
2
24
18
3
1
25
20
3
1
2
0
23
19
3
1
1
1
3
0
2
2
1
1
4
2
2
1
2
2
2
2
2
3
0
2
3
0
2
1
2
1
4
2
2
2
1
1
4
2
2
1
2
1
4
2
2
1
2
3
1
4
2
2
2
4
2
3
1
4
2
20
2
1
20
2
1
20
2
1
1
1
3
1
20
2
20
2
1
2
0
1
2
0
1
2
3
1
4
2
1
3
2
2
1
1
4
2
4
2
4
2
4
2
27 28
20 20
3
2
1
1
1
1
1
3
2
0
0
2
1
2
3
1
2
1
2
2
5
3
1
2
3
1
20 19
2
2
1
2
2
3
2
1
0
19
2
1
1
2
0
19
2
1
1
1
3
1
18
2
1
20
2
20
2
2
3
1
2
2
0
1
2
3
1
20 20
2
2
1
1
1
1
1
3
2
1
0
2
2
2
2
2
4
2
3
1
4
2
3
1
4
2
3
1
4
2
4
2
2
1
2
1
4
2
2
2
1
1
4
2
2
1
2
2
1
2
3
1
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
4
2
4
2
3
1
4
2
4
2
4
2
3
1
3
1
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
18
2
2
18
2
1
1
1
3
1
16
2
1
1
1
3
1
16
2
1
1
1
3
1
18
2
1
1
1
3
1
20 19
2
2
2
1
2
1
4
2
2
0
19
2
1
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
2
3
1
2
1
2
2
1
3
2
1
2
2
2
1
2
1
3
2
4
2
3
3
1
4
4
2
4
3
1
4
3
1
4
4
2
2
0
1
3
1
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
18
2
18
2
16
2
16
2
18
2
20 19
2
2
19
2
15
2
15
2
16
2
17
2
20 20
2
2
20
2
20
2
19
2
20
2
20
2
20 19
2
2
19
2
18
2
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
1
1
-1
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
2
2
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
1
2
2
1
2
2
1
2
2
1
2
2
1
2
2
1
2
2
1
1
1
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
0
3
3
1
4
3
1
2
0
2
1
3
1
4
2
3
1
2
3
1
26
20
3
1
1
1
3
0
4
2
2
3
1
3
1
2
1
2
1
4
2
2
1
2
3
1
2
2
2
1
5
3
18
2
20
2
20
2
20 20
2
2
2
2
0
1
1
-1
1
1
2
0
1
1
2
0
1
1
2
0
2
2
0
1
1
1
1
1
1
1
1
2
1
2
2
1
1
1
2
2
3
2
1
2
1
2
1
2
1
2
1
3
2
3
1
2
1
1
1
3
1
63
Unit:
Pembridge
Month:
February
Early:
Late
Night
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
1
2
3
4
5
6
7
8
9
10
11
12 13 14 15 16 17
18
19 20 21 22 23 24
25
26 27 28
5
5
6
6
5
6
7
6
6
6
7
7
7
7
7
7
8
10
10 11 11
9
8
8
9
9
7
8
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
4
4
3
3
3
2
2
2
2
2
2
3
2
2
3
4
1
1
2
3
1
2
2
2
2
1
4
1
1
1
1
2
1
2
2
1
2
2
1
3
2
2
1
2
1
1
1
1
1
2
1
4
4
4
4
4
4
3
4
4
4
2
4
4
4
4
4
4
4
4
4
4
4
4
2
3
2
2
4
0
0
0
0
0
0 -1
0
0
0
-2
0
0
0
0
0
0
0
0
0
0
0
0
-2
-1
-2 -2 0
2
2
2
2
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
2
1
1
2
1
1
2
1
1
2
1
1
2
2
2
2
1
1
2
2
0
2
0
2
0
2
0
2
0
2
0
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
5
2
2
6
2
2
6
2
2
6
2
3
5
2
2
2
0
2
0
2
0
3
1
4
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
1
2
1
1
2
2
2
1
2
0
2
0
1
-1
2
2
0
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
5
2
1
1
6
2
1
1
6
2
1
2
0
2
0
1
2
0
6
2
1
1
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
1
1
1
1
1
0
1
0
1
2
0
2
1
1
2
2
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
2
2
1
1
2
0
2
0
2
0
2
0
2
0
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
7
2
2
7
2
2
6
2
2
7
2
2
7
2
1
1
7
2
2
7
2
2
7
2
2
7
2
2
7
2
2
7
2
3
10
2
2
11
2
1
1
10
2
1
1
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
3
1
2
0
2
0
2
0
2
2
2
2
2
2
2
1
1
2
2
2
2
2
2
2
2
1
2
1
1
2
1
1
2
2
0
1
1
2
0
2
1
1
2
1
1
2
0
2
1
1
2
0
2
0
2
0
2
0
2
0
2
0
2
0
1
-1
1
2
0
2
0
2
0
6
2
1
7
2
1
7
2
1
6
2
1
1
7
2
1
1
7
2
1
1
7
2
1
7
2
1
1
7
2
1
1
7
2
1
1
7
2
1
1
10
2
1
1
11
2
2
10
2
1
1
2
0
2
0
2
0
1
2
0
7
2
1
1
2
0
1
2
0
1
2
0
1
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
2
2
2
2
2
1
2
1
1
3
1
2
2
0
11 11
2
2
1
1
1
1
2
0
2
1
1
1
3
1
4
2
1
2
1
1
1
3
1
4
2
1
2
1
1
2
1
1
2
0
2
0
9
2
1
1
8
2
2
9
2
1
1
9
2
2
8
2
1
1
9
2
2
8
2
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
1
2
2
2
2
4
2
4
1
3
4
2
4
2
2
2
1
1
1
3
1
4
2
1
2
9
2
1
7
2
2
8
2
1
1
8
2
1
2
3
1
4
2
3
1
4
1
2
0
1
2
0
2
1
1
1
3
1
4
2
1
2
2
2
1
3
1
2
3
1
2
3
1
4
11 11
2
2
9
2
1
1
8
2
1
1
9
2
1
1
2
0
2
0
2
0
1
2
0
2
0
2
0
1
2
0
1
3
1
4
3
1
4
2
0
1
1
2
0
1
1
2
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
64
Trust Total
RN
Trust Total
HCA
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Sun Mon Tue Wed Thu
1
2
3
4
5
68 69
69
69 69
39 48
54
53 45
7
10
5
9
7
13
8
10
8 13
59 66
69
70 65
-9
-3
0
1 -4
Agreed HCA 88 88
88
88 88
Regular HCA 48 52
62
61 62
Bank HCA 39 38
31
37 38
Agency HCA 18 13
13
6
7
Total 105 103 106 104 ##
Variance 17 15
18
16 19
Fri Sat Sun Mon Tue Wed Thu
6
7
8
9
10
11 12
69 68 68 69
69
69 69
47 41 41 44
38
42 44
9
4
10 10
17
15 12
11 16 10 12
12
7
10
67 61 61 66
67
64 66
-2 -7
-7
-3
-2
-5
-3
Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat
13 14 15 16
17
18 19 20 21 22 23
24
25 26 27 28
69 68 68 69
69
69 69 69 68 68 69
69
69 69 69 68
41 38 36 53
44
42 42 40 40 35 47
47
47 46 41 35
16 14 12
4
10
7 12 11 15 12
6
5
5
9 14 13
7
11 11
7
7
16 13 14
8
11 11
9
10 5
7
13
64 63 59 64
61
65 67 65 63 58 64
61
62 60 62 61
-5 -5
-9
-5
-8
-4 -2 -4 -5 -10 -5
-8
-7 -9 -7 -7
88 88 88 88
88
88 88 88
58 50 46 58
55
56 63 50
30 40 43 32
36
37 36 42
11 11 13 11
15
8
5 12
99 101 102 101 106 101 104 104
11 13 14 13
18
13 16 16
88 88 88
88
88 88
42 49 55
52
64 51
48 50 33
38
28 33
10
5
13
10
13 18
100 104 101 100 105 ##
12 16 13
12
17 14
88
48
45
15
108
20
88
59
40
5
104
16
88
52
35
9
96
8
88
88
88 88
48
48
53 55
43
43
33 40
16
12
16 12
107 103 102 ##
19
15
14 19
88
59
29
12
100
12
88
59
37
6
102
14
Early Census Total
194 194 192 193 ## 195 197 196 195 192 195 196 201 202 201 199 200 201 ## 204 205 203 200 196 199 ## 198 199
Late Census Total
194 195 191 194 ## 196 197 196 193 194 195 196 201 201 200 201 193 199 ## 204 205 194 200 197 199 ## 200 199
Night Census Total
194 195 191 195 ## 196 197 196 189 194 195 196 184 201 200 201 193 199 ## 206 205 194 198 196 199 ## 199 199
Average Daily Census 194 195 191 194 ## 196 197 196 192 193 195 196 195 201 200 200 195 200 ## 205 205 197 199 196 199 ## 199 199
65
Day
Registered nurses/
Day
Night
Care Staff
Total
monthly
actual
staff
hours
Total
monthly
planned
staff
hours
Total
monthly
actual
staff
hours
Total
monthly
planned
staff
hours
Total
monthly
actual
staff
hours
1050
1050
1470
1890
630
1470
1890
1260
990
11700
840
885
1305
1612.5
435
1417.5
1792.5
1200
1125
10612.5
1470
1680
2520
3360
630
1260
1260
840
840
13860
1680
2190
2557.5
3517.5
780
1260
2160
945
1522.5
16612.5
420
420
630
420
210
630
630
420
420
4200
420
420
420
420
202.5
652.5
772.5
420
405
4132.5
420
420
840
1260
420
420
420
210
210
4620
420
420
795
1260
195
435
855
210
427.5
5017.5
Average fill rate - care staff (%)
Total
monthly
planned
staff
hours
Average fill rate - registered
nurses/midwives (%)
Total
monthly
actual
staff
hours
Average fill rate - care staff (%)
Total
monthly
planned
staff
hours
Average fill rate - registered
nurses/midwives (%)
Athlone House
Ahlone Rehab
Garside
Princess Louise
Alexandra Rehab (PLK)
Jade
Marjory Warren
Pembridge
Winter Ward (CXH)
Whole Trust
Care Staff
Night
Registered nurses/
80%
84%
89%
85%
69%
96%
95%
95%
114%
91%
114%
130%
101%
105%
124%
100%
171%
113%
181%
120%
100%
100%
67%
100%
96%
104%
123%
100%
96%
98%
100%
100%
95%
100%
46%
104%
204%
100%
204%
109%
66
Ref
W28262
W28071
W28071
W28073
W28046
W28285
W28002
W28002
W28137
W28287
W28049
W28012
W27820
W27821
W28133
W28133
W28296
W28296
W28296
W27882
W27860
W28197
W28197
W28286
W27861
W28017
W28181
W27941
W27941
W28005
W28005
W28005
W27813
W27898
W27885
W27885
W28051
W28185
W28029
W28203
W28217
W27937
W27937
W27937
Indident type
Medication
Slips, Trips and Falls
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Unit
Alexandra Unit
Alexandra Unit
Alexandra Unit
Alexandra Unit
Alexandra Unit
Alexandra Unit
Athlone House Nursing Home
Athlone House Rehab Unit
Garside House Nursing Home
Jade Ward
Jade Ward
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren Ward - Charing X
Date
25/02/2015
15/02/2015
15/02/2015
16/02/2015
13/02/2015
26/02/2015
09/02/2015
09/02/2015
18/02/2015
25/02/2015
13/02/2015
12/02/2015
02/02/2015
02/02/2015
17/02/2015
17/02/2015
27/02/2015
27/02/2015
27/02/2015
02/02/2015
04/02/2015
22/02/2015
22/02/2015
27/02/2015
03/02/2015
08/02/2015
13/02/2015
07/02/2015
07/02/2015
03/02/2015
03/02/2015
03/02/2015
01/02/2015
04/02/2015
04/02/2015
04/02/2015
13/02/2015
20/02/2015
12/02/2015
22/02/2015
23/02/2015
07/02/2015
07/02/2015
07/02/2015
Time
16:30
14:35
14:35
06:00
12:00
16:00
12:03
12:03
23:30
16:00
11:30
05:20
09:30
09:45
12:30
12:30
17:00
02:30
15:00
15:00
10:00
23:00
06:30
16:55
13:00
13:00
10:00
11:00
14:50
14:50
10:00
14:30
19:30
22:00
08:30
67
W28294
W27918
W28260
W28096
W28241
W27998
W28251
W28216
W27833
W28281
W28190
W28072
W27809
W28244
W28244
W28106
W28023
W28087
Medication
Medication
Medication
Medication
Medication
Pembridge Palliative Care Unit
Princess Louise Nursing Home
26/02/2015
05/02/2015
25/02/2015
16/02/2015
24/02/2015
11/02/2015
21/02/2015
15/02/2015
02/02/2015
27/02/2015
21/02/2015
16/02/2015
01/02/2015
24/02/2015
24/02/2015
17/02/2015
12/02/2015
13/02/2015
16:15
19:00
19:00
15:15
21:00
02:00
05:50
04:30
12:30
03:30
11:30
04:10
08:27
15:00
15:00
12:00
10:40
19:45
68
Shift
Late
Early
Late
Night
Early
Late
Early
Late
Night
Late
Early
Night
Early
Early
Early
Late
Early
Late
Night
Late
Night
Early
Late
Early
Night
Night
Late
Early
Late
Early
Late
Night
Early
Early
Early
Late
Early
Early
Late
Night
Early
Early
Late
Night
Actual no. Staffing Actual no.
Staffing
on shift
Status
on shift
Status RN
RN
HCA
HCA
0
1
1
2
-1
1
0
2
0
1
1
2
0
1
-1
1
-1
1
0
2
0
1
1
2
-1
2
0
4
0
2
1
4
0
2
0
2
0
2
1
4
-1
2
2
6
0
2
0
2
0
3
2
6
0
3
2
6
0
3
2
6
0
2
1
5
-1
2
2
6
0
2
1
5
0
2
0
2
0
2
1
5
0
2
0
2
-1
2
1
5
0
2
0
4
-1
2
2
6
-1
2
0
4
-1
2
0
4
0
3
0
6
-1
3
1
7
0
3
0
6
0
4
0
6
0
3
0
6
-1
2
0
4
-1
3
0
6
0
4
0
6
0
4
0
3
0
3
0
3
-1
4
3
6
-1
4
3
6
0
4
2
5
1
4
2
4
0
3
2
4
0
2
1
3
0
2
2
4
0
2
1
2
69
Early
Early
Early
Early
Late
Night
Night
Night
Early
Night
Early
Night
Early
Early
Late
Early
Early
Late
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
-1
3
3
3
3
3
2
2
2
4
2
4
2
4
5
4
5
5
3
3
2
1
2
1
0
0
0
0
0
1
0
0
1
0
1
2
0
5
4
3
4
3
1
1
1
2
1
3
1
2
9
8
9
10
8
70
BOARD OF DIRECTORS
31 March 2015
Report title:
Draft KPIs 2015/16
Agenda item number:
2.3
Report of:
Ian Millar, FPCR
Contact officer:
Iain McMillan, Commercial Director, Joe Mills, Strategy Manager
and competence
Not confidential
status
Executive summary:
The Trust’s Board-level KPIs were extensively re-worked in 2014/15 with the aim of defining a series of
measures that would remain relatively unchanged over the next five years as we move toward foundation
trust status and beyond.
The following paper represents the suggested KPIs for 2015/16, their targets for delivery and amber
threshold levels.
Assurance provided: The proposed changes will be incorporated into the Trust KPI scorecard immediately
and measured as of 1st April 2015.
Report provenance: Please list where this paper has previously been discussed and/or agreed
Report for:
Decision
Discussion
Information
x
Recommendation: That the Board accept the proposed changes
71
Section 1: Trust Board KPI changes
Recommendations:
Goal 1
•
•
•
Remove national methodology FFT - Friends and family test will become local methodology only with
a target of 85
Keep the measure of “I am satisfied with the care I give to patients/service users” but change its
measurement methodology to make it more robust. This KPI is run by HR so the ELT lead will move
from LA to IM. The KPI is not considered robust and is too infrequent to be of use currently, so will
be changed to a monthly measure that goes direct to staff who will be chosen on a random basis.
We will ensure anonymity of this random sample.
New target for bank:agency from 65:35 to 60:40
Goal 2
•
•
The hand hygiene audit target will become 97% - the mean of the year’s current performance
The pressure ulcer KPI will become Number of new (CLCH acquired) pressure ulcers grade 3 / 4 in
bedded units with a zero target
Goal 3
•
•
•
New target for Net new business will be £22.0m (based on reaching £300m revenue in five years
from 2015/16)
New target for Proportion of Services capturing Patients' Clinical Outcomes of 100% by year end
New target for Percentage of incidents affecting patients that did not cause harm to be 48.4% to
align with Quality strategy
Goal 4
•
Percentage of appointments cancelled by CLCH target to change following further work to be done
by BIPA to provide benchmark against other community trusts
Goal 5
•
•
•
•
Percentage of Staff that recommend CLCH as a place to work- target changed to mean of two data
points for 2014/15 which equals 46%
Sickness absence rate target to change to 4% - agreed at ELT 12 March. HSCIC England shows
average Community Trust sickness at 4.43%
Vacancy level target to change to 14% - based on the RCN Safe Staffing report 2014 which found a
London average vacancy rate of 14%
New KPI that measures Staff with protected characteristics other than BME background at band 7
and above
72
Goal 6
•
New KPI on mobile working to be as follows Percentage of in scope clinical staff using mobile
technology
o The KPI will cover in scope clinical staff that are being issued with mobile devices that have
access to a virtual desktop
o Targets will be as per the mobile working project roll-out currently reflected in the target sheet
below.
•
KPI for continuous improvement program to change to Senior managers that are trained in the
continuous improvement methodology and the end of year target will be set at 80%. Senior
managers will count in this instance as NEDs, EDs, DDs, CBU managers and ADQs. It is not proposed
that these managers go through the same training as the previous cohorts, rather they will have a
shorter version of it that will enable them to encourage the mind set and behaviours required for
continuous improvement.
Appendix 1 shows current scorecard with 2014/15 information where available.
Target setting
•
•
•
•
General principle that nationally set, regulatory targets have an amber threshold at 5% tolerance
Targets which we have set ourselves internally have a threshold of 10%
Targets all defined by ELT
No KPI should be red if it hits the national target for that measure
Appendix 2 sets out full monthly target trajectories and amber thresholds with 2014/15 information where
available.
Appendix 3 - Other KPI considerations that were not included for this year
•
•
•
•
•
An additional KPI for operational effectiveness was discussed but not included, activity data will
continue to be monitored at FRIC
A KPI measuring clinical outcomes will be considered for 2016/17
A KPI measuring service developments will not be included but will make up part of the
transformation report to ELT
The IMT strategy reporting will include measurement of “the percentage of source systems feeding
the data warehouse”
The reduction in non-clinical time/ activities of staff will be considered next year when the national
guidance is clearer
73
KPIs 2015/16
KEY PERFORMANCE INDICATOR SCORECARD
End of Yr
Target
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
FYTD
15/16
target
ELT
Lead
National
Target
Benchmark
Cumulative
/Point
Patients who would recommend the service
(incl. "likely" Promoters)
85
84
82.6
83.9
84.5
86.0
76.0
79.0
78.0
82.0
82
85
LA
n/a
n/a
P
Patients agreeing with the statement “I was
treated with dignity and respect”
95%
94%
93%
94%
96%
95%
93%
93%
93%
94%
94%
95%
LA
94%
n/a
P
“I am satisfied with the care I give to
patients/service users” (quarterly)
85%
59%
N/A
(Quarterl
y
n/a
85%
IM
n/a
71% NSS CS
2014
P
The ratio of clinical bank : agency staff by
hours worked
65:35
49:51
51.3:47.7
60:40
IM
n/a
n/a
P
Key Performance Indicator Description
N/A
N/A
N/A
(Quarterl (Quarterl (Quarterl
y
y
y
73.2%
N/A
N/A
N/A
y
y
y
51:49
51.7 :
48.3
52.3 :
47.7
52.7 :
47.3
54.1:45.9 52.4:47.6 51.6:48.4 50.9:49.1
End of Yr
Target
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
FYTD
15/16
target
ELT
Lead
National
Target
Benchmark
Cumulative
/Point
Proportion of Patients with no NEW harms
identified (Safety Thermometer monthly
prevalence survey)
98%
97.3%
96.0%
96.8%
96.6%
97.7%
97.1%
96.4%
97.0%
97.2%
97%
98%
LA
96%
6/11
P
Hand hygiene audit, to be measured
quarterly
92%
99%
97%
97%
JM
n/a
n/a
P
Percentage of time bedded units achieve
minimum staffing each month
100%
N/A
106%
104%
100%
106%
103%
103%
103%
104%
104%
100%
LA
n/a
n/a
P
Statutory and mandatory training
compliance
90%
81%
82%
82%
83%
86%
88%
90%
91%
91%
86%
90%
LA
90%
5/12
P
0
LA
Number of new (CLCH acquired) pressure
ulcers grade 3 / 4 in bedded units
N/A
N/A
(Quarterl (Quarterl
y
y
98%
N/A
N/A
(Quarterl (Quarterl
y
y
New measure
94%
N/A
N/A
(Quarterl (Quarterl
y
y
74
1
KPIs
Net new business won - annualised figure of
committed changes to income
Proportion of Services capturing Patients'
Clinical Outcomes
End of Yr
Target
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
FYTD
15/16
target
ELT
Lead
National
Target
Benchmark
Cumulative
/Point
£3.1m
-8.8
-8.2
-11.1
-7.9
-11.5
-5.0
-3.2
-3.2
-3.5
-3.5
£22.0m
IM
n/a
n/a
C
66%
In
Develop
ment
20%
24%
18.9%
22%
37%
45%
49%
54%
54%
100%
JM
n/a
n/a
C
39%
53%
35%
52%
61%
36%
42%
46%
48%
46%
48.4%
LA
n/a
n/a
P
Percentage of incidents affecting patients that
49.0%
did not cause harm
End of Yr
Target
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
FYTD
15/16
target
ELT
Lead
National
Target
Benchmark
Cumulative
/Point
90%
100%
83%
57%
75%
75%
62%
79%
50%
71%
66%
90%
LA
n/a
n/a
P
Complaints resolved within timescales agreed
with the complainant
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
LA
n/a
n/a
P
Percentage of Appointments cancelled by
CLCH
2.1%
2.35%
2.3%
2.2%
2.1%
2.3%
2.64%
2.61%
2.49%
2.62%
2.4%
TBD
RM
n/a
CNWL =
10.47%
P
End of Yr
Target
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
FYTD
15/16
target
ELT
Lead
National
Target
Benchmark
Cumulative
/Point
50%
IM
n/a
54%
NSS CS
P
N/A
N/A
N/A
(Quarterl (Quarterl
Quarterly
y
y
40.0%
N/A
N/A
N/A
y
y
y
81.9%
83.8%
Not
reported
59.6%
62.4%
67.6%
75.8%
75%
90%
IM
90%
8/10
P
3.73%
4.02%
4.24%
4.16%
4.16%
3.97%
4.34%
4.00%
4%
4.0%
IM
3%
4.4%
P
15.8%
17.9%
17.1%
16.2%
17.8%
17.1%
16.1%
17.5%
18.7%
17%
14%
IM
n/a
n/a
P
30.8%
30.8%
30.7%
30.7%
31.7%
30.6%
30.5%
30.6%
30.6%
31%
34%
IM
n/a
n/a
P
Percentage of Staff that recommend CLCH as
a place to work
62%
Staff appraisal rates
90%
78.9%
78.8%
3.50%
3.74%
11%
34%
Vacancy level
Staff from BME backgrounds at bands 7 and
above
Staff with protected characteristics other than
BME at band 7 level or above
New measure
52%
N/A
N/A
(Quarterl (Quarterl
y
y
IM
75
2
KPIs
End of Yr
Target
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
FYTD
15/16
target
ELT
Lead
National
Target
Benchmark
Cumulative
/Point
Recurrent QIPPs achieved % of total for the
year
100%
92%
88%
95.6%
87.5%
86.5%
85%
85%
91%
91%
91%
100%
IM/RM
100%
n/a
P
Percentage of QIPP plans achieving the
planned level of savings in-year
100%
67%
70%
71.4%
83.6%
85.4%
82%
91%
84%
86%
86%
100%
IM/RM
100%
6/8
P
100%
IM
85%
IM
n/a
n/a
C
Percentage of staff using mobile technology
KPIs that are RAG rated GREEN on overall
data quality confidence level.
Senior managers that are trained in the
continuous improvement methodology
New measure
85%
In
In
In
In
In
Develop Develop Develop Develop Develop
ment
ment
ment
ment
ment
New measure
35%
Q3
Q3
N/A
N/A
Report Report
(Quarterl (Quarterl
not yet not yet
y
y
finalised finalised
80%
76
3
Target
Patients who would recommend the service (incl. "likely"
Promoters)
2014/15
Amber Threshold
Actual
ELT Lead: Louise Ashley
2015/16
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
83
83
83
83
84
84
84
84
85
85
85
85
76.5
74.7
74.7
74.7
74.7
75.6
75.6
75.6
75.6
76.5
76.5
76.5
84
82.6
83.9
84.5
86
76
79
78
82
78.1
n/a
FYTD
15/16 target
n/a
n/a
Target
78.1
78.7
79.4
80.0
80.7
81.3
81.9
82.6
83.2
83.9
84.5
85.1
Amber Threshold
74.2
74.8
75.4
76.0
76.6
77.2
77.8
78.5
79.1
79.7
80.3
80.9
85
National
Target
Bench-mark
Cumulative/P
oint
n/a
n/a
P
Comments: Target agreed at ELT March 12th. Trajectory is straight-line from January figure to end of year, 5% threshold
Patients agreeing with the statement “I was treated with
dignity and respect”
2014/15
2015/16
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
Amber Threshold
86%
86%
86%
86%
86%
86%
86%
86%
86%
86%
86%
86%
Actual
94%
93%
94%
96%
95%
93%
93%
93%
94%
91%
n/a
n/a
Target
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
Amber Threshold
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
n/a
95%
94%
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
n/a
85%
n/a
Comments: Target agreed ELT 12 March. Trajectory is to be on target from 1st April with a 5% threshold
“I am satisfied with the care I give to patients/service users”
ELT Lead: Ian Millar
2014/15
2015/16
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
Amber Threshold
74%
74%
74%
74%
75%
75%
75%
75%
76%
76%
76%
77%
Actual
n/a
n/a
n/a
73%
n/a
n/a
n/a
59%
n/a
n/a
n/a
n/a
Target
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
Amber Threshold
77%
77%
77%
77%
77%
77%
77%
77%
77%
77%
77%
77%
71% National
Staff Survey
Community Trust
average 2014
P
Comments: Change measurement methodology to make it more robust. This KPI is run by HR so the ELT lead will move from LA to IM. The KPI is not considered robust and is too infrequent to be of use currently, so will be changed to a monthly measure that goes direct to staff who will be chosen on a random basis. We will ensure anonymity of this random sample.
The ratio of clinical bank : agency staff by hours worked
Apr
2015/16
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
65:35
65:35
65:35
65:35
65:35
65:35
65:35
65:35
65:35
65:35
65:35
65:35
N/A
(Quarterly)
51:49
52.5:47.5
54:46
55.5:44.5
57:43
58.5:41.5
60:40
61.5:38.5
63:37
64.5:35.5
65:35
Actual
51:49
52 : 48
52 : 48
53 : 47
54:46
52:48
52:48
51:49
49:51
n/a
n/a
n/a
Target
49:51
50:50
51:49
52:48
53:47
54:46
55:45
56:44
57:42
58:42
59:41
60:40
Amber Threshold
44:56
45:55
46:54
47:53
48:52
49:51
50:50
51:49
52:48
53:47
54:46
55:45
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%
Target
2014/15
May
Amber Threshold
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
n/a
60:40
n/a
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
Comments: Target agreed at Board 25/2. Trajectory is straight line from current performance to target, 10% threshold
Proportion of Patients with no NEW harms identified (Safety
Target
77
p
Thermometer monthly prevalence survey)
(
y
2014/15
2015/16
Amber Threshold
88%
88%
88%
88%
88%
88%
88%
88%
88%
88%
88%
Actual
97.30%
96.00%
96.80%
96.60%
97.70%
97.10%
96.40%
97.00%
97.20%
n/a
n/a
88%
n/a
Target
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%
Amber Threshold
93%
93%
93%
93%
93%
93%
93%
93%
93%
93%
93%
93%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
92%
92%
92%
92%
92%
92%
92%
92%
92%
92%
92%
92%
Amber Threshold
83%
83%
83%
83%
83%
83%
83%
83%
83%
83%
83%
83%
Actual
n/a
n/a
98.00%
n/a
n/a
94.00%
n/a
n/a
99.00%
n/a
n/a
n/a
Target
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%
98%
Amber Threshold
93%
93%
93%
93%
93%
93%
93%
93%
93%
93%
93%
93%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
100%
97%
98%
96%
6/11
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
97%
97%
n/a
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
104%
100%
n/a
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
86%
90%
90%
5/12
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
New Target
0
Comments: Target as per quality strategy, 5% threshold
Hand hygiene audit. To be measured quarterly
ELT Lead: Joanne Medhurst
2014/15
2015/16
Comments: Target is mean of three data points agreed at ELT 12 March, 5% threshold
percentage of time bedded units achieve minimum staffing
each month
Target
2014/15
2015/16
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Amber Threshold
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Actual
n/a
106%
104%
100%
106%
103%
103%
103%
104%
n/a
n/a
n/a
Target
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
81%
81%
81%
82%
83%
84%
85%
86%
87%
88%
89%
90%
Amber Threshold
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Actual
81%
82%
82%
83%
86%
88%
90%
91%
91%
n/a
n/a
n/a
Target
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
Amber Threshold
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
85%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
0
0
0
0
0
0
0
0
0
0
0
0
Amber Threshold
Comments: Nationally requred target
Statutory and Mandatory training compliance
2014/15
2015/16
Comments: Nationally requred target
Number of new (CLCH acquired) pressure ulcers grade 3 / 4 in
bedded units
Target
2014/15
Amber Threshold
Actual
2015/16
Target
Amber Threshold
78
Comments: zero tolerance target
Net new business won - annualised figure of committeed
changes to income
ELT Lead:Ian Millar
Apr
2014/15
2015/16
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
3.1
Amber Threshold
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Actual
-8.8
-8.2
-11.1
-7.9
-11.5
-5
-3.2
-3.2
-3.5
n/a
n/a
n/a
Target
5.5
11.0
16.5
22.0
Amber Threshold
5.0
9.9
14.9
19.8
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
-£3.5m
£22m
n/a
n/a
C
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
54%
100%
n/a
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
46%
48.4%
n/a
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
66%
90%
n/a
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
Comments: Target agreed at Board 25/2. Monthly update of questionable use, we will use quarterly, 10% threshold
Proportion of services capturing Patients' Clinical Outcomes
ELT Lead: Joanne Medhurst
2014/15
2015/16
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
n/a
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
66%
Amber Threshold
n/a
18%
23%
27%
32%
36%
41%
45%
50%
54%
59%
59%
Actual
n/a
20%
24%
18.90%
22%
37%
45%
49%
54%
n/a
n/a
n/a
Target
69%
72%
75%
77%
80%
83%
86%
89%
92%
94%
97%
100%
Amber Threshold
62%
65%
67%
70%
72%
75%
77%
80%
82%
85%
87%
90%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
46%
46%
47%
47%
47%
47%
48%
48%
48%
48%
49%
49%
Amber Threshold
41%
42%
42%
42%
42%
43%
43%
43%
43%
44%
44%
44%
Actual
39%
53%
35%
52%
61%
36%
42%
46%
48%
n/a
n/a
n/a
Target
48%
48%
48%
48%
48%
48%
48%
48%
48%
48%
48%
48%
Amber Threshold
46%
46%
46%
46%
46%
46%
46%
46%
46%
46%
46%
46%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
Amber Threshold
81%
81%
81%
81%
81%
81%
81%
81%
81%
81%
81%
81%
Actual
100%
83%
57%
75%
75%
62%
79%
50%
71%
n/a
n/a
n/a
Target
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
Amber Threshold
86%
86%
86%
86%
86%
86%
86%
86%
86%
86%
86%
86%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Comments: Target agreed at ELT 12 March, 10% threshold
Percentage of incidents affecting patients that did not cause
harm
2014/15
2015/16
Comments: Target as per quality strategy, 5% threshold
Complaints resolved within 25 days
2014/15
2015/16
Comments: Target agreed ELT 12 March, 5% threshold
79
Complaints resolved within timescales agreed with the
complainant
2014/15
2015/16
Target
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Amber Threshold
81%
81%
81%
81%
81%
81%
81%
81%
81%
81%
81%
81%
Actual
100%
100%
100%
100%
100%
100%
100%
100%
100%
n/a
n/a
n/a
Target
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Amber Threshold
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
95%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
2.1%
2.1%
2.1%
2.1%
2.1%
2.1%
2.1%
2.1%
2.1%
2.1%
2.1%
2.1%
Amber Threshold
2.3%
2.3%
2.3%
2.3%
2.3%
2.3%
2.3%
2.3%
2.3%
2.3%
2.3%
2.3%
Actual
2.35%
2.30%
2.20%
2.10%
2.30%
2.64%
2.61%
2.49%
2.62%
n/a
n/a
100%
100%
n/a
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
2.4%
TBD
n/a
CNWL = 10.47%
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
n/a
50.0%
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
90.0%
90%
8/10
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
4.0%
4.0%
3%
4.43% (HSCIC
benchmark for CS
trsuts)
P
0.5 0.041667
Percentage of appointments cancelled by CLCH
ELT Lead: Richard Milner
2014/15
2015/16
n/a
Target
2.56
2.52
2.48
2.43
2.39
2.35
2.31
2.27
2.23
2.18
2.14
2.10
Amber Threshold
2.69
2.64
2.60
2.56
2.51
2.47
2.42
2.38
2.34
2.29
2.25
2.21
Comments: Target to be defined in light of benchmarking
Percentage of staff that recommend CLCH as a place to work
2014/15
2015/16
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
62.0%
62.0%
62.0%
62.0%
62.0%
62.0%
62.0%
62.0%
62.0%
62.0%
62.0%
62.0%
Amber Threshold
53.0%
53.0%
53.0%
53.0%
56.0%
56.0%
56.0%
56.0%
59.0%
59.0%
62.0%
62.0%
Actual
n/a
n/a
n/a
40.00%
n/a
n/a
n/a
52.00%
n/a
n/a
n/a
n/a
Target
52.8%
53.6%
54.5%
55.3%
56.1%
57.0%
57.8%
58.6%
59.4%
60.3%
61.1%
61.9%
Amber Threshold
47.5%
48.3%
49.0%
49.8%
50.5%
51.3%
52.0%
52.7%
53.5%
54.2%
55.0%
55.7%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
79.5%
85.0%
90.0%
90.0%
90.0%
90.0%
90.0%
90.0%
90.0%
90.0%
90.0%
90.0%
Amber Threshold
71.6%
76.5%
81.0%
81.0%
81.0%
81.0%
81.0%
81.0%
81.0%
81.0%
81.0%
81.0%
Actual
78.90%
78.80%
81.90%
83.80%
Not reported
59.60%
62.40%
67.60%
75.80%
n/a
n/a
n/a
Target
79.5%
85.0%
90.0%
90.0%
90.0%
90.0%
90.0%
90.0%
90.0%
90.0%
90.0%
90.0%
Amber Threshold
71.6%
76.5%
81.0%
81.0%
81.0%
81.0%
81.0%
81.0%
81.0%
81.0%
81.0%
81.0%
Comments: Agreed ELT 12 March, straight line, 10% threshold
2014/15
2015/16
Comments: Targets agreed ELT 12 March - appraisal rates dip in early year then revive, 10% threshold
Target
Sickness absence rates
2014/15
2015/16
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
4.3%
4.2%
4.1%
4.0%
3.9%
3.8%
3.7%
3.6%
3.5%
3.5%
3.5%
3.5%
3.9%
Amber Threshold
4.7%
4.6%
4.5%
4.4%
4.3%
4.2%
4.1%
4.0%
3.9%
3.9%
3.9%
Actual
3.74%
3.73%
4.02%
4.24%
4.16%
4.16%
3.97%
4.34%
4.00%
n/a
n/a
n/a
Target
4.0%
4.0%
4.0%
4.0%
4.0%
4.0%
4.0%
4.0%
4.0%
4.0%
4.0%
4.0%
Amber Threshold
4.4%
4.4%
4.4%
4.4%
4.4%
4.4%
4.4%
4.4%
4.4%
4.4%
4.4%
4.4%
80
Vacancy level
2014/15
2015/16
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
16.7%
15.9%
15.1%
14.3%
13.5%
12.7%
11.9%
11.1%
11.0%
11.0%
11.0%
11.0%
Amber Threshold
18.4%
17.5%
16.6%
15.7%
14.9%
14.0%
13.1%
12.2%
12.1%
12.1%
12.1%
12.1%
Actual
15.80%
17.90%
17.10%
16.20%
17.80%
17.10%
16.10%
17.50%
18.70%
n/a
n/a
n/a
Target
15.0%
14.9%
14.8%
14.7%
14.7%
14.6%
14.5%
14.4%
14.3%
14.2%
14.1%
14.0%
17%
16%
16%
16%
16%
16%
16%
16%
16%
16%
16%
15%
Amber Threshold
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
17.0%
14.0%
n/a
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
31.0%
34.0%
n/a
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
Comments: target agreed ELT 12 March, based on NHS London average of 14%
Target
Staff from BME backgrounds at band 7 and above
2014/15
2015/16
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
30.5%
30.5%
30.9%
31.2%
31.6%
31.9%
32.3%
32.6%
33.0%
33.3%
33.7%
34.0%
30.6%
Amber Threshold
27.5%
27.5%
27.8%
28.1%
28.4%
28.7%
29.0%
29.3%
29.7%
30.0%
30.3%
Actual
30.80%
30.80%
30.70%
30.70%
31.70%
30.60%
30.50%
30.60%
30.60%
n/a
n/a
n/a
Target
30.5%
30.5%
30.9%
31.2%
31.6%
31.9%
32.3%
32.6%
33.0%
33.3%
33.7%
34.0%
Amber Threshold
27.5%
27.5%
27.8%
28.1%
28.4%
28.7%
29.0%
29.3%
29.7%
30.0%
30.3%
30.6%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Comments: straight line, 10% threshold
Staff with protected characteristics other than BME at band 7
level or above
2014/15
New measure
TBD
P
2015/16
Comments: straight line, 10% threshold
Recurrent QIPPs achieved % of total for the year
ELT Lead: Richard Milner/Ian Millar
2014/15
2015/16
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Amber Threshold
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
Actual
92%
88%
95.60%
87.50%
86.50%
85%
85%
91%
91%
n/a
n/a
n/a
Target
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Amber Threshold
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Amber Threshold
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
Actual
67%
70%
71.40%
83.60%
85.40%
82%
91%
84%
86%
n/a
n/a
n/a
Target
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
91.0%
100.0%
100%
n/a
P
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
86.0%
100.0%
100%
6/8
P
Comments: 10% threshold
Percentage of Qipp plans achieving the planned level of savings
in-year
2014/15
2015/16
81
2015/16
Amber Threshold
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
-
-
-
10%
27%
37%
43%
48%
68%
79%
89%
100%
Amber Threshold
-
-
-
9%
24%
33%
38%
43%
61%
71%
80%
90%
Apr
May
Jun
Jul
Aug
Sep
Oct
Comments: 10% threshold
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
Target
Percentage of staff using mobile technology
2014/15
Amber Threshold
100.0%
Actual
2015/16
Comments: Target from mobile working project plan, 10% threshold
0.909091
KPIs that are RAG rated GREEN on overall data quality
confidence level
2014/15
2015/16
Nov
Dec
Jan
Feb
Mar
Target
In Development
35%
60%
60%
60%
60%
100%
100%
Amber Threshold
In Development
32%
54%
54%
54%
54%
90%
90%
Actual
In Development
35%
n/a
n/a
n/a
n/a
n/a
n/a
Target
75%
76%
77%
78%
79%
80%
80%
81%
82%
83%
84%
85%
Amber Threshold
68%
68%
69%
70%
71%
72%
72%
73%
74%
75%
76%
77%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
n/a
n/a
n/a
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
n/a
85.0%
n/a
n/a
C
FYTD
15/16 target
National
Target
Bench-mark
Cumulative/P
oint
Comments: Target agreed ELT 12 March, straight line 10% threshold
Senior managers that are trained in the continuous
improvement methodology
2014/15
2015/16
In Development
Amber Threshold
Actual
ELT Lead: Jo Medhurst
In Development
Target
In Development
80.0%
Target
Amber Threshold
Comments: • KPI for continuous improvement program to change to Senior managers that are trained in the continuous improvement methodology and the end of year target will be set at 80%. Senior managers will count in this instance as NEDs, EDs, DDs, CBU managers and ADQs. It is not proposed that these managers go through the same training as the previous
cohorts, rather they will have a shorter version of it that will enable them to encourage the mind set and behaviours required for continuous improvement.
82
BOARD OF DIRECTORS
31 March 2015
Report title: Patient Safety – Serious Incident & Being Open Report
Report of: Chief Nurse and Director of Quality Governance
Contact Officer: Director of Patient Safety
Relevant CLCH 14/15 Goal 2: Support people safely out of hospital: providing safe, high quality
Executive Summary: The attached report contains information on External and Internal Serious
Incidents which have occurred within the Trust together with lessons learned from those incidents,
where the Root Cause Analysis investigation has been completed. The incidents have been
anonymised in order to protect the identity of patients and staff. The report also includes Being
Open performance for January.
Assurance provided: The minutes of the Quality Committee and PSRG meetings provide evidence
of review of serious incidents.
Report provenance: Also presented to Trust Board and Patient Safety & Risk group
Discussion
Information
Page 1 of 12
83
1.
Purpose of the Report
1.1
Central London Community Healthcare is committed to providing the highest quality services possible for the people we serve. Every week
thousands of people are treated safely and successfully by CLCH staff. However, when incidents do happen, it is important that lessons are learned
in order to prevent the same incident occurring again. This report contains highlights of learning from Serious Incidents (SIs) but is highly
anonymised in order to protect patient and staff identity.
1.2
Benefits to Patient Safety quality domain are that the identification of the root causes and lessons learned will result in safer services.
1.3
Benefits to Clinical Effectiveness quality domain are that clinical policies and procedures are reinforced following a serious incident investigation.
1.4
Benefits to Patient Experience quality domain are that Being Open is an integral part of the serious incident management process, and contact is
made with patients/families to share findings.
2.
Introduction
2.1
Central London Community Healthcare has made a commitment to creating and maintaining a culture of being open and honest and takes seriously
its duty of candour. Whilst the Trust deals with underperformance of staff in a fair and appropriate way through clear policies and procedures, it is
also recognised that through genuine human error, mistakes do at times happen and it is therefore important to support staff to learn from those
incidents and act to prevent recurrence.
2.2
CLCH Serious Incident panels are meeting regularly. The non-pressure ulcer cases are booked to individually planned panels chaired by an Executive
Director. The pressure ulcer panels are chaired by the Deputy Chief Nurse, the Head of Patient Safety or an Associate Director of Quality. The
investigator and representatives from each clinical team involved in a serious incident attend to review and discuss the investigation findings, to
review the quality of the investigation report, to have an opportunity to reflect with senior management the issues which may have contributed to
the event. These may include system failures, service failures, and external constraints on the service or human error.
2.3
The Trust has in place a clear procedure for managing serious incidents in a timely manner. A serious incident is one which has resulted in a serious
or catastrophic outcome (severe harm (physical, clinical, reputational, financial), injury or death). Serious incidents are not necessarily an error in
practice or process and may have been unavoidable but when a serious incident occurs, an investigation is immediately commenced in order to
ascertain the root cause of the incident. CWHHE Clinical Commissioning Groups Collaborative has responsibility for overseeing the management of
the majority of serious incidents within CLCH. Some categories of serious incident are managed by NHS England directly. All externally reportable
Page 2 of 12
84
SIs are recorded on the NHS system ‘STEIS’. There is an obligation for the Trust to report the outcome of the investigation within a set timeframe
(45 or 60 working days depending on the STEIS classification) to CWHHE Clinical Commissioning Groups Collaborative /NHSE.
2.4
During February 2014 a total of 22 SI were reviewed by a serious incident panel, prior to submission of externally reportable reports to CWHHE
Clinical Commissioning Groups Collaborative
3.
Newly Reported SIs
New SIs reported
Newly Reported SIs in February 2015
Steis
Classification
Status
Datix ID
Steis ID
Incident Date
Locality
CCG
Location
Division
Specialty
Open
W27796
2015/4232
Pressure Ulcer
Grade 4
29/01/2015
Kensington &
Chelsea
NHS West
London CCG
Patient's Home
Networked Nursing & Community Rehab
Community
Nursing (Inner)
Open
W27819
2015/4237
Open
W27760
2015/4465
Open
C698
2015/4903
Open
W27720
2015/5451
Open
2015/5457
Open
W27940
and
W28001
W27941
Pressure Ulcer
Grade 4
Pressure Ulcer
Grade 3
Serious
Complaint
Pressure Ulcer
Grade 3
Pressure Ulcer
Grade 4
26/01/2015
Kensington &
Chelsea
Barnet
NHS West
London CCG
NHS Barnet
CCG
NHS Barnet
CCG
NHS West
London CCG
NHS West
London CCG
Patient's Home
Patient's Home
Barnet Community & Specialist Services
Community
Nursing (Inner)
Community
Nursing (Barnet)
Specialist
Therapies
Community
Nursing (Inner)
Community
Nursing (Inner)
2015/5444
Patient Injury
07/02/2015
Barnet
Open
W27886
2015/5471
Pressure Ulcer
Grade 3
03/02/2015
TBC
29/01/2015
20.11.2014
26/01/2015
07/02/2015
Barnet
Kensington &
Chelsea
Kensington &
Chelsea
Patient's Home
Patient's Home
NHS Barnet
CCG
Athlone House
Rehab Unit
TBC
TBC
Barnet
Community &
Specialist
Services
#N/A
Page 3 of 12
85
Open
W27459
2015/5622
Pressure Ulcer
Grade 4
06/01/2015
Barnet
NHS Barnet
CCG
Patient's Home
Barnet
Community &
Specialist
Services
Open
W28031
2015/5806
Pressure Ulcer
Grade 3
12/02/2015
Westminster
NHS Central
London CCG
Patient's Home
Community
Nursing (Inner)
Open
W28028
2015/6200
09/02/2015
2015/6423
13/02/2015
NHS West
London CCG
NHS Barnet
CCG
W28074
Kensington &
Chelsea
Barnet
Patient's Home
De-escalation
requested,
awaiting reply
Pressure Ulcer
Grade 4
Allegation
against
Healthcare
Professional
FMH Rehab
Community
Nursing (Inner)
Barnet
Community &
Specialist
Services
Open
W27942
2015/6445
Pressure Ulcer
Grade 3
05/02/2015
Barnet
NHS Barnet
CCG
Patient's Home
Barnet
Community &
Specialist
Services
Open
W26171
2015/6586
Pressure Ulcer
Grade 4
28/10/2015
Barnet
NHS Barnet
CCG
Patient's Home
Barnet
Community &
Specialist
Services
Open
W27030
2015/6588
Pressure Ulcer
Grade 3
16/12/2014
Kensington &
Chelsea
NHS West
London CCG
Patient's Home
Community
Nursing (Inner)
Open
W27137
2015/6591
Pressure Ulcer
Grade 4
24/12/2014
Westminster
NHS Central
London CCG
Patient's Home
Community
Nursing (Inner)
Open
W27651
2015/6595
23/01/2015
2015/6604
07/01/2015
NHS West
London CCG
NHS Barnet
CCG
W27332
Kensington &
Chelsea
Barnet
Patient's Home
Open
Pressure Ulcer
Grade 3
Pressure Ulcer
Grade 3
Patient's Home
Community
Nursing (Inner)
Barnet
Community &
Specialist
Services
Open
W27524
2015/6607
Pressure Ulcer
Grade 3
16/01/2015
Barnet
NHS Barnet
CCG
Patient's Home
Barnet
Community &
Specialist
Services
Open
W27681
2015/6612
Pressure Ulcer
Grade 4
24/01/2015
Barnet
NHS Barnet
CCG
FMH Rehab
Barnet
Community &
Specialist
Services
Page 4 of 12
86
Open
W28045
2015/6616
Pressure Ulcer
Grade 4
12/02/2015
Barnet
NHS Barnet
CCG
Patient's Home
Barnet
Community &
Specialist
Services
Open
W27653
2015/6985
Pressure Ulcer
Grade 4
22/01/2015
Barnet
NHS Barnet
CCG
FMH Rehab
Barnet
Community &
Specialist
Services
Open
W28213
2015/7481
Communicable
Disease and
Infection Issue
23/02/2015
Barnet
NHS Barnet
CCG
FMH Rehab
Barnet
Community &
Specialist
Services
Open
W28246
2015/7506
Pressure Ulcer
Grade 3
24/02/2015
Hammersmith
& Fulham
NHS
Hammersmith
& Fulham CCG
Patient's Home
Community
Nursing (Inner)
Open
W26458
2015/7533
Pressure Ulcer
Grade 3 and
Grade 4
08/11/2014
Barnet
NHS Barnet
CCG
Patient's Home
Barnet
Community &
Specialist
Services
Open
W28240
2015/7560
Pressure Ulcer
Grade 4
24/02/2015
Barnet
NHS Barnet
CCG
Patient's Home
Barnet
Community &
Specialist
Services
Open
W28080
2015/7562
Medication
12/02/2015
Barnet
NHS Barnet
CCG
Edgeware
Community
Hospital
Children's Health & Development
0-19 Services
Barnet
Page 5 of 12
87
4.
SI Status Update
SI status update
4.1
17 reports were sent to Commissioners in February 2015.
Status of Report
Closed - all actions completed
0
CSU require further assurance /
information
De-escalation Agreed
Sent to NWL CSU
Grand Total
5.
7
0
16
17
Overdue SIs
SI reports Currently Overdue
5.1
There are no overdue reports at present. No reports were sent to Commissioners past the completion target. Three requests for extensions were
requested in February 2015.
Page 6 of 12
88
6.
De-escalation Requests
De-escalation requests
6.1
One request was made for de-escalation from Commissioners during February 2015. Awaiting confirmation from CCG
•
•
•
•
•
StEIS reference: 2015/6423
• Trust Reference: W28074
Incident Type: Allegations of Abuse: Staff to Patient
Setting of Incident (hospital, patient’s home, care home, e.g.): Marjory Warren ward, Finchley Memorial Hospital
Date of incident: 29th January 2015
• Time of Incident:
CAG or Directorate: NHS Barnet
Reason / rationale for de-escalation request
Please outline below the rationale for the de-escalation request. Please comment on the following, as appropriate:
-
why the SI no longer meets the SI criteria (e.g. no harm, no CSDP, etc.) – this will vary depending on SI type
was a preliminary review undertaken?
were any care and/or service delivery problems identified? If yes, how are they being addressed?
Page 7 of 12
89
Following a 48 hour incident meeting, a safe guarding strategy meeting was held including the presence of the grandson. The case was discussed and the
grandson was informed that due to the allegations, we needed to speak to the patient. He agreed to this.
•
•
•
•
•
The Lead Investigator (CBU Manager) met with the patient at Barnet Hospital. An interpreter had been booked by Barnet and a family member and
Barnet OT were also present.
The patient had full capacity at the time of the interview which was evident from speaking to her and this was also confirmed by nursing staff
working on Palm ward, Barnet.
The patient remembered being on MWW, Finchley.
The patient adamantly denied that anybody hit her whilst on the ward and was very clear that "they looked after her like everyone else" and that
"no-one treated her badly".
Having spoken to the safe guarding team, they feel that this case is no longer a safe guarding issue and next week a meeting will be held to close
the case.
The Lead investigator will continue to investigate the other concerns raised as a complaint.
7.
Department of Health National Never Events
The DoH have published a list of twenty five Never Events which are incidents determined by the Department of Health (DH) as serious, largely
preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Commissioning
organisations are required to monitor the occurrence of Never Events within the services they commission and publicly report them on an annual
basis.
CLCH has had no incidents of national reportable Never Events since the list was published, in 2011.
Page 8 of 12
90
8.
Internal Serious Incidents
8.1
CLCH has identified incidents, complaints and audit results which in themselves would not be considered externally reportable serious incidents,
but might indicate poor quality of care, or be a cause for concern. This includes allegations of patients being left in soiled linen or clothing,
safeguarding queries regarding staff, information governance issues, complaints unresolvable to satisfactory conclusion and safety alerts not
actioned by deadline. Each case has a 48 hour meeting to determine the facts of the incident and determine the level of investigation required.
Table 4 below summarises the cases for which an investigation is ongoing, or has had the RCA report presented to panel.
Status
Datix ID
Incident Date
Date reported on
Datix
Locality
CCG (Clinical
Commissioning
Group) from 1st
April 2014
Location
Division
Open
W27865
Information
Governance
breach
03/02/2015 Barnet
Open
W27875
Delayed
Diagnosis
Open
W28128
Medication
29/01/2015 Hammersmith NHS
& Fulham
Hammersmith
& Fulham CCG
17/02/2015 Barnet
NHS Barnet
CCG
NHS Barnet
CCG
Community
Building
Children's
0-19 Services
Health &
Barnet
Development
Clinic
Allied
Primary Care
Services
Children's
Health &
Development
Health
Centre /
Clinic
Specialty
GPs with
Special
Interest
0-19 Services
Barnet
Summary of Incident/Team for
PU cases
Records found in
external outbuilding
that was being
demolished
Clinician triaged referral
as routing - possible
melanoma identified
Second BCG given to a 3
month old baby.
Incorrect risk
assessment by health
visitor
Page 9 of 12
91
9.
Management of Action Plans
9.1
The Standard Operating Procedure for closure of action plans is described below.
Closure of Serious Incidents:
 Associate Director of Quality and Patient Safety Manager to monitor the completion of actions at monthly divisional governance meetings
 SI Action Plan closure meetings will be arranged a week or so after the last action due date to confirm actions are completed robustly.
These meetings will be chaired by the relevant Executive Director. Attendance will be the Head of Patient Safety, the Divisional Associate
Director of Quality, CBU Manager, Patient Safety Manager and any other relevant member of staff.
 Once the case is agreed for closure Datix will be updated to confirm that all actions are completed, to include the date of the closure
meeting
 Update on closure to be included in the divisional monthly report to PSRG
 Patient Safety Team to update the SI database once a case is closed
9.2
Each division is currently working on reviewing the evidence available, getting it uploaded on to Datix before attending closure meetings.
10.
Whistleblowing
10.1
There have been no whistleblowing cases this month
11.
Child Deaths
11.1
There have been 7 child death cases reported from 8 Nov 2014 to 30 Jan 2015. Only one case has commenced the Child Death Process.
12.
Maternal Deaths
12.1
There have been no maternal death cases since the last report.
Page 10 of 12
92
13. Being Open
Being Open
13.1 Being Open, Performance by Division
There were no incidents that met the criteria for being open in Children’s Health & Development or Allied & Primary Care Services.
Barnet
Month
25/01/2015
25/01/2015
Patient safety incidents meeting
being open requirements
Initial conversation held within
10 days/date on datix
BCSS
4 Moderate
3 Major
BCSS
Moderate 3/4
(one incident has not passed
the deadline yet)
Major 2/3
(the other incident has not
passed the deadline yet)
Letter sent offering copy of report
within 10 days of approval and
recorded on datix
No. of cases were being being
open requirements were met
Not applicable as reports not finalised
yet
BCSS
Moderate 0/4
Major - NA
BCSS
Moderate 3/4
Major 3/3
Page 11 of 12
93
Networked Community and Nursing
Month
Patient safety incidents meeting
duty of candour requirements
West London
2 Moderate
5 Major
25/01/2015 Central
1 Moderate
24/01/2015 2 Major
Initial conversation held within
10 days/date on datix
West London
Moderate 0/2
Major 0/5
Central
Moderate 1/1
Major 0/2
Letter sent offering copy of report
within 10 days of approval and
recorded on datix
No. of cases were being duty
of candour requirements
were met
RCA are due for panel on 19th March
2015
RCA are due for panel on 19th
March 2015
14. Lessons Learnt
Lessons Learnt
Pressure Ulcers
Pressure Ulcer lessons learnt are collated and reviewed as part of the pressure ulcer reporting presented to quality committee 1/4ly.
Themes from Avoidable Cases:
1. Failure to adhere to the PU Policy
2. Delay in responding to a referral
3. Failure to maintain subsequent weekly wound assessment/evaluation records using provided tools
Themes from Unavoidable cases:
1.
Patient’s in receipt of End of life care
2.
Poor Nutritional Intake and mobility
3.
Poor or lack of concordance
4.
Chronic Disease process e.g. dementia, Alzheimer’s
No none PU lessons learnt to report in February data.
Page 12 of 12
94
BOARD OF DIRECTORS
31 March 2015
Report title:
People Strategy
Agenda item number:
3.2
Report of:
Interim Head of HR and OD
Contact officer:
Director of Finance Performance and Corporate Resources
and competence
Can be released
status
Executive summary:
The People Strategy is a key strategy for the Trust and the development of its workforce. This strategy takes
on board previous comments from board members and other colleagues and is designed to ensure that
every employee can deliver excellent care.
The Strategy, maturity matrix and action plan are built around three key themes of Workforce, Leadership
and Organisational Development.
The Strategy provides the outcomes for success in each theme and the success measures; the action plan is a
one year action plan showing current position against measures and key activities required to deliver them
and the maturity matrix shows the development required over 3 years I each of the key outcomes.
The action plan and maturity matrix will evolve during the life of the strategy.
Assurance provided: The Action Plan and Maturity Matrix will be monitored via the Workforce Group and by
exception the Workforce Committee. They will also be reviewed at Senior Management teams
Report provenance: The People Strategy, Action Plan and Maturity Matrix have been discussed at the
Workforce group, Executive Leadership Team and Workforce Committee. Board members have also
commented on previous drafts
Report for:
Decision
X
Discussion
Information
Recommendation: The trust Board is asked to approve the Strategy for ratification and the action plan and
maturity matrix for implementation
95
CLCH People Strategy
2015-2018
1
96
Table of Contents
Introduction ............................................................................................................................................ 3
CLCH vision, values and strategic goals .............................................................................................. 3
Local Context....................................................................................................................................... 4
Foundation Trust Status ...................................................................................................................... 4
National Context ................................................................................................................................. 4
Workforce ............................................................................................................................................... 7
Leadership ............................................................................................................................................... 8
Organisation development ................................................................................................................... 10
Conclusion ............................................................................................................................................. 11
Appendix 1: NHS Leadership Academy Leadership Framework ........................................................... 12
Appendix 2: NHS Leadership Academy Healthcare Leadership Model ................................................ 14
2
97
Introduction
As an employer of 3000 people, our People Strategy is a key document that relates all we
are doing in partnership with our workforce to achieve our vision of ‘Great Care Closer to
Home’. It represents strategically what the Trust can do to engage, lead, recruit, retain,
reward and support its people to operate as effectively as possible within a culture of
excellence.
The People Strategy has been developed in consultation with our Staff Side representatives
and the Senior Management Team, contributing together to a document that represents the
ambitions of our staff for our patients and for our organisation.
We know that our people are vital to the delivery of our Trust’s vision, mission and strategy
and so our People Strategy is designed to create an organisation that means every person
in our employ can deliver excellent care and feel supported, well led and managed,
engaged, healthy and happy at work. Equally the leadership of the Trust pledges to work to
make sure that the environment within which they work is the best it can be for staff who feel
valued and respected as envisioned by the NHS Constitution
CLCH vision, values and strategic goals
Vision
Grea t ca re
clo ser to
ho me
Values
Quality
Relationships
Delivery
Community
Strategic Goals
Vvvvvv
Embody the best of the NHS for our
patients
Deliver better value than competitors
Be responsive to our patients’ and
partners’ needs
Be innovation and technology
pioneers
.
3
98
.
CLCH is operating in a number of contexts that will impact and influence our ability to deliver
our mission and goals and work within a culture that respects and promotes our proclaimed
values.
Local Context
Our commissioners have high-level priorities to secure a shift in service provision from acute
to community care, characterised by reduced admissions and more rapid discharges;
proactive and integrated management of patients with complex long term conditions and
community services reconfigured around patient focused pathways and localities. However,
all this is also set alongside an expectation of cost improvements being achieved year on
year.
CLCH is also actively engaged with local partners on the Whole Systems approach to
integrated working. We also are engaged with Health Education England and the
development of their workforce planning for 2015/16 with the aim of designing and delivering
a transformed workforce that .is capable, confident and competent to deliver our reconfigured service.
Foundation Trust Status
The Trust is aspiring to become a Foundation Trust and it is recognised that the Trust will
then secure a range of enabling freedoms in how it operates that will impact on structure,
culture and performance standards and reward strategies of our workforce.
This strategy is an integral part of the Foundation Trust application process and
demonstrates our commitment to the robust workforce planning and transformation we have
planned over the next 4 years.
The strategy will form the basis of the workforce chapter of our Integrated Business Plan.
National Context
The NHS Constitution contains a number of key elements, including rights and pledges and
responsibilities for patients and the public as well as the responsibilities and rights and
pledges for staff. CLCH is committed to the following NHS pledges to staff:• The NHS commits to provide all staff with clear roles and responsibilities and
rewarding jobs for teams and individuals that make a difference to patients, their
families and carers and communities.
• The NHS commits to provide all staff with personal development, access to
appropriate training for their jobs and line management support to succeed.
• The NHS commits to provide support and opportunities for staff to maintain their
health, well-being and safety.
• The NHS commits to engage staff in decisions that affect them and the services they
provide, individually, through representative organisations and through local
partnership
• The NHS commits that staff will be treated fairly, equally and free from discrimination
Furthermore, as a statutory organisation the Trust has to operate in keeping with the law
(e.g. The Health and Safety at Work Act 1974, The Human Rights Act 1998, The Single
4
99
Equality Act 2010 and the Regulatory Framework for NHS Organisations (Care Quality
Commission). The Care Quality Commission’s standards include ensuring that patients
have the right to expect to be cared for by staff with the right skills to do their jobs properly
and that there are sufficient members of staff to keep people safe and meet their needs.
The publication of the Francis Report, 2011, the independent review of what happened at
Mid Staffordshire Hospitals NHS Foundation Trust, has produced several subsequent
reviews which impact on the workforce, not least the Compassion in Practice Strategy, 2012,
for nurses, which supports our commitment to provide every patient with a service that stays
true to the core NHS values of quality, care and compassion.
In response to these challenging contexts and to support delivery of Trust mission, goals and
values, we have developed a number of strategies (and action plans) that support and cross
reference with each. These include a clinical framework and strategy, an end of life strategy,
education strategy, quality strategy and an engagement strategy and this People Strategy
The People Strategy is key in providing our response to these challenges and is structured
to support three of the Trust Strategic Goals as shown below
Our Goals
Implications for the Workforce Strategy
Embody the best of the NHS for our
patients: delivering great results with
compassion and thoughtfulness
• A culture of quality, care and compassion
• Integrated multi-disciplinary teams working along patient
pathways and in partnership at network, borough and Trust
level
• Further devolution of decision making to Clinical Business
Units and
• Systematic appraisal, objective setting and personal
development planning
• Staff morale, engagement and motivation all high
• All workforce legal and compliance requirements met
• Partnership working with primary care, acute care and social
services
• Long term workforce planning and education commissioning
in place
• Various productivity improvements e.g. hours, locations,
mobile technology
• New roles and increased skill mix
• Appropriate mix of core and temporary staff
• Management development that emphasizes financial and
commercial acumen, making best use of information,
managing individual performance
• Explore sharing back office functions and out sourcing
• Culture of quality, care and compassion, openness, candour
and transparency
• A culture of staff working flexibly and responding quickly to
change
• Our people are positive advocates for CLCH.
• Targeted training, education and research
• Strong decision making processes in leadership roles
• Standard organisational improvement methodology
• A strong employer brand
• Values based recruitment
• Systematic appraisal, objective setting and personal
development planning
• Robust individual performance management with pay linked
Support people safely out of hospital:
providing safe, high quality value for money
alternatives to hospital admissions
Deliver better value than competitors in our
selected markets: securing our sustainability
by providing effective and efficient services
Be responsive to our patients and partners’
needs: promoting integration and partnership
by demonstrating our capacity, character and
competence
Employ only the best staff: selecting staff
who care and supporting them to go the extra
mile for patients
5
100
•
•
•
•
•
Be innovation and technology pioneers:
leading transformation of out-of-hospital
services to empower staff and improve patient
health
•
•
•
•
to performance
Talent management and succession planning
Innovative career development opportunities
Team leader development
Leader in employee health and well being
Action plan to deal with worst performing areas of staff
survey
Recognise and celebrate staff achievements
Standard organizational improvement methodology
Maximum use of mobile technologies and tele-medicine
Use of technology to maximise efficiency and effectiveness
of corporate/back office functions
The People Strategy focusses on three main strands
Workforce
Leadership
Organisational Development
6
101
Workforce
The Workforce of CLCH is essential to delivering the outcomes highlighted within
the People Strategy and the required service transformation.
The success of the Trust is based on the ability of the workforce to respond to
challenges and changes and be the right people for the role in terms of skills,
numbers and ability to change.
Outcomes for
success
Right numbers in
workforce
Right skills in
workforce
Actions to succeed
Success Measures
Appropriate mix of core and
temporary or contingent staff to
enable us to respond to changes in
demand from commissioners
Implementation of E-rostering during
2015/16
Bank :agency ratio 60:40
Compliance with safe staffing levels
(Hard Truths Reporting)
Recruitment metrics in best
quartile all of the time
Reduced vacancy rate
Robust resource and
workforce plans for each
CBU and division
Workforce and resource planning
embedded in division
Flexibility in size of workforce to
respond to growth agenda
Systematic appraisal, objective
setting and personal development
planning
Talent management and succession
planning
Registration and revalidation of all
appropriate staff
Training for leaders available to
deliver model of leadership required
Temporary staffing at less
than 10% of workforce
Shifts staffed in line with
safe staffing
Appraisals for 90% of
workforce feeding Training
Needs Analysis
Links with Education
Strategy
All staff appropriately
qualified, registered and
revalidated to conduct their
roles
Statutory and mandatory
training completed by 90%
of the workforce
A representative and
diverse workforce
throughout the hierarchy
of the Trust
Ensure all recruitment processes pay
attention to requirements for a
diverse workforce
Diversity of staff at all
grades of staff is reflective
of diverse workforce and
places us well in
benchmarking of WRES
and other diversity
markers.
Flexible workforce
Staff working across multiple sites
Increased uptake on
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to reduce costs of care and
services and to maximise the use
of our estate.
Staff working flexibly, outside of
traditional hours
mobile working
Less estates
Increased coverage of
services across the
Trust
Better utilisation of
space across the Trust
estate
Lone working staff
supported and feel safe
Non-traditional working
requests supported by
Employee Health
Leadership
Leadership within the NHS has been a consistently researched and discussed topic that has
been the subject of a range of DH recommendations (e.g. Berwick, 2013) that have
highlighted the importance of well led teams to high quality patient care and experience, the
delivery of harm-free care and culture.
The Francis report of 2013 clearly recognises the fact that organisational culture is informed
by the nature of its leadership. Stable and consistent leadership is one of the characteristics
of high-performing public sector organisations in other health care systems (Baker 2011), as
well as a notable feature in a significant number of well-performing NHS foundation trusts.
The King’s Fund Report (Leadership and Engagement for Improvement in the NHS,
Together we Can 2012) provided evidence that where staff are engaged, organisations
deliver a better patient experience, achieve better outcomes, and have lower staff
absenteeism. It further identified that engaging patients in their own care ensures that this
care is more appropriate and can also contribute to improving outcomes.
Recent reviews into patient safety, such as the Berwick Review (2013) have identified the
difference between leadership behaviours that promote patient safety and those that don’t,
whilst the Kings Fund Report into Patient-Centred Leadership summarised the key features
of leadership and culture required to ensure the safe care of patients and to avoid high
profile failures such as those seen at Mid Staffordshire NHS FT.
Further evidence of the importance of leadership in healthcare is shown by the introduction
of a “Well-Led” domain into the inspection approach used by the Care Quality Commission
(CQC) to assess the quality of care provided to patients.
In the 2015 review of evidence on leadership development in healthcare co-produced by the
King’s Fund, the Faculty of Medical Leadership and Management and the Center for
Creative Leadership the authors concluded that there is little empirical evidence on the best
way to develop leaders but suggested that:
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“Approaches to developing leaders, leadership and leadership strategy can and should be
based on robust theory with strong empirical support and evidence of what works in
healthcare.”
Leadership and management are different concepts but are of equal importance within
CLCH. We recognise that developing the workforce in the way we propose requires leaders
to function at all levels of the organisation with culturally appropriate skills, behaviours and
values and therefore this strategy will pay specific attention to the current thinking about
leadership and developing leaders in the NHS and will support the work being conducted
within the Trust on compassionate leadership and the consistent implementation of our
clinical framework and patient engagement programme.
Our People Strategy will draw on the work of the NHS Leadership Academy and specifically
the NHS Leadership Academy Leadership Framework (2011) and the NHS Leadership
Academy Healthcare Leadership Model (2013) to underpin the approach we will adopt to
develop leaders within the Trust (see Appendices 1 and 2). In addition the transformational
culture required for responsive healthcare Leadership will be drawn from Kings Fund work
following based on the principles identified within the Berwick review.
The framework not only explains how context makes a difference to the provision of high
quality care and to staff satisfaction, but also incorporates management activities beneath
the banner of leadership and can be used to map our internal programmes against the core
requirements enshrined within our strategy. The model is also designed to enable
employees to map their own behaviour against those expected of a leader in healthcare.
Outcomes for
success
Values of leadership –
based on Berwick
review
Behaviours of
leadership – NHS
Leadership Academy
Healthcare Leadership
Model
Actions to succeed
Success Measures
Are visible and set an example
Listen to patients and staff
Encourage clinical engagement
Share leadership with all staff,
and ensure that they feel valued,
respected and supported
Are able and willing to challenge
others
Are ready and able to exercise
collective leadership at board
level
Inspired shared purpose
Recruitment processes
provide assurance on
style of future leaders
Leading with care
Evaluating information
Survey results in
relations to staff
experiencing
discrimination, bullying
and harassment –
below national average
Increase satisfaction
with managers in staff
surveys – upper quartile
Increased Staff Friends
and Family test results
– upper quartile
Connecting our service
Sharing the vision
Engaging the team
Holding to account
Positive patient survey
results – upper quartile
Increased stability of
workforce turnover rates
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Culture of Leadership
– based on Kings Fund
“Developing collective
leadership for health
care”
Developing capability
at10% by 2018
Influencing for results
High performance
ratings in teams Improved retention
rates for senior
managers – target 10%
High levels of engagement with staff
and patients
Developing culture of compassionate
care
Clear objectives and priorities set for
every member of staff
High levels of team working and cooperation across boundaries
High degree of
appraisal rates across
the Trust – target 95%
Proportion of CBU
managers and senior
managers who have
received Leadership
Training – target 100%
Organisation development
The Central London Community Healthcare NHS Trust People Strategy supports and
enables delivery of the overall CLCH Strategic Goal of building a workforce that is fully
equipped to meet the challenges of a rapidly changing healthcare environment which
demands ‘more for less’ and where patient needs are more complex and their expectations
higher.
Our commissioners have high-level priorities of a shift from acute to community care,
reduced admissions and quicker discharges; proactive management of patients with
complex long term conditions and community services reconfigured around patient focused
pathways and localities. However, all this is also set alongside an expectation of cost
improvements being achieved year on year.
Together this means the Trust needs to produce a plan for innovative working with
potentially fewer staff and a different skill mix. Given the fact that it is not possible to
accurately predict what any new NHS environment will precisely look like, the Trust’s
strategy must be one which focusses on ensuring the flexibility within the workforce to meet
a landscape that will be radically different.
The Trust is committed to partnership working and will continue to support trade unions to
formally fulfil their roles through appropriate facilities and employment-related
agreements, and recognises our intention to engage with all employees, irrespective of
any trade union affiliation that they might hold.
Outcomes for success
Increasing staff
engagement
Actions to succeed
Increased numbers of
staff focus groups
Developing partnership
working with all staff
groups
Success measures
Increase staff satisfaction
with workplace – target
upper quartile
Introduction of Staff
Engagement Forum
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105
Enhanced Employer
Brand and publicity
Increased staff morale
and engagement scores
in survey – upper quartile
Seamless induction of
new business
Low turnover rate – 10%
by 2018
Organisational wide
understanding of
leadership and leadership
competencies
Reduced agency usage –
less than 10% of
workforce
Reduced sickness
absence rate – at national
average
Learning Culture
Continuous Improvement
Delivery of education
strategy
In line with the Education
Strategy
Reliable PDP outcomes
from appraisal and
objective setting process
Appraisal system
captures PDP outcomes
and feeds into Training
Needs Analysis, career
development and
succession planning.
In line with the CI
Programme
Delivery of the
Programme
Conclusion
The People Strategy supports the Trust’s other key strategies and overall goals and seeks
to deliver a right sized, appropriately skilled, engaged and compassionate workforce that not
only meets but exceeds the expectations of its commissioners, partners, patients and their
carers
The strategy has been designed to address the key challenges that have been identified
whilst being sufficiently flexible to adapt to the potentially radical changes in the community
healthcare environment over the coming years. The strategy will be a key enabler that
underpins the targets for growth, productivity, financial efficiency and transformation to FT
status that are demanded if the Trust is to ensure its sustainability into the future.
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Appendix 1: NHS Leadership Academy Leadership Framework
The framework explains how the ability to demonstrate leadership will become more
complex and demanding with career progression. In describing this and to help staff
understand their progression and development as a leader, they have used the following
four stages:
Stage 1
Own practice/immediate team- is about building personal relationships with patients and
colleagues, often working as part of a multi-disciplinary team. Staff need to recognise
problems and work with others to solve them. The impact of the decisions staff take at this
level will be limited in terms of risk.
Stage 2
Whole service/across teams - is about building relationships within and across teams,
recognising problems and solving them. At this level, staff will need to be more conscious of
the risks that their decisions may pose for self and others for a successful outcome.
Stage 3
Across services/wider organisation- is about working across teams and departments within
the wider organisation. Staff will challenge the appropriateness of solutions to complex
problems. The potential risk associated with their decisions will have a wider impact on the
service.
Stage 4
Whole organisation/healthcare system - is about building broader partnerships across and
outside traditional organisational boundaries that are sustainable and replicable. At this level
leaders will be dealing with multi-faceted problems and coming up with innovative solutions
to those problems. They may lead at a national/international level and would be required to
participate in whole systems thinking, finding new ways of working and leading
transformational change. Their decisions may have significant impact on the reputation of
the NHS and outcomes and would be critical to the future of the NHS
The framework consists of seven domains. Within each domain there are four sub
categories which are further divided into four descriptors. These statements describe the
leadership behaviours which are underpinned by the relevant knowledge, skills and
attributes all staff should be able to demonstrate.
Domain
Element
1. Demonstrating Personal Qualities
Developing self-awareness
Managing yourself
Continuing personal development
Acting with integrity
2. Working with Others
Developing networks
Building and maintaining relationships
Encouraging contribution
Working within teams
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3. Managing Services
Planning
Managing resources
Managing resources
Managing performance
4. Improving Services
Ensuring patient safety
Critically evaluating
Encouraging improvement and innovation
Facilitating transformation
5. Setting Direction
Identifying the contexts for change
Applying knowledge and evidence
Making decisions
Evaluating impact
6. Creating the Vision (particularly for those in
more senior roles)
Developing the vision of the organisation
Influencing the vision of the wider healthcare
system
Communicating the vision
Embodying the vision
7. Delivering the Strategy (particularly for those
in more senior roles)
Framing the strategy
Developing the strategy
Implementing the strategy
Embedding the strategy
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108
Appendix 2: NHS Leadership Academy Healthcare Leadership
Model
The Healthcare Leadership Model is an NHS Leadership Academy resource that is aimed at
anyone whether a formal or informal leader. It is made up of nine ‘leadership dimensions’.
For each dimension, leadership behaviours are shown on a four-part scale which ranges
from ‘essential’ through ‘proficient’ and ‘strong’ to ‘exemplary’. Although the complexity and
sophistication of the behaviours increase as we move up the scale, the scale is not tied to
particular job roles or levels. So people in junior roles may find themselves to be within the
‘strong’ or ‘exemplary’ parts of the scale, and senior staff may find themselves in the
‘essential’ or ‘proficient’ parts.
The table below outlines the nine dimensions and a brief description of what the dimension
covers
Dimension
What is it?
Inspired shared purpose
Valuing a service ethos
Curious about how to improve services and patient care
Behaving in a way that reflects the principles and values of the
NHS
Leading with care
Having the essential personal qualities for leaders in health and
social care
Understanding the unique qualities and needs of a team
Providing a caring, safe environment to enable everyone to do
their jobs effectively
Seeking out varied information
using information to generate new ideas and make effective
plans for improvement or change
making evidence-based decisions that respect different
perspectives and meet the needs of all service users
Understanding how health and social care services fit together
and how different people, teams or organisations interconnect
and interact
Sharing the vision
Communicating a compelling and credible vision of the future in
a way that makes it feel achievable and exciting
Engaging the team
Involving individuals and demonstrating that their contributions
and ideas are valued and important for delivering outcomes and
continuous improvements to the service
Holding to account
Agreeing clear performance goals and quality indicators
Supporting individuals and teams to take responsibility for
results
Providing balanced feedback
Building capability to enable people to meet future challenges
Using a range of experiences as a vehicle for individual and
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109
organisational learning
Acting as a role model for personal development
Deciding how to have a positive impact on other people
Building relationships to recognise other people’s passions and
concerns
Using interpersonal and organisational understanding to
persuade and build collaboration
15
110
16
111
Outcomes for
Success
People Strategy Action Plan 2015/16
22015/16 Actions
Current position
Success measures
1.
Right numbers in
workforce
Appropriate mix of
core and temporary
staff
Workforce
Bank agency ratio
50:50
Temp spend 15%
By When
Who
Bank:agency ratio at
60:40
Temporary staffing less
than 10% of workforce
March 2016
Interim Head of HR and
OD
Deputy Chief Nurse
Procurement of Erostering during
2015/16
Not applicable
Contract signed and
implementation plan
agreed
June 2015
OD
DDOs
HR BPs
Start of
implementation of erostering
Not applicable
In line with agreed
implementation plan
March 2016
OD
Compliance with safe
staffing levels
Compliant
Wards report staffing
compliant with safe
staffing levels
March 2016
OD
Recruitment Manager
DDOs
Stream lined
recruitment process
Time to hire in
lowest quartile
Reduced time to hire –
at lowest quartile for
sector
Vacancy rate 14% or
lower
Reduced sickness
absence
Increased well-being
score in staff survey
March 2016
OD
March 2016
OD
Deputy Head of EH
Vacancy rate 16%
Leader in employee
health and well being
Sickness absence at
4%. At Community
Trust average.
National average
3.5%
Current well being
RAG
Movement
112
Outcomes for
Success
22015/16 Actions
Current position
Success measures
Workforce and
resource planning
Rights skills in
workforce
Systematic appraisal,
objective setting and
personal development
planning
Appraisal rate 90%
Robust individual
performance
management with pay
linked to performance
A representative
and diverse
workforce
throughout the
hierarchy of the
Trust
By When
Who
Every CBU and
Divisions has robust
resource and workforce
plans
March 2016
OD
DDOs HR BPS
Appraisals for 90% of
workforce feeding
Training Needs Analysis
August 2015
CBU Managers
DDOs
OD
Objectives set for 100%
of workforce
June 2015
All managers
OD
Talent management
and succession
planning
No talent or
succession plans in
place
Introduction of talent
and succession
management process
Sept 2015
Head of OD
Registration and
revalidation of all
appropriate staff
100%
100% staff
appropriately qualified,
registered and
revalidated to conduct
their roles
On going
Chief Nurse
Medical Director
Od
All recruitment
processes (for new
hires and promotions)
pay attention to
requirements for a
diverse workforce
Not currently
recorded
Diversity of staff at all
grades of staff is
reflective of diverse
workforce and places us
well in benchmarking of
WRES and other
diversity markers.
March 2016
OD
All recruiting managers
RAG
Movement
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Outcomes for
Success
A Flexible
workforce
22015/16 Actions
Current position
Success measures
Staff working
across multiple
site and using
space to drive
down the costs of
care and services
and to maximise
the use of our
estate.
Not currently
recorded
Reduced estates costs,
less void space across
the Trust
Lone working devices
available for all relevant
staff
Development of
wellbeing strategy
March 2016
Staff working
flexibly, outside of
traditional hours
Not currently
recorded
Increased number of
staggered starts and
finishes across the Trust
March 2016
Implementation of
NHS Academy
Leadership Model
September
2015
2.
Values of
leadership –
based on Berwick
review
By When
Are visible and set an
example
Listen to patients and
staff
Encourage clinical
engagement
Leadership
Staff
engagement
score in survey
3.75
Who
RAG
Movement
OD
Head of OD
Increase
satisfaction with
managers in staff
114
Outcomes for
Success
Behaviours of
leadership – NHS
Leadership
Academy
Healthcare
Leadership Model
22015/16 Actions
Current position
Success measures
Share leadership with
all staff, and ensure
that they feel valued,
respected and
supported
Are able and willing to
challenge others
Are ready and able to
exercise collective
leadership at board
level
Inspired shared
purpose
Leading with care
Evaluating
information
Connecting our
service
Sharing the vision
Engaging the team
Holding to account
Motivation
score 3.91
surveys – upper
quartile
% of staff
believing Trust
equal
opportunity
82%
Increased Staff
Friends and Family
test results – upper
quartile
Turnover 18%
% of staff
experiencing
harassment,
bullying or
abuse from
staff 29%
Positive patient
survey results –
upper quartile
By When
Who
March 2016
OD
Manager
Stable turnover
rates – 10%
High performance
ratings in teams -
RAG
Movement
March 2016
Decrease in survey
results in relations
to staff
experiencing
discrimination,
bullying and
harassment – below
national average
Improved retention
rates for senior
115
Outcomes for
Success
22015/16 Actions
Current position
Success measures
Who
RAG
Movement
managers – target
10%
Culture of
Leadership –
based on Kings
Fund “Developing
collective
leadership for
health care
By When
High levels of
engagement with staff
and patients
Developing culture of
compassionate care
Clear objectives and
priorities set for every
member of staff
High levels of team
working and cooperation across
boundaries
High degree of
appraisal rates
across the Trust –
target 95%
Head of HR and OD
Head of OD
Proportion of CBU
managers and senior
managers who have
received Leadership
Training – target 100
Increased for CBU
managers in
commercial and
financial activity
Completion of the
compassionate care
programme
Increasing staff
engagement
Increased numbers
of staff focus groups
Developing
partnership working
3. Organisational Development
Staff
Increase staff
engagement
engagement with
workplace – target
currently 3.75
upper quartile
March 2016
OD
Head of OD
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Outcomes for
Success
22015/16 Actions
Current position
Success measures
with all staff groups
Leader in Staff Well
Being
Staff
motivation 3.91
Enhanced Employer
Brand and publicity
Agency usage
at 15%
Sickness
absence 4%
Learning
Culture
Delivery of Education
Strategy
Continuous
Improvement
Delivery of
Continuous
Improvement
Programme
By When
Who
March 2016
Deputy Chief Nurse
March 2016
Medical Director
RAG
Movement
Increased staff
motivation
Low turnover rate –
10%
Reduced agency
usage – less than
10% of workforce
Reduced sickness
absence rate – at
national average
In line with Education
Strategy
In line with CI
programme
Increased devolution
and automony to the
CBU Managers
117
2015/16
2016/17
Theme 1
2017/18
Workforce
Right numbers in workforce
Appropriate mix of
core and temporary
staff
Implement Erostering
Compliance with safe
staffing levels
Reduced vacancy
rate
Increase size of clinical bank to remove
reliance on agency and reduce to 10% of
workforce as temporary
Procure e-rostering system and commence
implementation
All shifts staffed in line with safe staffing
Embed use of TRAC as Applicant
Management System
Review retention initiatives to keep staff in
post
Aim for 10% of shifts filled by temporary workers
Aim for 10% of shifts filled by bank
workers
Continue roll out of system
E-rostering fully implemented
Develop automation of processes to increase
efficiency
Recruitment metrics in top 5 percentile
Retention strategy in place
Recruitment metrics (time to hire, turnover
rate, vacancy rate) all in upper quartile of
performance
Introduction use of social media (linked in)
as recruitment tool
Maintain efficient process
Continue development of social media
presence and have “pool” of candidates
Vacancy rate consistent for staff groups
and CBU
Regular use of social media to attract
candidates and have “pool” of candidates
available
Monitor vacancy rate targets by staff group
and/or CBU
Develop vacancy rate targets for staff
groups and CBU
118
Workforce and
resource planning
Leader in Employer
Health
Introduce regular workforce and resource
planning to division to cover 1 -6 month
periods
Develop plans to cover 6 – 12 month periods
Embed plans that cover 12 – 18 month
periods
SEQOHS (Safe Effective Quality
Occupational Health Service) accreditation
achieved
Embed service provision
Continual review and revision of
Employee Health practices to make us
best provider
Continue to learn from best practice Employee
Health services and evolve service accordingly
Review of service provision
Roll out of lone working alarms
Monitor and review use of lone worker
procedures and amend as appropriate
Right Skills in Workforce
Systematic appraisal,
objective setting and
personal
development
planning
Managers trained in setting objectives and
giving ratings for performance at appraisal
Introduction of objectives for leaders based
on NHS Academy Model
Appraisal timetable published and managed
Ratings linked to pay progression through
appraisal
All appraisals and objective setting
meetings run to set timetable
Staff receiving training identified as part
of PDP
Training needs reflected in Education Strategy
Procurement and implementation of
appraisal system
At least 90% of staff compliant with statutory and
mandatory training
At least 90% of staff compliant with
statutory and mandatory training
Monitoring of appraisals ratings and
publication of performance targets
Capture of Personal development plans to
support training needs
At least 90% of staff compliant with
statutory and mandatory training
119
Talent management
succession planning
Registration and
revalidation of all
appropriate staff
Develop Talent management and
succession planning processes and tools
Implement talent management and successions
planning tools
Introduce NHS Leadership Academy Model
for self assessment
Incorporate NHS Leadership Model in talent
management and succession discussions
Ensure 100% of registered staff maintain
their registration and introduce validation of
registered staff
Maintain registration and revalidation
Embed full suite talent management and
succession planning tools
Maintain registration and revalidation
A representative and diverse workforce throughout hierarchy of Trust
Ensure recruitment
processes support
requirements for a
diverse workforce
Monitor and report in line with the
Workplace Race Equality Scheme
Review actions from focus groups and amend
processes as required.
Review and amend processes with input
from staff focus groups
Use staff survey focus groups to identify
areas of discrimination
Continue with staff survey focus groups
Maintain representation in higher bands
of structure
Increase representation in higher bands of
structure
Flexible workforce
Staff working
across multiple
site reduce costs
of care and
services and to
maximise the use
of our estate.
Development of policies and practices to
support the increased use of mobile
working
Communicate work to support culture of
mobile working
Maintain support for culture of flexible working
Mobile working embedded in many of
the teams
Support reduction in use of estates via
consultation
Teams requesting mobile working
120
Theme 2
Leadership
Values of leadership – based on Berwick review
Are visible and set an
example
Listen to patients and
staff
Encourage clinical
engagement
Introduce values into Trust via
communications process and appraisal
system
Develop training packages to support
leaders in developing values
Embed values in appraisal system and monitor
ratings,
Continue cycle of appraisal rating, linked
to progression and development needs
Run training programmes based on who is rated
poorly in values
Recruitment processes test values of leaders
Develop recruitment and assessment
process to introduce values
Reward leaders with correct values
Share leadership with
all staff, and ensure
that they feel valued,
respected and
supported
Are able and willing to
challenge others
Are ready and able to
exercise collective
leadership at board
level
Behaviours of leadership – NHS Leadership Academy Healthcare Leadership Model
Inspired shared
purpose
Introduce behaviours into Trust via
communications process and appraisal
system
Leading with care
Support leaders in self assessing via
Embed behaviours in appraisal system and
monitor ratings,
Continue cycle of appraisal to identify
leaders and identified successors using
this tool
Run training programmes based on who is rated
poorly in values
121
model and provide feedback on outcomes
Develop training packages to support
leaders in developing values
Use testing of behaviours to inform recruitment
and talent and succession decisions
Reward leaders with correct behaviours
Sharing the vision
Engaging the team
Holding to account
Develop recruitment and assessment
processes that test behaviours
Culture of Leadership – based on Kings Fund “Developing collective leadership for health care”
High levels of
engagement with staff
and patients
Developing culture of
compassionate care
Clear objectives and
priorities set for every
member of staff
Design introduction of culture of
leadership for the Trust
Utilise appraisal system and surveys to establish
impact of interventions
Design interventions for leaders to
understand how they impact on culture
Evaluate position and revise/re design
interventions as appropriate
Roll out interventions on creating culture
of leadership
Hold leaders to account on culture they create
Culture, values and behaviours of
leadership embedded in Trust
High levels of team
working and cooperation across
boundaries
122
Theme 3
Increasing staff engagement
Increased numbers
of staff focus groups
Engagement with staff on development of
key interventions, ie
Regular cycle of staff focus groups in place
Staff creating and driving changes to
ways of engagement
Valued and utilised by staff
Staff Survey action plans
Ideas from staff on engagement implemented
Ways of engagement
Ways of raising morale
Developing
partnership working
with all staff groups
Explore ways of developing partnership
with staff
Embed partnership working model
Develop model to become business as
usual and viewed as valued by staff
Agree brand portfolio
Evaluate impact of brand
Continue to evolve and evaluate brand
Roll out brand activities such as job fairs,
school visits, advertising, social media
Review brand and revise based on evaluation
Implement preferred model of partnership
working
Enhanced Employer
Brand and Publicity
Continue reward and recognition schemes
to reflect values and behaviours of Trust
Develop reward strategies related to brand values
and behaviours
Seamless induction
of new business
Implement induction for all new business
post mobilisation
Implement induction for all new business post
mobilisation
Implement induction for all new business
post mobilisation
Organisational wide
understanding of
leadership and
leadership
competencies
Communicate NHS Leadership Academy
values, behaviours and the Culture of
Leadership
Evaluate understanding of leadership across the
Trust
Review relevance and evaluate
leadership behaviours, values and
culture
Embed behaviours, value and cultures and use as
recruitment tool
123
Learning Culture
Delivery of education
Strategy
Reliable PDP
outcomes from
appraisal and
objective setting
process
In line with strategy maturity matrix
Procurement of appropriate appraisal
system
Embed appraisal system
Evaluate data
Evaluate quality of data
Review/re design training if required
Implementation of appraisal system
Re design/review training if required
Training of managers in setting objectives
and training requirements
Delivery of the
Continuous
Improvement
Programme
Delivery of Continuous Improvement Programme
124
BOARD OF DIRECTORS
31 March 2015
Report title: Information Governance Annual Report 2014/15
Report of: – Director of Finance, Performance and Corporate Resources
Contact Officer: Head of IMT Governance and Business
Relevant CLCH 14/15 Goal: Embody the best of the NHS for our patients, Be responsive to our
patients and partners’ needs
Executive Summary
The Trust is required to make a submission against the Information Governance Toolkit on March
31st each year. In order to achieve compliance, the Trust is required to achieve a minimum of level 2
against each requirement in the toolkit. In-year monitoring of the Information Governance work
plan is delegated to the Information Governance Group, but it is a requirement that the Board is
annually updated on work around Information Governance and made aware of any issues arising.
Next Steps
The Internal Audit Report is expected in advance of the Trust confirming its submission against v12
of the IG Toolkit on 31st March 2015.
Assurance provided:
Operational oversight of IG activities by the Information Governance Group
Scrutiny of IG Toolkit evidence annually by our Internal Auditors
Evidence that the Trust is consistently performing well compared to other aspirant Community FTs
and its commissioners.
Report provenance: Annual briefing to the Trust Board
Discussion
Information
125
Information Governance Annual Report 2014/15
Introduction
The Trust is required to make a submission against the national Information Governance
Toolkit on March 31st each year. Compliance is assessed as the achievement of a
minimum score of level 2 against each of the requirements in the Toolkit, resulting in a
rating of “satisfactory”.
CLCH has made four finalised submissions to date, achieving the following overall scores:
Year
2010/11
2011/12
2012/13
2013/14
Overall score
68%
71%
76%
80%
Assessment
Not satisfactory
Satisfactory
Satisfactory
Satisfactory
Benchmarking within Community Trust cohort and Commissioners
The cohort of Community Trusts used as our benchmarking group all achieved
satisfactory compliance against the IGT at the end of March 2014.
The inner London CCGs made their first submissions in 2013-14. All our Clinical
Commissioning Groups declared compliance with Information Governance
requirements. The performance of the individual organisations is summarised in the
table below.
Organisation
Bridgewater Community Trust
Cambridgeshire Community Services Trust
CLCH
Liverpool Community Trust
Norfolk Community Trust
Wirral Community Services Trust
NWL Commissioning Support Unit
North Central London Support Unit
Barnet CCG
Central London CCG
Hammersmith and Fulham CCG
West London CCG
Overall IGT v11
Score
66%
66%
80%
70%
76%
71%
76%
68%
66%
71%
71%
71%
Information Governance – Work Plan 2014/15
The Information Governance (IG) annual work programme for 2014-15 is monitored via
the Information Governance Group. This year the IG team have been working to raise
the profile of IG and arising issues Trust wide. This report highlights the many areas of
126
progress for the IG Team which have been supported by the SIRO (Director of Finance,
Performance and Corporate Resources, the Caldicott Guardian (Medical Director) and
the Chief Information Officer.
Information Commissioners Audit
The Trust invited the Information Commissioners Office (ICO) to undertake a consensual
audit in May 2014. The audit focused on Records Management and Security of Personal
Data and was facilitated by the IG Team and supported by the Executive Leadership
Team (ELT). The audit commenced over 3 days where the ICO auditors visited several of
our sites spanning across 4 boroughs of London.
The Audit Report was provided to us in July 2014. The audit found reasonable assurance
in relationship to the Security of Personal Data and limited assurance around Records
management, resulting in an overall opinion of limited assurance. Areas of good practice
were noted as:
•
•
•
Remote and home working achieved through encrypted laptops and secure VPNs
A robust incident and risk management system accessible to all staff with
automatic alerts to relevant staff of incidents and near misses
Business continuity and security systems to protect IT systems, including robust
uninterruptible power supplies and a secure data centre
Notable recommendations for improvement included:
•
•
•
Aligning arrangements for disposal of confidential waste across the Trust
Ensuring there is a dedicated Records Management role within the organisation
Ensuring the Information asset register captured clinical information systems
The IG Team developed a work programme which set out to focus on and deliver
improvements throughout the Trust by 31st October 2014, including the following areas:
•
•
•
•
•
Developing and delivering training to support Information Asset
Owners/Administrators
Developing and launching Records Management training for non clinical staff
Assigning assets and ensuring there was robust information asset register
Increasing staff communications regarding Information Governance issues,
including security and tailgating
Establishing an in-house Data Protection audit programme with Director level
involvement
Assigning and maintaining responsibility for records management
The Trust’s final report was sent to ICO on 3rd November 2014. Although a revised audit
opinion was not provided, we received a statement confirming that the Trust had made
significant progress in meeting, completing or exceeding the action plan. They went on
to further state that to have made so much progress in such a short space of time was to
CLCH’s credit. The IG Team prepared communications jointly with the communications
team and presented the good news on the Trusts website.
127
Information Governance Toolkit
The IG Team have been working on the delivery of the annual Information Governance
toolkit submission to achieve minimum level 2 compliance. The areas of focus this year
have been:
•
•
•
•
•
•
•
•
•
•
•
•
•
Ensuring there is adequate Information Governance Management Framework to
support the current and evolving Information Governance agenda.
Reviewing formal contractual arrangements to ensure they include compliance
with information governance requirements, and are in place with all contractors
and support organisations.
Ensuring the Information Governance agenda is supported by adequate
confidentiality and data protection skills, knowledge and experience which meet
the organisation’s assessed needs.
Updating and providing staff with clear guidance on keeping personal
information secure and on respecting the confidentiality of service users and on
the duty to share information for care purposes.
Reviewing updating and disseminating the Trusts patient confidentiality leaflets.
This enabled changes to be reflected in line with our core clinical system so that
individuals are informed about the proposed uses of their personal information.
Ensuring the Information Governance agenda is supported by adequate
information security skills, knowledge and experience which meets the
organisation’s assessed needs.
Undertaking formal information security risk assessments and management
programme for key Information Assets has been documented, implemented and
reviewed.
Ensuring there are established business processes and procedures that satisfy the
organisation’s obligations as a Registration Authority.
Reviewing monitoring and enforcement processes to ensure NHS national
application Smartcard users comply with the terms and conditions of use.
Ensuring Business continuity plans are up to date and tested for all critical
information assets (data processing facilities, communications services and data)
and service - specific measures are in place.
Updating Policy and procedures to ensure that mobile computing and
teleworking are secure.
Ensuring a multi-professional audit of clinical records across all specialties has
been undertaken.
Updating and monitoring documented and publicly available procedures to
ensure compliance with the Freedom of Information Act 2000.
The above work programme of evidence has been scrutinised by our internal auditors.
The audit is conducted in two parts: the first part was undertaken in November 2014 and
the auditors were able to sign off seven of the thirteen requirements audited. The
second part of the audit was undertaken in early March and we are awaiting their final
report.
128
Training
The IG Team has produced two new training programmes which will be published as
online modules from April 2015. The training packages the IG Team now provide are:
• Mandatory Information Governance Training
• Information Asset Training
• Records Management Training (Admin)
The IG Team has successfully delivered classroom sessions to support the online training
programme and have achieved 95% compliance with Information Governance Training
this year.
Efax and Egress
The IG Team has been instrumental in providing support for the Efax solution and Egress
the local email encryption system. The IG Team has carried out an awareness campaign
to encourage staff to sign up to the service and provided localised training to teams to
ensure they gain the best use out of the service.
SystmOne
The IG Team has provided all IG support to the deployment of the core clinical
replacement system. In particular the IG Team has been the focal point for the consent
model within SystmOne. It has been necessary to work closely with CWHHE CCG with
regards to the Memorandum of Understanding (MoU) and data controller
responsibilities defined within the agreement. The IG and Risk Manager represents the
Trust on the CWHHE MoU Governance Group.
Incidents
In 2014/15 a deep dive on IG incidents reported via the Trusts Datix system has been
completed. The deep dive report was submitted to the Care Quality Group (CQG) for
transparency and was well received. The deep dive has enabled the IG Team to focus on
specific awareness campaigns such as keeping records secure, use of social media, spam
and secure email. The IG Team support the Trust with all incidents and investigations
whilst monitoring incidents reported externally to the Information Commissioner. This
year has shown an increase in reporting of incidents and queries for advice managed by
the IG Team and supported by the Caldicott Guardian. The work undertaken to date has
had a positive impact on services who have demonstrated more confidence in dealing
with Caldicott issues.
Records Management
A records management work programme has been set up to assist all services with
documenting protocols for the management of their records. This has been supported
by the DDOs and ELT as a drive to ensure the management of records is high on the
Trust’s agenda. Work will continue into next year when the team will endeavour to
support services streamline their processes and reduce paper.
A Records Management Facilitator role has been created within the IG team
establishment to ensure this work programme continues.
129
CQC
As part of the preparations for the CQC Inspection the IG Team has sourced and
provided confidential waste bins to all cluster sites to aid the removal of backlogs of
confidential waste. This is currently being monitored to ensure it is in line with the
Records Management NHS Code of Practice and the Trust is compliant with the
minimum retention schedules.
Audits
The Caldicott Guardian has remained a focal point for issues relating to confidentiality
and gaining Data Protection assurances. The IG Team completed the data protection
audit compliance programme which included the Caldicott Guardian, SIRO, and Deputy
Chief Nurse making unannounced site visits. The results of the audits were encouraging
with clear themes arising for most sites. The Caldicott Guardian has carried out work to
raise awareness of ensuring that areas are kept secure and clinical conversations are
discreetly managed to respect the privacy on the individuals. Due to the success of the
audit programme it has been agreed that this will continue as an annual work
programme.
130
BOARD OF DIRECTORS
31 March 2015
Report title:
Agenda item number:
3.4
Report of:
Chief Executive Officer
Contact Officer:
Trust Secretary
Relevant CLCH 14/15 Goal(s)
1. Embody the best of the NHS for our patients: delivering great
results with compassion and thoughtfulness
Status
Executive Summary:
In support of the NTDA phase of the application for FT process, the trust has been self-certifying
against Monitor Provider Licence conditions and the board statements (included in the Monitor
compliance framework for FTs, now superseded by Monitor’s Risk Assessment Framework which sets
out Monitor’s approach to making sure foundation trusts are well run and can continue to provide
good quality services for patients in the future).
Actions identified are now complete and the Trust is now compliant as far as possible with the licence
conditions and board statements. Any changes made since the previous report are shown in tracked.
Assurance provided: Sources of evidence to support statements are included in the table.
Report provenance: The draft self-certifications are routinely circulated to Executive leads in
advance, at the end of each month.
Discussion
Information
Recommendation:
To approve the provider licence, board statements for February 2015 for
submission to the TDA.
131
Monitor Provider License Conditions and Board Statements – February 2015 data for Board review on 31.03.15 and submission
later the same week.
License Conditions
Condition
Definition ( as per Monitor guidance)
Condition G4
– Fit and
proper
persons as
Governors
and Directors
(also
applicable to
those
performing
equivalent or
similar
functions)
1. The Licensee shall ensure that no person who is an unfit person may become or
continue as a Governor, except with the approval in writing of Monitor.
2. The Licensee shall not appoint as a Director any person who is an unfit person, except
with the approval in writing of Monitor.
3. The Licensee shall ensure that its contracts of service with its Directors contain a
provision permitting summary termination in the event of a Director being or becoming an
unfit person. The Licensee shall ensure that it enforces that provision promptly upon
discovering any Director to be an unfit person, except with the approval in writing of
Monitor.
4. If Monitor has given approval in relation to any person in accordance with paragraph 1, 2,
or 3 of this condition the Licensee shall notify Monitor promptly in writing of any material
change in the role required of or performed by that person.
5. In this Condition an unfit person is:
(a) an individual;
(i) who has been adjudged bankrupt or whose estate has been sequestrated and (in either
case) has not been discharged; or
(ii) who has made a composition or arrangement with, or granted a trust deed for, his
creditors and has not been discharged in respect of it; or
(iii) who within the preceding five years has been convicted in the British Islands of any
offence and a sentence of imprisonment (whether suspended or not) for a period of not less
than three months (without the option of a fine) was imposed on him; or
(iv) who is subject to an unexpired disqualification order made under the Company
Directors’ Disqualification Act 1986; or
(b) a body corporate, or a body corporate with a parent body corporate:
(i) where one or more of the Directors of the body corporate or of its parent body corporate
is an unfit person under the provisions of sub-paragraph (a) of this paragraph, or
(ii) in relation to which a voluntary arrangement is proposed under section 1 of the
Insolvency Act 1986, or
(iii) which has a receiver (including an administrative receiver within the meaning of section
29(2) of the 1986 Act) appointed for the whole or any material part of its assets or
undertaking, or
Responsible
officer
J Walbridge
for J Reilly
Trust position
Individual directors have all provided selfcertification as recommended by the People
and Remuneration Committee to the Trust
Board (now Remuneration Committee).
Contracts have been updated to include a
clause that gives the Trust the ability to
dismiss ‘unfit persons’.
NOTE
The introduction of the Health and Social Care
Act 2008 (regulated activities) regulations 2014
(implemented 27November for NHS Trusts)
requires the Trust to consider, separate, to the
Monitor license conditions, new CQC
requirements in relation to new and existing
directors, for example “persons employed for
the purposes of carrying on a regulated activity
must – be of good character, have the
qualifications, competence, skill and
experience”…… and that recruitment
procedures must be established and operated
effectively to ensure that persons employed
meet the conditions….
This goes beyond the existing requirements
and for CLCH will include NEDs, executive
directors and some other senior managers with
responsibility for safeguarding, risk and
finance.
An action plan in support of meeting regulatory
requirements has been prepared and is being
132
Condition
Responsible
officer
(iv) which has an administrator appointed to manage its affairs, business and property in
accordance with Schedule B1 to the 1986 Act, or
(v) which passes any resolution for winding up, or
(vi) Which becomes subject to an order of a Court for winding up.
Condition G5
– Monitor
Guidance
1 Without prejudice to any obligations in other Conditions of this Licence, the Licensee shall
at all times have regard to guidance issued by Monitor for any of the purposes set out in
section 96(2) of the 2012 Act.
implemented.
Board training in relation to the Care Act was
provided by Beachcrofts in November 2014.
I McMillan for
I Millar
Condition G8
– Patient
eligibility and
selection
criteria
1. The Licensee shall at all times be registered with the Care Quality Commission in so far
as is necessary in order to be able lawfully to provide the services authorised to be
provided by this Licence.
L Ashley
The Trust is registered with the CQC.
The Board approved the revised statement of
purpose and the amendments to the Trust’s
CQC registration, including the new locations
and regulated activities in October 2013.
2. The Licensee shall notify Monitor promptly of:
(a) any application it may make to the Care Quality Commission for the cancellation of its
registration by that Commission, or
(b) the cancellation by the Care Quality Commission for any reason of its registration by
that Commission.
3. A notification given by the Licensee for the purposes of paragraph 2 shall:
(a) be made within 7 days of:
(i) the making of an application in the case of paragraph (a), or
(ii) becoming aware of the cancellation in the case of paragraph (b), and
(b) contain an explanation of the reasons (in so far as they are known to the Licensee) for:
(i) the making of an application in the case of paragraph (a), or
(ii) the cancellation in the case of paragraph (b).
1. The Licensee shall:
(a) set transparent eligibility and selection criteria,
(b) apply those criteria in a transparent way to persons who, having a choice of persons
from whom to receive health care services for the purposes of the NHS, choose to receive
them from the Licensee, and
(c) Publish those criteria in such a manner as will make them readily accessible by any
persons who could reasonably be regarded as likely to have an interest in them.
This condition relates to the power of Monitor
in setting regulations in relation to price,
configuration and continuation of services.
At authorisation, Monitor guidance will be
followed and the board will be provided with
assurance of compliance.
2 In any case where the Licensee decides not to follow the guidance referred to in
paragraph 1 or guidance issued under any other Conditions of this licence, it shall inform
Monitor of the reasons for that decision.
Condition G7
– Registration
with the Care
Quality
Commission
Trust position
I McMillan for
I Millar
Eligibility criteria for all services (where this is
available) now published on the web site here
The eligibility criteria will beas reviewed and
updated by the contracts team during early
February.
2. “Eligibility and selection criteria” means criteria for determining:
(a) whether a person is eligible, or is to be selected, to receive health care services
provided by the Licensee for the purposes of the NHS, and
133
Condition
Responsible
officer
Trust position
(b) If the person is selected, the manner in which the services are provided to the person.
Condition P1
– Recording
of
information
1. If required in writing by Monitor, and only in relation to periods from the date of that
requirement, the Licensee shall:
(a) obtain, record and maintain sufficient information about the costs which it expends in the
course of providing services for the purposes of the NHS and other relevant information,
and
(b) establish, maintain and apply such systems and methods for the obtaining, recording
and maintaining of such information about those costs and other relevant information,
as are necessary to enable it to comply with the following paragraphs of this Condition.
2. From the time of publication by Monitor of Approved Reporting Currencies the Licensee
shall maintain records of its costs and of other relevant information broken down in
accordance with those Currencies by allocating to a record for each such Currency all costs
expended by the Licensee in providing health care services for the purposes of the NHS
within that Currency and by similarly treating other relevant information.
3. In the allocation of costs and other relevant information to Approved Reporting
Currencies in accordance with paragraph 2 the Licensee shall use the cost allocation
methodology and procedures relating to other relevant information set out in the Approved
Guidance.
I Millar
The Trust has maintained a system for
identifying the cost and activity relating to the
services provided.
Assurance is gained through the completions
on internal reports relating to activity and costs
such as SLR and the completion of external
reporting via monthly commissioner reports,
NTDA returns and annual reference costs.
I Millar has reviewed license statement P1
(recording of information – patient costing). It
has been confirmed that in reality most of the
Trust’s activity is non- payment by results and
reference costing for activity is maintained.
4. If the Licensee uses sub-contractors in the provision of health care services for the
purposes of the NHS, to the extent that it is required to do so in writing by Monitor the
Licensee shall procure that each of those sub-contractors:
(a) obtains, records and maintains information about the costs which it expends in the
course of providing services as sub-contractor to the Licensee, and establishes, maintains
and applies systems and methods for the obtaining, recording and maintaining of that
information, in a manner that complies with paragraphs 2 and 3 of this Condition, and
(b) Provides that information to Monitor in a timely manner.
5. Records required to be maintained by this Condition shall be kept for not less than six
years.
6. In this condition:
“the Approved Guidance” – means such guidance on the obtaining and maintaining of
information about costs and on the breaking down and allocation of cost by reference to
Approved Reporting Currencies as may be published by Monitor;
“Approved Reporting Currencies” – means such categories of cost and other relevant
134
Condition
Responsible
officer
Trust position
information as may be published by Monitor;
“other relevant information” – means such information, which may include quality and
outcomes data, as may be required by Monitor for the purpose of its functions under
Chapter 4 (Pricing) in Part 3 of the 2012 Act.
Condition P2
– Provision of
information
1. Subject to paragraph 3, and without prejudice to the generality of Condition G1, the
Licensee shall furnish to Monitor such information and documents, and shall prepare or
procure and furnish to Monitor such reports, as Monitor may require for the purpose of
performing its functions under Chapter 4 in Part 3 of the 2012 Act.
2. Information, documents and reports required to be furnished under this Condition shall
be furnished in such manner, in such form, at such place and at such times as Monitor may
require.
3. In furnishing information documents and reports pursuant to paragraphs 1 and 2 the
Licensee shall take all reasonable steps to ensure that:
(a) in the case of information or a report, it is accurate, complete and not misleading;
(b) in the case of a document, it is a true copy of the document requested; and
4. This Condition shall not require the Licensee to furnish any information, documents or
reports which it could not be compelled to produce or give in evidence in civil proceedings
before a court because of legal professional privilege.
I Millar
Condition G1 is not included in the current list
of conditions with which aspirant trusts must
comply, however at authorisation all
information will be submitted to Monitor in the
required format.
The management team and board will take all
reasonable steps to ensure that information is
accurate, complete and not misleading.
The Board of Directors have signed a code of
conduct consistent with the Nolan Principles
which include the requirement to “be honest,
and act with integrity and probity”.
135
Condition
Condition P3
– Assurance
report on
submissions
to Monitor
1. If required in writing by Monitor the Licensee shall, as soon as reasonably practicable,
obtain and submit to Monitor an assurance report in relation to a submission of the sort
described in paragraph 2 which complies with the requirements of paragraph 3.
Responsible
officer
J Reilly
Trust position
Not currently applicable, however the trust is
committed to meeting Monitor requirements as
an FT, including audit as required.
2. The descriptions of submissions in relation to which a report may be required under
paragraph 1 are:
(a) submissions of information furnished to Monitor pursuant to Condition P2, and
(b) submissions of information to third parties designated by Monitor as persons from or
through whom cost information may be obtained for the purposes of setting or verifying the
National Tariff or of developing non-tariff pricing guidance.
3. An assurance report shall meet the requirements of this paragraph if all of the following
conditions are met:
(a) it is prepared by a person approved in writing by Monitor or qualified to act as auditor of
an NHS foundation trust in accordance with paragraph 23(4) in Schedule 7 to the 2006 Act;
(b) it expresses a view on whether the submission to which it relates:
(i) is based on cost records which have been maintained in a manner which complies with
paragraph 2 in Condition P1;
(ii) is based on costs which have been analysed in a manner which complies with
paragraph 3 in Condition P1, and
(iii) provides a true and fair assessment of the information it contains.
Condition P4
– Compliance
with the
National
Tariff
1. Except as approved in writing by Monitor, the Licensee shall only provide health care
services for the purpose of the NHS at prices which comply with, or are determined in
accordance with, the national tariff published by Monitor, in accordance with section 116 of
the 2012 Act.
Condition P5
–
Constructive
engagement
concerning
local tariff
modifications
The Licensee shall engage constructively with Commissioners, with a view to reaching
agreement as provided in section 124 of the 2012 Act, in any case in which it is of the view
that the price payable for the provision of a service for the purposes of the NHS in certain
circumstances or areas should be the price determined in accordance with the national
tariff for that service subject to modifications.
I Millar
Majority of Trust services are provided under
block contract or locally agreed tariffs due to
lack of a national tariff.
Source of assurance: Trust contracts update.
2. Without prejudice to the generality of paragraph 1, except as approved in writing by
Monitor, the Licensee shall comply with the rules, and apply the methods, concerning
charging for the provision of health care services for the purposes of the NHS contained in
the national tariff published by Monitor in accordance with, section 116 of the 2012 Act,
wherever applicable.
I Millar
The Trust engages with commissioners
regarding local tariff due to the nature of Trust
business being local tariff based and block
contracts.
Source of assurance: Trust contract update.
136
Condition
Condition C1
– The right of
patients to
make choices
1. Subsequent to a person becoming a patient of the Licensee and for as long as he or she
remains such a patient, the Licensee shall ensure that at every point where that person has
a choice of provider under the NHS Constitution or a choice of provider conferred locally by
Commissioners, he or she is notified of that choice and told where information about that
choice can be found.
Responsible
officer
J Reilly
2. Information and advice about patient choice of provider made available by the Licensee
shall not be misleading.
The Trust has a policy on conflict of interests
(including gifts and hospitality). The trust’s
induction programme includes the Bribery Act
and there is an active counter fraud service.
4. In the conduct of any activities, and in the provision of any material, for the purpose of
promoting itself as a provider of health care services for the purposes of the NHS the
Licensee shall not offer or give gifts, benefits in kind, or pecuniary or other advantages to
clinicians, other health professionals, Commissioners or their administrative or other staff
as inducements to refer patients or commission services.
1. The Licensee shall not:
(a) enter into or maintain any agreement or other arrangement which has the object or
which has (or would be likely to have) the effect of preventing, restricting or distorting
competition in the provision of health care services for the purposes of the NHS, or
(b) engage in any other conduct which has (or would be likely to have) the effect of
preventing, restricting or distorting competition in the provision of health care services for
the purposes of the NHS,
to the extent that it is against the interests of people who use health care services.
Aside from carrying DH leaflets and posters
about patient choice, the trust does publish
information about patient choice. GPs and
commissioners have a primary role in patient
choice.
CLCH contracts with CCGs are based on the
NHS standard contract which mandates that
we follow national guidance on patient choice.
3. Without prejudice to paragraph 2, information and advice about patient choice of provider
made available by the Licensee shall not unfairly favour one provider over another and
shall be presented in a manner that, as far as reasonably practicable, assists patients in
making well informed choices between providers of treatments or other health care
services.
Condition C2
– Competition
oversight.
Trust position
I McMillan for
I Millar
The Board of Directors have signed a code of
conduct consistent with the Nolan Principles
which include the requirement to “be honest,
and act with integrity and probity”.
The Trust is aware of laws prohibiting anticompetitive behaviour (Competition Act 1998)
and the Procurement, Choice and Competition
Regulations 2013.
The trust understands that the Health and
Social Care Act 2012 marks a major milestone
for the NHS in England’s 20-year journey from
a planned system to a competitive market for
the supply of health care services.
The trust recognises that while it is the role of
commissioners to decide if, and when, to use
competition, Monitor polices the rules and
makes sure that choice and competition
137
Condition
Responsible
officer
Trust position
operate in the best interests of patients. In
particular, to prevent anti-competitive
behaviour by commissioners or providers
where it is against patients’ interests. This is
the role of Monitor’s co-operation and
competition directorate.
During January 2015 Managers from the
commercial team attended a Monitor seminar
on competition regulations"
Condition IC1
– Provision of
integrated
care
1. The Licensee shall not do anything that reasonably would be regarded as against the
interests of people who use health care services by being detrimental to enabling its
provision of health care services for the purposes of the NHS to be integrated with the
provision of such services by others with a view to achieving one or more of the objectives
referred to in paragraph 4.
interests of people who use health care services by being detrimental to enabling its
provision of health care services for the purposes of the NHS to be integrated with the
provision of health-related services or social care services by others with a view to
achieving one or more of the objectives referred to in paragraph 4.
interests of people who use health care services by being detrimental to enabling it to cooperate with other providers of health care services for the purposes of the NHS with a view
to achieving one or more of the objectives referred to in paragraph 4.
4. The objectives referred to in paragraphs 1, 2 and 3 are:
(a) improving the quality of health care services provided for the purposes of the NHS
(including the outcomes that are achieved from their provision) or the efficiency of their
provision,
(b) reducing inequalities between persons with respect to their ability to access those
services, and
(c) reducing inequalities between persons with respect to the outcomes achieved for them
by the provision of those services.
5. The Licensee shall have regard to such guidance as may have been issued by Monitor
from time to time concerning actions or behaviours that might reasonably be regarded as
against the interests of people who use health care services for the purposes of paragraphs
R Milner
The Trust works closely with its commissioners
and partners in social care.
As a member of Imperial College Partners, we
are committed to achieving population wide
health benefits in NW London and beyond
through collaborative research and the more
systematic dissemination of proven
innovation and best practice (closing the gap
between "what we know and what
we do").
The trust recognises that equality is key to
achieving our mission to provide the best
healthcare for people in their homes and in
their community. We work within a multicultural and diverse community and we are
committed to ensure: that we treat all
individuals fairly, with dignity and respect; that
the healthcare we provide is open to all; that
we provide a safe, supportive and welcoming
environment - for patients and staff.
We were the only NHS Trust in London to be
named as an Equality and Diversity Partner by
NHS Employers for 2011/12, and one of only
17 NHS Trusts across England.
138
Condition
Responsible
officer
Trust position
1, 2 or 3 of this Condition.
Board statements
The Board Statements and self-certification requirements form part of the TDA phase of the application process. The following table sets out each of
the Board statements against which the Trust must comply:
Where the Trust is not currently compliant, an explanation and timescales for achieving compliance must be given.
Board statement
Responsible
officer
Compli
ant Y/N
Sources of assurance
The Board has approved the
Quality Strategy and Quality
Account and receives regular
updates on performance and
service improvements through
a monthly performance report
and quarterly Quality Report.
The Quality Committee
routinely monitors of all issues
related to quality.
The Board approved the
revised statement of purpose
and the amendments to the
Trust’s CQC registration,
including the new locations
and regulated activities in
October 2013. The Quality
Committee and Audit
Explanation
where noncompliant or at
risk of noncompliance
For Clinical Quality that:
1. The Board is satisfied that, to the best of its knowledge and
using its own processes and having had regard to the TDA’s
oversight model (supported by Care Quality Commission
information, its own information on serious incidents, patterns of
complaints, and including any further metrics it chooses to adopt),
the trust has, and will keep in place, effective arrangements for
the purpose of monitoring and continually improving the quality of
healthcare provided to its patients.
L Ashley
Y
2. The board is satisfied that plans in place are sufficient to
ensure on-going compliance with the Care Quality Commission’s
registration requirements.
L Ashley
Y
139
3. The board is satisfied that processes and procedures are in
place to ensure all medical practitioners providing care on behalf
of the trust have met the relevant registration and revalidation
requirements.
J Medhurst
Y
Committee receive reports
regarding CQC compliance;
details of inspection visits are
routinely included in the CEO
report to the Board. In August
2014, the Quality Committee
received an update on the
Trust’s statement of purpose.
Medical revalidation process
assured by the Medical
Director who reports regularly
to the Board.
Employment appointment
checks undertaken at
recruitment
Medical appraisers group
established (MAG) by the
Medical director to ensure
there are clear arrangements
and support and that
revalidation best practice is
followed.
The organisation submitted, on
time, it's annual organisational
audit (AOA), for 2013/14 to
NHSE which reports on
revalidation and appraisal
For enhanced assurance the
internal audit team is reviewing
CLCH's compliance against
guidance in the final quarter of
2014/15'.
For Finance that:
140
4. The board is satisfied that the trust shall at all times remain a
going concern, as defined by the most up to date accounting
standards in force from time to time.
I Millar
Y
Finance report to board of
directors
6. All current key risks to compliance with the NTDA's
Accountability Framework have been identified (raised either
internally or by external audit and assessment bodies) and
addressed – or there are appropriate action plans in place to
address the issues in a timely manner.
J Walbridge for
J Reilly and
I Millar
Y
The process to identify and
manage risks has been
reviewed. Risks are recorded
in either the board assurance
framework
The Audit Committee reviews
all internal and external audit
reports and action plans on
behalf of the board.
Audit Committee minutes are
shared with the board.
The board receives an annual
report from the Audit
Committee.
7. The board has considered all likely future risks to compliance
with the NTDA Accountability Framework and has reviewed
appropriate evidence regarding the level of severity, likelihood of
a breach occurring and the plans for mitigation of these risks to
ensure continued compliance.
8. The necessary planning, performance management and
corporate and clinical risk management processes and mitigation
plans are in place to deliver the annual operating plan, including
that all audit committee recommendations accepted by the board
are implemented satisfactorily.
J Walbridge for
J Reilly and
I Millar
Y
The process to identify future
risks has been reviewed as far
as possible.
I Millar
Y
The trust has an annual plan
and goals. There is an internal
performance management
system (with internal
challenge), the ELT and Board
considers performance on a
monthly basis. Board
committees also consider
performance reports, for
example the quality KPI
monthly report by the quality
committee.
For Governance that:
141
9. An Annual Governance Statement is in place, and the trust is
compliant with the risk management and assurance framework
requirements that support the Statement pursuant to the most up
to date guidance from HM Treasury (www.hm-treasury.go
J Walbridge for
L Ashley
Y
10. The Board is satisfied that plans in place are sufficient to
ensure on-going compliance with all existing targets as set out in
the NTDA oversight model; and a commitment to comply with all
known targets going forward.
I Millar
Y
11. The trust has achieved a minimum of Level 2 performance
against the requirements of the Information Governance Toolkit.
I Millar
Y
12. The board will ensure that the trust will at all times operate
effectively. This includes maintaining its register of interests,
ensuring that there are no material conflicts of interest in the
board of directors; and that all board positions are filled, or plans
are in place to fill any vacancies.
J Walbridge for
J Reilly
Y
The statement is compiled in
line with most recent guidance
annually, agreed by the audit
committee and included in the
annual report
•
• “The Trust is currently
rated level 4 on the NTDA
oversight model – this is
the optimum score possible
without a CQC inspection.
Through a robust divisional
and Board performance
reporting framework, the
Board it assured that it has,
and will continue to have,
ongoing compliance with
all existing targets set out
in the NTDA oversight
model”
Level 2 has been confirmed for
2013/14
Evidence – Annual report
2013/14 and IG toolkit
submission / internal audit.
Evidence - register of
interests published on web site
Board and Committee
members are asked to declare
any interests at the start of
meetings – these are recorded
in the minutes.
The Remuneration Committee
consider succession planning
142
arrangements for existing and
future vacancies.
There are no Board vacancies.
For GOVERNANCE, that
13. The board is satisfied that all executive and non-executive
directors have the appropriate qualifications, experience and
skills to discharge their functions effectively, including setting
strategy, monitoring and managing performance and risks, and
ensuring management capacity and capability.
Y
J Reilly and P
Chesters
This is included in the annual
appraisal process for all
directors.
Evidence – annual appraisal
documentation
Executive directors appointed
through a rigorous recruitment
and selection process.
Annual board development
plan.
BGAF self-assessment and
validation.
For GOVERNANCE, that
14. The board is satisfied that: the management team has the
capacity, capability and experience necessary to deliver the
annual operating plan; and the management structure in place is
adequate to deliver the annual operating plan.
J Walbridge for
J Reilly
Y
The Remuneration Committee
terms of reference include
review of annual objectives for
very senior managers and
monitoring performance
against those objectives. It will
provide input to the chief
executive on the performance
of other executive members of
the board and will advise the
chair on the chief executives
annual appraisal.
Evidence – annual appraisal
143
documentation
144
BOARD OF DIRECTORS
31 March 2015
Report title:
Update following Quality Committee meeting of 16.03.15
Agenda item number:
3.5.1
Report of:
Quality Committee Chair
Contact Officer:
Trust Secretary
Relevant CLCH 14/15 Goal:
1 Embody the best of the NHS for our patients: delivering great results
Report can be published
Status
Executive Summary:
A summary of key issues discussed by the Committee is attached.
Report provenance: The Quality Committee discussed these issues in full on 16.03.15. A copy of the
confirmed minutes will be provided in April 2015.
Discussion
Information
Recommendation: To note.
145
Highlights:
QUALITY IMPROVEMENT
1
Dynamic patient story – compassion in care project
1.1
Bethany Golding provided an overview of the dynamic patient stories project which had been
successful in engaging and empowering patients.
1.2
Members welcomed this innovative work and value for patients, including those with limited
communication skills.
2
2.1
Chief Nurse and Medical Director report
Medical Director
An update on key issues was provided including: clinical audit, research and continuous
improvement. The Medical Director confirmed that a request for funding to recruit a band 6
research nurse was likely to be successful.
2.2
Chief Nurse
Members were informed that preparations for the Chief Inspector of Hospitals visit were
progressing well for which the team were congratulated. Earlier the same day, the CQC had
arrived at Princess Louise Nursing Home to undertake an unannounced inspection.
2.3
Nurse recruitment was progressing well and a highly productive pressure ulcer summit had been
held with front line staff.
3
3.1
Continuous improvement programme
The committee considered the options for the future of the programme and enthusiastically
supported the recommendation to develop continuous improvement capacity and capability
within CLCH by significantly increasing the dedicated central resource to deliver projects and be
creative in hwo these can be delivered to limit taking teams away from their workplace.
4
4.1
End of Life Strategy
The comprehensive strategy, which had been developed with stakeholders, was considered and
it was agreed that it would be helpful to share the strategy with the quality stakeholder reference
group and to cross-reference Charity Committee related discussions
5
5.1
Continuing care nursing homes
An oral update on the nursing home position was provided by the Chief Nurse and Deputy CEO.
Regular information is now being collated by the management team and will be shared with
Board members, including SI’s, occupancy and the number of registered nurses employed by
CLCH.
6
6.1
Assurance reports from groups reporting to the Quality Committee
Members were pleased to hear that an award had been won for the patient reported experience
work led by Dr Roman Raczka.
7
7.1
Clinical Commissioning Group
Members were informed that inner London CCG were dissatisfied with a number of issues and
an information breach notice had been received in relation to the submission of accurate and
timely information.
8
8.1
Quality Committee Observation by the TDA
The draft report was considered and it was agreed that, while generally positive, it would be
helpful for the Quality Committee Chair and Chief Nurse to discuss some of the key
recommendations with the TDA.
146
Central London Community Healthcare NHS Trust Charity and Related Charities
Registered charity No 1120231
BOARD OF DIRECTORS
31 March 2015
Report title:
Report following Charitable Funds Committee meeting in March 2015
Agenda item number
3.5.2
Report of:
Charitable Funds Committee Chair
Contact officer:
Trust Secretary
Relevant CLCH Goad
1 Embody the best of the NHS for our patients: delivering great results with
compassion and thoughtfulness
Report can be published
Status
Executive Summary
Together with financial reporting and resourcing issues, members discussed outcome
reports for Pembridge and bids for the use of charitable funds in relation to
Pembridge, the nursing homes and CLCH volunteers.
Report provenance
The Charitable Funds Committee discussed all matters in full at the meeting of
09.03.15. The confirmed minutes of the meeting will be shared with the Board in
July 2015.
Report for
Decision
Discussion
Information
1
147
Financial reporting and governance
1
Finance report and investment portfolio
Unfortunately a problem was identified with the finance report as it did not correlate to the
previous report. Finance confirmed that a corrected version of the report would be issued no later
than 23.03.15, including a graph showing the level of donation/ dividends by month.
The market value of the investment portfolio at 31 January 2015 was noted to be £2,782k
reflecting an unrealised gain compared to the previous year-end of £254k.
2
Finance and resources to support charitable funds administration
Members recognised the value and need for a dedicated resource (0.75 wte), supported as
required by senior managers, and agreed an increase from £17,000 to £50,000 for the year
2015/16. This would be subject to review, informed by benchmarking and the quality of service
provided, in the 4th quarter of the year.
The charge for 2014/15 would be calculated and agreed by email.
3
Investment manager
The Committee considered the outcome of the invitation to quote exercise. The Board will be
asked to approve the Committee’s recommendation on 31.03.15.
It was agreed that it would be helpful to consider the ethical policies of other NHS charities, and
what these exclude, to inform the review of the investment and reserves policy (planned for
2016), and to seek advice from the Association of NHS Charities / an external advisor.
4
Legacy issues regarding the transfer of funds from Westminster
It was possible that these funds should originally have been identified as exchequer rather than
charitable funds (believed to be accumulated through honorariums paid to staff employed by a
former NHS organisation). Having discussed the options and risks in detail and at length, it was
agreed, unanimously, that the funds should be transferred to the ‘CLCH general fund’.
It was agreed that the sexual health service should be informed of the Committee’s decision and
advised that bids from the CLCH general fund would continue to be welcomed.
5
Terms of reference review
The terms of reference were reviewed and updated for Board approval, including a reduction in
the minimum membership requirements from two to one executive director.
Use of charitable funds
6
Outcome reports on previous grants to Pembridge
The Committee welcomed a helpful report, including quantitative and qualitative data in relation to
funded posts for the year 2014/15 (arts and crafts teacher and two massage therapists). While
survey responses were noted to be quite low, other methods of seeking regular feedback from
patients are being explored.
Recruitment to the volunteer manager post had been successful and it was anticipated that the
successful applicant would be in post by May 2015. Interviews for the post of rehabilitation
assistant are taking place in March.
7
Pembridge – grant applications
The following fund requests or 2015/16 were considered and approved, subject to confirmation of
the staff contract positions:
Massage therapists
£76,726 [3 posts - 0.52 wte, 0.64 wte, 0.84 wte]
2
148
Arts and crafts teacher
Rehabilitation assistant
Reading services
Volunteer manager
£23,071 [1 post - 0.56 wte]
£28,656 [1 post - 1.0 wte]
£20,000
£40,000
Total £188,453
It was noted that the total value of the bids exceeded the likely level of annual income (including
donations) generated by the Pembridge Fund. Following discussion it was agreed that in the
short term this was acceptable but that if this level of funding was to continue on a longer-term
basis a strategy for fundraising would be required to promote the charity and encourage
donations.
8
Nursing home - grant applications
A list of items to purchase for each of the nursing homes was considered:
Garside – value £19,296
Athlone – value £8,575
Princess Louise – value £32,509 including some large electrical items.
It was agreed that subject to confirming the availability of funds in the relevant Charitable Fund,
the items requested for each of the homes should be purchased without further delay, supported
by the finance and procurement teams.
9
Volunteers – bid application
The Committee considered a paper providing an update on the volunteer service and seeking
funding to support CLCH volunteers across all four boroughs to the value of £7,483 which was
approved for 2015/16, subject to apportionment across the appropriate charitable funds, and the
provision of an outcome report in March 2016.
It was agreed that all promotional items should be branded to encourage donations to the charity,
including the proposed text donation initiative.
3
149
BOARD OF DIRECTORS
31 March 2015
Report title:
Finance, resources and investment committee (FRIC) , terms of reference
Agenda item number:
3.6
Report of:
Committee Chair
Contact officer:
Trust Secretary
Can be published
status
Executive summary:
The terms of reference were approved by the Board in January 2014. Proposed changes as recommended
by FRIC are shown tracked.
Report provenance:
The terms of reference were considered by FRIC on 24.02.15
Report for:
Decision
Discussion
Information
Recommendation: for approval.
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V13
FINANCE, RESOURCES AND INVESTMENT COMMITTEE
TERMS OF REFERENCE
Overview and purpose
The Finance, Resources and Investment Committee is responsible for seeking and
securing assurance that the Trust achieves the high levels of performance expected
by the board. is responsible for monitoring performance and gaining assurance on
the achievement of the objectives and targets set by the Board.
Alignment with Trust Strategic Goals
Support people safely out of hospital: providing safe, high quality value for money
alternatives to hospital admissions
Deliver better value than competitors in our selected markets: securing our
sustainability by providing effective and efficient services
1
1.1
1.2
1.3
Membership
The Committee will comprise a minimum of five members, including at least
two NEDs, the Chief Executive, Director of Finance, Performance and
Corporate Resources, Deputy Chief Executive (Operations). In exceptional
circumstances, members may appoint a deputy to represent them at a
Committee meeting.
Only members of the Committee have the right to attend and vote at
Committee meetings. The Committee may require other officers of the Trust
and other individuals to attend all or any part of its meetings.
The chair of the Committee will be an independent Non-Executive Director. In
the absence of the Committee Chair and/or an appointed deputy, the
remaining members present shall elect another member who is a NonExecutive Director to chair the meeting.
2
2.1
Secretary
The Trust Secretary or their nominee shall act as the secretary of the
Committee.
3
3.1
Quorum
The quorum will be at least three members, including at least one NonExecutive Director.
4
4.1
Frequency of meetings and attendance requirements
The Committee will normally meet at least ten times a year at appropriate
times in the reporting cycle and otherwise as required.
1
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V13
4.2
Committee members should aim to attend all scheduled meetings but must
attend a minimum of three six meetings per year. The Secretary of the
Committee shall maintain a register of attendance which will normally be
published in the Trust’s annual report.
5
5.1
Notice of meetings
Meetings of the Committee may be called by the Secretary of the Committee
at the request of any of its members or where necessary.
5.2
Unless otherwise agreed, notice of each meeting, confirming the venue, time
and date together with an agenda of items to be discussed, shall be
forwarded to each member of the Committee, any other person required to
attend and all other non-executive directors, no later than 2 working
days before the date of the meeting. Supporting papers shall be sent to
Committee members, attendees and the remaining board members for
information.
6
6.1
Minutes of meetings
The secretary or their nominee shall minute the proceedings of all meetings of
the Committee, including recording the names of those present and in
attendance.
Members and those present should state any conflicts of interest to be
recorded in the minutes.
Minutes of Committee meetings should be circulated promptly to all members
of the Committee and, once agreed, to all members of the Board of Directors
unless a conflict of interest exists.
6.2
6.3
7
7.1
Annual General meeting
The chair of the Committee will normally attend the Annual General Meeting
prepared to respond to any questions on the Committee’s activities.
8
Duties
The Committee should carry out the following duties for the Trust. To:
Consider the Trust’s finance strategy for revenue and capital
Oversee implementation of the Trust’s procurement strategy
Evaluate the Trust’s overall financial performance in terms of income,
expenditure, working capital and capital and seek assurance that the position
is in line with approved plans, targets and milestones.
Monitor the key financial and performance outcomes at business unit
level. Monitor the key financial outcomes at services line level: activity and
Seek assurance on the arrangements to ensure delivery of the cost
improvement programme and income growth, including monitoring progress
against plan.
Review debtor and creditor balances in excess of £5,000 and 6 months old
and other areas of financial performance and risk as decided by the board.
Monitor implementation of the IM&T and estates strategies.
Undertake those responsibilities in relation to investments, borrowings and
other treasury transactions as described in the treasury policy and to seek
assurance that investments and treasury policies are followed and remain fit
for purpose.
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
2
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V13
8.9
8.10
8.11
8.12
8.13
8.14
8.15
8.16
8.17
9
9.1
9.2
Recommend to the board any investments above the delegated limits of
individual Executive Directors or officer Committees, where relevant ensuring
appropriate external advice is sought.
Consider post project evaluation reports, to agreed criteria, for significant
investments approved by the Board of Directors (and others as required).
Seek assurance on the continuous development and embedding of Service
Line Reporting throughout all levels of management in CLCH. Seek
assurance on the continuous development and embedding of Service Line
Management throughout CLCH
Review lessons learned through comparisons between service lines that
perform well and those that perform less well.
CConsider tenders, acquisition or disposals in line with the business
opportunities framework and commercial strategy and make
recommendations to the Board as relevantonsider tenders, acquisitions or
disposals in excess of £1m.
Consider Monitor key non-financial performance metrics as set by the Board
including in relation to workforce, quality and operational performance (such
as waiting times) and refer areas of concern to the Board or other
Committee as relevant.non-finance performance, including workforce, quality
and operational performance (for example waiting times)
Seek assurance from the Executive Directors that, if necessary, appropriate
management action has been taken to return Trust performance to plan, and
that any such actions or recovery plans are in place, are adequately
resourced, implemented and monitored.
Report any material control issues to the Audit Committee.
Approve any policies delegated to the Committee by the Board and as set out
in the policy for the development and management of procedural documents
as amended from time to time.
Reporting responsibilities
The Committee will report to the Board of Directors on its proceedings after
each meeting.
The Chair of the FRIC will provide a verbal report to the next Board of
Directors Board after each Committee meeting. The chair of the FRIC will
draw to the attention of the Trust Board key issues arising from the
Committee’s monthly review of financial performance which require Board
discussion and/or decision. The Chair of the Committee will draw to the
attention of the Board any other issues that require disclosure to the full
Board, including those that affect the financial standing of the Trust or require
executive action Following each meeting, the Chair of the FRIC will provide a
written (or where time does not allow, an oral) report to the next meeting of
the Board of Directors. This will draw the attention of the Board to any issues
arising from the Committee’s monthly review of performance that require
Board discussion and/or decision. The Chair of the Committee will also draw
to the attention of the Board any other issues that require disclosure to the full
Board including those that affect the financial standing of the Trust or require
executive action
3
153
V13
9.3
The Committee shall make whatever recommendations to the Board of
Directors it deems appropriate on any area within its remit where action or
improvement is needed.
10
Other matters
The Committee should:
Have access to sufficient resources in order to carry out its duties, including
access to the Trust secretariat for assistance as required;
Be provided with appropriate and timely training, both in the form of an
induction programme for new members and on an on-going basis for all
members;
Give due consideration to laws and regulations;
At least once a year, review its own performance and terms of reference to
ensure it is operating at maximum effectiveness and recommend to the Board
of Directors for approval, any changes it considers necessary.
10.1
10.2
10.3
10.4
11
11.1
Authority
The Committee is a Non-Executive As a Committee of the Board of Directors,
the Committee and has no powers, other than those specifically delegated in
these terms of reference or otherwise delegated by the Board of Directors.
The Committee is authorised:
11.1.1 To seek any information it requires from any employee of the Trust in
order to perform its duties
11.1.2 To obtain outside legal or other professional advice on any matter
within its terms of reference via the Trust Secretary
11.1.3 To call any employee to be questioned at a meeting of the Committee
as and when required.
12
12.1
Monitoring and Review:
The Board will monitor the effectiveness of the Committee through receipt of
minutes or such written or verbal reports that the Chair of the Committee
provide.
The Secretary will assess agenda items to ensure they comply with the
Committee’s responsibilities.
The Secretary will monitor the frequency of the Committee meetings and the
attendance records to ensure minimum attendance figures are complied with.
The attendance of members of the Committee will be reported in the annual
report.
12.2
12.3
12.4
12.4
12.5
Terms of reference agreed by Committee 23 January 2014 to be considered
by the Committee in February 2014
Terms of reference to be considered for approval approved by the Trust
Board 25 February 2015
To be reviewed at least annually.
4
154
BOARD OF DIRECTORS
31 March 2015
Report title:
Charitable Funds Committee , terms of reference
Agenda item number:
3.6.2
Report of:
Committee Chair
Contact officer:
Trust Secretary
Can be published
status
Executive summary:
The terms of reference were approved by the Board in September 2013. Following review, a number of
amendments are suggested together with inclusion of an additional sentence in relation to the acceptance
of donations (8.6) shown tracked, including a proposed reduction in the number of executive director
members.
Report provenance:
The terms of reference were considered by the Committee on 09.03.15
Report for:
Decision
Discussion
Information
Recommendation: for approval.
155
V7
Charitable Funds Committee
Role
Central London Community Healthcare NHS Trust was appointed as corporate trustee of
Central London Community Healthcare Charity and related Charities on the 22 December
2011; the Board serves as its agent in the administration of the charitable funds held by the
trust.
The Committee has been formally constituted by the board in accordance with its Standing
Orders, with delegated responsibility to make and monitor arrangements for the control and
management of the Trust’s Charitable Funds and will report to the Board of Directors.
The Charitable Funds Committee has been established by the Board to make and monitor
arrangements for the control and management of Trust’s charitable funds.
Definitions
“the Trust” means Central London Community Healthcare NHS Trust
“the Committee” means the Charitable Funds Committee
“the Directors” means the Trust’s Board of Directors.
1
Membership
1.1
Members of the Committee shall be appointed by the Board of Directors.
1.2
1.3
1.4
The Committee shall be made up of at least two Non Executive Directors
and at least two one Executive Directors, including the Director of Finance,
Performance and Corporate Resources.
A senior finance manager will be in attendance at each meeting
The Chair of the Committee will be an Independent Non-executive Director.
In the absence of the Committee Chair and/or an appointed Deputy, the
remaining members present shall elect another member to Chair the
meeting.
Those in attendance may appoint a deputy to attend on their behalf but
should aim to attend a minimum of one out of the two scheduled meetings.
1.5
2
3
The Committee may require the attendance for advice, support and
information routinely at meetings from:
1.5.1 Charitable Fund Accountant
Trust Investment Adviser
To obtain, outside legal or other professional advice on any matter within its
terms of reference via the Trust Secretary
Secretary
2.1
The Trust Secretary or their nominee shall act as the Secretary of the
Committee.
Quorum
3.1
The quorum necessary for the transaction of business shall be threetwo,
including a NED member and the Director of Finance, Performance and
Corporate Resources or deputyan executive director or deputy. A duly
1
156
V7
convened meeting of the Committee at which a quorum is present shall be
competent to exercise all or any of the authorities, powers and discretions
vested in or exercisable by the Committee.
4
5
Frequency of meetings and attendance requirements
4.1
The Committee will normally meet at least two times a year at appropriate
times in the reporting cycle and otherwise as required.
4.2
Decision may be made outside of those two meetings (for example by
email), providing that a quorum of members are in written agreement.
4.3
Committee members should aim to attend all scheduled meetings but must
attend a minimum of one meeting. The Secretary of the Committee shall
maintain a register of attendance which will be published in the Trust’s
Annual Report.
Notice of meetings
5.1
Meetings of the Committee may be called by the Secretary of the
Committee at the request of any of its members or where necessary.
5.2
Unless otherwise agreed, notice of each meeting confirming the venue,
time and date together with an agenda of items to be discussed, shall be
forwarded to each member of the Committee, any other person required to
attend and all other Non-executive Directors, no later than five working
days before the date of the meeting. Supporting papers shall be sent to
Committee members and to other attendees as appropriate, at the same
time.
6
Minutes of meetings
6.1
The Secretary shall minute the proceedings of all meetings of the
Committee, including recording the names of those present and in
attendance.
6.2
Members and those present should state any conflicts of interest and the
Secretary should minute them accordingly.
7
Annual General meeting
7.1
The Chair of the Committee will normally attend the Annual General
Meeting prepared to respond to any questions on the committee’s
activities.
8
Scope and Duties
8.1
Within the budget, priorities and spending criteria determined by the Trust
as trustee and consistent with the requirements of the Charities Act 1993
(or any modification of that Act) to apply the charitable funds in accordance
with their respective governing documents.
8.2
To ensure that the Trust policies and procedures for charitable funds
investments are followed. To make decisions involving the sound
investment of charitable funds in a way which both preserves their capital
value and produces proper return consistent with prudent investment and
ensuring compliance with:
8.2.1 Trustee Act 2000
8.2.2 The Charities Act 1993
8.2.3 Terms of the Funds’ Governing documents
2
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8.3
To receive at least twice per year reports for ratification from the Director of
Finance, Performance and Corporate Resources on Investment decisions
and action taken through delegated powers upon the advice of the Trust’s
investment adviser.
8.4
To monitor the Trust’s scheme of delegation for expenditure for the levels
in accordance with policy.:
8.4.1
8.4.2
8.5
8.5
9
8.4.3
8.4.1
With the exception of the fund manager for the Pembridge unit who has the
authority to authorise payments up to £24,999 per annum.
To approve and acknowledge donations in excess of £5,000 in line with the
supplier and commercial company donations acceptance and refusal
policy.
Delegated Powers and Duties of the Director of Finance, Performance and
Corporate Resources
9.1
10
Between £1 and £999
Fund managers or Financial Controller
Between £1000 and £4,999 Director of Finance, Performance and
Corporate Resources
For £5,000 and above
Two Trustees
The Director of Finance, Performance and Corporate Resources has the
prime responsibility for the Trust’s Charitable Funds as defined in the
Trust’s Standing Financial Instructions. The specific powers, duties and
responsibilities delegated to the Director of Finance, Performance and
Corporate Resources are:
9.1.1 Administration of all existing charitable funds
9.1.2 To identify any new charity that may be created (of which the Trust
is trustee) and to deal with any legal steps that may be required to
formalise the trusts of any such charity.
9.1.3 Provide guidelines in respect of donations, legacies and bequests,
fundraising and trading income.
9.1.4 Responsibility for the management of investment of funds held on
Trust.
9.1.5 Ensure appropriate banking services are available for the charitable
funds.
9.1.6 Prepare reports to the Trust Board including the Annual Account.
Authority
10.2
The Charitable Funds Committee (CFC) shall have power to appoint an
investment manager to advise it on investment matters and may delegate
day-to-day management of some of all of the investments to that
investment manager. In exercising this power the CFC must ensure that:
a. The scope of the power delegated is clearly set out in writing and
communicated with the person or persons who will exercise it.
b. There are in place adequate internal controls and procedures which
ensure that the power is being exercised properly and prudently
c. It reviews regularly the performance of the person or person’s
exercising the delegated power.
3
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V7
d. Where an investment manager is appointed, that the person is
regulated under the Financial Services Act 1986
e. Acquisitions or disposal of a material nature always have written
authority of the CFC or the Chairman of the CFC in conjunction with
the Director of Finance, Performance and Corporate Resources.
f.
The banking arrangements for the charitable funds should be kept
entirely distinct from the Trust’s NHS other funds
g. Separate current and deposit accounts should be minimised
consistent with meeting expenditure obligations.
h. The amount to be invested or redeemed from the sale of
investments shall have regard to the requirements for immediate
and future expenditure commitments.
i.
It establishes and maintains an approved list of counter parties for
investment activities
j.
It will operate an investment pool when it is considered appropriate
to the charity in accordance with charity law and the directions and
guidance of the Charity Commission. The CFC shall propose the
basis to the Trust Board for applying accrued income to individual
funds in line with charity law and Charity Commissioner guidance.
k. It will obtain appropriate professional advice to support its
investment activities.
l.
11
It will regularly review investments to see if other opportunities or
investment managers offer a better return.
Monitoring and Review:
11.1
The Board will monitor the effectiveness of the Committee through receipt
of the Committee's minutes and such written or verbal reports that the
Chair of the Committee might provide.
11.2
The Secretary will monitor the frequency of the Committee meetings and
the attendance records to ensure minimum attendance figures are
complied with. The attendance of members of the Committee will be
reported in the Annual Report.
11.3
Terms of reference to be considered by Charitable Funds Committee
9 March 2015
11.4
Terms of reference approved by Board of Directors
31 March 2015
11.5
To be reviewed at least annually.
4
159
Quality Committee
Minutes of the meeting held on Monday, 16 February 2015
In the Boardroom, Westminster City Hall, Victoria Street, London
Present
Louise Ashley
Julia Bond
Pamela Chesters
Joanne Medhurst
Richard Milner
David Sines
Non-Executive Director (Committee Chair)
Non-Executive Director (Chairman)
Medical Director
Deputy Chief Executive
In attendance
James Benson
Patrick Geraghty
Sam O’Shea
Tony Pritchard
Charlie Sheldon
Alison Soliman
Jayne Walbridge
Laura Williams
Divisional Director of Operations
Clinical Business Manager
Patient Safety Manager
Deputy Chief Nurse (Director of Patient Experience)
Deputy Chief Nurse (Director of Patient Safety)
Programme Manager, Namaste Care
Trust Secretary
Head of Resilience and Compliance
Committee observers
Cliff Bean
Tanya de Hoet
Emily Karugaba
Sean Overett
Lori Taylor
Deputy Director, Clinical Quality (London) TDA
PWC
Clinical Lead, Kensington and Chelsea
Senior Delivery and Development Manager (NW London) TDA
Team Leader (0-19), Hammersmith and Fulham
QC/25/15
25.1
Welcome, Introduction and Apologies
Apologies had been received from C Cole, Non-Executive Director.
QC/26/15
26.1
Declarations of Interest
Following the Namaste presentation, D Sines declared an interest as a trustee to the
Burdett Nursing Charity - for inclusion in the register of interests declared at
meetings.
AQC/06/15 (J Walbridge)
Minutes of the meeting held on 19 January 2015
The minutes of the meeting held on 19.01.15 were agreed as a correct record,
subject to inclusion of the action (AQC/04/15) in relation to minute QC/16.1/15 and a
corresponding change to action numbers.
QC/27/15
27.1
QC/28/15
28.1
Action Log
The action log was reviewed and it was agreed that completed actions could be
closed, together with actions:
AQC/01/15 – Arrangements had been made for the internal audit plan for 2015/16 to
include the process for managing child health records.
AQC/04/15 – Management of omitted doses had been discussed with the medicines
management team who had elected to maintain the 100% target.
AQC/05/15 – A comprehensive response had been received from A Nottage who
was congratulated on her work.
28.2
AQC/90/14 – D Sines confirmed that he had discussed the risk process with A
Basham and C Sheldon and was satisfied these were robust. The Board would
undertake an annual review of all health and safety risks in February 2015. While
160
1
the process to strengthen the management of risks was noted, J Bond emphasised
the need to ensure mitigating actions were undertaken in a timely fashion.
QC/29/15
29.1
QC/30/15
30.1
Matters Arising
Having discussed the actions, it was agreed that it would be helpful for J Medhurst to
write and encourage Divisional Directors to share their challenges (for example
podiatry) and successes for inclusion in the regular GP newsletter1 and that this
would be useful to include in the stakeholder engagement plan – to be considered by
the Board in February 2015.
AQC/07/15 (J Medhurst)
Presentation – Namaste ‘honouring the spirit within’
Patrick Geraghty and Alison Soliman gave a presentation on the Trust’s Namaste
programme at the nursing homes which had been funded by a grant from the Burdett
Trust for Nursing. Members were delighted to learn about the success of this
innovative work, for which data showed a positive impact on patient care, for
example a reduction in depression and aggressive behaviour, improved sleep
patterns, improved appetite (weight gain) and increased staff satisfaction.
30.2
Members discussed how the work might be used in other bedded units, concluding
that it would be helpful to link the Namaste programme to the dementia care work led
by the Quality Team, particularly as the current programme lead (A Soliman) would
be retiring in March and replacement had been difficult to identify.
30.3
It was confirmed that the success of the work had been shared within the Trust’s and
in partnership for patients publication for GPs and that the programme had been
designed to be cost neutral, though this was challenging given the shortage of
permanent staff.
30.4
Resolved
The Namaste programme update was noted.
30.5
P Chesters acknowledged the challenges the nursing homes faced during the period
of transition from CLCH to a new provider and the impact of commissioning delays
and thanked the team on behalf of the Board for their work in support of patients. J
Bond cited this initiative as an example of the excellent and innovative work being
done within the Trust and the need to confidently share our progress and success
externally. This will be part of the engagement strategy the board is due to sign off.
QC/31/15
31.1
Chief Nurse and Medical Director Report
L Ashley highlighted work undertaken in preparation for nurse revalidation (every
three years, from 2015) confirming that at CLCH this would be kept separate from
the annual appraisal process. A risk in relation to general confusion regarding
fitness for post and fitness to practice (the purpose of revalidation) was discussed; it
was concluded that this would be kept under review after implementation with regular
reports to the Workforce Committee (already planned). This new requirement will be
resource intensive and L Ashley indicated she is hoping to secure some funding to
support efficient execution.
31.2
A significant amount of work had been undertaken in preparation for the forthcoming
CQC inspection, including sending the required pre-visit information back to the CQC
within the agreed timeline.
31.3
The RCN’s excess hours campaign, brought to the attention of the Chief Nurse by
the Trust’s communications team, was launched at CLCH. There has been positive
feedback from CLCH nursing staff, indicating that staff were paid for the hours they
worked.
1
In partnership for patients
161
2
31.4
Quality action team work at the nursing homes, in Barnet and on Marjory Warren
was discussed.
31.5
While recruitment to Marjory Warren remained a challenge (for which overseas
recruitment was being considered), leadership had improved and a new matron had
now been appointed. It was confirmed that the quality action team would remain in
place until a sustained positive improvement in KPIs and a reduction in the vacancy
rate could be demonstrated.
31.6
In response to J Bond’s question regarding stakeholder response to the Trust’s letter
regarding the delayed transfer of the nursing homes, R Milner confirmed that
Matthew Bazeley had acknowledged the need for the CCG to support and incentivise
recruitment to the homes which would be explored further.
31.7
L Ashley confirmed that if the vacancy rate increased to 60% an emergency meeting
with commissioners would have to be arranged as this would not be sustainable or
safe for patients.
31.8
J Medhurst confirmed that rather than quarterly reports to the Board, information
would be included in this, monthly, report with the benefit of providing more regular
information in relation to infection prevention and control.
31.9
Resolved
The Committee welcomed the new Chief Nurse and Medical Director’s report and
value in highlighting strategic issues and action taken to mitigate risks in relation to
the delayed transfer of the nursing homes which would be comprehensively
documented, shared with the CCG on a weekly basis and disclosed to the CQC.
31.10
Laura Williams and the team were congratulated for their hard work in preparing for
the CQC inspection.
QC/32/15
32.1
Production of CLCH Quality Account 2014/15
C Sheldon confirmed that the quality account production had been planned with a
view to providing the draft in April, for Board sign off in May and submission in June
2015.
32.2
A letter had been sent to local CCGs and stakeholders seeking ideas for 2015/16
priorities and members would be invited to participate in the survey to inform the
report.
32.3
Resolved
The plan for production of the quality account was noted.
32.4
It was agreed that it would be helpful for an external audit to be undertaken.
QC/33/15
33.1
Quality balanced scorecard
Members discussed the scorecard and performance in detail and at length,
specifically pressure ulcers.
33.2
L Ashley confirmed that there had been an increase across the health economy; a
more detailed quarterly report to the Quality Committee had already been instituted.
33.3
D Sines suggested that it would be helpful to arrange a peer review in order to
identify what else might be done to effect a reduction in pressure ulcers. Following
lengthy discussion and the fact that rates continued to be between the upper and
lower control limits, it was agreed that the April report to the committee would include
more detailed information by CBU / Division, including outliers and that the pressure
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3
ulcer peer review would then be reconsidered.
AQC/08/15 (L Ashley)
33.4
It was agreed that it would be helpful for the draft scorecard template to be shared
with NED committee members in advance of the April meeting.
33.5
The need to do more work with families and carers was recognised and was being
considered.
33.6
C Sheldon reported that, following discussions with the business intelligence unit,
inconsistencies in data should now be minimised by ensuring that data is extracted
on the same day and by avoiding transcription.
33.7
It was discussed that, with some exceptions (Pressure Ulcers) it was difficult to
benchmark CLCH given the lack of comparable data within the sector.
33.8
Resolved
The quality balanced scorecard was noted, including some positive and some
disappointing negative trends, which would in future be monitored closely at a CBU
level.
QC/34/15
34.1
Update on the plan to improve podiatry service and waiting times
J Benson reported that he had discussed with Barnet CCG and agreed a two-week
prospective audit of podiatry referrals, currently increased by GP annual podiatry
checks. It was possible that this would result in a GP referral only service – to be
discussed as part of the contract negotiations.
34.2
Resolved
The update on podiatry services was noted. A further update on the ongoing
contracting negotiations will be provided in March 2015 WP.
QC/35/15
35.1
Cost Improvement Programme review meetings - report
L Ashely confirmed that bimonthly meetings with divisions to assess the impact of
CIPs on quality continued. To date, all 2014/15 schemes had been managed well
with some innovative work led by R Milner’s team.
35.2
Some 79 savings schemes for 2015/16 required assessment, this work would
commence in the near future, led by the Medical Director and Chief Nurse.
Discussions are being held jointly with finance representation.
35.3
Resolved
The CIP review update was noted. A post implementation report for 2014/15 and
report on 2015/16 planned savings would be considered by the Committee in April
2015 WP.
QC/36/15
36.1
Assurance report from patient experience group
A Pritchard provided an update, reporting significant progress in the number of
patients responding to surveys and in implementing the engagement strategy,
including CBU engagement plans.
36.2
Response rates to patient complaints and accountability was discussed at length.
P Chesters felt strongly that primary responsibility should rest with CBU managers.
J Benson confirmed that it would be helpful for the weekly complaints report to
identify CBUs so that divisional directors could hold managers to account for
performance.
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4
36.3
D Sines added that the development of a service improvement culture would have
significant benefits to all patients and divisions. This was acknowledged and it was
confirmed that an improvement in performance should be demonstrated in the March
report
36.4
Resolved
The assurance report from the patient experience group was noted including action
to be taken to improve, as a matter of urgency, response rates to complaints which
remained unacceptably poor.
QC/37/15
37.1
Assurance report from the patient safety and risk group
Resolved
The assurance report from the patient safety and risk group was noted including
progress in relation to the sign up to safety campaign.
37.2
The Committee recorded their thanks to Sheila Pearce, who has recently been
appointed as an associate director of quality (ADQ,) for her work in support of the
Committee.
QC/38/15
38.1
Omitted doses update
See action AQC/04/15 above.
38.2
J Medhurst confirmed that the medicines management team wanted to maintain a
target of 100%. Conversations with two other community trusts had been helpful
and the team would consider auditing a monthly sample, similar to Derbyshire. It
was also evident that it would be helpful for audits to be owned at a CBU / divisional
level which would be discussed further.
38.3
Resolved
The omitted doses update was noted.
QC/39/15
39.1
Assurance report from clinical effectiveness group
J Medhurst confirmed that a bid for a research project manager was being prepared.
39.2
Resolved
The assurance report from the clinical effectiveness group was noted.
39.3
It was agreed that the end of life strategy would be shared with D Sines for comment.
AQC/10/15 (A Pritchard)
QC/40/15
40.1
Update of key issues from Clinical Commissioning Group Quality Meetings
L Ashley reported that meetings with the inner London CCG were becoming more
focused and productive which was helpful.
QC/41/15
41.1
Risks and issues arising for which further assurance is required
There were no new risks identified, however it was agreed that it would be useful for
J Benson to review the existing risks in relation to the nursing homes, given the
further delay in transfer to a new provider.
AQC/11/15 (J Benson)
Minutes of groups
Resolved
The following minutes were noted:
Quality stakeholder reference group 15 January 2015
Patient safety and risk group 26 January 2015
Patient Experience Group 20 January 2015
Clinical Effectiveness Group 20 January 2015
QC/42/15
42.1
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5
QC/43/15
43.1
Update on new regulation and guidance
Resolved
The committee noted the update on regulation and guidance.
43.2
It was agreed that the recommendations in the recent Francis report ‘Whistleblowing
in the NHS’ would be considered as part of the QGAF action plan (Francis review
after one year) about which staff would be surveyed.
43.3
It was agreed that this information should then be included in the quarterly report to
the Board (April 2015).
QC/44/15
44.1
Date and time of next meeting
16 March 2015, 10.00, Boardroom, Victoria Street.
The meeting closed at 12 noon
Signed ………………………………………………….. Julia Bond, Committee Chair
Date ……………………………………………………..
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6
Charitable Funds Committee
Minutes of the meeting held on Wednesday, 17 December 2014
Boardroom, Westminster City Hall, Victoria Street, London
Present
Members 1
Anne Barnard
Julia Bond
Joanne Medhurst
Ian Millar
James Reilly
Vice Chairman, Non-Executive Director (Committee Chair)
Medical Director (part: from CFC58/14 onwards)
Executive Director of Finance, Performance and Corporate Resources
Chief Executive
In attendance
Patrick Geraghty
Daniel Greenleaf
Ian Jones
Rob MacDonald
Olafemi Olatunde
Cathy Sarasby
Jon Scourse
Jayne Walbridge
Nursing Homes Lead (part)
Business Manager, Pembridge (part)
CBU Manager, Integrated Long Term Conditions (part)
Assistant Director of Finance, Financial Control
Deputy Head of Financial Control and Governance (part)
Pembridge (part)
Management Consultant (part)
Trust Secretary
CFC/52/14
52.1
Administrative Items
Welcome, Introduction and Apologies
All members were present
CFC/53/14
53.1
None declared.
CFC/54/14
54.1
Minutes of the Charitable Funds Committee 3 March 2014
The minutes of the meeting held on 9 September 2014 were agreed as a correct record
subject to a minor typographical error in paragraph 47.2.
CFC/55/14
55.1
The action log was reviewed and it was agreed that completed actions could be closed,
together with actions: CFC/19/14, CFC/22/14, CFC/31/14 and CFC/33/14.
55.2
CFC/08/14 – Legacy issue – to be discussed in March 2015.
55.3
CFC/20/14 – Outcome report for Pembridge to be updated to include quantitative data.
55.4
CFC/21/14 – Funds available to CBU managers – J Medhurst to follow-up letter by telephone
in the new year.
CFC/56/14
56.1
Finance report and investment portfolio – April – November 2014
The financial position was discussed; members were pleased to note that the Pharmacy
funds (£36,203) had been transferred to Central and North West London NHS FT as agreed.
56.2
Members discussed funding arrangements for 2014/15 Pembridge bids, agreeing that, in
future, funding should not be provided until expense is incurred.
56.3
It was noted that only two dividend payments (to September) were included in the statement.
56.4
R MacDonald confirmed that the K&C General fund had now been fully utilised.
1
Representatives of the corporate trustee (CLCH)
1
166
56.5
Resolved
The total balance (£2,709,830, represented by cash of £42,984 and the market value of
investments) at 30 November 2014 was noted.
56.6
It was agreed that funds managed, but not controlled by CLCH, would be clearly identified on
the schedule and that a line by line review of each fund would be undertaken at the meeting
in March 2015.
Action CFC/39/14 (R MacDonald)
CFC/57/14
57.1
Nursing Homes – grant applications
P Geraghty apologised that grants approved in March 2014 had not been progressed.
Members reiterated their support for all nursing home funds to be fully utilised for the benefit
of patients prior to handover, subject to ensuring that any replacement fixtures and fittings
would be retained by the new provider.
57.2
It was confirmed that each fund would have to be used as defined by the objects of the fund
and that it was not possible to redistribute funds between the homes.
57.3
It was noted that while the builders were working at Garside, there may be an opportunity to
further enhance the patient environment which P Geraghty would explore.
57.4
57.5
Resolved
It was agreed that R MacDonald would confirm the exact funding available for each home
and that P Geraghty and his team would prepare a final bid to expend all funds before the
end of March 2014, mindful of any likely replacement by the new provider.
Items under £1k to be approved by R MacDonald, items in excess of £1k to be agreed offline to avoid losing momentum.
Action CFC/40/14 (R MacDonald and P Geraghty)
CFC/58/14
58.1
Opportunities for the Pembridge Fund – phase 1
Members considered the review findings helpful, but were surprised that some of the
recommendations related to decisions already made by the Committee in March 2014, for
example funding a volunteer manager. Furthermore it was noted that the question regarding
how current and future proceeds might be used had not been answered but it was
acknowledged that there were opportunities, for example, improved furnishings, a reception
area and funding of discretionary staff.
58.2
J Scourse stated that while he had been surprised that the unit had no branding, donor
database, website or volunteers (described by one interviewee as Nottinghill’s best kept
secret), this presented a significant opportunity for the Trust.
58.3
In discussing opportunities for the fund, J Scourse had gained a sense of disconnect
between the hospice and Victoria Street which required careful consideration.
58.4
Fundraising opportunities were discussed, noting that units of a similar size in the charitable
sector generated funds in excess of £8m per year compared to £280k at Pembridge, as one
of only 4% of hospices that is not an independent charity.
58.5
Members considered the advantages and disadvantages of Pembridge having a distinct and
separate identity to the Trust, including possible unintended consequences; whilst also
wholeheartedly supporting the desire to maximise funding available for the Trust’s end of life
care provision.
Resolved
2
167
58.6
Decisions in relation to phase 1 recommendations were confirmed as shown below:
Volunteers - hospice based volunteer manager agreed in March 2014 reconfirmed
Governance – co-opted member to be considered
Process - venue for Committee meetings to include Pembridge and improved support for
bids to be provided 2
Systems – to be considered including the fund name
Services – improving staff engagement to be considered
Fundraising strategy – to be discussed with Board.
58.7
Recommendations to be revisited in March 2015.
58.8
It was agreed that the Corporate Trustee (the Board) would need to be consulted regarding
the strategic issues prior to making a decision on whether to progress to phase 2 of the
review.
Action CFC/41/14 (A Barnard)
58.9
The Committee thanked J Scourse for his report and for kindly offering to provide contact
details for Hospice UK and Cransley Hospice in Kettering which had recently become an
independent charity.
Action CFC/42/14 (J Scourse)
Pembridge grants - outcome
Members were keen to understand the outcome of approved grants. It was agreed that while
the qualitative information was helpful, quantitative information was required, using the
following report format as applicable, see action CFC/43/14 below.
CFC/59/14
59.1
Request and
date of
decision
Date
implemented
Actual
number (in
place)
Cost to date
Number of
patients
Benefit to
patients
59.2
Volunteer co-ordinator - I Jones explained the reasons for the delay in recruiting the
volunteer manager 3, confirming that this was now advertised through NHS jobs with a
closing date of 29.12.14. It was agreed that an appointment to this post should be made as
soon as possible, including advertising in voluntary sector publications if necessary.
59.3
Rehabilitation assistant – Currently with the recruitment team for advertisement in the near
future.
59.4
The long delay in progressing the two posts was noted; attendees were invited to share their
reflections with I Millar.
59.5
C Sarasby explained the role of the lecturer practitioner post and that it was anticipated that
the additional art and massage therapy hours would be provided by the existing therapists.
59.6
Members discussed funding and substantive contract arrangements, noting that this did not
correlate with the indication in the bids that these were fixed term appointments. Given that
current expenditure already exceeded income, it was agreed that a revised bid, including all
relevant information (likely income for educational events (alternative sources of educational
funding, eg HENWL), the updated outcome report, annual cost of reading service and
confirmation of what is fixed term and what substantive post funding) would be provided for
an urgent decision by members.
Action CFC/43/14 (R MacDonald and C Sarasby)
2
Dedicated (funded) finance manager approved which will free time for head of financial control to help co-ordinate
bids
3
Who would train volunteers at the hospice
3
168
59.7
CFC/60/14
60.1
60.2
60.3
Resolved
The bid for £40,000 to redecorate the family room, kitchen and staff room was approved for
immediate implementation.
Action CFC/44/14 (I Jones)
Investment manager – invitation to quote (ITQ)
The draft ITQ was considered.
Resolved
The draft documentation was agreed, subject to confirmation of the contract terms, payment
arrangements and review of the award criteria questions and weighting with which J Bond
kindly offered to assist.
Action CFC/45/14 (J Bond and J Walbridge)
Final ITQ to be circulated for agreement and action as soon as possible.
Action CFC/46/14 (R MacDonald)
CFC/61/14
61.1
Finance and resources to support charitable funds administration
Resolved
It was agreed that the cost of the dedicated charitable funds accountant should be met from
charitable funds.
61.2
Due to pressure on time, it was agreed that the remaining costs and proposed recharges
should be the subject of further debate in March 2015.
CFC/62/14
62.1
Legacy issues regarding the transfer of funds from Westminster (£90k)
Decision postponed to March 2015.
CFC/63/14
63.1
Risk register review
Resolved
The improved risk register was noted, it was confirmed that a single risk in relation to
compliance with charitable fund regulations had been included in the Trust’s risk register.
CFC/64/14
Grant applications – Barnet Children’s, diabetes, Westminster Children and
Westminster Homeless
See minute 55.4 (action CFC/21/14) above – for follow-up in March 2015. The general lack
of awareness on the availability and how to access charitable funds was discussed. It was
agreed that a more proactive approach should be taken, via the Chief Executive’s message
in the first instance. J Walbridge to prepare draft text.
Action CFC/47/14 (J Walbridge)
64.1
CFC/65/14
65.1
Application of charitable funds and method of approval
Resolved
The report was noted. It was agreed that the monthly cost of the reading service should be
aggregated and included in the revised Pembridge bid (see action CFC/43/14 above).
CFC/66/14
66.1
Progress update on recruitment of volunteers
There was insufficient time to consider the report, however it was noted that rather than an
update the paper sought charitable funding for various initiatives and that it was not clear
how similar items were funded in Barnet which it would be helpful for C Dale to confirm.
66.2
It was agreed that the bids for non-recurrent items could be considered by R MacDonald.
Action CFC/48/14 (C Dale and R MacDonald)
4
169
CFC/67/14
67.1
CFC/68/14
CFC funded retirement gifts
Resolved
Nil return noted.
68.1
Update on regulation and guidance
Resolved
Report noted.
CFC/69/14
69.1
2015 Committee dates
To be agreed off-line.
Action CFC/49/14 (A Barnard and J Walbridge)
The meeting closed at 1730 hours.
Signed ……………………………………………………….. Date ………………………………………………..
Anne Barnard, Committee Chair
5
170
Acronym
Alphabetical by
abbreviation
A&E
AHP
ALB
AQP
BAU
BGAF
BGM
CAS
CBU
CCG
CFT
CIO
CIP
CLCH
COPD
CQC
CQUIN
CRG
CSRR
CSU
DH
DN
EBITDA
ELT
ESR
FOI
FRR
FRIC
FT
FTE
GP
GRR
HCA
HDD
HR
HV
IBP
ICO
ICO
ICP
IG
IM&T
ITT
KPI
KSF
LA
Description
Accident & Emergency
Allied Health Professional
Arms Length Bodies
Any Qualified Provider
Business As Usual
Board Governance Assurance Framework
Board Governance Memorandum
Central Alerting System
Clinical Business Unit
Clinical Commissioning Group
Community Foundation Trust
Chief Information Officer
Cost Improvement Programme
Chronic Obstructive Pulmonary Disorder
Care Quality Commission
Commissioning for Quality and Innovation
Clinical
Continuity of Service Risk Rating
Commissioning Support Unit
Department of Health
District Nursing
Earnings Before Interest, Taxes, Depreciation and Amortisation
Executive Leadership Team
Electronic Staff Record
Financial Risk Rating
Finance, Resources and Investment Committee
Foundation Trust
Full Time Equivalent – see WTE
General Practitioner
Governance risk rating
Health Care Assistant
Historical Due Diligence
Human Resources
Health Visiting
Integrated Business Plan
Information Commissioner’s Office (1)
Integrated Care Organisation (2)
Integrated Care Pathway
Information Governance
Information Management and Technology
Invitation to Tender
Key Performance Indicator
Knowledge and Skills Framework
Local Authority
171
LETB
LTC
MAU
MIR
NHS
NHSLA
NICE
NRLS
NTDA
OBD
OD
OOH
ORSA
PASA
PID
PLD
PPE
PST
PQQ
QGAF
QIPP
RA
R&D
RIO
RTT
SDIP
SLR
STEIS
TAG
TDA
WTE
London Education Training Board
Long Term Conditions
Medical Admissions Unit
Monthly Information Return
National Health Service
National Health Service Litigation Authority
National Institute of Clinical Excellence
National Reporting and Learning System
NHS Trust Development Authority
Occupied bed days
‘Out of Hospital’ agenda or Out of Hours
Organisational Readiness Self-Assessment
Purchasing and Supply Agency
Project Initiation Document
Patient Level Data
Patient and Public Engagement
Patient Safety Thermometer
Pre-Qualifying Questionnaire
Quality Governance Assessment Framework
Quality, Innovation, Productivity and Prevention
Registration Authority
Research and Development
Is the name of a clinical system, it is not an abbreviation, it is a
Spanish word which correlates to ‘flow of work’.
Referral to Treatment
Service Development Improvement Plan
Service Line Reporting
Strategic Executive Information System
Technology Appraisal Guidelines (NICE)
Trust Development Authority
Whole Time Equivalent – see FTE
172
KEY PERFORMANCE INDICATOR SCORECARD
End of Yr Target
Friends and Family test - Net Promoter Score (National methodology)
58
Friends and family test - Net Promoter Score (CLCH methodology)
85
Patients agreeing with the statement “I was treated with dignity and respect”
95%
“I am satisfied with the care I give to patients/service users” (quarterly)
85%
The ratio of clinical bank : agency staff by hours worked
65:35
Key Performance Indicator Calculation
This KPI is calculated in accordance with "The NHS Friends and Family Test: Publication
Guidance". The calculation therefore reflects the proportion of respondents who reply
"extremely likely" to the survey question 'How likely is it that you would recommend this service
to a friend or family if they needed it', minus those who would not recommend the service
(response categories; "neither likely or unlikely", "unlikely" and "extremely unlikely"). The survey
to generate the responses for this KPI is the monthly patient experience survey.
The calculation of this KPI reflects the percentage of those respondents that gave either an
"extremely likely" or "likely" response to the survey question 'How likely is it that you would
recommend this service to a friend or family if they needed it', minus those who would not
recommend (response categories; "neither likely or unlikely", "unlikely" and "extremely
unlikely"). The survey to generate the responses for this KPI is the monthly patient experience
survey.
This KPI is also taken from the monthly patient experience survey and reflects the percentage of
respondents choosing the 'Yes, definitely' category when answering the question "Did the staff
treat you with dignity and respect?".
This measure reflects the percentage of staff that respond 'strongly agree' or 'agree' when asked
to what degree they agree with the statement "I am satisfied with quality of care I give to
patients/service users". This question forms part of the National Staff Survey and is replicated
internally in the Trusts quartely Pulse Survey.
This represents the simple ratio of the total hours worked by the two categories of a) Bank staff
and b) Agency staff within the four clinical directorates.
End of Yr Target
Proportion of Patients with no NEW harms identified (PST monthly prevalence survey)
98%
This metric represents the percentage of patients where one of the four categories of Patient
Safety Thermometer harms (Falls, Pressure Ulcers, Catheter Associated UTIs and Veneous
Thromboembolisms) did not occur within the current episode of care. The data is generated
from a monthly survey of mandated services and clinical teams.
QGAF Score, to be tested quarterly
2.5
This KPI reflects Monitors self assessment mechanism used in assessing the readiness for
Foundation Trust status. It is assessed quarterly by the Quality Directorate.
Hand hygiene audit, to be measured quarterly
92%
Percentage of time bedded units achieve minimum staffing each month
100%
Statutory and mandatory training compliance
90%
Reduction in incidence of Grade 2-4 Pressure Ulcer (by 10% from the previous year).
416
Monthly hand hygiene observations are carried out in bedded services by Infection Prevention
Link Practitioners(IPLPs), and this KPI calculation reflects the number of observed hand hygiene
opportunities achieving an Overall Confidence Rating of 'Green' as a percentage of the total
number of observed hand hygiene opportunities.
The calculation of this KPI reflects the NHS England guidelines published in May 2014 and as such
calculates a total 'fill rate' for Nursing and Care Assistant staff. The total hours worked by these
staff is shown as a percentage of the total hours that should have been worked if minimum
staffing levels were met.
This KPI reflects the percentage completion rate for all 10 training elements.
This measure is a straight count of the number of Grade 2 to Grade 4 Pressure Ulcers that
develop or deteriorate whilst the patient is within a CLCH service.
Net new business won - annualised figure of committed changes to income
Proportion of Services capturing Patients' Clinical Outcomes
Percentage of incidents affecting patients that did not cause harm
End of Yr Target
£3.1m
66%
49.0%
This metric reflects the full-year effect (annualised) of changes to our revenue stream, both
positive and negative, from acquisition or loss of business. The figure will be a cumulative total
for the year for all changes.
This KPI represents the percentage of the 67 services within the Trust which have identified 3
clinicical outcomes and are able to collect and report the data electronically.
This measure is the count of the number of harm free incidents expressed as a percentage of the
total number of reported incidents. It reflects only those incidents directly related to patients.
End of Yr Target
90%
This KPI reflects the number of Low/Moderate graded complaints (to which a 25 day completion
deadline applies) which are dealt with within 25 days. Formal complaints are administered using
the Trusts Datix system.
173
Complaints resolved within timescales agreed with the complainant
100%
This KPI applies to complaints which, due to their complexity fall outside of the 25 day
completion deadline, and whose completion deadline is agreed with the complainant. The
agreed completion date is recorded on the Datix system and the KPI reflects the percentage of
complaints which were completed within the agreed timescale.
2.1%
Data relating to both patient and service cancellations are collected on the Trusts Patient
Administration Systems. This KPI highlights the total number of appointments which were
cancelled by a service as a percentage of the total number of planned contacts.
End of Yr Target
Percentage of Staff that recommend CLCH as a place to work
62%
This KPI is collected quarterly via the Trusts Pulse Survey for Q1, Q2 and Q4 with the national
staff survey covering Q3. The measure reflects those staff who agree or strongly agree with the
question asking staff whether they would recommend the Trust as a place to work. The
percentage is calculated against total number of responses for that question.
90%
This KPI shows the number of staff assignments appraised as a percentage of the number due for
appraisal in the same period. The ESR and E-PADR systems provide this data.
3.50%
The measure simply reflects the number of hours recorded as being lost due to sickness absence
as a percentage of the total hours available in the same period. Data is taken from the ESR
system and is reported one month in arrears.
Vacancy level
11%
This KPI reflects the vacant full time equivalent (less frozen posts) divided by the budgeted
establishment. Data is taken from two sources namely the ESR system and the General Ledger.
Staff from BME backgrounds at bands 7 and above
34%
Taken from the Trusts ESR system, this KPI shows the percentage of all staff that self classify as
BME. The denominator figure includes those staff whose classification is recorded as not known
and not stated.
End of Yr Target
Recurrent QIPPs achieved % of total for the year
100%
Percentage of QIPP plans achieving the planned level of savings in-year
100%
The Innovation committee will see a number of projects each year, some of which will
be taken forward as pilots
30 : 6
KPIs that are RAG rated GREEN on overall data quality confidence level.
85%
Continuous improvement model in place and used across service lines
10%
This KPI shows the forecast end of year recurrent QIPP position (including any contingency in
reserve) as a percentage of the end of year QIPP target.
This KPI reflects the financial position of the year to date 'actual' QIPPS achieved as a percentage
of the year to date planned position.
This measure reflects the number of projects presented to the Innovation committee and the
number which are to be progressed.
This KPI reflects the number of board KPIs which are assessed as having appropriate levels of
data quality. The assessment is carried out by the Data Quality Forum using a Data Quality
Assessment Framework.
This measure is currently under development but is expected to reflect the total number of staff
successfully undertaking the course.
174

Board of Directors - Central London Community Healthcare NHS Trust

Transcription

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