Board of Directors - Central London Community Healthcare NHS Trust

Transcription

Board of Directors
Time: 1130 – 1330 hours
Date: Tuesday, 28 October 2014
Venue: Board Room, Level 7, 64 Victoria Street
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 and Quality report
Time
1.1
Welcome, introduction and apologies:
Pamela Chesters
Verbal
1130
J Reilly, CEO (first part of meeting 1)
1.2
Patient story
Stephanie
Verbal
Matuszak 2
1.3
Written questions from the public 3
Pamela Chesters
To be tabled 4
1.4
Interests to declare
Pamela Chesters
Verbal
Pages 3-11
1.5
Minutes of meeting held 30.09.14
Pamela Chesters
Pages 12
1.6
Matters arising and action log
Pamela Chesters
Pages 13-15
1.7
Chairman’s report
Pamela Chesters
Pages 16-26
1.8
Chief Executive’s report
James Reilly
Pages 27-52
1.9
Quality report – Q2
Louise Ashley
2
Operational items
Pages 53-72
2.1
Integrated performance and finance report 5
Ian Millar
1200
Pages 73-92
2.2
Staffing monthly report
Louise Ashley
3
Governance / assurance items
Pages 93-127
3.1
Serious incident report
Louise Ashley
1230
Pages 128-147
3.2
Francis and other national reports – six month
James Reilly
update
Pages 148-173
3.3
Board Governance Memorandum – update
James Reilly
Pages 174-178
3.4
FT Timeline - update
Ian Millar
Pages 179-183
3.5
Safeguarding mid-year review
Louise Ashley
6
Pages 184-191
3.6
Medical Director’s report
Joanne Medhurst
Pages 192-197
3.7
Medicines management annual report
Joanne Medhurst
Pages 198-211
3.8
Health and safety – quarterly report
Ian Millar
Pages 212-224
3.9
Board self-certifications (September 2014)
James Reilly
Verbal
3.10 Board committee reports
Committee chairs
Pages 225-231
3.10.1 Quality Committee Terms of Reference
Pages 232-242
3.10.2 Quality Committee report, 22.10.14
Verbal
3.11 Risks identified during meeting
Pamela Chesters
Verbal
3.12 Issues/items for which further assurance is
Pamela Chesters
required
4
Items to agree/note without discussion7
Committee Minutes
4.1
4.1.1 Quality Committee 16.09.14
Pages 215-221
Date of next meetings in public:
4.2
Board meeting in public - Thursday, 27 November 2014, 64 Victoria Street, London SW1E 6QP
Attached – list of commonly used abbreviations Pages 243-244 and key performance indicator
definitions Received 245-246
1
2
3
4
5
6
7
Meeting with David Flory, NTDA tripartite meeting to 1300 hours
Occupational therapist
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
including formal review of KPIs and review of reserves and surpluses
including role as Caldicott Guardian, clinical framework update and telemedicine
Unless notified in advance
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
Agreed by chairman 06.10.14
Board of Directors 1
Minutes of the meeting held on Tuesday, 30 September 2014
Soho Centre for Health, Frith Street, London W1D 3HZ
Present
Pamela Chesters
Louise Ashley
Anne Barnard
Julia Bond
Tony Brown
Carol Cole
Joanne Medhurst
Ian Millar
Richard Milner
James Reilly
David Sines
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
Deputy Chief Executive
Chief Executive
In attendance 2
Rachael Bhella
Ken Erharhine
Louisa McGeehan
Neil Snee
Jayne Walbridge
Care Navigator, Care Navigation Service (part)
Case Manager, Care Navigation Service (part)
Head of Communications and External Relations (part)
Service Transformation Director (part)
Trust Secretary
BoD/163/14
163.1
Welcome, introduction and apologies
The Chairman welcomed Dr Carol Cole to the meeting who had joined the Trust as a NonExecutive Director on 1 August 2014.
163.2
All members were present.
BoD/164/14
164.1
Written questions from the public
No written questions had been received; however a new facility for staff to ask executive
directors questions on any subject had now been introduced.
164.2
Questions and the Board’s responses to all previous questions are published on the Board
Meetings page of the web site.
BoD/165/14
165.1
Interests to declare
There were no interests declared.
BoD/166/14
166.1
Minutes of the Board of Directors meeting held on 31 July 2014
The minutes of the Board of Directors meeting held on 31 July 2014 were agreed as an
accurate record, subject to correction of minute 142.1 to read “slowed due to CQC staff
pressures” and minute 145.1 to read I Millar.
BoD/167/14
167.1
Minutes of the annual general meeting (AGM) held on 19 September 2014
The minutes of the Board of Directors meeting held on 19 September 2014 were agreed as
an accurate record.
BoD/168/14
168.1
Matters arising and action log
The action log was reviewed and it was agreed that completed actions could be closed,
1
2
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Sentences marked include an action for ELT members that does not require report back to the Board.
1 member of the staff in attendance, and 4 external assessors (Grant Thornton and Niche Consultancy) who were observing the meeting.
1
3
subject to correction of the comment for action BoD/50/14 - to confirm that the proposed
suggestions regarding children had been incorporated into the safeguarding annual report.
168.2
It was noted that issues in relation to Winterbourne would be referenced in the dementia
strategy and the learning disabilities protocol.
168.3
BoD142.7 Information Commissioner’s Office – it was confirmed that the report had been
circulated to all Board members.
BoD/169/14
169.1
Chairman’s report
The Chairman reported that she had hosted an interesting medicine for members event the
previous day with an excellent presentation by the falls team which had been very well
received.
169.2
Members had found the engagement workshops following the AGM helpful and sought
confirmation on how feedback would be used.
169.3
It was confirmed that the Executive Team would review actions in response to table
discussions and that themes would be used to inform the listening events planned in all
boroughs later in the year.
169.4
Resolved
The Chairman’s report was noted.
169.5
It was agreed that a copy of the engagement workshop report would be circulated to all
members.
Action BoD/56/14 (J Walbridge)
Chief Executive’s report
J Reilly introduced his report, highlighting the achievements of staff. R Milner added that
since publication of the report, the Trust had received an HSJ award for the ‘redesigning of
acute care’ work with Chelsea and Westminster.
BoD/170/14
170.1
170.2
Foundation Trust Status
The Trust intended to seek confirmation in October regarding the timing of the CQC
inspection in order to clarify the programme timetable for the foundation trust application.
170.3
Better Care Fund
It was noted that this had direct implications for the Trust and that services in Barnet had
already seen an increase in urgent care centre attendances which would be discussed with
commissioners.
170.4
Unison
J Reilly reported that the Trust had been notified of industrial action on 13/10/14 (for 4 hours)
and plans for a work to rule on 4 other days; for which contingency plans were in place.
170.5
CQC Inspections
Members were pleased to note that a recent unannounced inspection of Garside House
Nursing Home had found standards in relation to the care and welfare of people who use
services and assessing and monitoring the quality of service provision had been met. The
inspection had been in response to a former member of staff’s concerns raised directly with
the CQC.
170.6
L Ashley confirmed that the issue also being investigated internally to help understand the
reason why concerns had been raised; conclusions would be included in the serious incident
report to the Board.
170.7
Annual General Meeting
It was noted that the annual report and accounts had in fact been received (having
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4
previously been approved) by the Board.
170.8
Resolved
The Chief Executive’s report was noted, including the success of the annual staff awards
and recognition of individuals and teams for their projects which the executive team were
encouraged to use to promote the Trust.
BoD/171/14
171.1
Patient story 3
Ken Erharhine read a story from a patient who had been referred to the Trust’s Care
Navigation Service. While reluctant to accept help, the patient had found the service ‘first
class’ and a great benefit, particularly the liaison undertaken by the team with her GP and
pharmacist.
171.2
In response to questions, K Erharhine confirmed that care navigators were part of a
multidisciplinary team, including mental health, primary care, acute care, social services and
the London Ambulance Service; in order to provide a holistic assessment of patients’ needs.
171.3
Discharge medication from acute care was noted to be a complex and common problem;
largely due to multiple admissions at different hospitals and delays in GPs receiving
discharge summaries from acute care. It was confirmed that all patients referred to the
service had a medication review. While a single clinical system between community care
and GPs would help, this would not resolve communication issues with acute trusts.
171.4
J Medhurst confirmed that issues in relation to discharge medication were being discussed
by medical directors and that this was on the Trust’s risk register.
171.5
Resolved
The Board noted the positive feedback on the Care Navigation Service and the risks and
issues being managed in support of patient safety and care.
BoD/172/14
172.1
Future engagement strategy
L Ashley thanked members of the Quality Committee for their comments which had been
incorporated as far as possible within the timescale. It was emphasised that the strategy
sought to integrate the key themes of the Trust’s engagement plans in support of patients,
staff and stakeholders.
172.2
Clinical business units (CBU) had been tasked with preparing individual plans. Engagement
events for each borough, hosted by members of the Board 4, would be arranged twice
annually.
172.3
Events for CBU staff (fit for the future) had commenced the previous day, hosted by L
Ashley, and this first event had been well received.
172.4
The engagement of clinical staff would also be prioritised and throughout December quality
team leads would be visiting clinical areas across the Trust.
172.5
The following comments / amendments were agreed for inclusion:
• A direct link to the commercial strategy (commissioners)
• How CBUs will engage directly with commissioners
• To expedite timelines from 2015/16 to 2015 as far as possible
• To correct Herefordshire to Hertfordshire
• To ensure all sections include measures of success
• To clarify how staff will be involved in redesigning care pathways and organisational
decision making.
3
4
Delayed to due travel problems
NEDs where possible
3
5
•
172.6
To confirm how governors will engage members in informing the Trust’s plans
Action BoD/57/14 (T Pritchard for L Ashley)
Resolved
The Board approved the strategy, subject to the comments and correction listed above, for
promotion through the Hub and publication on the web site and circulation to membersT.
172.7
Progress to be monitored quarterly by the Quality Committee.
BoD/173/14
173.1
Whole systems - update
Neil Snee provided an extensive overview of the programme - a 5 year journey to re-shape
the way care is provided across north west London to make integrated care ‘business as
usual’. This had been actively discussed by stakeholders for some 9 months. While the
programme and pioneer bids did not include Barnet, the principles were being applied to the
borough through a more local strategy. The Chairman commented that, notwithstanding the
need for further detailed discussion at the confidential Board meeting later the same day, it
would have been helpful if the details reported had been included in the published report.
173.2
CLCH had been actively participating in the programme, including locally agreed priorities
and plans, specifically ‘models of care’ for implementation in 2015/16.
173.3
J Medhurst emphasised the need to consider quality and to ensure that plans did not widen
the gap in health inequalities.
173.4
It was confirmed that commissioners were planning to continue the whole systems work with
existing providers over the next three years rather than re-tendering contracts.
173.5
Resolved
The Board received the progress report noting the challenge of getting detailed information
regarding referrals and costs for a nominated population, without which it was difficult to
make decisions.
BoD/174/14
174.1
Current communications and engagement implementation update
Louisa McGeehan explained that having agreed the strategy in January 2014, the report
provided an update on implementation against the key objectives and themes.
174.2
Members discussed various initiatives, noting the refreshed approach to staff engagement
which had commenced the previous day (see minute 172.3 above).
174.3
In response to C Cole’s questions regarding alignment of the strategy with the overarching
engagement strategy, L McGeehan confirmed that this had been developed in liaison with
the communications team and these would remain complementary.
174.4
It was noted that the team no longer included any agency staff.
174.5
Resolved
The Board congratulated the team on progress against the key themes of the strategy which
would in future include measurable objectives.
BoD/175/14
175.1
Integrated performance and finance report
I Millar introduced the report which had been considered in detail at the Finance, Resources
and Investment Committee the previous week, including KPIs against goals which were
rated red (complaints resolved within 25 days of receipt; vacancy level; recurrent QIPP5 and
planned QIPP savings in-year).
175.2
The financial position at month 5 (August) confirmed a surplus of £1,064k in line with plan.
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Quality, innovation, productivity and prevention
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6
The recurrent value of identified QIPP remains £10.4m against a target of £12m; focused
work to confirm recurrent savings for estates and networked community nursing would
continue.
175.3
I Millar reported that the cash position had improved significantly (£4-5m receivables in
September).
175.4
With regards to cost improvement plans, L Ashley confirmed that the next quality
assessment with the Medical Director had been scheduled for October. Any reduction in
quality identified would have to be addressed and thus have an adverse impact on CIP
savings. Should this be the case, then new schemes would need to be identified. In order
to seek greater assurance, a joint letter to all staff had been planned to ask staff to report
any concerns about the impact of CIPs on quality.
175.5
In response to J Bond’s questions regarding 5 staff leaving due to lack of opportunities and
the serious concerns regarding the accuracy of appraisal data, I Millar confirmed that he
T
would seek further information . It had been identified that there were problems with the
way the appraisal system software (PADR) had been written, for example the ability to reset
objectives at year end, and it was therefore possible that managers would have to revert to
paper.
175.6
Statutory and mandatory training compliance was discussed at length. L Ashley confirmed
that revised, robust processes had been implemented and that she expected to see
improved compliance in future. It was agreed that when the figures for resuscitation had
been received, a comprehensive report would be circulated to all Board members and that
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this would be discussed at the Workforce Committee in October .
175.7
Resolved
The integrated finance and performance report was noted. A revised format had been
agreed for implementation from October and it was agreed that it would be helpful for the
requirement for resuscitation training for non-clinical posts (ie only registered professionals)
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to be clearer in the report .
175.8
It was agreed that it would be helpful for I Millar and C Cole to discuss the service
development improvement plan risks and performance trajectory monitoring arrangements
prior to the October meeting.
Action BoD/58/14 (I Millar and C Cole)
175.9
It was agreed that a position paper on the appraisal system would be considered by the
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Workforce Committee in October .
BoD/176/14
176.1
Monthly nurse staffing skill mix review
The monthly (not six monthly as stated in paragraph 2.2) staffing report was discussed at
length and in detail. Overall, percentages had been met and risks in relation to the nursing
homes were being managed, including the recruitment of a retired CLCH matron to lead the
service until the formal handover to a new provider. Overstaffing issues (Marjory Warren)
were being addressed by the Divisional Director of Operations (J Benson).
176.2
A crude attempt to compare staffing levels with prevalence and incidence quality data had
been included, however it was recognised that while this was useful for pressure ulcers
which developed over time, it would be better to triangulate the information for falls and
T
omitted doses with the number of staff on shift at the time of the fall .
176.3
Resolved
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The Board noted the monthly nurse staffing skill mix review report for August and action
being taken to address risks in relation to the nursing homes.
BoD/177/14
177.1
Serious incident report
L Ashley introduced the serious incident report which included internal incidents which the
Trust chooses to investigate.
177.2
While there had been a welcome decrease in the total number of pressure ulcers, work
continued to reduce level 3 and 4 pressure ulcers. The Quality Committee had received a
helpful presentation from Jean Lewis, Professional Lead, Adult Nursing, at their meeting in
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September which it was agreed would be useful to repeat at the end of a Board seminar for
the other Board members.
177.3
Resolved
The serious incident report was noted including the reduction in pressure ulcers.
BoD/178/14
178.1
Patient stories, six month update
In response to A Barnard’s questions regarding the low number of stories to date, L Ashley
confirmed that the focus had been on training staff; having appointed a patient experience
facilitator for each division, a rapid increase in the number of stories recorded could be
expected.
178.2
Resolved
The patient stories update was noted. It was agreed that providing the process to learn from
stories (which are monitored by the patient experience group which reported to the Quality
Committee) remained robust, and that all directors could have access to the library of
stories, no further reports would be required.
178.3
The Executive Team were asked to consider how the lessons from patient stories could be
used to promote the Trust and whether it would be possible for some stories to be presented
T
by patients .
BoD/179/14
179.1
Charitable trust annual report and accounts
A Barnard and I Millar confirmed that the auditors, KPMG, had been given an unqualified
opinion on the accounts which had been agreed by the Charitable Funds Committee and
recommended for Board approval.
179.2
Resolved
As the corporate trustee, the Board approved the charitable trust annual report and accounts
for signature and submission.
BoD/180/14
180.1
Quality governance assurance framework – action plan
Further to the self-assessment in July, an action plan had been prepared to address areas
where the score was considered to be higher than zero. L Ashley highlighted that much of
the work was being progressed in support of the risk management strategy, quality strategy
and quality account with which staff had been involved. Risks and mitigations had been
considered and it was noted that paragraph 7.1 should read ‘areas of development’ rather
than ‘concern’.
180.2
The quality assessment of CIPs was discussed. It was confirmed that while no CIPs had
been refused, some were being tested through pilots. The reason for a reduction in the total
recurrent value of CIPs in some divisions was noted to be due to changes in the
management team and a review of inherited schemes to ensure these were feasible.
180.3
Progress in implementing Qlikview was discussed. I Millar confirmed that the focus was on
delivering support for KPIs and functionality was progressing. R Milner was confident that
this robust and comparable data at CBU level would be in place during October and
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confirmed that Divisional Directors of Operations had been asked to prioritise their needs
over and above scorecard requirements.
180.4
Resolved
The Board approved the action plan, for submission to the Trust Development Agency (TDA)
within the agreed timescale.
BoD/181/14
181.1
Board governance memorandum – action plan
The draft action plan was considered in detail and suggested amendments were recorded by
the author for inclusion. It was agreed that Board evaluation requirements and timing would
be reconsidered following receipt of the external assessment report and that J Reilly would
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clarify with the TDA any further evaluation required .
180.4
Resolved
The Board approved the action plan, subject to the comments above and inclusion of actions
in response to the external assessor’s report (Grant Thornton).
BoD/182/14
182.1
Annual infection prevention and control report
J Medhurst introduced the summary annual infection prevention and control report; a copy of
the full report was also available on request. The Trust continued to perform well against
national targets for infection prevention with the exception of mandatory training for which a
recovery plan to improve compliance had been launched.
182.2
It was confirmed that the risk in relation to student nurse immunisation had been referred to
the Local Education Training Board (LETB), kindly supported by D Sines.
182.3
Resolved
The Board noted the annual report and asked for the outcome of discussions with the LETB
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regarding student nurse immunisation to be shared with all Board members .
BoD/183/14
183.1
Annual update on revalidation and appraisal
J Medhurst explained that the discrepancy regarding the number of doctors with a
prescribed connection (23 in the report and 25 in the letter from Dr Berwick) was due to a
timing issue; 23 was correct.
183.2
A number of other doctors working for the Trust were not prescribed 6 but, as Medical
Director, J Medhurst had responsibility for the quality of their work. The governance
arrangement to manage this issue had been discussed by responsible officers and it was
proposed that the summary appraisal (form 4) would be shared with the Medical Director of
Trust’s for whom the doctor provided services.
183.3
L Ashley reported that revalidation of nurses (>1000) would commence in 2015; it was
expected that other family health practitioners, for example pharmacists would follow
thereafter.
183.4
Resolved
The Board noted the report and confirmed that they would expect form 4 to be shared by any
doctor working for the Trust who was not prescribed.
183.5
It was noted that, of the total number of doctors appraised, only 7 had been recommended
for revalidation to date.
183.6
It was agreed that all information regarding staff appraisals should be linked on a single
database.
6
Having been prescribed to other designated bodies
7
9
BoD/184/14
184.1
Risk management strategy
Following extensive review and helpful input from NEDs, particularly A Barnard and J Bond,
the improved strategy was presented for approval.
184.2
Resolved
The Board approved the risk management strategy.
BoD/185/14
185.1
Board self-certifications
Resolved
The self-certifications for August 2014 were approved, for submission to the TDA.
BoD/186/14
186.1
Board Committee reports
An update following the Finance, Resources and Investment Committee would be provided
at the confidential meeting later the same day.
186.2
Charitable Funds Committee – 09.09.14
A Barnard reported that the Committee had considered the Charitable Fund annual report
and accounts and had agreed a strategic review of the options for Pembridge, to include the
optimum use of available charitable funds. The first stage of the review would cost a
maximum of £5k. J Medhurst added that J Scourse’s work would commence in October
and members would be invited to be interviewed.
186.3
An urgent decision in relation to the investment manager had been taken at a virtual
committee meeting, due to very late notification. Resources to support the Charity would be
considered in December.
186.4
A tender document provision of investment management services was being drafted for
consideration in December, including the proposed signatory on behalf of the corporate
trustee.
186.5
Quality Committee – 16.09.14
J Bond provided a summary of matters discussed at the Quality Committee which included:
a presentation on pressure ulcer management and reduction, the quality scorecard, an
update on volunteers and serious incidents. Triangulation of information (linking staffing
levels with quality of care and records management) was also discussed. It had been
agreed that in order for contemporary information to be received from groups reporting to the
Quality Committee, unconfirmed minutes would be acceptable.
186.6
Audit Committee – 09.09.14
T Brown summaries agenda items discussed which included: counter fraud, economic crime
rates, the draft risk management strategy, clinical audit, data quality and information
governance. A confidential report had also been circulated with the confidential Board
papers.
BoD/187/14
187.1
Risks identified during meeting
A risk in relation to linking quality data with staffing levels was noted and would be assessed
by L Ashley as agreed (see minute 176.2 above) for report to the Quality Committee.
BoD/188/14
188.1
Issues / items for which further assurance is required
Governance arrangements in relation to doctors working for the Trust who are not prescribed
to be assessed by J Medhurst (see minute 183.2 above)
188.2
Statutory and mandatory training compliance (see minute 175.6 above)
188.3
Student nurse immunisations (see minute 182.2 above)
BoD/189/14
189.1
CLCH annual audit letter 2013/14
Noted for publication on the web site with annual report and accounts.
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BoD/190/14
190.1
Confirmed Committee minutes received
Charitable Funds Committee, 03.03.14 and 06.08.14
Audit Committee, 03.06.14
Quality Committee 23.06.14 and 07.08.14
BoD/191/14
191.1
Date of next meetings in public
Board meeting in public - Tuesday, 28 October 2014, 64 Victoria Street, London SW1E
6QP
The meeting closed at 1320 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 ………………………………………………
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Board of Directors Public Action Log
Items marked complete will be closed following the meeting
Action number
Date of meeting
Subject
BoD/56/14
30.09.14
Chairman's report (AGM
enagement workshop)
BoD/57/14
30.09.14
Engagement strategy
BoD/58/14
30.09.14
Integrated Finance and
Performance Report
Action
Responsible officer
Due date
Comments
Last reviewed / to be reviewed
Status
14.10.14
Circulated 07.10.14
28.10.14
Complete
The following comments / amendments were
T Pritchard for L Ashley
agreed for inclusion: A direct link to the
commercial strategy (commissioners); How
CBUs will engage directly with commissioners;To
expedite timelines from 2015/16 to 2015 as far
as possible; To correct Herefordshire to
Hertfordshire; To ensure all sections include
measures of success; To clarify how staff will be
involved in redesigning care pathways and
organisational decision making; To confirm how
governors will engage members in informing the
Trust’s plans
20.10.14
Full minutes shared with TP for
clarity
28.10.14
Complete
It was agreed that it would be helpful for I Millar
and C Cole to discuss the service development
improvement plan risks and performance
trajectory monitoring arrangements prior to the
October meeting.
28.10.14
Meeting took place on 15
October.
28.10.14
Complete
It was agreed that a copy of the engagement
workshop report would be circulated to all
members.
J Walbridge
I Millar and C Cole
12
BOARD OF DIRECTORS
28 OCTOBER 2014
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. Be responsive to our patients and partners’ needs: promoting
integration and partnership by demonstrating our capacity,
character and competence
3. Employ only the best staff: selecting staff who care and
supporting them to go the extra mile for our patients
Freedom of Information
Status
Report can be made public
Executive Summary: External events, approval of minute, membership and engagement update.
Report for: Decision
Discussion
Information
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1.0
Urgency Committee
1.1
During early October 2014, a virtual urgency committee met (reference Business Opportunities
Framework) to consider the Hertfordshire Sexual Health Tender which had been provisionally
submitted. Having considered the information, the urgency committee confirmed that the bid
submitted by the trust was compliant with Trust guidelines and should stand.
2.0
Membership update
2.1
Membership numbers
The monthly target of 70 new members was not met this month. The shortfall is expected to be made up
in October as there are three major recruitment days planned including HR recruitment at the London job
show (Westfield) and an Age UK Health and Wellbeing Fair in Kensington Town Hall.
August
No. of members as at 31 August
2014
New public members September
2014
Total as at 30 September 2014
Public
Clinical
staff
5,780
Non-clinical
staff
Total
2,173
739
8,692
2,047
723
8,558
41
5,788
34 members deleted
The membership target is less than the previous month’s figure. The net increase in public
members increased by just 8 in September but the reduction in staff members has contributed to
the decrease.
3.0
Membership engagement
3.1
I chaired a medicine for members talk on falls prevention was held on 29 September at the Abbey
Centre in Westminster. The talk was attended by FT members and the Monday club, a group who
meet regularly at the community centre. Natasha Booton, clinical lead for falls and bone health,
presented an overview of the falls service and offered people much re-assurance of the benefits
and support provided through the service.
3.2
Barnet members were invited to attend the carers afternoon tea held at Edgware Hospital on
2 October organised by the PPE team with a view to collecting patient stories.
3.3
Members from the inner boroughs have been informed about the Age UK Health and Wellbeing
fair on 17 October where CLCH will have a strong presence from a range of services including
membership, diabetes, stroke, oral health and continence.
3.4
Members have been invited to attend another talk on falls prevention, this time in association
with Chelsea and Westminster NHSFT on the topic of falls and fracture prevention on Thursday, 13
November. Natasha Booton, clinical lead for falls and bone health will present for CLCH and Emer
Bouanem, nurse specialist for orthopaedics for Chelsea and Westminster.
4.0
Listening events
As set out in the integrated engagement strategy a planned programme of engagement events
will be arranged to strengthen the ways in which our engagement with members, patients and the
public informs the quality strategy. The following provisional dates for 2015 have been booked. A
14
series of pilot events, one in each borough, will be arranged for end of January 2015.
Borough
Barnet
Hammersmith
& Fulham
Kensington &
Chelsea
Westminster
Venue
Education Centre,
conference room 1&2
tbc
St Charles, large room
Soho Centre, 1st Floor
conference room
May date
Thursday
21 May
Tuesday
19 May
Thursday
14 May
Tuesday
12 May
Time
17.00 20.30
13.00 16.30
17.00 20.30
13.00 16.30
Nov date
Thursday 19
November
Tuesday 10
November
Thursday 12
November
Tuesday 17
November
Time
13.00 - 16.30
17.00 - 20.30
13.00 - 16.30
17.00 - 20.30
15
BOARD OF DIRECTORS
28 OCTOBER 2014
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
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
Freedom of
Information Status
6. Be innovation and technology pioneers: leading
transformation of out of hospital services to empower
staff and improve patient health
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
1
16
1.
REGULATION
1.1
Care Quality Commission (CQC)
There have been no CQC inspections since the September Board meeting.
CQC have informed the Trust that its Trust Wide Inspection planned to take
place in the first quarter of 2015 is now scheduled for April 2015. This
represents a short delay on the timescale planned which we will discuss at our
monthly meeting with the Trust Development Agency but it is not anticipated to
impact materially on our Foundation Trust Application timetable.
1.2
CQC have published their Annual State of Care report for 2013-14.
Since 2013/14 the CQC introduced a new, tougher approach to inspecting
care services. These are now providing a deeper understanding of the quality
of health and social care, including widespread unacceptable variations in
quality. Using the new rating system, we rated 38 NHS acute trusts by the end
of August 2014.
• 9 trusts achieved an overall rating of good
• 24 trusts were rated requires improvement
• 5 trusts were rated inadequate.
1.3
The consultation setting out the CQC’s proposed guidance for providers to
help them meet the requirements of the regulations, and the proposed
guidance on how the CQC will use their enforcement powers concluded on 17
October 2014. This will lead to the replacement in its entirety, from April 2015,
of CQC’s current Guidance about compliance: Essential standards of quality
and safety and the 28 ‘outcomes’ that it contains. It will also replace CQC’s
current enforcement policy.
1.4
Health and Social Care Act 2008 (regulated activities) Regulations 2014
Implementation of the draft regulations, including the fit and proper persons
test (FFPT) and fundamental standards (duty of candour), have been
postponed from October to mid-November.
2.
CLCH DEVELOPMENTS
2.1
Central London Community Healthcare to deliver new and improved
respiratory service
Following the successful tender I am pleased to announce the launch of the
Trust’s new and improved community respiratory service for patients in West
Hertfordshire. Beginning this October, the new service will mean hundreds of
patients with respiratory conditions such as asthma; bronchiectasis and
obstructive sleep apnoea will be seen, assessed and treated in the
community. The new service expands on CLCH’s current community chronic
obstructive pulmonary disease service which already provides healthcare to
patients across West Hertfordshire.
2
17
2.2
Emergency Care Service Award
I extend congratulations to all in CLCH and our partners, Chelsea and
Westminster Hospital Foundation Trust with North West London Clinical
Commissioners for their success in the Health Service Journal (HSJ) ‘Values
in Healthcare’ awards, for jointly initiated Emergency Care Pathway
Programme to improve boundary less patient flow between their services. We
partnered with GE Healthcare Performance Solutions to achieve this. The HSJ
award judges said: “The winner offered an excellent and grounded piece of
work, demonstrating solid outcomes. The plan was well integrated and
recognised the need for close system working and effective partnership”.
2.3
CLCH fit for the future staff engagement events
Our “Fit for the Future” Executive Leadership Team (ELT) engagement
sessions commenced on Monday, 29 September led by Louise Ashley, Chief
Nurse and Director of Quality Governance. There are twenty four sessions
scheduled across all the Clinical Business Units (CBU) and 4 sessions in the
corporate services between now and the end of November and ELT are
committed to attend up to 6 sessions each. The purpose of these sessions is
to share our strategy for CLCH and hear thoughts on it, find out more about
CBU’s plans to develop services for patients and to create more opportunities
for staff to engage with ELT. Feedback so far has shown that staff have
welcomed the opportunity to share their views and appreciate the increased
visibility of ELT.
2.4
Senior Staff Changes: I am pleased to welcome new Clinical Business Unit
managers for the Network Community Nursing and Rehabilitation division
(NCNR), Kathryn Brook, Stephen Lord, Francis Mulhern and Dr Phil Lee the
new Acute Divisional Clinical Director. At the end of November, Jennifer Allen
our Divisional Director of Operations for the same division will be going on
maternity leave and we welcome Gerard Timson who will be joining us as an
interim from 1 December 2014 to cover this role. Gerard is doing a similar role
in Bridgewater Community Healthcare Trust in Merseyside and has many
years of experience in community and primary care services.
2.5
Congratulations to the CLCH Specialist Weight Management Service
(SWMC) who received the best practice award for the innovative work of the
team. The service was recognised at the inaugural annual congress of the
Association for the Study of Obesity (ASO) in Birmingham last month for their
significant contribution to the treatment of overweight and obese individuals or
to obesity prevention. Congratulations to the team members:- Dr Veronica
Greener, Obesity Consultant, Perryn Carroll, Dietitian, Charlotte Butlin,
Physiotherapist, Lucy Turnbull, Clinical Lead Dietitian, Troy Chase, Clinical
Psychologist.
2.6
Mobile Working: Kensington and Chelsea and Westminster Community
Rehabilitation Services, represented by Helen Curry, Nigel Miller and Melissa
Andison, presented two papers at the International Digital Health and Care
Congress organised by the King’s Fund in September. The team shared their
experiences of mobile working at the congress and presented at two of the
breakout sessions at the three day event which saw 500 delegates from all
over the globe. The presentations presented were ‘digitally enabling service
3
18
transformation’ and ‘Age is not a barrier to using healthcare technology’, these
presentations can be accessed via the links here and here.
2.7
Further progress in our roll out of digital patient data records was achieved
when SystmOne went live in six of our bedded rehabilitation units. This is a
further stage in progressively moving our patient records from RiO to
SystmOne to improve our capacity to work in an integrated fashion with
primary care and other key partners.
2.8
Congratulations to Isabel dos Santos who has achieved a first class honours
degree in counselling. Isabel works in the North East locality in Westminster
as a rehabilitation assistant and took up the opportunity to go into higher
education by making use of the CLCH flexiwork and bursary scheme.
Isabel faced many challenges in managing her work and study together with
the restructuring of the service, and none of this would have been a success
without the support and encouragement from her managers, Clare Nyanzi and
Neal Gething whom she is grateful for their full support.
2.9
CLCH FOUNDATION TRUST (FT) APPLICATION:
The external assessments for the Board Governance Assurance Framework
(BGAF), conducted by Grant Thornton, and the Quality Governance
Assurance Framework (QGAF), conducted by NICHE consultancy, have been
completed. We have received the final report on the BGAF and a separate
report updating the action plan in the light of it 14 recommendations are being
presented to the Board. We expect to receive the final QGAF report within the
next fortnight. The feedback that we have received indicates that our
application will proceed according to the timetable agreed with the Trust
Development Agency.
There will be a separate quarterly briefing document submitted by the FT
project team.
3
Regional Developments
3.1
The inner London Clinical Commission Groups together with the Tri-Borough
Council Commissioners have just issued a process to select from amongst
existing local health Trusts and GP’s a leading healthcare partner to lead with
social care in co-ordinating the delivery of a Community Independence Service
to reduce the level of non- elective admissions to hospitals. They intend to
invest £1.7m in further developing rapid response, community rehabilitation
and re-ablement services to achieve this aim. Our Trust will be submitting an
application for this role.
3.2
In October, Imperial College Health Partners, published their partner briefing
providing an update on interoperable clinical systems, patient safety, mental
health and chronic obstructive pulmonary disease projects. I participated in a
partnership board workshop reviewing the work and processes of the board
which will inform its future direction, programmes and structures.
4
19
This partnership hosts the Academic Health Sciences Network (AHSN).
Jeremy Hunt, Secretary of State for Health, launched a new national
programme to improve the safety of patients and ensure continual learning sits
at the heart of healthcare in England. The programme, coordinated by NHS
England and NHS Improving Quality (NHS IQ) will see a network of 15 patient
safety collaboratives established, each led by an Academic Health Science
Network (AHSN). These collaboratives will focus on improving safety and
empowering patients, carers and staff to highlight, challenge and implement
local improvements in patient care. NHS IQ and NHS England will work with
AHSNs to provide support and opportunities for the collaboratives to learn
from each other, ensuring the most effective and successful solutions are
shared and adopted across England. The programme is borne out of
Professor Don Berwick’s report last year into the safety of patients in England,
and builds on learning from the Francis and Winterbourne View
recommendations. Each collaborative will be funded for the next five years by
NHS England. For more information, visit the NHS IQ website.
3.3
Winter Pressures Plans: The flu campaign is underway and we would urge
you all to have the flu vaccination to reduce the incidence of flu. We are totally
committed to patient safety and it is very serious for young children and
vulnerable adults. Clinics are available throughout October and there will be a
flu fighter clinic for senior managers and clinicians at the next senior
managers’ workshop on 13 November.
3.4
I attended the formal launch of the London Healthcare Commission Report at
City Hall where Lord Ara Darzi presented the report to Mayor Boris Johnson.
The report contains a range of recommendations to secure better public health
for London’s population and system changes to advance these. Particular
value has been placed on the wider debate and engagement across
communities in London that this process has engendered. Included in the
recommendations are population based categories and outcomes as well as
the deployment or capitated budgets. The report references and commends
how these are being developed in the North West London whole systems
integrated care programme in which the Trust is fully engaged.
3.5
Transforming London Community Services: Caroline Alexander, Chief
Nurse for NHS England in London has led a group focused on city wide
transformation of community services to which our Trust has been
contributing. Attached as an appendix to my report is the declaration which
was distilled from an analysis of 10,000+ ideas, propositions, comments and
votes, from 1,000+ people within 100+ organisations, 45 papers and 32 Better
Care Fund Plans. It describes, in the words of staff, the consensus that is held
across London on how a community-led revolution in health and social care
can be delivered, which will ultimately transform the health and well-being of
our city.
4
National Developments and Reports
4.1
On 16 October the Secretary of State for Health made a speech at
Birmingham Children’s Hospital on the theme of good care costs less. This
referenced the CQC’s annual state of care report published on the same day.
5
20
He emphasised the themes of the ‘Sign up to Safety’ campaign to which our
Trust was one of the initial signatories. To illustrate this key theme a poster
has been produced drawn from independent research published by Frontier
Economics suggesting that the NHS spends up to £2.5bn a year – the annual
cost of 60,000 nurses – treating patients harmed by avoidable errors. The
independent study found that each year, almost 800,000 patients – one in 20
of all those admitted to hospital in England – suffer harm which could have
been avoided. The speech received wide media coverage in which Louise
Ashley our Chief Nurse and Director of Quality Governance was interviewed
by Sky News on our participation in the “Sign up to Safety” campaign.
4.2
Healthcare Foundation and the Foundation Trust Network: The Health
Foundation and the Foundation Trust Network (FTN) co-hosted a workshop on
5 August 2014 to tackle the question of whether the NHS can maintain quality
in the short to medium term without additional resources. The event brought
together around 25 senior representatives of provider organisations, covering
the acute, mental health, community and ambulance sectors. The workshop
was part of the Health Foundation's work examining the implications of the
NHS’s ‘financial gap’ for quality of care. The workshop is further discussed in
the report More than money: closing the NHS quality gap.
6
21
4.3
The King’s Fund: In October, The King’s Fund published a report ‘financial
failure in the NHS – what causes it and how best to manage it’.
Key findings include that:
• even the best managed organisations face a financial struggle in the
current climate
• the balancing act between finance and performance cannot be
maintained
• there are many factors that contribute to financial failure and some of
these are not under the control of one organisation
• there is a lack of leadership within local health economies following the
abolition of strategic health authorities
• national bodies need to agree a shared approach to dealing with funding
challenges.
This comes at a time when all the main parties in the party conference
seasons have made their pledges including increases to NHS funding, better
access to general practice and integrated care.
An analysis by Monitor published in October its quarterly performance report,
also indicates that Foundation Trusts are providing more treatment and that
this increased activity, when combined with the continuing need to make cost
savings and an over-reliance on expensive agency staff, is putting trusts under
unprecedented pressure. Both Monitor and the Trust Development Agency
have reported to their boards a forecast deficit in the region of £500m for the
outturn of this financial year.
Systems Leadership in Integrated Care published by the Kings Fund in
October 2014.
This report details lessons and learning from the Advancing Quality Alliance’s
(AQuA) integrated care discovery communities. It seeks to identify the skills,
knowledge and behaviours required of new system leaders and to learn from
systems attempting to combine strong organisational leadership with
collaborative system-level leadership approaches. The paper draws on three
years' development work with leaders in health care systems in north-west
England, undertaken by the Advancing Quality Alliance (AQuA) and The
King's Fund which has adopted a 'discovery' approach to developing
integrated care and the leadership capabilities supporting it.
4.4
Industrial Action: On October 13 a number of unions took strike action for
four hours and a work to rule in the following days of that week (for Unite
members this continues for the rest of the month). This was to support a claim
for all staff to receive the 1% pay award. It is reported that nationally 8000
took this action of the 200,000 staff who are members of these unions and the
impact was greatest within the ambulance services. In CLCH the returns
received indicated that 10 staff supported this action.
5
Summary of key decisions from recent Private Board meetings
7
22
5.1
At the confidential Board meeting on 30 September 2014 we considered a
report on contracts and new business, later discussing at our seminar event
the proposed commercial strategy for the Trust.
An update on the Trust’s long term financial position was also discussed.
6
Report on the use of the Trust Seal: The Trust seal has been applied in the
following circumstances:
Date of Reason for use
Use
6 October Contract between CLCH and
2014
Virgin Medical Business Limited
for the provision of services for
the wireless project.
Seal 53
Signatory
Witness
Ian Millar,
Director of
Finance,
Information
and
Corporate
Resources
Jayne
Walbridge,
Trust
Secretary
James A Reilly
Chief Executive
October 2014
8
23
# TR A NSF O
t ra ns fo r ming Londo n’s co mm unity se rvi ces
RMLDN
*1,000+ health and social care staff from 100+ organisations,
representing all 32 London boroughs have co-created this declaration.
WE DECLARE THAT A COMMUNITY-LED REVOLUTION IN
HEALTH AND SOCIAL CARE
WILL TRANSFORM THE HEALTH AND WELL-BEING OF LONDON
THE FOUNDATION OF OUR REVOLUTION HAS FOUR PARTS…
GET PERSONAL
London’s community health and social care services
touch our lives at times of basic human need, when care
and compassion are what matter most. They support us
to keep mentally and physically well, to get better when
we are ill and when we cannot fully recover, to stay as
well and independent as we can till the end of our lives.
They are here to improve the health and well-being in our city.
London’s growing population with more complex needs is
creating unsustainable pressure for our partners in
hospital, social and primary care. Something needs to
change and the solution lies close to home.
AROUND THEIR PERSONAL NEEDS
INSPIRING LEADERS
TO COORDINATE CARE
focus on improving
AND A SKILLED,
FULFILLED AND
THE HEALTH AND
WELL-BEING
OUTCOMES FOR LONDONERS
Those at RISK ARE IDENTIFIED to enable
early intervention and PROMOTE
WELL-BEING, rather than reacting to
crises.
OF
CARE
EVERYTHING DESIGNED & DELIVERED
We must have
WE MUST ALWAYS
ALL HEALTH AND SOCIAL CARE
organisations SHARE RESPONSIBILITY
and incentives for improving health and
well-being outcomes.
THE HEART
REAL LEADERS,
HAPPY WORKERS
FOCUS ON
OUTCOMES
We understand the desired HEALTH AND
WELL-BEING OUTCOMES of individuals,
groups and the population we serve.
We must place LONDONERS at
MOTIVATED
PERSONALISED CARE PLANS use simple language to help people decide
their own goals and manage their own health.
CARE is provided in PLACES THAT ARE CONVENIENT for those that need it.
One point of contact makes ACCESS SIMPLE.
Londoners have a POSITIVE EXPERIENCE of services in the community.
ALL SERVICES are designed around the NEEDS OF LONDONERS and the
resources available.
PERSONALISED CARE PLANS are developed in partnership between those
who use and provide services and they support partnerships between
the community, primary and secondary care and the voluntary sector.
People who commission, provide and use services DEVELOP AND ASSESS
SERVICES TOGETHER.
MAKE
BOUNDARIES
INVISIBLE
WE MUST ENSURE THE
BOUNDARIES
OF ORGANISATIONS & SERVICES ARE
INVISIBLE TO OUR SERVICE USERS
WORKFORCE
RESOURCES, INVESTMENT AND
RISK ARE SHARED between all
organisations involved in
delivering care.
The amount of time people
spend in acute and residential
care is reduced as health and
well-being are improved and
more people are supported to
MANAGE THEIR OWN CARE NEEDS
AND HEALTH CONDITIONS IN THE
COMMUNITY.
OUR LEADERS INSPIRE AND COACH their people, this nurtures the right
skills and talent for London's complex needs.
ORGANISATIONAL BOUNDARIES ARE
IRRELEVANT to Londoners.
STAFF HAVE CLEAR CAREER DEVELOPMENT PLANS that value and nurture
their talent, this makes the community an attractive place to work.
We have SEAMLESS TRANSITIONS
between services and organisations
because communication and
trust are actively developed
between everyone involved in
providing care.
LEADERS of different organisations WORK TOGETHER WITH PATIENT LEADERS
to bridge boundaries and share knowledge.
LOCAL TEAMS ARE EMPOWERED with autonomy to flexibly meet local needs.
Teams of health and social care
staff, with different and
complementary skills, WORK
TOGETHER.
We help people access SERVICES
FROM THEIR OWN HOME and
community - THIS IS OUR
COMMUNITY FIRST APPROACH.
SERVICE USERS can access their OWN CARE RECORDS, as can the teams involved
in their care and these records are shared across all professionals providing
care.
FIND OUT HOW YOU CAN USE OUR DECLARATION AND JOIN THE COMMUNITY REVOLUTION TODAY,
VISIT WWW.
. TRANSFORMLDN.ORG
24
How was our
declaration built?
This project was designed
to capture a crucial
perspective in the debate
surrounding the
transformation of London’s
community services: the
voice of the frontline practitioners, volunteers,
carers and leaders from
organisations that deliver or
commission health and
social care.
Who was involved in this project?
The Design Group: leaders from the following organisation steered this project and its outputs
To achieve this, we
deployed a research
process blended with
physical and on-line
crowdsourcing events. This
created and empowered a
network of people to share
their views on what
excellent community
services look like.
Our design group analysed
10,000+ ideas, comments
and votes, from 1,000+
people, representing 100+
organisations as well as 45
papers and 32 Better Care
Fund Plans. The distillation
of this work led to the
creation of a new
declaration for community
services.
How can you use
our declaration?
Our declaration is designed
as a tool to support and
inspire service
improvements in the
delivery and commissioning
of health and social care
services in the community.
Some parts of London have
already implemented these
foundations, some still have
work to do and others are
yet to set clear plans.
Whatever stage your
organisation is at, our
declaration can support and
inspire your work. We want
staff to spread the word.
Visit our community
website to share and learn
from best practice and to
access and enhance latest
thinking.
The Crowd: 1,000+ people from the following 100+ organisations had their voices heard
Adult Social Care Newham
Allied Healthcare
Barking, Havering and Redbridge University
Hospitals NHS Trust
Barnet CCG
Barnet, Enfield and Haringey Mental Health
NHS Trust
Barts Health NHS Trust
Bexley CCG
Brent CCG
Buckinghamshire County Council
Bucks New University
Camden Adult Social Care
Camden and Islington NHS Foundation Trust
Camden CCG
Care & Repair England
Central London CCG
Central London, West London, Hammersmith
and Fulham, Hounslow and Ealing CCG
partnership
Chelsea and Westminster Hospital NHS
Foundation Trust
Circle Podiatry
Compass Wellbeing CIC
Connect Physiotherapy
Cricket Green Medical Practice
Croydon Care Solutions Ltd
Croydon Health Services NHS Trust
Department of Health
Dulwich Podiatry Limited
Ealing Hospital NHS Trust
East One Health
Enfield CCG
Epsom and St Helier University Hospitals NHS
Trust
First Community Health & Care
Great Ormond Street Hospital for children
NHS Foundation Trust
Groundswell
Guy’s & St Thomas’ NHS Foundation Trust
Hammersmith and Fulham CCG
Haringey CCG
Haringey Learning Disability Partnership
Havering CCG
Hertfordshire community NHS trust
Hillingdon Hospitals NHS Foundation trust
Homerton University Hospital NHS Foundation
Trust
Housing Learning and Improvement Network
Imperial College Healthcare NHS Trust
Institute of Sport, Exercise & Health
Islington CCG
Kensington and Chelsea Age UK
King’s College Hospital NHS Foundation Trust
Kingston CCG
Kingston Council
Kingston Hospital NHS Foundation Trust
Lambeth Council
Lewisham and Greenwich NHS Trust
London Ambulance Service NHS Trust
London Borough of Barnet
London Borough of Bromley
London borough of Hillingdon
London Borough of Lewisham
London Borough of Newham
London Borough of Sutton
London Clinical Senate
London Councils
London Leadership Academy (NHS)
London South Bank University
Londonwide LMCs
Merton CCG
Ministry of Defence Rehabilitation Services
Monitor
Moorfields Eye Hospital NHS Foundation Trust
Namaste Care CIC
NHS England
NHS Partners Network
North East London Commissioning Support Unit
North East London NHS foundation Trust
North West London Collaboration of CCGs
Pembridge Podiatry Practice
Populus Health
Public Health England
Redbridge CCG
Regents Park Foot Clinic
Richmond CCG
Royal Brompton and Harefield NHS Foundation
Trust
Royal College of Nursing
Royal Free London NHS Foundation Trust
Royal National Orthopaedic Hospital NHS Trust
Society of Chiropodists & Podiatrists
South Essex Partnership NHS Foundation NHS
Trust South London and Maudsley NHS Trust
South London CSU
South West London and St George’s Mental
Health NHS Trust
Southern Health NHS Foundation Trust
Southwark council
St Andrew’s Medical Practice
St George’s Healthcare NHS Trust
St Joseph’s Hospice
Surrey county council
Sussex community NHS Trust
Sutton Age UK
Sutton CCG
The Hillingdon Hospitals NHS Foundation Trust
The King’s Fund
The North West London Hospitals NHS Trust
The Tavistock and Portman NHS Foundation
Trust
UCL Partners Academic Health Science
Partnership
University College London
University College London Hospitals NHS
Foundation Trust
University of East London
Virgin Care
Waltham Forest CCG
Wandsworth Council
Watling Medical Centre
West London CCG
West London Mental Health NHS Trust
West Middlesex University Hospital NHS Trust
Whitfield Podiatry
Whittington NHS Trust
Wragge & Co.
Learn more and help turn our declaration into
a movement, visit www.transformldn.org
25
Appendix – Transforming London Community Services Declaration
www.transformldn.org has been completely repurposed in direct response to the crowd's
requests. Instead of producing a long report, our site now shares the details behind the
declaration and, importantly, shares case studies, literature and best practice to support
learning across the city. It is now live already, for you to draw from and to contribute to. A
great resource to share successes and challenges and to learn from others.
We now need your help...
1.
Transform London has started a movement, a movement that could help create the
revolution that so many of us seek. Here's how you can support:
2.
Please read Our Declaration, print out the attached poster and share it with your
networks and colleagues. You can find out more about our declaration and how to
use it on our project website: www.transformldn.org
3.
Please let us know what you think broadly about this project by visiting
www.transformldn.org and offering you feedback
https://email.clevertogether.com/l/Jcq5ZeHsdlVNvMb6Er763mfg/Q2tsa1mHmjaG64
MPqJc5Bw/ZIfwX
Please share your experiences of transforming community health and social care services
so we can continue to learn from each other; specifically, how you have or have struggled to
achieve the four foundations of community transformation:
Get
Personal https://email.clevertogether.com/l/Jcq5ZeHsdlVNvMb6Er763mfg/opOYF5w0M44jk
aY7eUbOGQ/ZIfwX6jadxtnq32mLHm98A
Make Boundaries Invisible
https://email.clevertogether.com/l/Jcq5ZeHsdlVNvMb6Er763mfg/ZIfwX6jadxtnq32mLHm98A
/ZIfwX6jadxtnq32mLHm98A>
Real Leaders, Happy Workers
https://email.clevertogether.com/l/Jcq5ZeHsdlVNvMb6Er763mfg/t8k3w88KuAk9ei7LDngJPA
/ZIfwX6jadxtnq32mLHm98A>
Focus on Outcomes
https://email.clevertogether.com/l/Jcq5ZeHsdlVNvMb6Er763mfg/oeaVpQSvIVYVXKQQRbQ
bQA/ZIfwX6jadxtnq32mLHm98A>
To share your views on our declaration at [email protected] or post
on www.TransfomLDN.org
26
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title:
Quality Report Q2 2014/15
Agenda item number:
1.9
Report of:
Contact Officer:
Director of Patient Safety
Relevant CLCH 14/15 Goal:
• Embody the best of the NHS for our patients
• Support people safely out of hospital
• Deliver better value than competitors in our selected market
• Be responsive to our patients and partners’ needs
Status
Summary:
• The RAG rating on the balanced score card this month shows:
o 11 green KPIs
o 6 amber KPIs
o 10 red KPIs
Key areas for focus:
o Pressure Ulcers
o PALS response times
o Clinical Outcomes
Assurance provided: Continue monthly reporting to the Quality Committee
Report provenance: First presented at the Quality Committee on 20.10.14
Discussion
Information
27
1.
Purpose
To provide a summary key quality indicators for the Q2 2014/15
2.
Introduction
Please see main body of report
5. Proposal
Not applicable for information only
6.
Quality Implications and Clinical Input
The report is focussed on quality. The quality committee has significant clinical
representation.
7.
Equality Implications
None
8.
Comments of the Director of Finance, Performance & Corporate Resources
Not applicable
9.
Risks and Mitigating Actions
Quality indicators at risk of not being achieved are highlighted throughout the report
10. Consultation with Partner Organisations
Quality reports are broken down to CCG level and presented at relevant Clinical Quality
Review Meetings between CLCH & CCGs.
28
11. Monitoring Performance
Quality dashboard is submitted to the Quality Committee monthly
12. Recommendations
None, for information only.
29
1
Trust Quality Report Quarter 2 2014/15
Report Contents
Item
number
1.0
2.0
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
3.0
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
4.0
4.1
4.2
5.0
5.1
5.2
Item
Balanced Score Card
Positive Patient Experience
Patient Reported Experience Measures (PREMS)
Number of PREMS received
Respect & Dignity
Friends & family test
Overall experience
Involvement in care
Explaining care
Complaints, Claims, PALS and Compliments
Details of complaints received in Quarter 2 2014
PALS Performance
Preventing Harm
Incidents
Category of harm
Incidents reported by Clinical Commissioning Group (CCG)
Serious incidents
Timeliness of reporting serious incidents to North West London Commissioning
Support Unit (NWLCSU)
Harm free care
Patients free from venous thromboembolism (VTE)
Patients free from catheter associated urinary tract infections (CAUTI)
Patients free from pressure ulcers
Patients who did not fall
Smart Effective Care
Satisfaction with wait for treatment
Goal attainment score
Inspections
Compliance programme
Page
number
2
3
3
3
3
4
5
5
6
6
7
11
15
15
15
16
16
17
18
19
19
19
20
21
21
22
22
22
22
30
2
1.0
Balanced Scorecard
A Positive Patient Experience
Patients' Experience
Proportion of patients who were treated with Respect and
Dignity
Patients who would recommend the service (National)
Patients who would recommend the service (incl. "likely"
Promoters)
Proportion of patients whose care was explained in an
understandable way
Proportion of patients who were involved in planning their
care
Proportion of patients rating their overall experience as
excellent or good
Number of PREMS responses is above threshold
Number
of
Records
14-09
End of Yr.
Target
Trajectory
Target
1095
95%
1103
This Month
Sept 14
Ytd / Avg
Mth
95%
93%
94%
58
54.5
47
52
1103
85
84
77
83
1063
90%
90%
91%
91%
1026
80%
80%
76%
78%
1090
80%
80%
88%
91%
1424
1090
1090
Patients' Complaints, Concerns and Compliments
The number of compliments received this month
Proportion of patients' concerns (PALS) resolved within 1
week
36
n/a
n/a
36
33
56
80%
80%
71.4%
76%
The number of complaints received this month
9
n/a
n/a
9
7
Proportion of complaints responded to within 25 days
13
80%
80%
61.5%
64%
Proportion of complaints responded to within agreed deadline
8
100%
100%
100%
100%
Incidents & Risk
Proportion of Patient related Incidents that were Harm Free
10% reduction in incidents affecting Patients that caused harm
366
366
49%
204
43%
204
36.1%
234
46%
215
10% reduction in Pressure Ulcer Incidents
53
416
35
52
46
10% reduction in Medication Incidents that caused harm
43
13
13
12
18
10% reduction in Falls that caused Harm
35
13
15
9
15
68
20
20
40
19
20
100%
100%
95%
98%
Prevalence NHS Safety Thermometer)
Proportion of Patients with Harm free care
1293
98%
98%
91.3%
92.1%
Proportion of Patients who did not have a Pressure Ulcer
1293
98%
98%
93.5%
94.2%
Proportion of Patients who did not have a Catheter Associated
UTI
1293
98%
98%
99.7%
99.2%
Proportion of Patients who did not have a Fall
1293
98%
98%
98.2%
98.6%
Proportion of Patients who did not have a Venous
Thromboembolism
1293
98%
98%
99.7%
99.7%
Proportion of Patients who did not have any NEW Harms
129
98%
98%
97.1%
97.1%
Preventing Harm
Reported incidents affecting patients per 1000 OBDs (bedded
units)
Proportion of external S.I.s with reports completed within
deadline
Smart, Effective Care
0%
Standardised Mortality Ratio in Bedded Units
Proportion of Services capturing Patients' Clinical Outcomes
Proportion of patients who were satisfied with the wait for
treatment
Proportion of Patients reporting a Positive Goal Attainment
Score
74
66%
66%
22%
20%
1044
80%
80%
77.50%
76%
283
90%
90%
90%
88%
31
3
2.0
Positive Patient Experience
2.1
Patient Reported Experience Measures (PREMS)
PREMS are predominately collected through telephone interviews with patients and service
users. The Trust is committed to receiving feedback from as many patients as possible and
from a group that represents our patients’ diversity. To this end CLCH also uses electronic
tablet surveys, face to face interview and paper questionnaires through the post. CLCH has a
long established program that works with our patients who have learning disabilities to
make sure their voice is heard.
2.2
Number of PREMS received
Each division is establishing targets for the number of PREMS they aim to receive every
month. The number of PREMS received was artificially elevated in the autumn of 2013 when
the new company contracted to conduct the surveys over performed. The company collating
the surveys did not count all positive responses over the last few months; this has now been
corrected, as reflected in current and historical data presented in this report.
Graph 1: Number of PREMS responses received
2.3
Respect & Dignity
Patients are asked if they were treated with respect and dignity. The data presented in the
graph represents the proportion of patients who responded “yes definitely” to this question.
The target of 80% for 2013/14 was comfortably achieved, the new target for 2014/15 of 95%
is more challenging, but the Compassion in Care Coordinator is continuing to work across all
services to improve performance in this area.
32
4
Graph 2: Proportion of patients who reported that they were treated with respect and
dignity
2.4
Friends & Family Test
In the friends and family test patients are asked how likely they would be to recommend our
services to their friends and family. The local CLCH metric includes those patients who
respond that they are “likely” to recommend the service; the national metric excludes these
patients. This explains the difference between the two sets of data in Graphs 3 & 4. A
national standard has not been set for this test in community trusts, but the CLCH Board has
set a target of 58% for 2014/15 (graph 4). CLCH significantly and consistently exceeded the
locally set target of 58% for the local metric (graph 3) in 2013/14 and due to this high
performance a stretch target of 85% has been set for the current year. The Compassion in
Care project continues to work with staff to improve scores in this area.
Graph 3: Number of patients who would recommend the service to their families and friends
(including likely promoters, local metric)
33
5
Graph 4: Number of patients who would recommend the service to their families and
friends (excluding likely promoters, national metric)
2.5
Overall Experience
Patients are asked to rate their overall experience of care. The data presented below
represents those patients who said that their care was good or excellent. CLCH has set a
threshold for this measure of 80% and continues to consistently exceed this.
Graph 5: Proportion of patients who rated their overall experience as good or excellent
2.6
Involvement in care
Patients are asked how involved they are in planning their own care. The data below
represents those patients who said that they were as involved as they wanted to be. The
target set for this PREM is 80%. Involvement in care has been set as a priority in the 2014/15
CLCH Quality Account and it is hoped that this level of commitment will address this month’s
performance, together with the compassion in care project.
34
6
Graph 6: Proportion of patients who were as involved in planning their care as they would
like to be.
2.7
Explaining Care
Patients are asked if their care was explained to them in a way they could understand, the
data below represents those patients who said that their care was explained in an
understandable way. For 2013/14 the CLCH Board set a target that 80% of patients would
report that their care was explained in an understandable way. The Trust exceeded this
expectation throughout 2013/14. This excellent performance led to a more challenging
target of 90% for 2014/15, which is being achieved.
Graph 7: Proportion of patients who said their care was explained to them in an
understandable way.
2.8
Complaints, Claims, PALS and Compliments
CLCH categorises complaints as either simple or complex. This decision is made on an
individual basis depending on the nature of the complaint and the difficulty involved in
effectively investigating it, to provide the complainant with a response which thoroughly
addresses their concerns. The national target required NHS Trusts to respond to all
complaints within a time limit agreed with the person making the complaint. The Trust had
good performance against this target in 2013/14 and so to drive quality and performance a
more challenging target has been set of responding to 80% of simple complaints in 25
working day and 100% of complex complaints within the agreed timescale. This level of
35
7
performance has not yet been sustained but there has been overall improvement since
March 2014 and recent recruitment within the team is expected to further improve
performance.
Graph 8: The number of complaints received.
Graph 9: Percentage of complaints resolved within 25 days.
2.9
Details of complaints received in Quarter 2 2014/15
This table shows the number of complaints received by Borough (July to September 2014)
CCG
July
August
September
Total
Barnet CCG
2
5
4
11
0
1
1
2
West London CCG
2
3
1
6
Central London CCG
1
2
4
7
Totals:
5
11
10
26
36
8
In a change from the last Quarter report, but in line with the previous 2 quarter reports,
Barnet has received the most complaints in the second Quarter of this year, with London
receiving the next highest amount of complaints.
This table records the total number of new Complaints received by Division
July
Division
August
Total
Received
September
Allied Primary Care Services
0
2
0
2
Children's Health and Wellbeing
1
1
2
4
Corporate Services
0
0
0
0
Networked Nursing and Community Rehab
0
2
4
6
Specialist Community Nursing & Therapies
4
6
4
14
Totals:
5
11
10
26
Specialist and Community Nursing and Therapies received the most complaints. Most of
these were concerning all aspects of clinical care and treatment however s no particular
trend was identified in respect of specific location or staff group from these complaints,
since they relate to a variety of services across the boroughs.
This table shows complaints received for July - September 2013 and 2014 and a decrease for
two of the three months compared with last year.
Month
2013
July
August
September
2014
7
5
16
11
8
10
This table shows the comparison of complaints received by subject for April - June 2013 and
2014, as noted ‘All aspects of Clinical Treatment’ is still the main theme of complaints.
Complaints received by Subject
2013
2014
Aids and Appliances, Equipment, Premises (Including Access)
0
1
Appointments, Delay / Cancellation (Out-patient)
5
6
Attitude of Staff
5
7
All aspects of Clinical Treatment
17
9
Communication
1
2
Personal records
2
0
Records management
1
0
Appointments, Delay/Cancellation (inpatient)
0
1
37
9
Graph 10 shows complaints received July to September 2014 by CCG and Clinical Business
Unit.
10
9
8
7
6
West London
5
Hammersmith & Fulham
4
Barnet
3
Central London
2
1
0
APCS
CHD
SCN
NCNR
Complaint Closure Data
Of the 31 complaints closed in Quarter 2, 17 were closed following issue of first responses, 6
were closed following onward referral or withdrawal from the complaints process, and 8
were re-opened cases that were closed after further work to achieve local resolution.
Graph 11 documents the number of complaint closed by subject and CCG during Quarter 1
38
10
Graph 12 documents total complaint closures in Quarter 1 by month and CCG
14
12
10
8
6
Jul
4
Aug
2
Sep
0
Barnet CCG Hammersmith West London
Central
and Fulham
CCG
London
CCG
Health CCG
Totals:
Graph 13
This demonstrates the timescale achieved by Division of complaints closed in Quarter 1. Also
shown are cases that were not subject to these timescales [N/A], which includes those
referred on or withdrawn and re-opened cases.
20
18
16
14
12
10
8
6
4
2
0
NCNR
CHD
APCS
SCN
<25 working >25 working
days
days
Re-opened
N/A
Re-opened Complaints / Referrals to Second Stage (Ombudsman)
7 Complaints were re-opened following issue of a CEO response for further work/local
resolution meetings during the period July to September 2014. This is the same amount as
complaints that were re-opened in the previous quarter. The complaints to which these
cases related were originally opened and handled between January 2014 and July 2014.
Of these cases, 1 had originally been “upheld”, 1 had been partially upheld and 5 were not
upheld. The case that was “partially upheld” has been going on for some time and the
service has received multiple letters from the complainant. A further investigation was
conducted to clarify issues, and some parts of the response were reiterated. The response
was issued no further contact has been made by the complainant so far.
39
11
The 1 case that was “fully upheld” had originally been upheld but the complainant asked for
further information, which was given along with unreserved apologies.
Of the 5 cases that had been “not upheld” when first responded to, all received further
written responses and the service has not received any further or outstanding issues from
the complainant.
There are no cases at present that the Ombudsman has confirmed they will be investigating.
However, one complainant who received a further response in Quarter 1 has approached
the Ombudsman dissatisfied with the outcome of his complaint, and a decision is awaited
following provision of the case file to the Ombudsman’s office.
Claims
5 claims have been logged with the NHSLA during Quarter 2. 2 of these claims are regarding
the CHD division, 1 concerns the NCNR division, 1 concerns APCS and 1 is for CORP division.
All of these are at very early stages and we are currently providing further documentation to
the NHSLA.
2.10
PALS Performance
PALS logged 290 contacts in Quarter 2, mostly received via telephone and email. This
includes 134 Issues for Resolution and 117 Compliments.
Of 109 PALS contacts that were deemed “Issues for Resolution”, the following is a list of
areas where more than one contact with PALS was logged.
Sexual Health Services
Child Health Information Hub
4
Intermediate Care
2
4
3
Health Visiting
Dental Services
2
Nutrition and Dietetics
Continence Care
2
Phlebotomy
12
District Nursing
15
MSK Physiotherapy
18
5
Podiatry
32
2
Rehabilitation - Community
4
4
Rehabilitation - Inpatient
2
2
Urgent Care / Walk In Centre
6
Wheelchair Services
5
General Practice
Intermediate Care
Health Visiting
Phlebotomy
12
2
The following documents the top 10 main themes associated with the “Issues for
Resolution” logged and handled by PALS in Quarter 2.
Appointment Issues
29
Appointments, Delay/Cancellation (Out-patient)
22
Communication/information
20
Attitude of Staff
14
Clinical Care
12
Access to Services
9
Aids and Appliances, Equipment, Premises (Including Access)
7
Admissions, Discharge and Transfer
5
Staff relations
3
Waiting times / delays
3
40
12
In keeping with the trends reported in previous Quarterly reports, Appointment issues
continue to be the top concern received by PALS, but rather than staff attitude being the
next main concern, as in the previous 2 quarters, it is communication/information.
Whilst not all PALS “Issues for Resolution” specify a service, the following indicates the total
number of enquiries received by Division, and where known, by Service.
APCS
4
Dental Services
2
General Practice
5
Offender Healthcare
1
6
CHD
Child Health Information Hub
3
Children and Young People Occupational Therapy
1
Health Visiting
4
Speech and Language Therapy
1
NCNR
Continuing Care Assessment
1
Community Neuro-Rehabilitation
1
District Nursing
10
1
Rapid Response Nursing Team
1
Wheelchair Services
5
SCN
Continuing Care
1
Continence Care
2
District Nursing
5
Ear, Nose and Throat
1
Intermediate Care
2
2
Orthopaedic
1
Phlebotomy
12
MSK Physiotherapy
18
Podiatry
32
3
2
Respiratory / COPD
1
Rheumatology
1
Single Point of Access (SPA)
1
41
13
A comparison of PALS concerns raised in the last 2 Quarters of 2013-14 and Quarter 1 201415 by CCG.
CCG
Q4 (2013-14)
Q1 (2014-145)
Q2 (2014-15)
Barnet CCG
59
57
67
Central London Health CCG
28
18
19
West London CCG
26
19
22
16
13
23
1
4
3
Corporate Services
1
Grand Total
130
111
117
Graph 14: The number of PALS issues received.
Graph 15: The percentage of PALS issues resolved within five working days.
Compliments
117 Compliments were received between July and September 2014.
The following indicates how these were distributed between Divisions:
42
14
Children's Health and Wellbeing
Corporate Services
22
4
4
Networked Nursing and Community Rehab
21
Barnet Community and Specialist Services
66
Totals:
117
Of the services receiving more than one compliment in the period July to September 2014,
the following are noted:
3
Primary Care Mental Health
6
6
Health Visiting
3
Patient Safety Team
3
Community Neuro-Rehabilitation
9
District Nursing
2
3
Wheelchair Services
3
Continuing Care
11
Continence Care
3
District Nursing
3
Palliative Care (Inpatient)
3
Parkinson’s Service
4
Phlebotomy
2
MSK Physiotherapy
4
Podiatry
Respiratory / COPD
3
11
6
Of the compliments received, the most were about Clinical care (61) which saw a big
increase from the 14 received last quarter. Compliments around staff attitude received the
second highest amount (44).
Graph 16: The number of compliments received
43
15
3.0
Preventing Harm
3.1
Incidents
CLCH is actively encouraging the reporting of all incidents; both through datix training and
regular contact between the Patient Safety team and divisional staff. The total incidents
reported, excluding rejected incidents, for Q2 July – Sept 2014 was 1,614.
The graph below depicts rate of reporting by quarter since April 2013. The decrease in
reporting seen in Q1 Apr – June 2014 has continued in Q2 July – Sept 2014. The Patient
Safety Managers will explore possible reasons for the decrease in reporting with their
divisions. The top 5 types of reported incident for Q2 July – Sept 2014 are: Medication (195);
Pressure ulcers developed within CLCH(151); Slips, trips & falls (142); staffing issues (81); and
problems with appointments (81).
Graph 17: Number of incidents reported 2013-14
3.2
Category of harm
Severity of each incident is assessed at the time of reporting. The range of severity is “no
harm/minor harm/moderate harm/major harm/catastrophic”. The table below depicts the
total incidents by severity for Q2 July – September 2014. The major severity incidents were
mostly pressure ulcers (52) and one adult safeguarding incident. (Note: This graph includes
all reported incidents).
Graph 18: Number of incidents by severity
44
16
3.3
Incidents reported by Clinical Commissioning Group (CCG)
The graph below depicts incidents reported by CCG. Barnet CCG has the highest at 585
incidents, with Central London CCG second with 498 incidents; then West London with 296
incidents and Hammersmith & Fulham with 207 incidents.
Graph 19: Incidents by CCG.
3.4
Serious Incidents
Forty Five Serious Incidents were reported to North West London Commissioning Support
Unit (NWL CSU) in Q 2 July - September 2014. All SI’s are managed via the SI process and the
Board is informed of all SI’s via the monthly SI report. The graph below depicts the total
reported serious incidents by category for Q 2 July - September 2014. Pressure ulcers grade
3 remain the highest category (23), with Pressure ulcers grade 4 next highest (18). The
remaining categories had one of each type reported.
Graph 16: Categories of serious incidents
25
20
15
10
5
0
Pressure Ulcer Pressure Ulcer Adverse Media Slip/Trip/Fall Safeguarding
Grade 3
Grade 4
of Vulnerable
Adult
Confidential
Information
Leak
45
17
Graph 20: Serious incidents by month and STEIS classification
Graph 21: External serious incidents by division and month
3.5
Timeliness of reporting serious incidents to North West London Commissioning Support
Unit (NWLCSU)
Graph 22: STEIS reporting to NWLCSU against due date
46
18
Harm Free Care
This metric determines the percentage of patients participating in the NHS safety
thermometer survey day who did not have any of the harms being monitored. It includes
harms which occurred within CLCH care (new harm) and those that occurred elsewhere. It
should be noted that the vast majority of patients suffer no harm at all.
It is important to differentiate between all harms and new harms. New harms are those
which occurred when the patient was under CLCH care and exclude harms that the patient
had already sustained when they arrived in our care, for example a patient discharged from
an acute hospital to the district nursing service with a pressure ulcer. CLCH consistently
meets the national target (96%), but has not yet achieved the local stretch target for the
New Year (98%) in main due to the number of pressure ulcers. However, 97.5% of our
patients do not sustain any harm under our care.
Graph 23: Proportion of care that was harm free (new and old - all harms)
The proportion of patients who's
care was harm free
Percentage
3.6
100%
98%
96%
94%
92%
90%
88%
86%
Jan
Feb
Mar
Apr May
2014-15
percentage
Jun
Jul
Aug
Sep
threshold
Graph 24: Outliers
47
19
3.7
Patients free from venous thromboembolism (VTE)
This metric counts the number of patients on the day of the survey who have a VTE such as a
deep vein thrombosis (DVT). The Trust has an excellent record in this area, almost always
having 100% of patients VTE free. The Trust continues to easily exceed its new stretch
target.
3.8
Patients free from catheter associated urinary tract infections (CAUTIs)
This category of harm counts the number of patients on the day of the survey who have a
urinary tract infection associated with their catheter. This is another category where CLCH
has excellent performance. For the whole of the last year more than 99% of patients were
free from a CAUTI. The new stretch target, which exceeds national expectations, has also
been met.
3.9
Patients free from pressure ulcers
Our prevalence of pressure ulcers as measured by the NHS Safety Thermometer is 93.5% (all
ulcers) and 99.3 % new ulcers in September.
Graph 25: Outliers – Pressure Ulcers
In relation to incidence of ulcers during September the grade 3 and 4 ulcers were in the
following areas:
Grade Three
Grade Four
Total
Athlone House Nursing Home
0
1
1
Jade Ward
1
1
2
Marjory Warren Ward
0
1
1
Princess Louise Nursing Home
0
1
1
Totals:
1
4
5
48
20
The Trust work on pressure ulcers was presented to the Quality Committee in September
2014.
Graph 26: Incidence of pressure ulcers
3.10
Patients who did not fall
During the safety thermometer survey day the number of patients who fell whilst in CLCH
care is counted. For the last year as a whole more than 98% of our patients did not fall. Both
the national and local targets were exceeded. We have also improved this month for the
number of patients who fell with harm (incidence).
Graph 27: The proportion of patients who did not fall.
49
21
Graph 28: NHS safety thermometer outlier chart for the prevalence patients who
sustained harm from a fall July - September 2014
4.0
4.1
Satisfaction with wait for treatment
Graph 29: The percentage of patients who were satisfied with their wait for treatment
50
22
4.2
Goal attainment statement
Graph 30: Percentage of patients who reported a positive goal attainment score
5.0
5.1
Inspections
CLCH have had one unannounced inspection in Q2 at Garside Nursing Home.
On 7th August 2014, the CQC arrived at Garside Nursing Home unannounced. The inspection
was not a routine inspection but in response to allegations raised of staffing issues on the
unit, record keeping, management issues and claims of bullying.
The Inspector spoke to a number of residents and staff on the unit and informally advised
that they did not find any areas of non-compliance. However, they did request a number of
documents to be sent on as evidence for review before a formal outcome of the visit could
be given. The final report has been published and CLCH were found to be meeting the
following standards:
Outcome 4 - Care and welfare of people who use services
Outcome 16 - Assessing and monitoring the quality of service provision
5.2
Compliance Programme
CLCH have refreshed the compliance programme in line with the new way CQC are
inspecting community health services. The self-assessment templates are currently being
reviewed. More detailed work is planned with the services on completing these templates
and the outcomes will be shared in due course.
The Quality Inspection Teams (QITs), i.e. mock-CQC inspections are well underway, with
positive feedback from the inspection teams. This is an ongoing programme of work and is
being received well. In addition to these the Compliance team are actively attending various
team meetings to discuss CQC compliance and how they can become involved in the
inspections and to share the learning and key themes so far.
51
23
We have carried out 14 inspections, broken down as follows:
Bedded Rehab Unit
1
Children’s Community Nursing
2
Community Independence Service
1
Community Matrons
2
Community Rehab
2
District Nursing
1
Health Visiting
3
MSK
1
PCMH
1
Overall, Staff are proud of the work they do and would recommend their service to friends
and family.
Some of the key themes arising from the inspections are as follows:
•
•
•
•
Many staff are unaware of the management structure above their line manager
Some staff not sure of which CBU or division their service sits within
Some staff reported not receiving feedback following the logging of an incident on Datix
Mixed knowledge of emergency evacuation procedures and low knowledge of who the
nominated fire wardens and first aiders are within their site
A Compliance Group to be chaired by the Chief Nurse is being formed and all key themes will
be discussed and action plans put in place where required. The Group will also consider the
best way in sharing the experience from these inspections across the whole organisation.
52
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title:
Integrated Finance and Performance Report
Agenda item number:
2.1
Report of:
Director of Finance, Performance and Corporate Resources
Contact Officer:
Status
Divisional Director of Performance and Resources
Performance Manager
This report relates to all Trust Goals for 2014/15
Report can be made Public
Executive Summary:
This report provides the Board with an integrated view of performance, both financial and nonfinancial, for September 2014.
Assurance provided:
This report is a standardised monthly report reflecting a series of pre-agreed performance indicators.
Report provenance:
This paper is a summary report of the more detailed Performance & Finance Report presented on a
monthly basis to the Finance, Resources and Investments Committee. It also contains the Quality of
Care Balanced Scorecard which is also presented to the Quality Committee on a monthly basis.
Discussion
Information
53
1.
Purpose
This report provides the Board with an integrated view of performance, both financial and nonfinancial, for September 2014. It is designed to provide Members with a monthly progress report on
Key Performance Indicators and other key metrics.
2.
Introduction
The report is in a new format from Month 6 and now continues to include a summary of the financial
performance of the Trust and reports on a suite of KPIs aligned to each of the six strategic objectives
for CLCH. The non-financial performance section now shows a series of graphs which show monthly
performance for the current year, corresponding performance for 2013/14, the trajectory targets and
the performance thresholds for each target. Where applicable each graph also shows a divisional RAG
rating for each KPI.
Where KPI is reporting a red RAG rating at Trust level a separate exception report is included.
The report continues to include the Quality Information Balanced Scorecard.
3.
Proposal
Members are asked to note the contents of this report
4.
This report contains the Quality of Care Scorecard which reflects a number of Quality/Clinical issues.
Comment regarding the performance of any indicators of a quality/clinical nature, and in particular
any corrective action being taken, has been provided by the appropriate part of the Trust.
5.
There are no equality implications within this paper.
6.
The Director of Finance, Performance & Corporate Resources is involved in the production
of this report in addition to presenting the content at the monthly Finance, Resources and
Investment Committee.
7.
54
Where corrective action is required in order to improve the performance of a particular
indicator, this has been identified and provided. The Board will also be assured that
considerable discussion regarding the data contained within this report has previously
taken place at both the Finance, Resources and Investment Committee and the Quality
Committee.
8.
Consultation with Partner Organisations
No external consultation is required
9.
Monitoring Performance
The contents of this report is subject to monthly performance monitoring
10.
Recommendations
Members are asked to note the contents of this report.
55
Central London Community Healthcare NHS Trust
Contents
INTEGRATED FINANCE &
PERFORMANCE REPORT
TO
30th September 2014
Page
• Overview
2
• Trust KPIs
3
• Finance
14
• Key Financial Issues
15
• Key Financial Risks
16
• Corporate and Service Transformation Summary 17
56
Overview – The Must Knows
Quality
Finance
I&E Performance: Trust surplus £1.2m YTD, favourable variance against plan of
£26k. Forecasting £1.8m surplus due requiring £2.3m surplus on reserves, all of
which is identified. The key issue impacting on the unadjusted YTD position is
unachieved / unidentified QIPP (causing a £1.1m adverse variance) with usage
of temporary staffing the other main concern.
QIPP: Trust is currently under-achieving in QIPP YTD and forecast. P17 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 below plan to date primarily due to late recovery of
WIC/UCC and LA income.
Cap Ex: The Trust Cap Ex is ahead of plan and it is expected that the full
allocation will be spent in year.
The Quality Scorecard presents some good progress across the Trust, but also a
couple of areas for improvement that the Quality Committee has been sighted
on:
Friends & Family Test: There has been a reduction in the net promoter score in
September with Red performance when using the national methodology and
Amber when using CLCH methodology. The Quality Team are in the process of
undertaking a root cause analysis to ascertain the reasons for the slippage.
Grade 2-4 Pressure Ulcer Incidents: The incidence of Pressure Ulcers has
increased this month to 52. The pressure ulcer group is reviewing this by area to
note any issues relating to Septembers performance and the focus on training
compliance continues, backed up by the Pressure Ulcer Policy in place across the
Trust. The Percentage of Incidents Affecting Patients that did not Cause Harm
has decreased this month due to this increase in grade 2 – 4 pressure ulcer
incidents.
Working Capital: Receivables >90 days 15%, Payables >90 days 9%.
Workforce
Performance
Ratio of Bank to Agency Staff: Performance against a number of workforce
targets has deteriorated this month. In particular, the ‘Bank to Agency’ ratio
has slipped from Amber to Red. The exception report under Trust KPIs sets
out remedial actions.
–
The Trust is conduction a review of its activity – both year on year activity and
comparisons to contract commitments. Some services have seen activity reduce
while others are over performing against contract and research is under way to
inform discussions with commissioners and avoid unanticipated capacity
management issues.
Staff from BME backgrounds at Band 7 and Above: Performance has slipped
from Green to Amber due to increase in trend target while actual %age has
remained consistent with previous months.
Staff Appraisal Rate: KPI has dropped from AMBER TO RED due to the use of a
new methodology for the calculation of the figures supporting this KPI. The
exception report under Trust KPIs sets out remedial actions.
Note:
= Trust KPI
= Other Must Know
.
57
2
Trust KPIs
58
September 2014 – Strategic KPIs (1)
Embody the best of the NHS for our patients
Red
Friends and Family test - Net Promoter Score (National Methodology)
60
Friends and Family test - Net Promoter Score (CLCH Methodology)
Amber
Patients agreeing they were treated with dignity and respect
Amber
88
99%
86
56
97%
84
95%
82
52
48
44
40
April
May
June
Actual 2014-15
July
August
Sept
Actual 2013-14
APCS
NCNR
Oct
Nov
Dec
Target Trajectory
SCNB
Jan
Feb
March
Amber Threshold
CHD
93%
78
91%
76
89%
74
87%
72
April
May
June
July
August
Sept
Oct
Actual 2013-14
Actual 2014-15
APCS
Lead Director: Louise Ashley
The record count for this month is 1090.
The Quality Team is in discussion with the Picker organisation regarding any potential data
quality issues this month. The team is also investigating specific service areas to determine
and address the root cause of any actual drop in performance.
Red
80
Nov
Dec
Target Trajectory
NCNR
SCNB
Jan
Feb
85%
March
Amber Threshold
Actual 2014-15
CHD
APCS
Staff agreeing with the statement "I am satisfied with the care I give to
patients/services users" (quarterly)
NCNR
CLCH 2014 Target
Amber Threshold
SCNB
CHD
Ratio of Bank to Agency Staff (Hours Based)
Red
90
Actual 2013-14
70
65
85
60
80
55
75
50
70
65
45
40
Q1
Q2
Actual 2013-14
Target
Q3
Q4
Jul-14
Aug-14
Bank Actual
Actual 2014-15
Amber Threshold
APCS
The performance fi gure i s taken from the Pul se survey on a quarterl y basi s. The
fi gure for Q1 14-15 was 73.2%. The Q2 fi gures wi l l be avai l abl e i n November.
Sep-14
Oct-14 Nov-14 Dec-14
Agency Actual
NCNR
Jan-15
Feb-15 Mar-15
Bank Target
SCNB
CHD
Lead Director: Steve Graham
The Corporate Di vi si on (Corporate departments), al so fai l ed to achi eve the target thi s
month, and was therefore RAG rated RED.
59
NB. RAG ratings are shown against Trajectory targets, not End of Year targets
Apr-14 May-14 Jun-14
2
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%
QGAF Score
Green
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
Q1
Actual 2013-14
National Target 2014-15
Q2
Q3
Actual
Target
Hand Hygiene Audits
Green
Q4
0%
Q1
Q2
Actual
Amber Threshold
Q3
Target
Q4
Amber Threshold
APCS
NCNR
SCNB
CHD
Lead Director: Dr Jo Medhurst
The
results
of
the
external
audit
which
took
place
during
Q2
will
be
available
in
October
2014.
Despite falling short of the Trusts 'stretch' target, this KPI is achieving the national target of
There has been a slight deterioration in this KPI during September, however the
96%. There were no figures for the CHD Directorate this month.
Trust is still meeting the monthly trajectory target.
Green
Percentage of time bedded units achieving
minimum staffing each month
Green
Statutory & Mandatory Training
100.0%
120%
90.0%
100%
400
80.0%
70.0%
80%
300
60.0%
50.0%
60%
200
40.0%
40%
30.0%
20%
10.0%
20.0%
100
0.0%
0%
Grade 2-4 Pressure Ulcer Incidents - Monthly & Annual Targets
Red
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
Lead Director:
Louise Ashley
Highest Value:
Lowest Value:
123% (Marjory Warren)
87% (Alexandra Rehab)
Trajectory Target
Actual 2014-15
Actual 2013-14
APCS
NCNR
SCNB
Trajectory Target
CHD
APCS
May
June
July
Aug
Monthly Actual 2014-15
Cumulative 2014-15
Linear (Cumulative 2014-15)
NCNR
Sept
Oct
Nov
Dec
Jan
Feb
Annual Target
SCNB
This KPI continues to improve on a monthly basis. The Trust-wide figure for
Please see attached Exception Report for further details.
September 2014 exceeds the monthly trajectory target, and is very close to the
end of year target of 90%. The Corporate Directorate is rated Amber, with 87.19%
compliance
NB. RAG ratings are shown against Trajectory targets, not End of Year targets except where stated
April
3
60
Mar
CHD
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
Not
Rated
Proportion of Services capturing
Patients' Clinical Outcomes
Amber
4
65%
70.00%
60%
60.00%
2
55%
50.00%
0
50%
40.00%
-2
-4
-6
YTD Value
45%
30.00%
40%
20.00%
35%
10.00%
30%
25%
0.00%
-8
20%
End of Year
Target
-10
Lead Director: Iain McMillan
The adverse movement is due to the admin and Nursing support contract for OPD & DSU in
Barnet being taken back by RFL as from Q4. A trajectory target is not applicable to this KPI
Percentage of incidents affecting patients that did not cause harm
Red
YTD Value (Actual)
Trajectory Target
Amber Threshold
Lead Director: Jo Medhurst
Performance has improved substantially since last month, and is now Amber against the
trajectory target. Currently 66.2% of services have identified at least two outcome
measures and several have indicated that they will be returning their third measure
definition this month. DDOs/ADQs will shortly receive a monthly progress report with the
status of their division and identified actions for outstanding responses.
April
May
June
July
Monthly Value 2014-15
August
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Trajectory Target
APCS
NCNR
SCNB
CHD
This performance figure relates to a total of 366 incidents, 132 of which were harm free. The
drop in performance during September is linked to the increase in pressure ulcers this
month.
Be responsive to our patients and partners needs
120%
120%
100%
100%
80%
80%
Red
Percentage of Appointments cancelled by CLCH
3.0%
2.5%
2.0%
1.5%
60%
60%
Monthly Value
1.0%
40%
40%
Trajectory Target
0.5%
20%
0%
Complaints resolved within timescales agreed with the complainant
Green
Complaints resolved within 25 days of receipt
Red
Amber Threshold
20%
April
May
June
July
August Sept
Oct
Nov
Dec
Target
Jan
Feb
March
Amber Threshold
APCS
NCNR
SCNB
CHD
These figures relate to 8 out of a total of 13 complaints that were resolved within 25 days.
There have been delays in responses to complaints, as a result of which training for key
divisional staff on good complaints management is being established.
0%
0.0%
April
May
June
July
August Sept
APCS
Oct
Nov
Dec
NCNR
SCNB
Jan
Feb
Mar
Target
CHD
APCS
NCNR
SCNB
CHD
Lead Director: Richard Milner
The sample size for September was: 3699 cancellations out of 139,875 appointments.
The drop in performance appears to be related to sickness/absence rates within the
Divisions leading to a lack of cover for clinics (linked to cost pressures), combined with an
increase in activity. The definition for this KPI needs to be reviewed, as the denominator
currently does not include DNA'd appointments.
61
4
September 2014 – Strategic KPIs (4) NB. RAG ratings are shown against Trajectory targets, not End of
Year targets except where stated
Employ only the best staff
Percentage of Staff that recommend CLCH as a place to work
Red
Staff Appraisal Rates
Red
6.00%
100.00%
70%
90.00%
60%
Sickness absence rate
Amber
5.00%
80.00%
4.00%
70.00%
50%
60.00%
3.00%
50.00%
40%
2.00%
40.00%
30%
20%
10%
Monthly Value 201415
Trajectory Target
30.00%
Amber Threshold
10.00%
Linear (Monthly
Value 2014-15)
0%
Q1
Q3
Q2
1.00%
20.00%
0.00%
0.00%
Actual 2014-15
Q4
Lead Director:
The performance figure is taken from the Pulse survey on a quarterly basis. The Q1 14-15
figure was 40% with Divisional performance ranging from 30.3% to 72.7%. The Q2 figures
will be available next month.
APCS
Actual 2013-14
SCNB
NCNR
Amber Threshold
Actual 2013-14
Actual 2014-15
Trajectory Target
Amber Threshold
CHD
APCS
NCNR
SCNB
CHD
Monthly performance against target remains stable, while the YTD value dropped slightly
An alternative methodology is being used to provide these figures with effect from September over last month. The figures include the Corporate Department, which achieved the target
this year. Please see the KPI Exception Report for further details.
this month, and is therefore RAG rated GREEN.
Vacancy Rates
Red
Trajectory Target
Staff from BME Backgrounds at bands 7 and above
Amber
35.00%
20.0%
18.0%
16.0%
14.0%
30.00%
12.0%
10.0%
8.0%
25.00%
6.0%
4.0%
2.0%
0.0%
Actual 2013-14
APCS
20.00%
Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
Actual 2014-15
NCNR
Trajectory Target
SCNB
Actual 2014-15
CHD
APCS
Thi s KPI has i mproved very s l i ghtl y over l as t month, but i s s ti l l not cl os e to ei ther the
monthl y or year end targets . The excepti on i s the CHD Di vi s i on wi th a vacancy rate of 9.65%
whi ch meets both targets . Fi gures i ncl ude the Corporate Department, whi ch has the hi ghes t
vacancy rates i n the Trus t (24.9%).
Amber Threshold
5
Trajectory Target
NCNR
Amber Threshold
SCNB
CHD
Lead Director:
Steve Graham
Performance agai nst thi s KPI has sl i pped sl i ghtl y thi s month, and i s now just sl i ghtl y bel ow
the trajectory target, but wi thi n the amber threshol d. Fi gures i ncl ude the Corporate Di vi si on
whi ch fai l ed to achi eve the target thi s month, and i s therefore RAG rated RED.
62
Be innovation and technology pioneers
Red
Recurrent QIPPS achieved % of total for the year
Red
Percentage of QIPP plans achieving the planned level of savings in-year
Not
Rated
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%
30
25
90.00%
90.00%
20
80.00%
80.00%
15
10
70.00%
5
70.00%
60.00%
0
YTD Value
Trajectory Target
YTD Value
Lead Director: Richard Milner
Trajectory Target
Amber Threshold
Actual
Projects taken forward
End of Year Target
Lead Director: Jo Medhurst
Lead Director: Ian Millar
There has been a slight fall in performance this month, continuing a declining trend in
performance over a three month period. Please see the Finance Section for further
information.
Not
Rated
Projects Reviewed
Amber Threshold
Please see the Finance Section for further information.
Not
Rated
KPIs that are RAG rated GREEN on overall data quality confidence level.
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
There has been a pause in this committee recently, although it has since
been reconstituted, and the ToR redrafted. Due to this pause, there
have been no further changes to the KPI during the last month, and no
further innovations have been taken forward.
Continuous improvement model in place and used across service lines
This KPI is under development:
As of the 31st September, there are no new successful completions as the first cohort of this year is still
underway. Currently there are 11 participants, all of whom are due to complete successfully on the 23rd
October.
Q1
Q2
Actual 2014-15
Q3
Q4
The next cohort (Jan-15) will be expanded to accommodate 21 participants which should enable the KPI to
be achieved. There is an open Risk on Datix (#1167) relating to this KPI.
Trajectory Target
Lead Director: Mike Fox
The DQAF meetings for Q2 2014-15 have not yet taken place, there are therefore no further
updates to this KPI at this point in time. The meetings are due to take place during October.
NB. RAG ratings are shown against Trajectory targets, not End of Year targets except where stated
6
63
Exception Report: Pressure Ulcer Incidence – September 2014
Monthly Performance 2014-15 v.2013-14
60
Review of Performance
In relation to incidence of ulcers during September the grade 3 and 4 ulcers were in the
following areas:
50
40
Grade Three
30
20
10
0
Actual 2013-14
Actual 2014-15
Monthly Threshold
Cumulative Performance 2014-15
Grade Four
0
1
1
Jade Ward
1
1
2
Marjory Warren Ward
0
1
1
0
1
1
Totals:
1
4
5
The majority of PUs are in District Nursing and are grade 2 ulcers.
Proposed remedial actions
Status
450
400
350
300
Total
Timescale
The pressure ulcer group will review by area to note any
issues relating to Septembers performance.
On-going
New
The focus on training compliance continues.
On-going
New
250
200
150
100
50
0
April May June July Aug Sept Oct Nov Dec Jan Feb Mar
Cumulative 2014-15
Annual Threshold
Monthly Threshold
Cumulative 2014-15
Cumulative Threshold
Annual Threshold
A Pressure Ulcer Policy is now in place across the Trust.
Complete
Cumulative Threshold
On Target
Direction
of Travel
35
X
↓
381.26
416
64
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
35
34
35
32
28
35
35
35
35
35
207.96
416
242.62
416
277.28
416
311.94
416
346.60
416
9
Exception Report: Staff Appraisal Rates – September 2014
Staff Appraisal Rates
Red
The appraisal rate is taken directly from the online appraisal system (e –PADR) used
within the Trust.
100.00%
90.00%
Following a data quality review it became apparent that the rates being reported were not
accurate.
80.00%
70.00%
During August investigations were carried out to identify a robust way of producing the
reports. This is now in place, but during this investigation it became apparent that several
staff and managers were not completing the online process to allow the system to register
the appraisal.
60.00%
50.00%
40.00%
30.00%
Status
20.00%
10.00%
0.00%
Timescale
Review process for running reports
September 14
Inform managers and Staff of need to complete whole on
line process
October 14
Inform managers of revised appraisal rates
October 14
Communicate to managers staff without an appraisal
October 14
Actual 2014-15
Actual 2013-14
Trajectory Target
Amber Threshold
APCS
NCNR
SCNB
CHD
The Corporate Division (Corporate departments) is included in these figures: the division
also failed to achieve the target this month, and is therefore also RAG-rated RED on this KPI.
Risk to achieving target
Severity
Engagement of managers and
staff
Mitigated
M
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Actual 2013-14
83.30%
85.80%
89.10%
90.50%
85.80%
82.50%
83.00%
83.10%
82.80%
81.50%
81.00%
79.50%
Actual 2014-15
78.85%
78.76%
81.9%
83.8%
Not reported
60%
Trajectory Target
80%
85.00%
90.00%
90.00%
90.00%
90.00%
90.00%
90.00%
90.00%
90.00%
90.00%
90.00%
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%
On Target
Travel
X
↓
65 10
Exception Report: Bank to Agency Ratio – September 2014
Ratio of Bank to Agency Staff (Hours Based)
Red
The bank: agency ratio has dropped off trajectory in the last month.
70
A review of the bank is currently underway. This review will provide metrics on the bank
workforce and compare it with the Trust requirements and also recommend improvements
that can be made to deliver a more effective and efficient temporary workforce.
65
60
Work will continue with Divisions to understand their temporary staffing requirements and
drive their substantive recruitment.
55
50
45
40
Bank Actual
APCS
Status
Agency Actual
NCNR
Bank Target
SCNB
Severity
Number of staff registered to work with
bank
Mitigated
Bank Actual
Bank Target
Agency Actual
51
51
49
October 14
Review bank payment methods and rates
October 14
Make recommendations on ways to increase numbers of bank
staff available
October 14
Review use of agency in light of staff flow to identify more workers
that can go through that system
October 14
H
Incentives to work on the bank
Apr-14
Review current bank workforce against Trust requirements
CHD
The Corporate Division (Corporate departments), also failed to achieve the target this
month, and was therefore RAG rated RED.
Timescale
May-14
51.7
51
48.3
Jun-14
52.3
52.5
47.7
Jul-14
52.7
54
47.3
Aug-14
54.1
55.5
45.9
Sep-14
52.4
57
47.6
Oct-14
58.5
Nov-14
60
Dec-14
61.5
Jan-15
63
Feb-15
64.5
Mar-15
65
On Target
Travel
X
↓
66
11
Exception Report: Vacancy Rates – September 2014
Vacancy Rates
Red
The Trust vacancy rate has historically been higher then the target of 11%. This year a
number of changes have been made within the recruitment to increase activity and
numbers of starters. This has shown some success, however over the last 3 months the
number of leavers has also increased reducing the impact of the increased starters.
Work continues within the recruitment team to increase the time to hire and raise the
profile and brand of the Trust.
Work is underway within the divisions to understand the reasons for leaving and create
retention initiatives. This will be supported by a redesigned and robust Exit Interview
process
Consideration is being given to overseas recruitment
It is projected that the vacancy rate will be met by March 2015
20.0%
18.0%
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
Actual 2013-14
Actual 2014-15
APCS
NCNR
Trajectory Target
Status
Amber Threshold
SCNB
CHD
This KPI has improved very slightly over last month, but is still not close to either the
monthly or year end targets. The exception is the CHD Division with a vacancy rate of 9.65%
which meets both targets. Figures include the Corporate Department, which has the highest
vacancy rates in the Trust (24.9%).
Severity
Skills shortage means good candidates
are not available
Timescale
Invest in applicant management system to reduce time to hire
December 14
Review opportunity for overseas recruitment
December 14
Review reasons of leaving, exit interview process
November 14
Increased attendance at job fairs, schools and recruitment events
On going
Mitigated
M
Apr-14
May-14
Jun-14
Jul-14
12.8%
Actual 2014-15
15.8%
16.8%
16.9%
16.8%
Trajectory Target
16.7%
15.90%
15.10%
14.30%
13.50%
Amber Threshold
15.9%
15.1%
14.3%
13.5%
12.7%
Actual 2013-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
14.1%
14.9%
14.7%
14.9%
14.9%
16.1%
16.7%
18.7%
17.3%
17.07%
12.70%
11.90%
11.10%
11.00%
11.00%
11.00%
11.00%
11.9%
11.1%
11.0%
11.0%
11.0%
11.0%
11.0%
On Target
Travel
X
↓
67 12
Quality Scorecard – September 2014
Number
of
Records
14-09
End of Yr.
Target
Trajectory
Target
Proportion of patients who were treated with Respect and Dignity
1095
95%
Patients who would recommend the service (National)
1103
Patients who would recommend the service (incl. "likely" Promoters)
1103
Proportion of patients whose care was explained in an
understandable way
A Positive Patient Experience
This Month
Sept 14
Ytd / Avg
Mth
95%
93%
94%
58
54.5
47
52
85
84
77
83
1063
90%
90%
91%
91%
Proportion of patients who were involved in planning their care
1026
80%
80%
76%
78%
Proportion of patients rating their overall experience as excellent or
good
1090
80%
80%
88%
91%
Number of PREMS responses is above threshold
1090
1424
1090
Patients' Experience
Patients' Complaints, Concerns and Compliments
The number of compliments received this month
36
n/a
n/a
36
33
56
80%
80%
71.4%
76%
9
13
n/a
80%
n/a
80%
9
61.5%
7
64%
8
100%
100%
100%
100%
Proportion of Patient related Incidents that were Harm Free
366
49%
43%
36.1%
46%
10% reduction in incidents affecting Patients that caused harm
366
204
204
234
215
10% reduction in Pressure Ulcer Incidents
10% reduction in Medication Incidents that caused harm
10% reduction in Falls that caused Harm
53
43
35
416
13
13
35
13
15
52
12
9
46
18
15
Reported incidents affecting patients per 1000 OBDs (bedded units)
68
20
20
32
19
Proportion of external S.I.s with reports completed within deadline
Proportion of patients' concerns (PALS) resolved within 1 week
The number of complaints received this month
Proportion of complaints responded to within 25 days
Proportion of complaints responded to within agreed deadline
Preventing Harm
Incidents & Risk
20
100%
100%
95%
98%
Prevalence NHS Safety Thermometer)
Proportion of Patients with Harm free care
Proportion of Patients who did not have a Pressure Ulcer
1293
1293
98%
98%
98%
98%
91.3%
93.5%
92.1%
94.2%
Proportion of Patients who did not have a Catheter Associated UTI
1293
98%
98%
99.7%
99.2%
Proportion of Patients who did not have a Fall
Proportion of Patients who did not have a Veneous
Thromboembolism
Proportion of Patients who did not have any NEW Harms
1293
98%
98%
98.2%
98.6%
1293
98%
98%
99.7%
99.7%
129
98%
98%
97.1%
97.1%
0%
Standardised Mortality Ratio in Bedded Units
Proportion of patients who were satisfied with the wait for treatment
Proportion of Patients reporting a Positive Goal Attainment Score
74
66%
66%
22%
20%
1044
80%
80%
77.50%
76%
283
90%
90%
90%
88%
68 13
Finance
69
Key Financial Issues
Income
Expenditur
e Year to
Date
At Month 6, CLCH has achieved a £1,232k surplus (£1,046k surplus at
Month 5); this represents a £26k favourable variance against plan.
The Trust achieved an EBITDA margin of 3.7% as at the end of Month 6
which is broadly in line with plan.
I&E
Forecast
The Trust is forecasting a surplus of £1.8m which is in line with the
annual plan. The forecast assumes an underspend of £2.3m (£1.9m at
Month 5) on reserves (all of which is identified).
Risks to the Trust achieving the financial plan for 2014/15 include:
achieving CQUIN and SDIP in full and resolving the charging issue re.
Pathology costs from Imperial.
Quality,
Innovation,
Productivit
y and
Prevention
(QIPP)
Balance
Sheet,
Capital and
Cash
The QIPP target for 2014/15 is £12m. As at Month 6 the Trust has
identified QIPP schemes with the value of £11.6m and is reporting underachievement of £899k against a year to date plan of £4,994k (£577k at
Month 5).
The Trust is currently forecasting achievement of £9.7m (£10.1m at
Month 5) of QIPP by the end of the financial year but once the
contingency reserve for QIPP achievement is factored in this reduces the
gap to £0.2m. During 2014/15 £8.8m of the forecast QIPP will be
achieved in year through recurrent schemes.
The recurrent value of the delivered QIPP is £10.3m meaning there is at
present a £1.6m recurrent gap.
At the end of Month 6 CLCH had a cash balance of £14.7m (11.9m at
Month 5). This is £0.7m higher than plan and is due to year to date
redundancy payments being £0.6m lower than plan. This will reduce to
£10.3m by the end of 2014/15.
Total Capital Resource Limit for 2014/15 is £7.1m. As at Month 6, the
Trust had capitalised £2.1m (£1.7m at Month 5) of expenditure. This is
£0.3m ahead of plan and will be subject to monthly monitoring through
the Capital Investment Group.
Income and Expenditure Summary
Year-to-Date (£'000)
Income & Expenditure
Income
96,617
97,400
783
1,838
Pay Expenditure
68,361
68,980
-619
-2,531
Non-Pay Expenditure
24,591
24,773
-182
534
EBITDA
3,665
3,647
-17
-159
Depreciation
2,067
2,019
48
44
417
430
-13
106
Dividend
Interest Received
26
34
8
9
Surplus/(Deficit)
1,206
1,232
26
-0
EBITDA Margin
3.8%
3.7%
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 new Monitor
Risk Assessment Framework.
Month 6
£'000
Forecast
Year end
£'000
39,444
13,968
15,107
68,519
39,506
14,747
19,181
73,434
42,646
10,307
7,721
60,675
-28,624
39,895
0
31,700
7,993
202
39,895
-32,307
41,127
1,232
31,700
7,993
202
41,127
-18,947
41,728
1,833
31,700
7,993
202
41,728
QIPP Plan Summary
CIP Target Identified RAG Adj YTD Plan
Identified
The %age of Trust payables over 90 days was 9% and receivables 15%
compared to a target of 5%.
CSRR
Forecast
Variance
YTD Plan YTD Actual Variance
Total CIPs 2013/14
£'000
11,958
£'000
11,592
£'000
10,024
£'000
4,994
YTD Act
YTD Var FOT Var
against against
Plan
Target
£'000
£'000
£'000
4,096
-899
-2,270
70
15
Key Financial Risks
Risk
Description
1
QIPP: Directorates have identified plans to achieve £11.6m of the £12.0m CIP target for 2014/15.
The forecast CIP as at Month 6 is only £9.7m; once the £2m CIP contingency reserve is factored in the residual risk is
£0.3m. This shortfall will be offset by funds identified in reserves which are no longer required for their original purpose.
0 Green
2
CQUIN: The Trust has agreed the total level of CQUIN income for 2014/15 (C.£3.0m). Although the Trust has a good trackrecord for achieving this form of income there is an underlying risk given it is variable and dependant on achieving
outcomes. The Trust has established a CQUIN monitoring group and funded bids to achieve agreed milestones
-1,000 Amber
3
4
5
Note:
Service Development Implementation Plan: As part of the annual contracting negotiations the Trust agreed investments
from commissioners linked to achieving certain IT developments and transformation initiatives which are yet to be
quantified and risk assessed. The Trust is confident of achieving these schemes however there is a risk given this income
stream is dependant on achieving and evidencing improvements.
Pathology Charges: CLCH has been invoiced £365k for 13/14 Pathology charges (credit notes have been received against
some invoices raised hence the reduction from the £500k reported in month 5) and £195k for months 1- 5 14/15 charges.
CLCH has not historically been funded for this and up until now invoices have not been received for this service. The DD
of Resources and Performance has written to Imperial disputing the charges and the invoices have also been formally
disputed through the Q2 Agreement of Balances exercise. CLCH will need to raise with commissioners if a resolution
cannot be reached with Imperial.
Escorts and Bed watchers: HMPS have invoiced CLCH £180k for the month of June whereas the normal monthly charge is
£40k. The increase is linked to a disabled patient. NHSE have now agreed to pay this increased cost in full .
Value
£000s
RAG
-1,000 Amber
-850 Amber
0 Green
A negative number = a potential negative impact on the forecast
A positive number = a potential positive impact on the forecast
71
16
Corporate and Service Transformation Summary
M6 CIP/QIPP position: Operational Divisions
Plan
FY
Target
Corp
Servs
NNCR
£3,834
£1,511
Forecast
M5 YE
£2,807
£1,144
Variation
Change inM6 YE
month
£3,016
£713
Comments re: in month changes
Plan vs.
YE
£209
Inclusion of additional CIPs in Estates and S&BD have improved the YE forecast
slightly.
-£431
Timescale of Admin review has resulted in reduction of £130k. Workforce
management reduction of £28k as post was double counted in Admin review. Home
to Clinic schemes have decreased by £224k, following initial pilot review. Merge of
CIS and CRT has decreased as timescale will not allow for savings in current year,
however a vacant post will be frozen to compensate.Procurement efficients have
not identified savings , and Con Care Restructure will not offer savings due to
timescale to implement and pay protection.
£798
Additional schemes to meet this gap are currently being explored, including
freezing vacant posts. The development schemes total value is £108,000
£658
CIP2, 5, 16 actual finance figures were amended to £0 for all months against cost
code AXX105, as no further savings can be identified. A change request to amend
the value of these CIPS is in progress for inclusion in M7 report, and the gap will be
addressed in CIP23 and other schemes.
This forecast gap includes the expected further non-delivery within CIP2, 5
and 16. There is also further slippage within CIP9. Change Requests are
£603 in progress to move expected gaps in CIP 2,4, 5 and 16 into a new CIP that
will focus on 2% savings across all divisional pay and non-pay. The
development schemes total value is £223,000 in year.
£157
No Changes in month
£44
£44
£2,473
£2,143
£1,870
-£273
CHD
£2,181
£2,137
£2,137
£0
Change in position is due to the following:
20. Invoicing for dental out of area patients, the CIP was removed after further advise
from NHSE
25. Extra income from WICs have increased to £128,000
APCS
£1,958
£1,900
£1,951
£51
Total
£11,957 £10,131
£9,687
-£444
15%
19%
Plan vs. YE
including
pipeline
Following the instruction by the Director of FPCR for all Services within the
Directorate to identify additional CIP opportunities in order for action to be
taken to ameliorate the impact of the Estates under-delivery,
£818
Directors/Heads of Service have developed new schemes. In addition to
those already in delivery, new pipeline schemes are being worked up in HR,
Estates and IM&T. Pipeline schemes have an in-year value of £696,000.
BCSS
% gap to plan
Comments re: gap to YE target
Extra schemes will be indentifed to cover -£7,000 required
£7
£ gap to plan (excluding pipeline potential)
£122
£2,270 £ gap to plan if current pipeline potential is included
£7
£988
Positive movement/position
Negative movement/position
No change in movement/position
72
17
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title:
Monthly Nurse Staffing Report
Agenda item number:
2.2
Report of:
Contact Officer:
Director of Patient Safety / Deputy Chief Curse
Status
Executive Summary: This report provided 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 staffing return
Appendix 2 shows the no. on shift when a medication error or fall occurred.
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
Discussion
Information
73
1.
1.1
Purpose
To provide the Trust Board with assurance that the Hard Truths Commitments are being
appropriately actioned and that the Trust is managing minimum staffing levels
appropriately.
2.
2.1
Introduction
NHS England and the Care Quality Commission have issued 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 Trust Board has, in line with the
guidance, approved minimum staffing levels for all bedded units across the Trust
(Appendix One) and has received the action plan outlining the Trust’s commitment to
meeting the national requirements. In June 2014 the Trust Board received the first report
on actual staffing levels against agreed minimum staffing levels.
2.2
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.
2.3
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.
3.
3.1
Report
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.
Overall the Trust average fill rate for nursing and care staff was as follows:
74
3.1.1 Garside Nursing Home
The continuing care homes are running on high vacancies with a high percentage of bank and
agency, due to the recruitment and retention issues resulting from the divestment process.
Bank and agency do not arrive on a number of occasions. If RN not available HCAs are over
booked. Where there are additional nurses they are providing 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 in place, which have been largely unsuccessful and our
commissioners are aware; The CLCH recruitment team has been asked to approach Nurse
Agencies regarding a guaranteed work for next 6 months for Band 5 and Band 6 nurses - this
is a new initiative and progress will be reported back through the DMT.
3.1.2 Athlone Nursing Home
See 3.1.1
75
3.1.3 Jade Ward
Staffing shortfall relates to RN vacancies and subsequent bank staff availability; additional
HCA rostered where possible to mitigate and ensure care needs met. Recruitment in
progress.
3.1.4 Marjorie Warren Ward
Some patients requiring 1-1 care due to falls risks.
76
3.1.5 Pembridge Unit
This is a small service, where occasional altered staffing levels impact upon total percentage.
3.1.6
See 3.1.1
77
3.1.7 Athlone Rehab / Alexandra Rehab.
Vacancies within the units have been successfully recruited to, with new staff
starting in October.
3.2
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.
78
4.
The implications of staffing levels falling below minimum numbers for a prolonged amount
of time are significant.
Incidents are being reviewed, and actions plans agreed between the Quality team and the
operational team.
5.
The majority of patients using continuing care beds are elderly and frail, many with
reduced mental capacity. The Trust therefore recognises the importance of ensuring
staffing levels are maintained at least at minimum levels so as not to compromise the
safety of these vulnerable patients.
6.
Financial implications have been raised with commissioners regarding the staffing issues
as a result of the transfer of the continuing care beds and agreement has been reached
to fund the extra staffing costs.
7.
As described in section 3. The risk relating to poor retention of staff in the continuing
care homes has been added to the Trust risk register.
8.
This paper will be shared with the Trust’s commissioning CCGs and monthly mandatory
returns have been submitted on time.
9.
With the database designed in house, staffing levels can be checked daily by any staff
member who is given authorisation to use the system. This includes all Directors and
Board members.
10. Recommendations
10.1 The Board is asked to confirm assurance in relation to the action being taken against the
Hard Truth Commitments.
10.2 The Board is asked to note the staffing levels for September.
79
Unit:
Athlone House
Month:
September
Early:
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
Late
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
Night
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
Reason Codes
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 Sun Mon Tue
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 29 30
20 18
18 18 18 18 18 18 18
18 19 21 21 21 20 20
20 20 20 20 20 20 20
20 21 21 21 21 21 22
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
3
3
2
1
1
2 2
1
2
2
1
2
2 2
1
1
2
2
2
2 2
1
2
2
2
2
1 2
1
1
2
2
1
1
1
1
1
1
1
1
1
1
2
-1
6
2
-1
6
2
-1
6
2 2
-1 -1
6 6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
4
2
2
4
3
1
4
3
1
4
3
1
4
0
4
0
4
0
4
0
20
2
1
1
18
2
2
18
2
1
1
2
0
2
0
2
0
2
0
3
2
2
3
2
2
3
2
2
4
1
6
4
1
6
4
1
6
20
2
2
18
2
1
1
18
2
2
2
0
2
0
2
0
2
0
2
2
2
2
2
1
1
2
0
2
0
2
0
2 2
-1 -1
6 6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
4
2
2
4
3
1
4
3
1
4
3
1
4
3
1
4
4
4
3
1
4
0
4
0
4
0
4
0
4
0
4
0
4
0
18 18
2 2
1 1
1 1
18
2
1
1
18
2
2
18
2
2
18
2
1
1
18
2
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
3
2
2
3
2
2
3
3
1
3
3
1
3
2
2
3
2
2
3
2
2
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
18 18
2 2
2 2
18
2
2
18
2
1
1
18
2
1
1
18
2
1
1
18
2
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
2
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2 2
-1 -1
6 6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
4
4
4
4
4
4
4
4
4
3
1
4
4
4
3
1
4
0
4
0
4
0
4
0
4
0
4
0
4
0
19 21
2 2
1 1
1 1
21
2
1
1
21
2
2
20
2
2
20
2
1
1
20
2
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
3
3
1
3
2
2
3
3
1
3
3
1
3
3
1
3
4
3
3
1
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
19 21
2 2
2 1
1
21
2
1
1
21
2
2
20
2
2
20
2
2
20
2
1
1
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
1
1
2
2
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
0
2
0
2 2
-1 -1
6 6
2
-1
6
2
-1
6
2
-1
6
2
-1
6
4
3
1
4
4
4
2
2
4
2
2
4
3
1
4
2
2
4
3
1
4
2
2
4
2
2
4
2
2
4
2
2
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
20 20
2 2
2 2
20
2
2
20
2
1
1
20
2
2
20
2
2
20
2
2
21 21
2 2
1 2
1
21
2
1
1
21
2
1
1
21
2
2
22
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
3
2
2
3
3
1
3
2
2
3
2
2
3
3
1
3
3
1
3
2
2
3
3
1
3
2
2
3
2
2
3
2
2
3
2
2
3
2
2
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
4
1
6
20 20
2 2
1 2
1
20
2
1
1
20
2
1
1
20
2
2
20
2
2
20
2
1
1
20 21
2 2
2 2
21
2
1
1
21
2
1
1
22
2
1
1
22
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
2
2
1
1
2
1
1
2
2
2
2
2
2
2
2
2
1
1
2
2
2
1
1
2
1
1
2
1
1
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
1
2
3
4
5
6
7
8
Sickness
Unfilled bank shift
Escort
Special
Unauthorised absence
Vacancies
Annual Leave
Mandatory Training
80
Unit:
Athlone Rehab
Month:
September
Early:
Late
Night
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
4
5
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
21
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
4
5
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
21
2
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
1
1
Agreed RN
Regular RN
Bank RN
Day Total
Agency RN
Total
Variance
Day Total
Reason Codes
Mon Tue Wed Thu Fri
1
2
3
4
5
Number of patients 21 21 22 22 19
3
3
3
3
3
Agreed RN
2
3
2
1
2
Regular RN
1
2
Bank RN
Agency RN
Total
3
3
2
3
2
Variance
0
0
-1
0
-1
7
7
Reason
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
4
6
5
1
2
4
6
6
2
21
2
1
1
2
0
4
6
6
2
22
2
1
1
2
0
4
6
6
2
22
2
1
1
2
0
4
4
1
5
1
21
2
1
1
6
2
2
0
4
5
6
2
19
2
1
1
2
0
4
5
5
1
22
2
2
2
0
2
1
1
4
5
1
5
1
19
2
3
2
0
3
1
4
6
6
2
6
2
20
2
2
20
2
2
0
4
4
1
5
1
22
2
1
1
2
0
4
4
1
5
1
19
2
1
2
1
1
2
0
2
1
1
4
5
4
5
5
1
21
2
2
1
1
2
0
4
4
1
5
1
21
2
1
1
4
6
5
1
22
2
1
1
4
5
6
2
22
2
1
1
4
6
Tue Wed Thu
16 17 18
22 22 22
3
3
3
2
1
2
1
2
-1
7
2
-1
7
2
-1
7
4
5
1
4
5
1
4
5
1
5
1
6
2
6
2
6
2
22
2
2
22
2
2
22
2
1
1
22
2
2
2
0
2
0
2
0
2
0
Fri
19
22
3
3
3
0
4
6
6
2
22
2
2
Sat Sun Mon
20
21 22
22
22 22
3
3
3
2
2
3
2
-1
4
6
6
2
22
2
2
2
-1
4
6
6
2
22
2
2
3
0
4
6
Tue Wed Thu
23 24 25
21 20 19
3
3
3
3
3
3
3
0
4
6
3
0
4
6
3
0
4
6
6
2
6
2
6
2
6
2
22
2
2
21
2
1
1
20
2
1
1
19
2
2
2
0
2
0
2
0
2
0
Fri
26
17
3
3
3
0
4
6
6
2
19
2
2
Sat Sun Mon
27
28 29
17
17 17
3
3
3
1
3
2
1
1
2
-1
4
6
6
2
17
2
2
3
0
4
6
6
2
17
2
1
3
0
4
6
Tue
30
16
3
3
1
2
3
4
5
6
7
8
Sickness
Unfilled bank shift
Escort
Special
Vacancies
Annual Leave
Mandatory Training
3
0
4
6
6
2
6
2
6
2
17
2
2
16
2
1
1
19
2
2
2
0
2
0
2
0
1
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
7
4
4
5
1
19
2
1
1
1
2
0
2
-1
Tue Wed Thu Fri Sat Sun Mon
9
10 11 12
13
14 15
20 21 21 22
22
22 22
3
3
3
3
3
3
3
1
2
2
3
1
3
3
1
1
1
3
3
2
2
3
2
3
3
0
0
-1
-1
0
-1
0
0
7
7
7
4
5
5
1
2
-1
4
6
19
2
1
1
7
Sat Sun Mon
6
7
8
19
19 20
3
3
3
2
3
2
4
3
2
4
0
19
2
1
4
5
5
1
5
1
20
2
1
20
2
1
1
1
-1
2
2
0
1
2
0
2
2
2
0
2
2
2
0
2
1
1
2
2
2
1
1
4
6
4
4
1
6
2
4
3
1
5
1
21
2
1
21
2
1
1
1
4
5
4
0
22
2
1
4
5
5
1
22
2
2
2
0
2
1
1
2
0
2
2
1
-1
2
2
2
4
5
4
5
4
5
5
1
5
1
5
1
5
1
22
2
1
1
22
2
1
22
2
1
1
22
2
1
1
2
0
2
0
2
0
2
2
4
4
1
2
0
2
2
1
2
0
2
2
4
5
5
1
22
2
1
1
4
5
5
1
22
2
2
4
5
5
1
22
2
1
1
4
5
4
5
4
4
1
4
5
5
1
5
1
5
1
5
1
22
2
21
2
1
20
2
2
20
2
2
1
-1
1
2
0
2
0
4
5
5
1
19
2
1
4
5
5
1
17
2
2
4
5
5
1
17
2
2
4
4
4
5
5
1
4
0
5
1
17
2
2
16
2
1
19
2
2
2
0
1
-1
2
2
0
2
1
2
2
2
2
2
0
2
1
1
2
0
2
2
2
0
2
2
2
0
2
2
2
2
2
1
1
2
2
2
0
2
1
1
2
0
2
2
2
0
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
2
0
2
0
7
4
3
0
7
0
7
5
2
0
7
0
7
5
1
0
6
-1
7
3
4
0
7
0
7
4
1
1
6
-1
7
2
4
0
6
-1
7
6
0
1
7
0
7
6
0
0
6
-1
7
2
3
2
7
0
7
5
0
1
6
-1
7
4
1
1
6
-1
7
5
1
0
6
-1
7
2
4
0
6
-1
7
6
1
0
7
0
7
6
0
1
7
0
7
4
2
0
6
-1
7
4
2
0
6
-1
7
5
1
0
6
-1
7
5
2
0
7
0
7
5
1
0
6
-1
7
4
2
0
6
-1
7
5
1
0
6
-1
7
6
1
0
7
0
7
7
0
0
7
0
7
6
0
1
7
0
7
7
0
0
7
0
7
4
1
1
6
-1
7
7
0
0
7
0
7
4
2
0
6
-1
7
7
0
0
7
0
10
11
1
0
12
2
10
11
2
0
13
3
10
12
1
0
13
3
10
12
1
0
13
3
10
12
1
0
13
3
10
12
1
0
13
3
10
10
1
0
11
1
10
10
3
0
13
3
10
12
1
0
13
3
10
12
1
0
13
3
10
11
1
0
12
2
10
9
2
0
11
1
10
13
0
0
13
3
10
12
0
0
12
2
10
12
1
0
13
3
10
12
1
0
13
3
10
12
1
0
13
3
10
11
2
0
13
3
10
13
0
0
13
3
10
13
0
0
13
3
10
13
0
0
13
3
10
13
0
0
13
3
10
12
1
0
13
3
10
12
1
0
13
3
10
12
1
0
13
3
10
13
0
0
13
3
10
13
0
0
13
3
10
13
0
0
13
3
10
12
0
0
12
2
10
13
0
0
13
3
Summary of key risks & challenges
Corrective action plan
81
Unit:
Garside House
Month:
September
Early:
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
Reason Codes
Mon Tue Wed Thu Fri
1
2
3
4
5
38 38 37 36 36
4
4
4
4
4
3
3
2
2
1
1
2
1
2
1
1
4
4
4
4
3
0
0
0
0
-1
2
6
2
2
2
6
0
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
38
3
4
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
6
4
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
38
3
2
38
3
1
1
3
0
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
4
2
1
1
4
0
4
4
1
2
2
4
4
4
4
4
Day Total
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
10
9
0
2
11
1
10
6
1
3
10
0
10
6
1
4
11
1
10
4
3
4
11
1
10
3
6
1
10
0
Day Total
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
16
8
3
5
16
0
16
10
4
3
17
1
16
12
3
1
16
0
16
8
7
1
16
0
16
8
8
1
17
1
Night
6
5
1
6
0
6
2
3
6
0
38
3
2
37
3
3
1
1
4
1
3
0
4
1
6
3
3
Sun Mon Tue Wed Thu Fri
7
8
9
10 11 12
35 35 35 35 35 35
4
4
4
4
4
4
2
3
4
4
2
3
1
1
1
1
1
1
3
3
4
4
5
4
4
-1
-1
0
0
1
0
0
2
1
4
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
Late
6
5
1
Sat
6
35
4
2
1
5
-1
1
36
3
1
1
2
4
1
6
4
1
1
6
0
6
4
1
1
6
0
6
0
6
4
1
1
6
0
6
4
1
1
6
0
4
35
3
2
2
4
1
35
3
1
1
2
4
1
35 35 35
3
3
3
2
2
2
1
1
2
1
1
4
4
4
1
1
1
14 15 16 17 18 19
35 35 36 37 37 37
4
4
4
4
4
4
2
3
2
3
2
3
1
1
1
3
1
1
1
1
1
4
4
4
4
6
4
4
0
0
0
0
2
0
0
4
6
6
3
1
10
4
4
6
3
2
1
35
3
2
1
35
3
2
1
1
4
1
35
3
2
1
1
4
1
35
3
3
35
3
3
1
1
6
3
3
6
2
3
1
6
4
1
1
3
0
6
4
1
1
Sat
13
35
4
4
6
0
6
4
2
6
0
6
4
1
1
6
0
4
6
0
4
4
1
4
1
6
3
2
1
6
0
4
6
4
1
1
6
0
4
6
6
0
6
0
35
3
3
1
36
3
3
37
3
3
2
1
6
3
4
37
3
2
1
1
4
1
37
3
3
1
6
3
1
3
7
1
4
6
3
1
3
6
2
4
6
3
3
37
3
2
1
4
1
1
4
1
1
2
6
0
6
4
1
1
6
5
1
6
0
6
4
1
1
6
0
4
6
2
3
1
6
0
6
2
1
3
6
0
6
3
2
1
6
0
6
0
6
3
2
1
6
0
4
3
0
37
3
1
1
1
3
0
36
3
1
1
1
3
0
35
3
1
2
4
2
1
1
4
2
3
4
3
2
5
1
4
0
35
3
1
2
6
4
2
2
8
2
6
0
6
0
6
3
3
6
0
6
0
35
3
2
35
3
1
35
3
2
35
3
2
1
1
3
0
2
3
0
1
1
4
2
2
1
5
1
4
4
3
2
4
4
2
1
1
4
0
4
4
4
4
4
4
10
4
4
2
10
0
10
6
2
2
10
0
10
7
2
2
11
1
10
7
2
2
11
1
10
8
2
1
11
1
10
6
2
3
11
1
10
6
3
2
11
1
10
9
0
2
11
1
16
8
4
4
16
0
16
9
5
3
17
1
16
9
4
3
16
0
16
9
5
4
18
2
16
13
7
3
23
7
16
8
8
1
17
1
16
7
7
3
17
1
16
8
6
3
17
1
3
0
4
2
2
5
1
3
0
4
2
2
1
4
0
5
1
6
3
3
6
0
4
35
3
2
3
0
5
1
6
3
2
2
7
1
4
3
0
3
0
4
2
3
5
1
6
4
2
4
6
3
3
21 22 23 24 25 26
37 37 37 37 37 37
4
4
4
4
4
4
2
3
4
2
2
2
1
1
1
1
1
1
1
2
4
4
4
4
4
4
4
0
0
0
0
0
0
0
6
2
2
2
2
7
1
Sat
20
37
4
3
1
6
0
6
3
2
1
6
0
37
3
3
1
4
1
6
0
4
1
6
2
2
2
6
0
6
0
6
4
1
1
6
0
2
6
3
2
1
6
2
2
2
37
3
1
2
37
3
2
1
37
3
2
1
3
0
3
0
6
0
35
3
2
36
3
2
1
1
1
3
0
1
3
0
4
1
3
1
4
4
1
1
5
1
4
4
3
1
1
5
1
4
4
4
3
2
4
3
2
4
4
3
2
4
4
4
4
4
10
7
1
3
11
1
10
8
2
1
11
1
10
7
1
3
11
1
10
8
6
1
15
5
10
6
2
3
11
1
10
8
2
1
11
1
10
8
1
3
12
2
10
5
2
3
10
0
16
7
7
3
17
1
16
9
7
1
17
1
16
10
3
5
18
2
16
7
3
8
18
2
16
10
4
3
17
1
16
10
7
0
17
1
16
7
4
6
17
1
16
8
7
2
17
1
5
1
5
1
5
1
5
1
1
1
1
3
0
5
1
3
0
4
4
1
5
1
3
0
4
2
2
1
2
5
1
37
3
2
1
3
0
4
3
5
-1
6
3
3
35
3
2
3
0
6
0
6
3
2
1
37
3
3
1
35
3
2
3
0
37
3
2
6
3
1
1
37
3
2
1
1
4
1
6
2
4
2
8
2
4
37
3
2
6
3
2
1
37 37
3
3
2
2
1
1
3
1
4
4
3
1
1
0
6
0
37
3
2
6
2
2
1
5
-1
2
37
3
1
35
3
1
1
1
3
0
3
0
6
1
3
1
5
-1
1
5
1
4
3
1
5
1
4
1
6
0
Sat Sun Mon
27
28 29
37
37 38
4
4
4
3
3
3
2
1
1
1
6
4
4
2
0
0
6
4
1
1
6
3
2
1
6
4
1
1
6
0
38
3
3
1
38
3
2
1
4
1
4
1
3
0
9
3
6
3
3
3
9
3
6
3
1
2
6
0
38
3
2
1
38
3
1
6
0
37
3
2
1
1
4
1
37
3
1
2
1
4
1
37
3
3
1
6
3
2
1
6
2
2
2
6
3
3
3
6
0
6
0
6
0
Sickness
Unfilled bank shift
Escort
Special
Vacancies
Annual Leave
Mandatory Training
2
37
3
2
37
3
2
1
1
3
0
3
0
4
4
1
3
0
37
3
2
4
1
3
1
4
2
3
1
3
0
3
0
2
3
0
4
2
2
1
5
1
4
4
4
1
5
1
4
4
4
4
4
4
4
3
1
1
5
1
4
10
6
4
1
11
1
10
8
2
0
10
0
10
6
3
2
11
1
10
7
2
2
11
1
10
6
1
4
11
1
10
5
5
3
13
3
10
8
2
1
11
1
10
8
2
1
11
1
10
7
1
2
10
0
16
6
8
3
17
1
16
10
4
2
16
0
16
10
5
2
17
1
16
9
4
3
16
0
16
8
5
3
16
0
16
7
6
4
17
1
16
8
8
4
20
4
16
9
6
6
21
5
16
9
4
4
17
1
5
1
4
2
1
1
37
3
1
1
1
3
0
4
4
1
4
0
1
2
3
4
5
6
7
8
4
0
6
3
2
2
7
1
6
0
6
0
Tue
30
38
4
4
5
1
4
0
5
1
5
1
Summary of key challenges and risks
The continuing care homes are running on high vacancies with a high
percentage of bank and agency, due to the recruitment and retention issues
resulting from the divestment process. Bank and agency do not arrive on a
number of occasions. If RN not available (red) HCAs are over booked (yellow).
Where there are additional nurses they are providing 1-1 care as agreed with
commissioners and the continuing care assessment team due to the complexity
of the residents needs.
Regular recruitment drives in place, which have been largely unsuccessful;
commissioners aware; CLCH recruitment team asked to approach Nurse
Agencies regarding a guaranteed work for next 6 months for Band 5 and Band
6 nurses - this is a new initiative and progress will be reported back through the
DMT.
82
Unit:
Princess Louise
Month:
September
Early:
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
Reason Codes
Mon Tue Wed Thu Fri
1
2
3
4
5
42 42 42 42 43
5
5
5
5
5
2
3
4
3
3
1
1
1
3
4
4
4 3
-2
-1
-1
-1 -2
7
6
7
7
7
Fri
12
42
5
4
Sat Sun Mon
13
14 15
42
42 42
5
5
5
1
1
4
3
3
Tue Wed Thu
16 17 18
43 45 45
5
5
5
3
3
3
1
1
1
Fri
19
44
5
2
2
Sat Sun Mon
20
21 22
44
44 44
5
5
5
2
2
3
2
2
Tue Wed Thu
23 24 25
44 43 43
5
5
5
2
3
3
2
1
Fri
26
43
5
2
1
Sat Sun Mon
27
28 29
44
44 44
5
5
5
2
2
2
2
2
1
Tue
30
43
5
3
2
4
-1
6
3
-2
6
4
-1
6
3
-2
2
4
-1
2
4
-1
2
4
-1
2
4
-1
6
4
-1
6
4
-1
2
4
-1
2
4
-1
2
4
-1
2
4
-1
2
4
-1
6
4
-1
6
3
-2
2
4
-1
8
4
-1
2
3
-2
2
3
-2
6
4
-1
6
4
-1
6
3
-2
6
5
0
8
4
5
8
2
6
8
5
5
8
5
5
8
6
4
8
4
5
8
4
5
8
5
4
8
6
2
8
2
8
8
5
4
8
5
5
8
4
5
8
3
6
8
5
4
8
4
5
8
4
5
8
1
8
8
3
6
8
3
7
8
1
6
10
2
6
10
2
4
10
2
4
9
1
4
9
1
4
9
1
4
8
0
10
2
4
9
1
5
10
2
4
9
1
4
9
1
3
9
1
4
9
1
4
9
1
4
9
1
4
9
1
4
10
2
4
7
-1
2
8
4
3
1
8
0
8
3
6
8
0
8
4
3
1
8
0
8
4
5
9
1
4
8
4
3
1
8
0
9
1
3
9
1
4
43
4
2
1
1
4
0
43
4
1
3
42
4
1
2
42
4
2
1
42
4
1
2
42
4
2
1
42
4
42
4
2
1
42
4
2
2
42
4
2
2
42
4
2
1
43
4
2
1
45
4
2
1
44
4
1
2
44
4
2
2
44
4
2
1
44
4
2
44
4
2
2
43
4
43
4
1
2
44
4
4
43
4
1
3
4
44
4
3
1
44
4
2
1
43
4
2
2
4
0
3
-1
6
3
-1
2
3
-1
2
3
-1
2
4
0
3
-1
2
4
0
4
0
3
-1
2
3
-1
2
45
4
2
1
1
4
0
3
-1
2
3
-1
2
4
0
3
-1
2
2
-2
2
4
0
4
0
4
0
3
-1
6
4
0
4
0
3
-1
1
4
0
8
5
3
8
3
5
8
3
6
8
2
8
8
6
4
8
5
5
8
5
4
8
4
4
8
3
5
8
2
6
8
4
6
8
7
1
8
2
5
8
6
4
8
4
4
8
6
2
8
3
7
8
2
7
8
2
6
8
1
6
8
4
4
8
3
7
8
4
5
8
4
4
8
3
6
8
3
6
8
0
8
0
9
1
6
10
2
4
10
2
4
10
2
4
9
1
4
8
0
8
0
8
0
10
2
4
8
0
7
-1
2
10
2
4
8
0
8
0
10
2
4
9
1
4
8
0
7
-1
2
8
0
10
2
4
9
1
4
8
0
9
1
4
9
1
4
43
2
1
1
43
2
2
42
2
2
42
2
2
42
2
1
1
42
2
1
1
42
2
1
1
42
2
2
42
2
2
42
2
1
1
42
2
1
1
43
2
1
1
45
2
1
1
45
2
2
1
44
2
1
1
44
2
2
44
2
2
44
2
1
1
44
2
43
2
1
1
43
2
1
1
43
2
1
1
44
2
2
44
2
2
44
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
3
1
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
2
0
6
5
1
6
6
6
5
1
6
4
2
6
3
3
6
6
6
6
6
5
1
6
2
4
6
3
3
6
5
1
6
5
1
6
4
2
6
4
2
6
4
2
6
5
1
6
4
2
6
6
6
5
1
6
5
1
6
4
2
6
4
2
6
3
3
6
3
3
6
4
2
6
4
2
8
2
5
3
10
2
6
8
4
2
1
7
-1
6
4
4
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
42
4
1
2
42
4
2
42
4
3
42
4
2
2
3
-1
6
3
-1
6
3
-1
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
8
2
2
5
9
1
4
8
2
5
8
3
7
7
-1
6
4
4
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
42
2
2
42
2
2
42
2
1
42
2
1
1
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
6
5
1
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
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
6
0
Day Total
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
11
5
3
0
8
-3
11
7
0
2
9
-2
11
8
0
1
9
-2
11
6
4
0
10
-1
11
6
2
1
9
-2
11
5
5
0
10
-1
11
4
4
0
8
-3
11
8
1
0
9
-2
11
5
3
0
8
-3
11
6
3
0
9
-2
11
4
6
0
10
-1
11
8
1
0
9
-2
11
5
5
0
10
-1
11
4
6
0
10
-1
11
7
2
0
9
-2
11
6
3
0
9
-2
11
6
3
1
10
-1
11
7
3
0
10
-1
11
4
5
0
9
-2
11
6
4
0
10
-1
11
6
3
0
9
-2
11
6
1
0
7
-4
11
4
5
1
10
-1
11
4
6
0
10
-1
11
5
4
0
9
-2
11
4
4
0
8
-3
11
4
6
0
10
-1
11
7
3
0
10
-1
11
5
3
0
8
-3
11
6
5
0
11
0
Day Total
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
22
9
8
8
25
3
22
10
9
1
20
-2
22
13
12
0
25
3
22
12
11
1
24
2
22
14
9
0
23
1
22
11
11
0
22
0
22
13
12
0
25
3
22
11
15
0
26
4
22
15
11
0
26
4
22
15
10
0
25
3
22
15
9
0
24
2
22
14
9
0
23
1
22
9
12
1
22
0
22
11
11
0
22
0
22
11
15
0
26
4
22
17
6
0
23
1
22
11
12
0
23
1
22
14
11
0
25
3
22
11
12
0
23
1
22
16
7
0
23
1
22
11
14
0
25
3
22
12
12
0
24
2
22
8
15
0
23
1
22
9
13
0
22
0
22
11
13
0
24
2
22
8
15
0
23
1
22
11
11
1
23
1
22
11
10
1
22
0
22
11
13
0
24
2
22
10
14
0
24
2
Night
8
5
3
1
Tue Wed Thu
9
10 11
42 42 42
5
5
5
3
3
3
1
1
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
Late
8
5
4
Sat Sun Mon
6
7
8
43
42 42
5
5
5
2
1
4
2
2
9
1
9
1
1
4
0
8
4
5
10
2
9
1
4
1
2
0
2
0
6
4
2
2
0
6
5
1
2
0
6
3
3
1
1
2
0
Summary of key challenges & risks
The continuing care homes are running on high vacancies with a high
percentage of bank and agency, due to the recruitment and retention issues
resulting from the divestment process. Bank and agency do not arrive on a
number of occasions. If RN not available (red) HCAs are over booked (yellow).
Where there are additional nurses they are providing 1-1 care as agreed with
commissioners and the continuing care assessment team due to the complexity
of the residents needs.
Regular recruitment drives in place, which have been largely unsuccessful;
commissioners aware; CLCH recruitment team asked to approach Nurse
Agencies regarding a guaranteed work for next 6 months for Band 5 and Band 6
nurses - this is a new initiative and progress will be reported back through the
DMT.
1
2
3
4
5
6
7
8
Sickness
Unfilled bank shift
Escort
Special
Vacancies
Annual Leave
Mandatory Training
83
Unit:
Princess Louise Rehab
Month:
September
Early:
Late
Night
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
Reason Codes
Mon Tue Wed Thu
1
2
3
4
7
6
6
8
2
2
2
2
1
1
1
1
Fri
5
9
2
1
Sat Sun Mon Tue Wed Thu
6
7
8
9
10 11
8
8
7
7
7
6
2
2
2
2
2
2
1
1
1
1
2
1
Fri
12
6
2
1
13
14 15 16 17 18
6
6
6
6
5
5
2
2
2
2
2
2
2
2
1
2
1
1
Fri
19
7
2
1
20
21 22 23 24 25
7
7
7
9
10 10
2
2
2
2
2
2
1
1
2
1
1
1
Fri
26
9
2
1
Sat Sun Mon Tue
27
28 29 30
9
9
9
9
2
2
2
2
1
1
1
1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
2
0
1
-1
1
-1
2
0
2
0
1
-1
2
0
1
-1
1
-1
1
-1
1
-1
1
-1
2
0
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
1
-1
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
1
1
2
1
1
2
1
1
2
2
2
1
1
2
1
1
2
1
1
2
1
1
2
2
1
2
1
1
2
2
2
2
1
2
2
1
2
2
2
1
1
2
2
2
2
1
1
2
1
2
1
1
2
1
1
2
1
1
2
2
2
2
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
1
-1
2
0
2
0
2
0
1
-1
1
-1
1
-1
2
0
2
0
2
0
2
0
2
0
1
-1
2
0
2
0
2
0
1
-1
2
0
2
0
2
0
2
0
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
6
1
1
6
1
1
8
1
1
9
1
1
8
1
1
8
1
1
8
1
1
7
1
1
7
1
1
7
1
2
6
1
1
6
1
1
6
1
1
6
1
1
6
1
1
5
1
2
5
1
1
7
1
1
7
1
1
7
1
1
7
1
1
7
1
2
10
1
1
10
1
1
9
1
1
9
1
1
9
1
1
9
1
1
9
1
1
9
1
1
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
2
1
1
0
1
0
1
0
1
0
1
0
2
1
1
0
1
0
1
0
1
0
1
0
2
1
1
0
1
0
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
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
2
1
1
1
1
1
1
0
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
1
0
2
1
2
1
2
1
1
0
1
0
1
0
1
0
2
1
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
7
1
1
6
1
1
8
1
1
9
1
1
8
1
1
8
1
1
8
1
1
7
1
1
7
1
1
7
1
1
6
1
1
6
1
1
6
1
1
6
1
1
6
1
1
5
1
1
5
1
1
7
1
1
7
1
1
7
1
1
7
1
1
7
1
1
10
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
1
0
1
0
1
0
1
0
1
0
1
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
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
2
2
1
2
1
2
1
2
1
1
1
2
2
2
1
1
2
1
1
2
1
2
1
2
1
1
1
2
1
1
1
2
1
2
1
2
1
2
1
2
1
10
1
1
9
1
1
9
1
1
9
1
1
9
1
1
9
1
1
9
1
1
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
2
2
2
2
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
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
Day Total
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
5
0
0
5
1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
4
0
0
4
0
4
4
0
0
4
0
4
3
0
0
3
-1
4
5
0
0
5
1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
5
0
0
5
1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
4
3
0
0
3
-1
Day Total
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
5
2
2
0
4
-1
5
3
2
0
5
0
5
3
2
0
5
0
5
4
1
0
5
0
5
2
3
0
5
0
5
3
2
0
5
0
5
3
2
0
5
0
5
3
2
0
5
0
5
1
4
0
5
0
5
3
0
0
3
-2
5
3
2
0
5
0
5
1
4
0
5
0
5
3
2
0
5
0
5
3
0
0
3
-2
5
1
2
0
3
-2
5
2
1
0
3
-2
5
3
1
0
4
-1
5
3
2
0
5
0
5
1
4
0
5
0
5
4
1
0
5
0
5
3
2
0
5
0
5
2
2
0
4
-1
5
2
3
0
5
0
5
2
3
0
5
0
5
2
3
0
5
0
5
1
2
1
4
-1
5
5
0
0
5
0
5
5
0
0
5
0
5
4
1
0
5
0
5
3
2
0
5
0
1
2
3
4
5
6
7
8
Sickness
Unfilled bank shift
Escort
Special
Vacancies
Annual Leave
Mandatory Training
84
Unit:
Jade Ward
Month:
September
Early:
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
Reason Codes
Mon Tue Wed Thu
1
2
3
4
20 20 20 20
4
4
4
4
2
3
4
2
1
2
2
4
4
4
4
0
0
0
0
Sun Mon Tue Wed Thu
7
8
9
10 11
20 20 20 20 20
4
4
4
4
4
1
3
1
3
3
1
2
2
1
4
3
3
3
4
0
-1 -1 -1
0
1
2
2
4
0
4
0
3
1
1
1
3
0
3
1
1
2
4
1
3
3
3
3
0
3
0
3
1
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
20
3
1
1
1
3
0
20
3
2
20
3
3
20
3
2
1
20
3
2
20
3
1
20
3
1
1
3
0
3
0
3
0
2
-1
2
1
2
-1
2
1
2
-1
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
3
3
2
1
3
2
1
3
3
0
3
2
5
2
3
3
2
1
1
4
1
2
3
1
1
1
3
0
3
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
20
3
20
3
20
3
20
3
1
1
1
2
-1
2
1
2
3
0
2
2
-1
2
3
3
0
3
3
0
3
3
0
1
2
3
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
2
2
1
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
0
1
2
0
2
0
2
0
2
0
2
0
Day Total
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
10
3
2
4
9
-1
10
5
2
3
10
0
10
7
0
2
9
-1
10
4
3
3
10
0
10
5
1
3
9
-1
Day Total
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
8
3
2
3
8
0
8
3
3
2
8
0
8
4
4
0
8
0
8
3
3
2
8
0
8
2
5
4
11
3
Late
Night
2
1
3
0
2
1
3
0
3
1
2
Sat
6
20
4
3
1
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
3
0
3
Fri
5
20
4
3
1
3
0
3
2
1
3
3
3
1
4
5
2
3
2
1
3
0
1
1
2
-1
2
20
3
20
3
3
20
3
1
3
0
2
3
0
1
1
2
-1
1
Sat
13
20
4
2
3
1
1
1
3
0
3
1
1
2
4
1
3
3
2
20
3
20
3
1
20
3
1
20
3
2
1
2
-1
2
2
3
0
3
1
3
2
1
2
3
0
3
1
1
1
3
0
3
1
2
20
3
20
3
1
20
3
1
2
3
0
3
3
0
2
3
0
1
2
-1
2
2
2
2
1
2
1
2
2
1
2
0
2
0
1
2
0
1
2
0
10
4
1
4
9
-1
10
2
2
5
9
-1
10
4
1
3
8
-2
10
4
0
5
9
-1
8
6
2
1
9
1
8
4
3
1
8
0
8
2
2
6
10
2
8
2
4
2
8
0
1
2
3
0
3
1
2
Fri
12
20
4
2
1
1
4
0
3
0
3
0
2
4
0
Sun Mon Tue Wed Thu
14 15 16 17 18
20 20 20 20 20
4
4
4
4
4
1
3
2
3
3
1
1
3
4
3
3
4
3
0
-1 -1
0
-1
2
2
2
3
3
2
1
1
4
1
3
3
2
1
3
0
20
3
1
1
1
3
0
3
3
3
2
2
1
3
0
2
-1
2
3
3
1
4
0
Sun Mon Tue Wed Thu
21 22 23 24 25
20 20 20 20 20
4
4
4
4
4
1
2
4
4
2
2
1
1
3
2
4
4
4
-1 -2
0
0
0
2
2
3
1
2
3
0
20
3
2
20
3
2
20
3
2
20
3
2
1
3
0
1
3
0
1
3
0
3
3
2
3
3
1
3
0
2
3
0
20
3
3
20
3
2
3
0
2
-1
2
3
3
2
3
1
Sat
20
20
4
2
1
1
4
0
3
1
1
1
3
0
2
1
3
0
3
1
1
1
3
0
3
1
2
20
3
2
1
20
3
2
1
1
3
0
3
0
3
0
3
3
3
3
3
3
0
3
4
1
3
0
3
1
1
2
4
1
3
3
1
1
1
3
0
20
3
1
1
1
3
0
20
3
3
2
Fri
26
20
4
2
1
1
4
0
Sat
27
20
4
2
Sun Mon Tue
28 29 30
20 20 20
4
4
4
2
4
3
2
4
0
2
4
0
4
0
3
3
2
3
2
1
3
2
1
1
2
3
0
1
3
0
3
0
3
0
20
3
3
20
3
1
20
3
2
20
3
1
1
3
0
2
3
0
1
3
0
3
1
1
1
3
0
3
2
3
2
3
2
1
1
3
0
1
3
0
20
3
1
1
1
3
0
20
3
1
2
2
2
-1
2
2
-1
2
1
4
0
2
3
0
3
2
3
0
3
1
1
1
3
0
20
3
20
3
20
3
20
3
1
1
2
-1
2
3
3
0
3
3
0
3
3
0
3
3
0
1
3
0
3
0
3
0
20
3
20
3
20
3
20
3
20
3
20
3
20
3
2
3
0
20
3
1
1
1
3
0
2
1
3
0
1
2
3
0
1
2
3
0
3
3
0
3
3
0
3
3
0
1
2
3
0
2
3
0
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
2
1
1
2
1
1
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
3
0
2
4
1
3
20
3
1
1
1
3
0
20
3
1
1
1
3
0
20
3
1
1
1
3
0
20
3
1
2
2
2
2
2
2
1
3
0
20
3
1
3
0
1
3
0
3
1
2
1
3
1
4
2
0
2
0
2
0
2
0
2
0
1
2
0
10
5
0
4
9
-1
10
4
1
4
9
-1
10
4
2
3
9
-1
10
4
1
5
10
0
10
4
1
5
10
0
10
5
1
3
9
-1
10
6
2
1
9
-1
10
5
3
1
9
-1
10
5
1
3
9
-1
10
6
1
3
10
0
10
4
1
5
10
0
10
3
2
4
9
-1
10
4
1
3
8
-2
10
6
2
2
10
0
10
6
1
3
10
0
10
3
2
4
9
-1
10
6
3
1
10
0
10
3
1
5
9
-1
10
4
0
6
10
0
10
5
1
3
9
-1
10
4
0
6
10
0
8
2
2
3
7
-1
8
4
4
1
9
1
8
4
1
5
10
2
8
6
0
2
8
0
8
5
2
0
7
-1
8
6
1
3
10
2
8
4
1
2
7
-1
8
4
2
2
8
0
8
2
0
6
8
0
8
5
0
3
8
0
8
6
1
1
8
0
8
3
3
3
9
1
8
3
3
2
8
0
8
3
5
0
8
0
8
5
1
3
9
1
8
3
3
2
8
0
8
3
2
3
8
0
8
5
1
2
8
0
8
5
3
0
8
0
8
4
3
1
8
0
8
4
2
2
8
0
Corrective actoin plan
RN VACANCIES
ACTIVE RECRUITMENT IN PROGRESS
Sickness
Unfilled bank shift
Escort
Special
Vacancies
Annual Leave
Mandatory Training
Competency Training
20
3
1
1
3
0
1
3
0
1
2
3
4
5
6
7
8
9
3
1
1
1
3
0
2
1
3
0
2
3
0
1
1
2
-1
1
Fri
19
20
4
4
85
Unit:
Marjory Warren
Month:
September
Early:
Late
Night
Tue Wed Thu Fri
2
3
4
5
34 33 33 34
5
5
5
5
2
5
3
3
1
2
1
4
5
4
4
-1
0
-1
-1
2
2
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
3
2
2
3
3
2
4
1
4
5
2
3
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
34
4
4
1
5
0
1
5
0
2
7
2
7
2
4
-1
8
2
5
0
1
5
0
5
0
3
3
3
3
2
1
6
3
4
3
3
1
4
1
8
3
2
2
1
5
2
4
3
2
2
1
5
2
4
3
2
2
1
5
2
4
3
2
1
1
4
1
4
3
3
1
2
5
2
4
3
3
2
1
6
3
4
4
3
34
4
3
34
4
2
1
1
4
0
34
4
3
34
4
3
34
4
3
1
4
0
1
4
0
3
2
1
1
4
1
4
3
3
1
3
3
1
4
1
4
4
1
4
34
3
1
1
34
3
3
33
3
1
2
2
-1
2
3
0
3
0
1
2
-1
2
2
2
2
2
4
Sat Sun Mon Tue Wed Thu Fri
20
21 22 23 24 25 26
32
33 33 32 34 34 32
5
5
5
5
5
5
5
4
4
4
4
4
5
5
1
5
0
5
0
5
0
3
1
3
3
4
Sat Sun Mon Tue
27
28 29 30
32
32 32 33
5
5
5
5
5
3
3
3
1
1
2
5
4
4
5
0
-1 -1 0
2
2
4
-1
1
4
-1
2
4
-1
2
4
-1
2
3
2
3
1
6
3
4
4
1
4
2
6
3
4
3
0
3
0
34
4
3
33
4
4
33
4
3
32
4
3
32
4
3
32
4
3
4
0
34
4
2
1
1
4
0
1
4
0
4
0
3
-1
1
4
0
1
4
0
2
5
1
4
1
4
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
3
2
2
3
3
1
3
2
1
3
2
1
3
0
3
0
3
2
2
1
5
2
4
3
1
2
1
4
1
4
3
2
3
4
1
3
3
1
3
1
5
2
4
3
1
3
4
1
4
3
1
1
1
3
0
4
1
4
5
2
4
3
2
3
1
6
3
4
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
34
3
2
1
33
3
1
1
1
3
0
33
3
1
1
1
3
0
34
3
1
34
3
1
1
32
3
1
2
32
3
1
2
-1
2
2
-1
3
0
3
0
3
0
34
3
1
1
1
3
0
34
3
1
1
1
3
0
34
3
1
1
1
3
0
34
3
1
3
32
3
1
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
1
1
1
3
1
4
2
2
2
2
2
1
3
2
1
2
4
2
4
3
1
4
2
1
1
2
4
2
4
2
1
2
1
4
2
4
3
1
4
2
4
2
1
3
1
5
3
4
2
2
1
1
4
2
4
2
2
2
2
0
2
2
1
1
4
2
4
2
2
0
2
2
1
1
4
2
4
4
2
4
3
5
3
4
4
2
4
5
3
4
5
3
4
5
3
4
2
2
3
1
6
4
4
12
10
1
0
11
-1
12
5
2
4
11
-1
12
9
1
2
12
0
12
8
0
2
10
-2
12
7
2
0
9
-3
12
8
2
2
12
0
12
7
3
2
12
0
12
9
2
4
15
3
12
6
1
4
11
-1
12
7
1
3
11
-1
12
7
2
3
12
0
12
9
0
2
11
-1
12
7
2
2
11
-1
12
6
3
2
11
-1
12
8
3
1
12
0
12
5
0
3
8
-4
12
6
2
1
9
-3
12
7
2
2
11
-1
12
6
2
3
11
-1
12
8
1
2
11
-1
12
9
1
1
11
-1
12
7
2
2
11
-1
12
9
2
0
11
-1
12
10
1
1
12
0
12
10
0
2
12
0
12
11
1
0
12
0
12
10
1
1
12
0
12
7
2
2
11
-1
12
8
3
0
11
-1
12
7
3
2
12
0
8
5
5
1
11
3
8
8
3
0
11
3
8
7
1
2
10
2
8
5
5
0
10
2
8
3
4
2
9
1
8
6
4
4
14
6
8
7
5
3
15
7
8
5
5
4
14
6
8
5
6
1
12
4
8
4
8
2
14
6
8
5
8
3
16
8
8
6
4
3
13
5
8
7
4
1
12
4
8
8
2
3
13
5
8
4
7
3
14
6
8
3
7
5
15
7
8
6
7
2
15
7
8
6
5
5
16
8
8
4
6
4
14
6
8
3
9
4
16
8
8
3
12
2
17
9
8
8
5
0
13
5
8
6
7
6
19
11
8
7
5
3
15
7
8
6
5
3
14
6
8
7
3
3
13
5
8
7
4
1
12
4
8
5
6
2
13
5
8
8
2
3
13
5
8
6
5
0
11
3
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
3
2
1
13
14 15 16 17 18 19
34
34 34 33 31 32 32
5
5
5
5
5
5
5
3
3
5
2
4
2
3
1
1
1
1
1
1
1
1
5
4
5
3
5
4
4
0
-1
0 -2
0
-1
-1
2
2
2
2
2
5
2
3
3
0
3
3
6
7
8
9
10 11 12
34
32 32 32 34 34 34
5
5
5
5
5
5
5
4
4
5
2
3
4
5
3
1
1
1
3
0
Agreed RN
Regular RN
Bank RN
Day Total
Agency RN
Total
Variance
Day Total
Reason Codes
Mon
1
Number of patients 34
5
Agreed RN
4
Regular RN
Bank RN
Agency RN
Total
4
Variance
-1
2
Reason
3
-1
2
3
-1
2
2
3
0
4
1
4
3
2
2
1
5
2
4
3
3
1
2
6
3
4
3
2
2
1
5
2
4
3
1
1
4
6
3
4
3
3
2
2
4
1
4
3
1
4
1
4
3
2
4
3
3
1
6
3
4
4
1
4
3
3
1
2
6
3
4
34
4
2
1
1
4
0
31
4
2
33
4
2
32
4
3
32
4
2
33
4
3
33
4
4
33
4
3
32
4
4
34
4
4
34
4
3
32
4
4
1
3
-1
2
2
-2
2
1
4
0
2
4
0
3
-1
1
4
0
4
1
4
0
2
4
0
4
0
1
4
0
3
2
1
2
5
2
4
3
3
2
2
1
5
2
4
3
3
1
1
5
2
4
3
2
1
1
4
1
4
3
1
4
2
7
4
4
3
5
1
6
3
4
3
1
3
2
6
3
3
3
3
1
33
3
32
3
2
1
32
3
1
2
3
0
3
0
33
3
1
1
1
3
0
33
3
2
-1
2
33
3
1
1
2
4
1
5
2
2
3
2
2
3
2
2
2
1
5
3
4
2
1
3
1
5
3
4
2
2
3
1
3
4
1
4
31
3
1
2
3
2
1
3
3
4
1
5
2
4
32
4
3
32
4
3
33
4
4
33
4
3
1
4
0
1
4
0
1
4
0
4
0
4
0
3
2
2
3
2
2
3
2
2
3
3
1
3
2
2
4
1
4
4
1
4
4
1
4
4
1
4
4
1
4
3
2
2
1
5
2
4
4
1
4
34
3
1
2
34
3
2
1
34
3
2
32
3
2
1
32
3
2
1
32
3
1
2
33
3
1
2
33
3
1
2
3
0
3
0
3
0
3
0
3
0
3
0
3
0
2
2
1
2
5
3
4
2
3
1
1
5
3
4
2
2
2
1
2
3
6
4
4
2
1
1
1
3
1
4
2
2
2
5
3
4
2
2
3
2
7
5
4
4
2
4
1
3
1
4
3
1
4
4
1
4
2
1
3
0
1
3
0
2
3
Patients in room 23 and 39 are still one to one. High risk of fall patients, Rn
vacancies requests not filled by bank
Active recruitment for RN's in progress
Sickness
Unfilled bank shift
Escort
Special
Vacancies
Annual Leave
Mandatory Training
Competency Training
3
3
1
3
2
5
2
4
3
3
1
1
2
3
4
5
6
7
8
9
4
1
4
86
Unit:
Pembridge
Month:
September
Early:
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
Reason Codes
Mon Tue Wed Thu
1
2
3
4
9 10 10
9
4
4
4
4
3
2
3
3
1
1
1
1
4
4
4
3
0
0
0
-1
1
Sat
6
6
4
2
1
2
1
1
1
3
1
6
2
1
1
1
3
1
6
2
1
1
2
1
1
2
0
2
0
7
2
1
1
3
-1
2
Sun Mon Tue Wed Thu
7
8
9
10 11
7
7
5
5
6
4
4
4
4
4
1
2
2
2
2
1
1
1
1
1
1
1
1
3
3
3
4
4
-1 -1 -1
0
0
2
2
2
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
1
1
2
1
1
2
2
0
2
0
2
0
2
0
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
9
2
2
10
2
2
10
2
2
9
2
2
7
2
2
7
2
1
2
0
2
0
2
0
2
0
2
0
1
2
0
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Reason
2
1
1
2
1
1
2
2
1
1
2
1
1
2
2
2
0
2
0
2
0
2
0
2
0
2
0
1
-1
2
2
0
Number of patients
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Reason
9
2
2
9
2
2
8
2
2
9
2
2
6
2
1
1
7
2
1
1
7
2
1
1
5
2
1
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
1
1
1
1
1
1
1
1
1
1
1
1
1
0
1
0
1
0
1
0
1
0
Day Total
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
8
7
0
1
8
0
8
6
1
1
8
0
8
7
0
1
8
0
8
7
0
0
7
-1
Day Total
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
5
2
3
0
5
0
5
2
3
0
5
0
5
0
5
0
5
0
5
3
2
0
5
0
Late
Night
2
2
Fri
5
8
4
1
1
1
3
-1
6
2
Fri
12
7
4
2
1
3
-1
2
Sat
13
8
4
2
1
1
4
0
2
1
1
1
3
1
2
2
1
1
2
1
1
2
1
1
2
2
2
0
2
0
2
0
2
0
5
2
2
5
2
2
6
2
2
7
2
1
8
2
2
2
0
2
0
2
0
2
0
1
2
0
2
1
2
2
2
2
1
1
2
2
0
Sun Mon Tue Wed Thu
14 15 16 17 18
8
8
6
6
6
4
4
4
4
4
2
2
2
1
1
1
1
1
1
1
2
2
3
3
4
3
4
-1 -1 0
-1
0
2
2
2
1
1
1
3
1
1
2
2
8
2
1
2
0
2
2
0
5
2
1
1
1
2
0
1
1
1
0
8
4
2
1
7
-1
5
3
2
1
6
1
2
4
0
Sat
20
8
4
2
1
1
4
0
Sun Mon Tue Wed Thu
21 22 23 24 25
6
7
7
8
8
4
4
4
4
4
2
2
4
1
2
1
2
1
2
1
2
4
4
4
4
4
0
0
0
0
0
2
1
1
2
1
1
2
1
1
2
2
2
1
3
1
2
0
2
0
2
0
2
0
2
0
2
0
2
0
8
2
1
8
2
2
6
2
1
6
2
2
6
2
2
8
2
1
8
2
1
1
6
2
1
1
2
0
1
2
0
2
0
1
2
0
2
0
2
0
1
2
0
2
0
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
2
1
1
2
1
1
2
1
1
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
6
2
1
1
7
2
1
1
8
2
1
1
8
2
1
1
2
1
1
8
2
1
6
2
1
1
6
2
1
1
6
2
1
8
2
1
8
2
1
2
0
2
0
2
0
2
0
1
2
0
2
0
1
2
0
2
0
2
0
1
2
0
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
8
4
2
1
7
-1
8
3
3
1
7
-1
8
5
0
2
7
-1
8
5
2
0
7
-1
8
5
2
1
8
0
8
4
2
2
8
0
8
5
1
1
7
-1
8
4
1
3
8
0
8
4
1
2
7
-1
8
5
0
2
7
-1
8
4
2
2
8
0
5
2
3
1
6
1
5
3
1
0
4
-1
5
2
3
0
5
0
5
4
1
1
6
1
5
3
2
0
5
0
5
2
3
0
5
0
5
3
2
0
5
0
5
4
1
0
5
0
5
3
2
1
6
1
5
4
1
1
6
1
5
2
3
0
5
0
2
2
2
Fri
19
8
4
2
2
2
2
2
2
Fri
26
10
4
2
-2
Sat
27
10
4
2
1
1
4
0
2
Sun Mon Tue
28 29 30
11 9 10
4
4
4
2
3
3
1
1
1
1
4
4
4
0
0
0
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
1
1
2
2
1
-1
2
2
0
2
0
2
0
2
0
2
0
2
0
2
0
7
2
3
7
2
2
8
2
2
10
2
2
10
2
2
11
2
2
10
2
2
10 10
2
2
3
2
3
1
6
2
0
2
0
2
0
2
0
2
0
2
0
3
1
6
2
0
2
2
1
1
2
2
1
1
2
2
2
1
1
2
1
1
2
1
2
2
1
1
1
-1
6
2
0
2
0
2
0
2
0
2
0
2
0
1
-1
6
2
0
6
2
1
7
2
2
6
2
2
8
2
2
10
2
2
10
2
11
2
11
2
10
2
2
9
2
2
2
2
2
1
2
0
1
2
0
2
0
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
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
8
4
1
2
7
-1
8
4
1
3
8
0
8
4
0
4
8
0
8
4
2
2
8
0
8
4
1
3
8
0
8
7
0
2
9
1
8
8
0
0
8
0
8
5
2
1
8
0
8
6
0
2
8
0
8
2
4
0
6
-2
8
4
3
1
8
0
8
4
3
1
8
0
8
8
0
1
9
1
8
7
0
1
8
0
5
2
3
0
5
0
5
3
2
0
5
0
5
3
2
0
5
0
5
4
1
0
5
0
5
5
0
0
5
0
5
3
1
0
4
-1
5
2
2
0
4
-1
5
2
3
0
5
0
5
3
2
0
5
0
5
2
3
0
5
0
5
3
2
0
5
0
5
3
2
0
5
0
5
3
1
0
4
-1
5
4
1
0
5
0
1
1
2
0
1
1
2
3
4
5
6
7
8
Sickness
Unfilled bank shift
Escort
Special
Vacancies
Annual Leave
Mandatory Training
87
Trust Total
RN
Agreed RN
Regular RN
Bank RN
Agency RN
Total
Variance
Trust Total
HCA
Agreed HCA
Regular HCA
Bank HCA
Agency HCA
Total
Variance
Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu
1
2
3
4
5
6
7
8
9
10 11
62 62
62 62 62 62 62 62 62
62 62
44 37
44 37 34 32 35 42 33
46 36
7 10
5 11 13 15 11
6 11
5
9
7 11
9
9
6
9 11 11 13
10 13
58 58
58 57 53 56 57 59 57
61 58
-4 -4
-4 -5 -9 -6
-5
-3 -5
-1 -4
83
46
28
17
91
8
83
54
29
6
89
6
83
57
32
3
92
9
83
54
33
4
91
8
83
49
37
8
94
11
83
55
30
10
95
12
83
56
32
7
95
12
83
48
38
13
99
16
83
83
54
60
36
32
8
8
98 100
15
17
83
55
38
5
98
15
Fri
12
62
39
9
8
56
-6
83
52
31
11
94
11
13 14 15 16 17 18
62 62 62 62
62 62
37 40 44 41
38 38
11
8
6
8
15
8
12 12
8
9
5 11
60 60 58 58
58 57
-2
-2
-4 -4
-4 -5
83
58
27
7
92
9
83
57
26
7
90
7
83
55
36
8
99
16
83
59
23
12
94
11
83
53
31
12
96
13
83
56
29
14
99
16
Fri
19
62
41
7
11
59
-3
83
54
34
7
95
12
20 21 22 23 24 25
62 62 62 62
62 62
39 35 45 49
45 42
8 10
8
7
8
6
12 11
8
2
7 11
59 56 61 58
60 59
-3
-6
-1 -4
-2 -3
83 83
60 52
26 42
11
7
97 101
14 18
83
54
34
5
93
10
83
51
39
8
98
15
83
53
35
8
96
13
83
53
34
8
95
12
Fri
26
62
44
9
5
58
-4
83
48
34
10
92
9
Sat Sun Mon Tue
27 28 29 30
62 62 62 62
35 39 44 42
14 10
9
6
11 10
5 11
60 59 58 59
-2
-3
-4 -3
83
56
29
8
93
10
83
55
34
7
96
13
83
56
31
10
97
14
83
55
32
6
93
10
Early Census Total
191 189 188 188 187 183 181 181 179 182 183 187 188 188 187 186 186 187 190 190 189 190 190 192 192 189 190 191 190 191
Late Census Total
190 189 191 189 183 182 181 179 147 183 184 188 188 188 187 183 188 189 190 191 189 189 190 191 193 189 191 190 191 194
Night Census Total
191 187 188 190 183 182 181 179 181 183 184 188 188 181 186 183 188 189 190 191 189 189 191 192 192 189 191 191 192 150
Average Daily Census 191 188 189 189 184 182 181 180 169 183 184 188 188 186 187 184 187 188 190 191 189 189 190 192 192 189 191 191 191 178
88
Day
Total
monthly
planned
staff
hours
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
Total
monthly
planned
staff
hours
Total
monthly
actual
staff
hours
1125
1125
1575
2025
675
1575
2025
1350
11475
900
1035
1800
1620
510
1447.5
1875
1275
10462.5
1575
1800
2700
3600
675
1350
1350
900
13950
1800
2415
2805
3967.5
810
1410
2070
907.5
16185
450
450
675
450
225
675
675
450
4050
450
420
675
457.5
225
645
645
450
3967.5
450
450
900
1350
450
450
450
225
4725
450
450
1080
1350
225
465
960
225
5205
Average fill rate - care staff (%)
Care Staff
Average fill rate - registered nurses (%)
Registered nurses
Average fill rate - care staff (%)
Athlone House
Ahlone Rehab
Garside
Princess Louise
Alexandra Rehab (PLK)
Jade
Marjory Warren
Pembridge
Whole Trust
Care Staff
Night
Average fill rate - registered nurses (%)
Registered nurses
Day
Night
80%
92%
114%
80%
76%
92%
93%
94%
90%
114%
134%
104%
110%
120%
104%
153%
101%
118%
100%
93%
100%
102%
100%
96%
96%
100%
98%
100%
100%
120%
100%
50%
103%
213%
100%
111%
Percentage fill rates September 2014
Day
Athlone House
Ahlone Rehab
Garside
Princess Louise
Alexandra Rehab (PLK)
Jade
Marjory Warren
Pembridge
Whole Trust
RN
80%
92%
114%
80%
76%
92%
93%
94%
90%
HCA
114%
134%
104%
110%
120%
104%
153%
101%
118%
Night
RN
HCA
100%
100%
93%
100%
100%
120%
102%
100%
100%
50%
96%
103%
96%
213%
100%
100%
98%
111%
89
Unit
Alexandra Unit (PLK)
Athlone Rehabilitation
Garside
Garside
Garside
Garside
Garside
Garside
Garside
Garside
Jade
Jade
Jade
Jade
Jade
Incident type
Falls
Medication Errors
Falls
Fall
Falls
Falls
Falls
Medication Errors
Medication Errors
Falls
Medication Errors
Medication Errors
Medication Errors
Falls
Falls
Fall
Fall
Fall
Fall
Fall
Medication error
Medication error
Medication error
Falls
Falls
Falls
Medication error
Medication error
Date
Time
09-Sep
10-Sep
16-Sep
0005
1600
0615
21-Sep
01-Sep
05-Sep
08-Sep
15-Sep
15-Sep
16-Sep
17-Sep
17-Sep
17-Sep
24-Sep
26-Sep
02-Sep
02-Sep
03-Sep
17-Sep
17-Sep
19-Sep
19-Sep
19-Sep
01-Sep
01-Sep
07-Sep
09-Sep
15-Sep
19:50
1838
0820
1220
1100
1230
0000
no time
no time
no time
1700
0510
14:00
14:00
11:30
15:30
15:30
no time
no time
no time
0145
0400
1805
0800
1400
Shift
Night
Late
Night
Late
Late
Early
Early
Early
Early
Night
Early
Late
Night
Late
Night
Early
Late
Early
Early
Late
Early
Late
Night
Night
Night
Late
Early
Early
Staffing
Status RN
0
1
0
0
0
-1
0
0
0
0
-1
0
0
0
0
0
0
0
2
3
0
1
0
-1
-1
-1
-1
-1
Staffing Status
HCA
-1
0
-1
1
1
2
2
2
2
0
2
1
0
1
-1
0
0
0
0
1
0
0
1
0
0
0
0
1
Actual no. on
shift RN/HCA
1/1
2/1
1/1
2/4
2/5
2/6
3/6
3/6
3/6
2/2
2/6
2/5
2/2
1/2
1/1
4/6
4/6
4/6
4/6
6/7
4/6
4/6
3/5
2/2
2/2
2/3
3/3
3/4
90
Jade
Jade
Jade
Jade
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Marjory Warren
Pembridge
Pembridge
Pembridge
Pembridge
Pembridge
Pembridge
Pembridge
Medication error
Falls
Medication error
Medication error
Falls
Falls
Falls
Medication Errors
Falls
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Falls
Medication Errors
Medication Errors
Falls
Falls
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Medication Errors
Medication Errors
15-Sep
16-Sep
18-Sep
20-Sep
02-Sep
02-Sep
02-Sep
05-Sep
06-Sep
07-Sep
08-Sep
08-Sep
08-Sep
09-Sep
09-Sep
09-Sep
12-Sep
13-Sep
18-Sep
18-Sep
24-Sep
24-Sep
26-Sep
26-Sep
02-Sep
06-Sep
06-Sep
22-Sep
23-Sep
23-Sep
24-Sep
01-Sep
01-Sep
1400
0915
1620
2030
2050
1400
1400
1800
0330
1800
no time
no time
no time
no time
no time
no time
2015
2200
1100
1030
2000
1800
1400
1400
0620
1300
1300
1730
1625
1130
1200
1400
1400
Late
Early
Late
Late
Late
Early
Late
Late
Night
Late
Early
Late
Night
Early
Late
Night
Late
Night
Early
Early
Late
Late
Early
Late
Night
Early
Late
Late
Late
Early
Early
Early
Late
0
-1
0
0
0
-1
0
-1
-1
0
2
1
0
-1
0
0
-1
-1
-1
-1
0
0
0
0
0
-1
0
1
0
0
0
-2
-1
1
0
0
0
1
2
1
0
1
2
3
1
2
1
1
2
1
2
3
3
1
1
3
1
0
1
0
-1
0
-1
0
2
1
3/4
3/3
3/3
3/3
4/4
4/5
4/4
3/3
2/3
4/5
7/6
5/4
3/4
4/4
4/4
3/4
3/4
2/4
4/6
4/6
4/4
4/4
5/6
4/4
2/1
3/3
2/2
3/1
2/2
4/1
4/2
3/10
3/9
91
Medication Errors
Falls
Falls
Falls
Medication Errors
Falls
Falls
Falls
Falls
Falls
Falls
03-Sep
09-Sep
10-Sep
10-Sep
10-Sep
12-Sep
16-Sep
16-Sep
20-Sep
20-Sep
24-Sep
1130
0005
1230
1230
1600
0545
0715
0615
1300
1300
1755
Numbers in the staffing status columns are the variance against agreed staffing levels
Early
Night
Early
Late
Late
Night
Night
Night
Early
Late
Late
-1
0
-1
-1
-1
0
0
0
-1
0
0
Green
Yellow
Red
1
0
1
2
2
0
0
0
1
0
-1
4/9
2/6
4/9
3/10
3/10
2/6
2/6
2/6
4/9
4/8
4/7
Staffing at
agreed level
Staffing above
agreed level
Staffing below
agreed level
92
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title: Patient Safety – Serious Incident Report for cases to end September 2014
Agenda item number: 3.1
Report of: Chief Nurse and Director of Quality Governance
Contact Officer: Head of Patient Safety
Relevant CLCH 14/15 Goal 2: Support people safely out of hospital: providing safe, high quality
value for money alternatives to hospital admissions
Executive Summary: Central London Community Healthcare NHS Trust (CLCH) is committed to
creating and maintaining a culture of openness, learning from experience and fair blame. Whilst
everything is done to ensure services and care given are of a high quality, at times mistakes do
happen. The Trust has robust structures and processes in place to identify any errors at an early
stage, thoroughly investigate in a transparent and honest way, identify how things may have been
done differently and learn from those mistakes in order to improve care. 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 area of concern currently is the number of grade 3 and 4 pressure ulcer cases, attributable to
CLCH. Although the total in June 2014 fell to 9, it increased again in July 2014 with a total of 21,
and a total of 12 for August 2014 and September 2014. Currently the majority of cases are
occurring in patients’ homes The management of pressure ulcers is monitored within the Pressure
Ulcer Performance Review Group.
Assurance provided: The minutes of the Quality Committee meeting provide evidence of review of
serious incidents.
Report provenance: Also presented to Trust Board and Patient Safety & Risk group
Discussion
Serious Incident Report/Trust Board/Oct 2014
Information
Page 1 of 35
93
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. North West London Commissioning Support Unit (NWLCSU) has responsibility for overseeing the
Page 2 of 35
94
management of the majority of serious incidents within CLCH. Some categories of serious incident are managed by NHS England directly. All
externally reportable 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 NWLCSU/NHSE.
2.4
From 1st October 2014 the NWLCSU ceased to exist. Future management of serious incidents will be overseen by Central London, West London,
Hammersmith and Fulham, Hounslow and Ealing (CWHHE) Collaboration of Clinical Commissioning Groups.
2.5
A total of thirteen new serious incidents were declared to NWLCSU in September 2014. Details are presented in section 3 below.
2.6
During September 2014 a total of twenty three cases were reviewed by a serious incident panel, prior to submission of externally reportable
reports to NWLCSU. Twenty of these were pressure ulcers cases, and one each of the following category: Slip, trip & fall, Safeguarding of a
Vulnerable Adult and Allegation against a Healthcare Professional. Details of each case is included in sections 7 (external cases) and 9 (internal
cases) below.
2.7
Twelve pressure ulcers were reported to NWLCSU during September 2014. Details are reported in Sections 3 and 4 below.
3.
Newly Reported SIs
New SIs reported
3.1
3.2
There were thirteen new SIs reported to NWL CSU during September 2014. Twelve of these were pressure ulcers; Seven grade three and five
grade four. The non-pressure ulcer case was a Confidential Information Leak incident, detailed in Table 1 below.
There have been some delays in reporting a number of pressure ulcer cases on to STEIS, explanation given in Table 3 below.
Table 1 – Newly Reported SIs in September 2014
No
CCG
ID
Number
(STEIS)
Date of
Incident
Date put
on Datix
Date
reported
on STEIS
Incident
Category
Description of Incident
SI RCA Report
Due Date
(investigation)
1
NHS Central
2014/
24/07/14
24/07/14
02/09/14
Pressure Ulcer
Pressure Ulcer Grade 3. Late reporting
03/11/2014
Page 3 of 35
95
London CCG
28488
2
NHS Barnet
CCG
2014/
28498
06/08/14
06/08/14
02/09/14
Pressure Ulcer
3
NHS Barnet
CCG
NHS West
London CCG
NHS Barnet
CCG
NHS Barnet
CCG
2014/
29928
2014/
29917
2014/
29921
2014/
29922
04/09/14
05/09/14
15/09/14
Pressure Ulcer
27/08/14
12/09/14
15/09/14
Pressure Ulcer
09/09/14
10/09/14
15/09/14
Pressure Ulcer
04/07/14
07/07/14
15/09/14
Pressure Ulcer
7
NHS Barnet
CCG
2014/
29923
18/07/14
20/07/14
15/09/14
Pressure Ulcer
8
NHS Barnet
CCG
2014/
29927
22/07/14
28/07/14
15/09/14
Pressure Ulcer
4
5
6
as initially graded incorrectly as a
grade 2. When datix was changed by
the DN team on 16/08/14 no
notification was sent to the RCA/Datix
inboxes. Found during quality check on
1 Sept.
Pressure Ulcer Grade 4.
Not declared when originally entered
on datix. Found during quality check
on 1 Sept 14.
Pressure Ulcer Grade 4. Delayed
reporting due to admin backlog.
Pressure Ulcer Grade 3. This incident
was initially incorrectly reported on
datix as a non CLCH case. It was
highlighted during preparation for a
safeguarding conference.
03/11/2014
14/11/2014
14/11/2014
14/11/2014
14/11/2014
14/11/2014
14/11/2014
Page 4 of 35
96
9
NHS Barnet
CCG
2014/
30156
15/08/14
29/08/14
17/09/14
Confidential
Information
Leak
10
NHS West
London CCG
NHS Barnet
CCG
NHS Barnet
CCG
NHS
Hammersmit
h & Fulham
CCG
2014/
30619
2014/
30621
2014/
30622
2014/
30623
19/09/14
19/09/14
19/09/14
Pressure Ulcer
16/09/14
16/09/14
19/09/14
Pressure Ulcer
01/09/14
16/09/14
19/09/14
Pressure Ulcer
15/09/14
15/09/14
19/09/14
Pressure Ulcer
11
12
13
4.
A Hertfordshire HV team received an
A4 envelope via normal mail
containing a large number of A&E
attendance slips from CLCH. The A&E
slips contain confidential patient
information. 10 of the referrals
received were for children living in the
London area not Hertfordshire.
Pressure Ulcer Grade 3
17/11/2014
18/11/2014
18/11/2014
18/11/2014
18/11/2014
Pressure Ulcer Update
SI Pressure Ulcer update
4.1
Following national guidance, all grade 3 & 4 pressure ulcers, acquired within CLCH, are reported as SIs. Table 2 below shows the number initially
reported, those cases subsequently de-escalated and the total cases attributable to CLCH, since April 2013.
Table 2 – Numbers of Pressure Ulcers reported to NWL CSU since April 2013
Newly
De-escalated following investigation
reported cases
Total attributable
to CLCH
Page 5 of 35
97
4.2
T April 2013
May 2013
June 2013
July 2013
Aug 2013
September 2013
October 2013
November 2013
December 2013
January 2014
February 2014
March 2014
April 2014
May 2014
June 2014
July 2014
August 2104
September 2014
8
21
10
9
4
10
18
11
16
9
10
14
16
21
9
21
12
12
1
2
0
0
4
2
4
3
6
3
5
6
3
2
0
3 (Awaiting decision on 1 more case)
0
0
7
19
10
9
0
8
14
8
10
6
5
8
13
19
9
18
12
12
Pressure Ulcer Trends
Graph 1: Standard Process Chart
since April 2013.
Page 6 of 35
98
Pressure Ulcer Serious Incident Reported on STEIS since April 2013 to
September 2014
25
20
15
10.39
10
19
18
17
16
15
14
13
12
11
9
8
10
-5
7
6
5
4
3
2
0
1
5
0
Referrals per month
30
-10
UCL
LCL
Average
New Pressure Ulcer Serious Incidents Reported on STEIS per month
Graph 2: Line Graph with change in process
Page 7 of 35
99
PU Information
on hub.
Poster
circulated
20
18
Pressure Ulcer Serious Incidents CLCH
Training
enhanced
OSCE commence.
Dietetics rep for
patients at risk
16
14
12
10
8
6
4
2
Wound
Forms
amended
Training in
4 Nursing
Homes
Stop the
Pressure
New PU
Policy
0
Policy Revised.
App introduced
month
2013 04 2013 05 2013 06 2013 07 2013 08 2013 09 2013 10 2013 11 2013 12 2014 01 2014 02 2014 03 2014 04 2014 05 2014 06 2014 07 2014 08 2014 09
4.3
Breakdown of newly reported pressure ulcers by CCG/Location of Origin for September 2014, in table 3 below. Currently the majority of cases are
occurring in patients’ homes.
Table 3 – Numbers of Pressure Ulcers by CCG & grade for September 2014
CCG
Barnet
H&F
West London
Central London
Grade 3
4
1
1
1
Grade 4
4
0
1
0
Location of Origin
3: Patient’s Homes; 4: Other non-CLCH Residential Home; 1:FMH
Patient’s Home
All Patient’s Homes
Patient’s Home
Total
8
1
2
1
Page 8 of 35
100
4.4
CLCH is committed to reducing the number of pressure ulcers in the community and the Pressure Ulcer Performance Review Group is in place to take
forward work to reduce the incidence and promote the healing of pressure ulcers. A trust wide action plan has been agreed.
4.5
Components of the Trust-wide pressure ulcer action plan include:
1. Monitoring the trend of reported pressure ulcer incidence
2. Implementation of Pressure Ulcer policy
3. Pressure ulcer training
4. Pressure Ulcer Link Nurses Forum
5. Pressure ulcer documentation including core care plan and wound assessment & evaluation
6. Pressure ulcer competency development and assessment
7. Delivery of innovative initiatives – e.g. Pressure Ulcer CQUIN
8. NICE Pressure Ulcer compliance audit
9. Strategic work across the health economy
10. Pressure Ulcer Quality Action Teams
5.
SI Status Update
SI status update
5.1
No
1
2
All reports were submitted on time to NWLCSU in September 2014. Table 4 below depicts the cases due and sent.
Table 4 –SIs sent to NWLCSU September 2014
CCG
ID Number
(STEIS)
Incident Category
NHS West London
CCG
NHS Central
London CCG
2014/21260
2014/21261
Date RCA sent to
NWLCSU
SI RCA Report Due
Date
(investigation)
02/09/2014
02/09/2014
02/09/2014
02/09/2014
Page 9 of 35
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3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
NHS Central
London CCG
NHS Central
London CCG
NHS Central
London CCG
NHS Central
London CCG
NHS West London
CCG
NHS West London
CCG
NHS Barnet CCG
NHS Barnet CCG
NHS Barnet CCG
NHS Central
London CCG
NHS Barnet CCG
NHS Barnet CCG
NHS Barnet CCG
NHS Barnet CCG
NHS Barnet CCG
NHS West London
CCG
NHS Barnet CC
NHS Barnet CCG
NHS West London
CCG
NHS West London
CCG
NHS West London
2014/21265
Pressure Ulcer Grade 4. Subsequently de-escalated
02/09/2014
02/09/2014
2014/21272
02/09/2014
02/09/2014
2014/22189
10/09/2014
08/09/2014
2014/22199
10/09/2014
08/09/2014
2014/22203
10/09/2014
10/09/2014
2014/22226
10/09/2014
10/09/2014
2014/22548
2014/22549
2014/22551
2014/22556
Slip/trip/fall
12/09/2014
12/09/2014
12/09/2014
12/09/2014
12/09/2014
12/09/2014
12/09/2014
12/09/2014
2014/22909
2014/22910
2014/24532
2014/24533
2014/24535
2014/24537
Pressure Ulcer Grade 3. Subsequently de-escalated
15/09/2014
15/09/2014
29/09/2014
29/09/2014
29/09/2014
29/09/2014
12/09/2014
12/09/2014
12/09/2014
25/09/2014
25/09/2014
10/09/2014
2014/24538
2014/24541
2014/26059
29/09/2014
29/09/2014
10/10/2014
25/09/2014
25/09/2014
30/09/2014
2014/26062
10/10/2014
30/09/2014
2014/26066
10/10/2014
30/09/2014
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CCG
6.
Overdue SIs
SI reports Currently Overdue
6.1 There are no overdue reports at present.
7.
De-escalation Requests
De-escalation requests
7.1 There were two request s for de-escalation during September 2014, shown in Table 5 below.
Table 5 –De-escalations requested in September 2014
No
ID Number/
CCG
Date of
Incident
Date
entered
onto STEIS
Incident
Category
Comment
Rationale for de-escalation
Date Deescalation
requested
CSU
decision
1
2014/21265
Central
London
26/06/2014
01/07/2014
Pressure
Ulcer
On review this was considered to be a blister not a
pressure ulcer.
02/09/2014
Agreed
10/09/2014
2
2014/24535
Barnet
21/07/14
28/07/14
Pressure
Ulcer
At SI panel it was clarified that the wound had developed
as the patient walks on sides of feet causing pressure and
had gone for a long walk for shopping on the day the
ulcer deteriorated
26/09/14
Agreed
06/10/2014
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8.
External Serious Incidents/Lessons Learned
External Serious Incidents/Lessons Learned
8.1 Learning from the Serious Incidents listed below is being taken forward across the Trust overseen by the Chief Nurse and Director of Quality
Governance. The external cases presented to SI panel are described in table 6 below. All cases have agreed action plans, monitored via the SI
process. The lessons learned are shared at CLIPS meeting, and for pressure ulcer cases at the Pressure Ulcer Working Group. Out of the pressure
ulcer cases reviewed at SI panel sixteen were deemed to be unavoidable, with three avoidable. Details in the table below.
Table 6 – Completed investigation – Lessons Learnt
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/22548
Slip. Trip & fall
Barnet
A patient was found on the floor in his room in one of the bedded units, in a pool of
blood. It was not clear if he fell or collapsed. He was transferred to Barnet Hospital
where a CT showed hemorrhagic contusions to both frontal lobes, a small
parenchymal hemorrhage in the right cerebellum, and subdural blood but no bony
injury. The patient was transferred to the neurosciences centre at The Royal London
Hospital where he was managed conservatively. He was subsequently transferred
back to CLCH where it became clear he had a neurological deficit and was transferred
to a neurological rehab ward.
Investigation completed ,
presented to SI panel and
approved on 3rd September
2014
Root Causes
Whilst the investigation was unable to determine if the patient fell or collapsed, it concluded that the position he was found in, on his front with
the right side of his face against the floor, suggests a collapse rather than a fall. Therefore there is no clear root cause for his fall.
Lessons learned
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
1. Falls assessments need to be completed for all patients on admission. This has already been addressed with training programmes on the falls
assessment
2. Mr X was a rehabilitation patient but was on a ward where rehabilitation skills and ethos have been diluted as a consequence of admitting
other patients who do not have rehabilitation needs
3. Loss of clinical leadership at both nursing and therapy senior levels has been detrimental to the culture of learning and development of staff.
This is already being addressed and interviews are in the pipeline / have taken place for these roles
4. There is a lack of continuity when operational managers change. This has been addressed with the appointment of a substantive operational
manager at CBU level
5. Admission of patients late at night should only be undertaken when it is absolutely necessary
6. Inadequate assessments lead to poor clinical reasoning and treatments
7. A systematic process is required to capture patients who are admitted to acute trusts. This has already been addressed and is in process of
being implemented.
Recommendations, which have been made in to an action plan:
1.
2.
3.
4.
5.
6.
7.
8.
Training in falls assessments for all staff
All staff to have training in the rehabilitation process and the necessity for MDT working
Outcome of this investigation is fed back to staff as part of culture of learning from experience
Rehabilitation processes are put in place including:
•
MDT goal setting
•
Patient timetables for therapy
There is a review of assessments to include:
• Clinical assessments to be discussed in supervision to ensure they are thorough, relevant and probe for sufficient information as a
regular part of supervision process
• Therapy staff use an assessment form
All therapy / nursing staff to have training in neurological assessments
Nursing and therapy staff are able to demonstrate they can conduct an assessment to the required standard
Training is given a high priority and includes:
• cognitive and dementia training for all staff on ward
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STEIS Reference/
Classification/
CCG
9.
10.
11.
12.
13.
14.
Summary of Incident
Update
• Dedicated time for regular MDT training with sufficient numbers of nursing staff on shift to allow for attendance
• Dedicated time for regular uniprofessional training
• Medical training
Supervision includes joint clinical sessions with junior staff
Appointment of senior clinical roles in nursing and therapy
Division considers whether rotation of band 6 therapy staff would be possible
Operational managers set out clearly what the processes are for late admissions, and for not accepting patients with no rehabilitation
potential. Staff are supported in the decisions they make and are not pressured by either the acute trust or CLCH to accept patients with no
rehabilitation potential
A process to be introduced for capturing information for patients transferred to acute trusts from CLCH bedded units
There is a monthly forum led by the CBU manager and AHP lead until all the senior therapy leadership is in place to discuss patients on
ward in regard to rehabilitation needs
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/21260
West London CCG
Grade 4 Identified when a scab lifted from the patient’s toe
approved on 2nd September
2014
Root Causes
1
Poorly fitting footwear (supplied by family)
2
Peripheral neuropathy
3
Peripheral vascular disease
4
Previous history of ulceration and multiple predisposing factors
Lessons learned
No care or service delivery problems identified. No actions to take forward.
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/21261
Central London CCG
Grade 3 on both heels. Chronic medical history, with a history of pressure damage
2014
Conclusion
Unavoidable pressure ulcer.
Root Causes
1. Previous history of pressure damage
2. Diabetic neuropathy
3. Declined appropriate equipment
4. Poor mobility and high BMI.
Lessons learned
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/21265
Central London CCG
Grade 4 right heel. Chronic medical history.
2014
Root Causes
Prolonged periods sitting and not elevating both legs, when mobilising patient not wearing appropriate foot wear. Blister arose from ill-fitting
shoes
Lessons learned
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/21272
Central London CCG
Grade 3 on the sacrum. The patient was completely bedbound with end of life
terminal condition and was very frail and fragile.
approved on 28th September
2014
Root Causes
Resident factors associated with end of life care needs and moisture lesion as well as complex mobility issue.
1. The nursing home manager to have a meeting with qualified nurses to do a reflective account and discuss this case at the next staff
meeting.
2. All qualified nursing staff to do practical training/competency assessment
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/22189
Central London CCG
Grade 4 Right hip, chronic medical history
2014
Conclusion
Root Causes
1. Did not always comply with pressure area care advice
2. Faulty equipment
3. Decreased mobility
4. Diagnosis of lung cancer /Increasing shortness of breath/decreased oxygen saturation (77% on room air) – lack of perfusion to pressure
area
5. Nutritional status
Lessons learned
Conclusion
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/22199
Central London CCG
Grade 3 on the sacrum
2014
Root Causes
1. Non-compliant with equipment
2. Immobility
3. Extremes of Age
4. Terminal Phase
Lessons learned
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/22203
West London CCG
Grade 3 on Sacrum, Left buttock and right buttock.
approved on 10th
September 2014
Root Causes
1. Patient is now palliative with poor nutritional intact
2. Patient had previous history of pressure damage to sacral area in 2013.
3. Patient’s mobility has reduced and she is spending more time sitting in her chair
4. Patient declined pressure relieving equipment which had contributed to her developing pressure ulcers.
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
Lessons learned
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/22226
West London CCG
Grade 3 Right stump (right knee amputee)
approved on 10th
September 2014
Root Causes
1. Dementia
2. Chronic Long Term Condition – poor vascular supply
3. Poorly controlled diabetes due to compliance issues related to nutritional intake
4. Non-compliant with medication, food and fluids.
Lessons learned
No care or service delivery problems identified which contributed to the development of the pressure ulcer
Ensure staff are up to date with supporting patients with diabetes with their nutritional intake
Conclusion
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/22549 and
2014/24532
Barnet CCG
Grade 3 right and left hip, chronic medical history
Case conference held – outcome was that care home staff required additional
training.
approved on 12th
September 2014
Root Causes
1. Frail elderly patient with fragile skin and history of pressure ulcers
2. Patient care dependent on care home staff
Lessons learned
1. Ongoing management by nurses who have current PU training and OSCE
2. All staff to be assessed as competent to manage patients who are at high risk of PU.
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/22551
Grade 3 right buttock. Chronic medical history.
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STEIS Reference/
Classification/
CCG
Summary of Incident
Barnet CCG
Update
approved on 12th
September 2014
Root Causes
1. Very challenging patient environment and chaotic lifestyle
2. Patient non-compliant with advice
Lessons learned
A pathway is devised to ensure that in these situations, all the appropriate liaison with other professionals is undertaken
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/22556
Central London CCG
Grade 3 sacrum
2014
Root Causes
1. Patient is incontinent of urine and has developed moisture lesion.
2. Patient spends long hours sitting in chair watching TV
3. Non-compliance with pressure relieving cushion/mattress- sent them back to mediquip when ordered although she initially agreed.
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
4. Patient will only use a repose cushion which is not appropriate for her.
Lessons learned
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/22909
Barnet CCG
Grade 4 sacrum
2014
Root Causes
1. Advanced age, diminished acuities, immobility and lack of capacity resulting in noncompliance (scratching site and removing dressings
2. Care of patient largely dependent on carers. ? knowledge and skills on Pressure ulcers, SSKIN bundle, turning charts etc.
3. Continued use of dressings identified as causing an allergic reaction
4. New staff in post without PU training. Inappropriate assessment by nurse on 8/7/14
5. Issues picked up by TVN relating to patient care not followed through by DN team.
6. Failure to follow pressure ulcer policy
7. Monitoring of carers by use of turning charts not evident in nursing record, to ensure turns are being done
Lessons learned
1. Advise by TVN not followed through
2. Staffing levels and skill mix of team: Little senior nurse availability through sickness and leave. Band 6 nurse also had to support the HAB
service two mornings per week for a period of approximately 6 months. New starters in place without the correct knowledge and skill
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
base.
1. Nurses to work closely with carers to ensure care is achieved
2. Nurse doing joint visit with TVN to ensure advice and new instructions are followed through
Conclusion
Avoidable pressure ulcer.
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/22910
Barnet CCG
Grade 4 sacrum
2014
Root Causes
1. Irregular ongoing assessment of patient, until 27th June 2014 and from then until 11th July.
2. Staff attending to the patient without the appropriate training and skills, deterioration in PU and overall patient condition not recognized.
3. Senior Staff not reviewing
4. Frail elderly patient at end of life
Lessons learned
1. Poor ongoing assessment of patient needs from initial assessment in February 2013 until 27th June 2014. Challenges faced by the wider
team in regard to nursing numbers and skill mix
2. over recent months
3. Little evidence of palliative care provision by DN team for patient, due to staffing challenges; lack of knowledge and skills of new staff.
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
1. All team members are able to undertake a comprehensive assessment
2. All DN staff in Barnet to have current PU management training and OSCE.
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/24533
Barnet CCG
Grade 4 Right heel
Grade 3 Right foot
Complex health needs
2014
Root Causes
1. Deteriorating general physical health
2. Patient is bed bound
3. Extremes of age
Lessons learned
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
Page 24 of 35
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/24537
West London CCG
Grade 3 left buttock, history of pressure damage
2014
Root Causes
1. Patient is now palliative and his appetite has decreased, which may lead to poor nutritional intake.
2. Patient had previous history of pressure damage to sacral area in 2013.
3. Patient’s mobility has reduced and he is spending more time sitting in his chair
Lessons learned
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/24538
Barnet CCG
Grade 3 sacrum. Chronic medical history.
approved on 24th
September 2014
Root Causes
1. Poor concordance of patient at times, by patient and carer, including refusal to have care staff and transferring technique used by patient
which required further monitoring and advise.
2. Management of patient with end stage LTC on long term O2 – some aspects of patient care not addressed as quickly as needed – slide
sheet not ordered at first assessment.
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
Lessons learned
1. Poor concordance of patient at times with advise.
2. Timely clinical assessments of DN team
3. Refusal to have care staff, wife is the main carer who also has health problems
4. Limited mobility
5. Transferring technique used by patient causing shearing
1. Some aspects of patient care delivery not acted on appropriately. Pressure ulcer documentation not completed fully
2. Little evidence of full holistic care of patient – focus on the PU, when LTC should also be addressed.
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/24541
Barnet CCG
Grade 4 left ear. History of pressure damage. Attends an acute trust several times a
week for dialysis, no pressure relieving equipment available at that venue.
2014
Root Causes
1. Prone to pressure sores due to his chronic condition.
2. Always turns to his left side.
Lessons learned
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
No care or service delivery problems identified. Further follow up to be undertaken with the acute trust’s Safeguarding lead.
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/26059
West London CCG
Grade 3 sacrum
2014
Root Causes
1. Cancer diagnosis and radiotherapy treatment
2. Poor concordance with equipment, client did not want to use overlay mattress or dressings
Lessons learned
1. On the first assessment the category may have been a category 2 and not a moisture lesion but there were no pictures to verify this grade.
2. Lack of awareness about when to send a safeguarding referral and when it is not needed.
1. Reflection session to take place with the team to discuss:
2. Taking photographs; Grading/identification of sores/moisture lesions; Safeguarding referrals
Conclusion
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/26062
West London CCG
Grade 4 right ischial tuberosity. Complex history, underweight, history of pressure
damage
approved on 30th
September 2014
Root Causes
High dependency and at high risk of developing pressure sores - Complexity of condition/disability, Underweight, Lack of mental capacity, change
of environment (stayed at his parents’ house), previous skin breakdown.
Lessons learned
Conclusion
STEIS Reference/
Classification/
CCG
Summary of Incident
Update
2014/26066
West London CCG
Grade 4 Mid spine
approved on 30th
September 2014
Root Causes
1. Patient is for palliative care and has poor nutritional intact.
2. Patient declined pressure relieving equipment for a long time but no mental capacity was recorded
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STEIS Reference/
Classification/
CCG
Summary of Incident
Update
Lessons learned
Conclusion
9
Department of Health National Never Events
9.1 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.
9.2 CLCH has had no incidents of national reportable Never Events since the list was published, in 2011.
10.
Internal Serious Incidents
Internal Serious Incidents/Lessons Learned
10.1
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,
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121
safeguarding queries regarding staff, information governance issues, complaints unresolvable to satisfactory conclusion and safety alerts not
actioned by deadline. Table 7 below summarises the cases for which an investigation is ongoing, or has had the RCA report presented to panel.
Table 7 – Internal Serious Incidents
CCG
Datix Classification
Incident Date
Summary of Incident /Progress of case
NHS West
London
CCG
NHS
Drug Incident
(general)W23517
21/05/2014
When entering vaccination data following a BCG clinic, it was noted that a baby
had already received the BCG vaccination in hospital prior to discharge. The BCG
given at the clinic was therefore a second dose.
Investigation ongoing. SI panel arranged.
Central
London
CCG
Safeguarding of Vulnerable
Adult W24347
13/07/2014
Two Health Care Assistants reported to the Senior Staff Nurse that they had
found a patient lying in urine and faeces when they had arrived to attend to the
patient. They reported that it appeared the patient had been soiled for a
significant amount of time.
The RCA was presented to SI panel but not accepted as more information was
required. To be revised and reviewed again by SI panel members once changes
are made.
NHS Barnet
CCG
Allegation against
Healthcare Professional
W24899
08/08/2014
A patient reported to an OT on the ward that she had been roughly handled by a
member of staff a few nights previously.
The RCA was presented to SI panel but not accepted as more information was
required. To be revised and reviewed again by SI panel members once changes
are made.
NHS
Hammersm
ith &
Fulham
CCG
Drug Incident
(general)W25372
12/08/2014
A mother attended for her baby’s BCG vaccination. The mother said that the
baby had not received the BCG in the hospital. The hospital discharge summary
stated that the BCG was refused by the mother. A few weeks later the mother
informed the health visiting service that she had found the pink BCG notification
slip indicating that her baby had received the BCG before discharge home from
the maternity unit.
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122
11.
Management of Action Plans
111
During the review of the Incident Reporting and Serious Incident Policy the process for the closure of serious incident action plans was revised. The
Standard Operating Procedure 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
 Once completed Head of Patient Safety to attend an SI Action Plan closure meeting with the Associate Director of Quality, CBU Manager,
Patient Safety Manager and any other relevant member of staff to confirm actions are completed robustly and to update Datix notepad to
confirm that all actions are completed and date of 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
11.2
The table (8) below depicts the serious incident cases, reported from 1st April 2014, broken down by division, awaiting final closure. Each division is
currently working on reviewing the evidence available, getting it uploaded on to datix before setting closure meetings with the Head of Patient
Safety. Some cases have not reached the last action due date. As each new RCA is approved in future it will be added to the list.
Table 8 – current open serious incidents since April 2014.
No
ID Reference
Classification
1
2014/20399
Confidential Information Leak
1
2014/17199
Division
EXTERNAL SIs
EXTERNAL SIs
Networked Nursing & Community Rehab
Date Last
Action Due
01/07/2015
18/08/2014
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123
1
W24347
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
2014/10997
2014/14703
2014/11107
2014/13102
2014/14699
2014/15625
2014/16489
2014/20388
2014/20392
2014/21261
2014/22189
2014/22203
2014/22556
2014/24537
2014/26059
2014/26062
2014/26066
1
2
2014/12896
2014/14319
3
4
2014/16092
2014/22548
1
2
3
4
2014/11727
2014/18217
2014/13114
2014/14711
INTERNAL SIs
Safeguarding of Vulnerable Adult
PRESSURE ULCERS
EXTERNAL SIs
Barnet Community & Specialist Services
Adverse media coverage or public concern Barnet Community & Specialist Services
about the organisation or the wider NHS
Slip/trip/fall
PRESSURE ULCERS
31/12/2014
31/05/2014
31/07/2014
30/07/2014
30/06/2014
31/07/2014
06/06/2014
31/07/2014
31/08/2014
16/08/2014
12/09/2014
04/09/2014
20/09/2014
21/09/2014
30/09/2014
31/10/2014
10/10/2014
10/10/2014
30/06/2014
31/07/2014
01/01/2015
28/02/2015
30/06/2014
30/09/2014
30/06/2014
31/07/2014
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124
12.
12.1
5
2014/13124
6
2014/13502
7
2014/13507
8
2014/13512
9
2014/13971
10
2014/15724
11
2014/16105
12
2014/15954
13
2014/16106
14
2014/16763
15
2014/16932
16
2014/18234
17
2014/20376
18
2014/20389
19
2014/20397
20
2014/21272
21
2014/22226
22
2014/22549
23
2014/22551
24
2014/22909
25
2014/22910
26
2014/24532
27
2014/24533
28
2014/24535
29
2014/24538
30
2014/24541
Whistleblowing
31/05/2014
31/08/2014
31/08/2014
31/07/2014
31/07/2014
30/09/2014
31/07/2014
30/08/2014
17/08/2014
01/09/2014
30/10/2014
30/10/2014
24/08/2014
01/12/2014
31/10/2014
30/11/2014
31/10/2014
30/11/2014
30/11/2014
30/11/2014
05/10/2014
30/11/2014
30/11/2014
30/09/2014
30/11/2014
30/09/2014
There was a whistleblowing case in August 2014. The CQC visited one of the bedded unit as a result of a concern raised directly to CQC. The visit
and subsequent report were positive. No further concerns were raised. The report is available on the CQC website.
Page 33 of 35
125
13.
Child Deaths
13.1
There has been one expected child death since the last report.
14.
Maternal Deaths
14.1
There have been no maternal death cases since the last report.
15.
15.1
The Trust will continue to identify and investigate all serious incidents, from which themes and trends will be identified. Review of the root causes
and the lessons learned enables the organisation to identify risks resulting from such incidents.
16.
16.1
The Complaints, Litigation, Incidents, PALS and Serious Incidents (CLIPS ) Group meetings review themes from complaints, litigation, incidents,
PALS contacts and Serious Incidents and would highlight any access issues or communication barriers for patients if identified. By tracking
information in these areas the organisation can help to demonstrate equality of service to all and recommend improvements where necessary.
17.
17.1
The main area of concern currently is the management and documentation of pressure ulcers, which continues to be the highest reported category
of serious incident (grade 3 & 4), although the total reported pressure ulcer incidents has dropped to second highest category for quarter 2 July –
September 2014. Management of pressure ulcers is represented on the risk register as Risk ID 435, and is currently being reviewed. This is
monitored at Patient Safety & Risk Group.
18.
18.1
18.2
Serious Incident reports are sent to both Clinical Quality Review group meetings: Barnet and Tri-Borough
All serious incidents are sent to the Commissioning Support Unit.
Page 34 of 35
126
18.3
All external reporting requirements are met, for reporting serious incidents to North West London Commissioning Support Unit, NHS England
and to the National Reporting & Learning System.
19.
19.1
19.2
NWLCSU monitors performance against achieving deadlines.
The achievement of the deadlines is monitored internally and reported to the Quality Committee quarterly.
20.
Recommendations
20.1
The Board is asked to review the report and note the progress of the management of Serious Incidents across the Trust.
Page 35 of 35
127
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title:
Francis and other national reports – six month update
Agenda item number:
3.2
Report of:
Chief Executive
Contact Officer:
Trust Secretary
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
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
Report can be published
Status
Executive Summary:
In January 2014, the Board welcomed the Government’s acceptance of the inquiry recommendations in
support of high quality care and acknowledged its role in continuing to lead and promote an open culture
of learning and improvement.
The Trust’s response included 15 key milestones, the majority of which are now business as usual. An
update on outstanding actions at April 2014 are included in this report.
Assurance provided: Progress made against the Trust’s national report recommendations maturity matrix
was reviewed throughout 2013/14, with a final report considered in April 2014. At that point it was
agreed a report would be considered in 6 and 12 months to ensure that organisational governance
arrangements remain compliant.
Report provenance: A paper (Francis 1-year on) was shared with the Board in April 2014. It was agreed
that the high level action plan template prepared by the trust secretary would be used by the Board to
monitor progress in October 2014 and April 2015.
Discussion
Information
Recommendation: To discuss the Trust’s position in relation to key national report recommendations
and to highlight where any further assurance may be required.
128
1
1.1
Purpose
To provide an update to the Board regarding the implementation of relevant Francis and related
report recommendations (Berwick and Keogh).
2
2.1
Introduction
The final report of the public inquiry into Mid Staffordshire NHS Foundation Trust provided
detailed and systematic analysis of what contributed to the failings in care at the trust. It identified
how the extensive regulatory and oversight infrastructure failed to detect and act effectively to
address the trust's problems for so long, even when the extent of the problems were known. The
Trust’s position in relation to the Francis report and related reports is attached.
With regard to milestones set in 2013, the report in April 2014 confirmed that the majority of
milestones had been met.
The outstanding milestones at that time were:
Milestone
Position at April 2014
Current position
Reduction in paperwork for
front line staff (by a third),
creating time to care by
introducing electronic/ digital
solutions to reduce paperwork
Work continued however
reductions in paperwork were
not being realised. Electronic
systems gradually being
implemented slowly.
SytmOne being implemented.
Mobile devices deployed to
increase efficiency of
community care workers –
increasing patient visits by 10%.
Deployment of e-fax solution to
decrease paper load.
Interoperability will enable the
receipt of referrals in Barnet
and the receipt of notifications
to Child Health from the Acute
providers to be automated.
Removing paper and releasing
the time of Administrative staff.
Audit of recruitment processes
to demonstrate values
questions asked and staff
survey to shows high levels of
understanding and
commitment to Trust values
Audit will be completed by
April.
Managers are advised to make
2 of the 10 questions they ask
values based and are given
examples from which to
choose.
Audit of three files from each
division demonstrated 100%
compliance with this
requirement.
Further work between October
2014 and March 2015 will be
undertaken to audit the impact
of those questions on recruiting
decisions.
Audit of dementia, mental
health and learning disability
care and of vulnerable adults
policy
No plans in place. Under
discussion - to be included in
work plans for 2014/15 but
audits will not be achieved by
Plans and training now in place
for both dementia care and
learning disabilities. These
areas will be audited in quarter
129
April 2014.
1, 2016 when they have been
embedded into services. Care
of vulnerable adults will be
audited alongside the audit of
safeguarding adults policy, in
quarter 4.
3
3.1
Quality implications and clinical input
The Francis report and related reports are focused on providing high quality care.
3.2
The Medical Director and Chief Nurse have contributed to the production of this report.
4
4.1
Legal implications
Draft regulations have been published, including the duty of candour and the fit and proper
persons test. The regulations were originally intended to be introduced for NHS Trusts from
October; however this has been postponed to mid-November (at least). Similarly, the Care
Quality Commission has been consulting on their proposed guidance for providers to help them
meet the requirements of the regulations, and the proposed guidance on how the CQC will use
their enforcement powers. This will lead to the replacement in its entirety, from April 2015, of
CQC’s current Guidance about compliance and current enforcement policy. The consultation
closes 17.10.14.
Note 1 - it has been proposed that the Remuneration Committee should consider practical steps to
ensure / continuously review the ‘fitness’ of directors.
Note 2 - it has been proposed that the Quality Committee should further consider the duty of
candour, fundamental care standards and notifiable incidents.
5
5.1
Equality implications
The Francis report and related reports support the provision of equality of care.
6
6.1
Consultation with partner organisations
This paper will be shared with the CCG clinical quality review groups.
7
7.1
Monitoring performance
A further report will be provided in April 2015.
130
This table provides the Trust’s summary position in relation to relevant Francis recommendations as at October 2014.
Section
Implementing the
recommendations
(R11)
Recommendation / requirement
To hold listening events to discuss how
safe, effective and compassionate care
can be delivered.
Implementing the
recommendations
(R1)
To consider the findings and
recommendations and to decide how to
apply them to their own work.
Implementing the
recommendations
(R1)
Publish a report at least annually,
information regarding progress in
relation to planned actions
Implementing the
recommendations
(R1)
To publish the Trusts response to the
recommendations on the website.
Implementing the
recommendations
(R1)
Leadership to drive improvements in
safety, quality and compassionate care.
CLCH position / sources of assurance (evidence)
Four listening events held in April 2013, feedback
shared with all attendees in June 2013.
An overarching engagement strategy was approved
by the Board in September 2014, including a
commitment to hold listening events in each of the
four key boroughs, at least twice annually.
Inquiry findings considered in March 2013, maturity
matrix updates provided to Quality Committee and
Board quarterly to January 2014. This paper (for
Board meeting in October 2014).
All papers considered by the Board in response to
Francis Inquiry and related reports are published on
the CLCH website. The maturity matrix tracked
progress against action planned - now business as
usual. This report will be included with Board papers
for 28.10.14 and shared with CCG clinical quality
review groups.
A position paper ‘Francis 1 year on’ was published in
January 2014. This report will be included with Board
papers for 28.10.14 and shared with CCG clinical
quality review groups.
CLCH has developed its own compassion in care
project, linked to the national 6Cs (care, compassion,
competence, communication, courage and
commitment) initiative led by the Chief Nurse for
1
Board Lead(s)
Chief nurse and
director of quality
governance /
medical director
All directors
Chief executive /
Chief nurse and
director of quality
governance
Chief executive
Chief nurse and
director of quality
governance /
medical director
Recommendation / DH response number
131
Section
England. Our project was developed in partnership
with City University, building on their work on patient
dignity and best practice in care for older people and
quality of life in care homes. The project aimed to
promote compassionate care with frontline staff
across a number of areas of CLCH services including
adult rehabilitation services, HMP Wormwood Scrubs
and our Pembridge Palliative Care unit. Staff
developed their own workstreams in consultation with
patients and we are developing ways in which the
positive impact of these can be measured.
Board Lead(s)
The Compassion in care programme focuses in
2014/15 on End of Life Care and the development of
the Leadership Strategy.
Separate to this programme ‘Clinical Fridays’ and
‘Back to the Floor’ have been implemented, with
members of the senior team visiting clinical areas
across the Trust.
Implementing the
recommendations
(R1)
Clarity of values and
principles (R3)
Central responsibility of the Board to
pay attention to the culture of their
organisation, actively dealing with
cultural risks and seeking
improvements in their organisation’s
culture.
NHS constitution as a central reference
point for all NHS staff and patients.
A leadership strategy is being developed for
implementation in 2015.
The Board recognises its role in creating and leading
a culture of compassion and thoughtfulness.
CLCH goals (embody the best of the NHS for our
patients, support people safely out of hospital, deliver
better value than our competitors in our selected
Board of directors
Board of directors
132
Section
principles (R5) and
R174 and R181
Statutory duty of candour to be open
and honest where there have been
failings in care.
markets, be responsive to our patients and partners’
needs, and employ only the best staff).
Values (quality, relationships, delivery and community)
Serious incident reports are published with Board
papers.
Board Lead(s)
Board of directors
Learning from experience team have a role in
encouraging staff to report all incidents and promoting
an open safety culture.
We have made a commitment to creating and
maintaining a culture of being open and honest and
our contractual arrangements include the duty of
candour.
The Trust’s ‘being open’ policy has been re-written
and launched and will be audited in Q1 of 2015/16.
principles (R7)
NHS staff should be required to enter
into an express commitment to abide by
the NHS values and the constitution,
both of which should be incorporated
into the contracts of employment.
Fundamental
Healthcare professionals should be
standards of
prepared to contribute to the
behaviour (R11)
development of, and comply with,
standard procedures in the areas in
which they work.
Responsibility for,
Suitability and competence of staff and
and effectiveness of, related guidance published by the
healthcare
National Quality Board How to ensure the
No reference to NHS values and constitution in
contracts of employment, however CLCH values are
included in job descriptions and are core to the staff
appraisal process.
Director of finance,
performance and
corporate resources
The clinical education and practice team lead this
work; staff are actively involved in the preparation of
guidelines which are published on the intranet.
Chief nurse and
director of quality
governance
Guidance issued by the National Quality Board,
is being taken forward by the chief nurse and director
of quality governance.
Chief nurse and
director of quality
governance
133
Section
standards (R23)
Use of information
right people, with the right skills, are in the right
place at the right time. This includes the
expectation (1) that the “Board takes full
responsibility for the quality of care provided to
patients, and as a key determinant of quality,
take full and collective responsibility for nursing,
midwifery and care staffing capacity and
capability.
Board papers are accessible to patients and
staff working at all levels, boards seek to involve
staff at all levels and across different parts of the
organisation, facilitating a strong line of
communication from ward to Board, and Board
to ward. Boards ensure their organisation is
open and honest if they identify potentially
unsafe staffing levels, and take steps to maintain
patient safety”.
Expectation 7 (openness and transparency)
includes that “boards receive monthly updates
on workforce information, and staffing capacity
and capability is discussed at a public Board
meeting at least every six months on the basis of
a full nursing and midwifery establishment
review. Boards receive monthly updates on
workforce information, including the number of
actual staff on duty during the previous month,
compared to the planned staffing level, the
reasons for any gaps, the actions being taken to
address these and the impact on key quality and
outcome measures.
At least once every six months, nursing,
midwifery and care staffing capacity and
capability is reviewed (an establishment review)
and is discussed at a public Board meeting. This
information is therefore made public monthly and
six monthly. This data will, in future, be part of
CQC’s Intelligent Monitoring of NHS provider
organisations.
Co-ordinated collection of accurate
Board Lead(s)
Monthly and the six monthly staffing level reports are
included with Board papers and published on the
Trust’s web site and notice boards publicising the
expected and actual daily staffing figures are at the
front of each bedded unit.
Board of directors
There is also a Chief Nurse email and contact number
on the notice boards if patients, relatives or staff have
any concerns regarding staffing.
An external review of the Trust’s performance
134
Section
for effective
regulation (R36)
information about the performance of
organisations
Use of information
about compliance by
regulator from
quality accounts
(R37)
and
Comparable quality
accounts (R246)
and
Accountability for
quality accounts
(R247, R248 and
R251)
Quality account to include a fair
representation of areas where
compliance has not been achieved.
and
R249 – R250)
Use of information
about compliance by
regulator from
media (R44)
Quality accounts should be comparable
management reporting processes was undertaken in
early 2014 and recommendations are being
implemented. Data quality remains a high priority
and the Audit Committee will review the
implementation of the Data Quality Strategy and seek
assurance that the actions in the implementation plan
achieve the strategy’s stated aims during 2014/15.
The quality directorate led the production of the
2013/14 quality account which was published in June
2014 in line with regulatory requirements and
guidance.
Board Lead(s)
performance and
corporate resources
Chief nurse and
director of quality
governance and
chief executive
The Trust’s quality account is published on the
website and made available to all our stakeholders.
Quality accounts should be shared with
commissioners, stakeholders and
regulators
Independent audit of quality accounts.
A retrospective audit of the 2012/13 quality account
was been undertaken by KPMG.
Certification by all directors that the
quality account is accurate
The quality account includes a statement from the
chief executive that “the information contained in this
document is an accurate reflection of our performance
for the period covered by the report”.
The learning from experience team co-ordinate and
support the incident reporting process.
The requirement for the Trust to
demonstrate that learning from serious
incidents has been successfully
implemented.
The Trust has a regular CLIP (Complaints, litigation,
Chief nurse and
director of quality
governance
135
Section
Need for
constructive working
with other parts of
the system
(R75/76/77)
Accountability of
providers’ directors
(R79/81)
and
complaints (C), litigation (L), incidents (I) PALS (P)
Serious Incidents (S) (CLIPS) newsletter for staff. By
learning from experiences we will be better able to
continually improve the safety and quality of the
services that we provide.
Council of Governors - role, training
A guide for governors is being prepared for agreement
and stakeholders
by the quality stakeholder reference group and
approval by FT steering group. This guide will
include the statutory duties of governors, together with
the role of governors in support of quality and will
reinforce their role in relation to both members and the
wider public. Training and development of Governors
will include the FTN (GovernWell) programme.
Compliance with code of conduct and fit All directors have self-certified that they are ‘fit and
and proper person test.
proper persons’ within the current Monitor
requirements; this is also included in executive board
Disqualification of directors
member job descriptions. The Board has also agreed
a code of conduct which is consistent with the Nolan
principles.
Board Lead(s)
Chief executive
Chief executive
Practical steps to ensure / continuously review the
‘fitness’ of all directors, under the proposed statutory
regulations will be considered by the Remuneration
Committee.
The constitution will be updated to include serious
misconduct and incompetence in the list of director
disqualification criteria.
Shared code of
ethics
(R215)
Common code of ethics
Board members have all signed a code of conduct.
All staff receive a copy of the Trust’s customer care
standards, confidentiality code of conduct, the code of
136
Section
conduct for NHS manager and the conflict of interest
policy.
Board Lead(s)
Requirement for the
training of directors
(R86)
FTs will have to have in place an
adequate programme for the training
and continued development of directors
The Board has a development programme which
includes 360 degree feedback, structured induction
and individual appraisal.
Chief executive and
Chairman
Recent Board evaluation has included the board
governance assurance framework and quality
governance assurance framework.
Health Protection
Agency coordination and
publication of
providers’
information (R106)
Healthcare acquired infections
Effective complaints
handling
(R109/111/113/114/
118)
Methods to comment or complain must
be readily accessible and easily
understood.
The board development programme as an FT will be
focused on CQC / Monitor Well-Led Framework.
The annual infection prevention and control report is
published with board papers. The medical director is
the responsible officer, supported by the infection
prevention and control team.
Any new requirements will be included in future
annual reports.
The complaint policy has been updated to reflect
findings from the 2013 report of handling complaints
by NHS hospitals. Actions in response to the ClywdHart review of complaints has been considered and
implemented through the patient experience group.
Medical director
Chief nurse and
director of quality
governance
The Trust has a Customer Service Team and do you
have something to tell us about our services?” leaflets
are available in all care settings and via the website.
In liaison with NHS England, the Trust has developed
an iPad based App for people with learning disabilities
137
Section
to be supported to answer the NHS Friends and
Family Test. A short film about the Project has been
produced for service users and families/carers - which
will be available to be viewed on YouTube My Health,
My Say films with captioning to increase accessibility.
Board Lead(s)
Complaints received are escalated as appropriate
having considered the risk to patient safety.
There is board led scrutiny of complaints and the
executive team and chairman receive weekly
information on all complaints.
The medical director, chief nurse and deputy chief
nurse meet regularly to review complaints information
and to consider whether there are any safety/clinical
practice issues, for example staff repeatedly being
named.
Restrictive
contractual clauses
(R179)
‘Gagging clauses’ or disparagement
clauses
Focus on culture
and caring (R185)
System and standards of training,
including recognition of achievement,
The Trust publishes an annual report on complaints
management, and reports quarterly to Quality
Committee and Board via the Quality Report. All
Board members (NEDS and executive directors
receive a weekly update on complaints.
Should the Trust be required to enter into a
compromise agreement, it will be made clear that staff
signing the agreement may make a disclosure in the
public interest in accordance with the Public Interest
Disclosure Act, regardless of what other clauses may
be included in the agreement.
The Trust holds an annual awards ceremony to
recognise the achievements and excellence of staff.
performance and
corporate resources
performance and
138
Section
Recruitment for
values and
commitment (R191)
Nurse leadership
(R195)
Nurse leadership
(R196)
Measuring cultural
health (R198)
comprehensive feedback on
performance and concerns, priority to
patient well-being.
A regulatory (provider) requirement for
the recruitment of qualified and
unqualified nursing staff should include
assessment of candidates’ values,
attitudes and behaviours towards the
well-being of patients and their basic
care needs.
Ward nurse managers should operate
in a supervisory capacity, and not be
office bound or expected to double up,
except in emergencies as part of the
nursing provision on the ward.
Training and professional development
of nurses should include leadership
training from student to director
The development of transparent
measures of the cultural health of frontline nursing
All staff are required to have an annual appraisal.
See also response to R1 – compassion in care and
‘Clinical Fridays’ and ‘Back to the Floor’ above.
The Trust has already agreed a goal “to employ only
the best staff”.
In support of the delivery of the quality strategy, the
quality team and HR function will be initiating values
based recruitment.
Board Lead(s)
corporate resources
Chief nurse and
director of quality
governance and
director of finance,
performance and
corporate resources
A detailed paper was considered by the Board at their
meeting in January 2014 regarding safer staffing. All
ward leaders are supervisory and not included in
minimum numbers.
Chief nurse and
director of quality
governance
See response to R23 – compassion in care above.
Performance and development reviews (PADR) are
undertaken for all staff to identify potential leaders and
leadership development needs.
The learning and development team commission
external training and provide in-house training as
relevant to individual posts.
The clinical supervision policy has been reviewed and
a leadership strategy is being prepared.
Separate to this programme ‘Clinical Fridays’ have
been implemented, with members of the senior team
visiting clinical areas across the Trust.
The PADR process is directly linked to the Trust’s
values.
The staff survey is a formal measure of cultural health
Chief nurse and
director of quality
governance /
medical director
Chief nurse and
director of quality
governance
139
Section
Key nurses (R199)
Named key nurse for each shift to coordinate the provision of care needs for
each allotted patient.
The requirement for healthcare
providers to have at least one executive
director who is a registered nurse and
to consider recruiting nurses as nonexecutive directors
Strengthening the
nursing professional
voice (R204)
Strengthening the
nursing professional
voice (R205)
Strengthening
identification of
healthcare support
workers and nurses
(R207)
Communication with
Commissioning arrangements should
require the boards of provider
organisations to seek and record the
advice of its nursing director on the
impact on the quality of care and
patient safety of any proposed major
change to nurse staffing arrangements
or provision facilities, and to record
whether they accepted or rejected the
advice, in the latter case recording its
reasons for doing so.
The need for a uniform description of
healthcare support workers, with the
relationship with currently registered
nurses made clear by the title.
Regular ward rounds and constructive
and progress against the subsequent action plan is
reported quarterly to the Board.
Staff engagement is a high priority for 2014/15 – ‘fit for
the future’ events are being rolled out across all
clinical business units between September and
November 2014.
The Trust’s bedded units are compliant.
The chief nurse and director of quality governance is
an executive director. One of our non-executive
directors was previously a nurse. The composition of
the Board in our constitution for FT includes that “one
of the executive directors is to be a registered nurse or
a registered midwife”.
The chief nurse and director of quality governance
would be consulted on any major changes to the
nursing establishment.
Board Lead(s)
Chief nurse and
director of quality
governance
Chief executive /
chairman
Chief nurse and
director of quality
governance
The medical director and chief nurse lead the clinical
assessment of all cost improvement proposals.
A key action from the Compassion in Care programme
included publication of staffing levels, linked to quality
of care and patient experience (see also R23 above).
Work has started in north west London (NWL) to
develop the role of the healthcare support work in
collaboration with the local education and training
board (LETB) and Buckinghamshire New University.
Chief nurse and
director of quality
governance
Chief nurse and
140
Section
and about patients
(R238)
interaction between nurses and patients
‘Clinical Fridays’ have been implemented, with
members of the senior team visiting clinical areas
across the Trust.
Board Lead(s)
director of quality
governance
Provision of food
and drink (R241)
Constant review and monitoring of best
practice for providing food and drink to
patients
Process of the administration of
medication needs to be overseen by
the nurse in charge of the ward or their
nominated delegate, together with
frequent checks that all patients have
received what they have been
prescribed and what they need
Chief nurse and
director of quality
governance
Medical director
Medicines
administration
(R242)
Common
information
practices, shared
data and electronic
records (R244)
Need for common information
practices, including patient access to
their records, system prompts and
defaults in support of safe and effective
care, patient engagement in system
design.
See response to R1 – compassion in care above
which includes documentation / patient records.
The Trust has a medicines management team have
ward clinical pharmacists who undertake daily checks
in liaison with the nurse in charge.
The Board receives an annual medicines
management report.
There is an annual omitted doses audit all bedded
units, including the prison and palliative care unity.
Patients that wish to gain access to their medical
record under the Data Protection Act 1998 are
required to submit a request form which will include
consent to release the information. This process is
managed by the IG Team and is logged on a central
system to ensure the records are collated, reviewed
and released as appropriate within the 40 calendar
day statutory deadline.
performance and
corporate resources
Electronic data on our current clinical systems (RiO,
Adastra) is not shared outside the organisation without
explicit patient consent. Systems provided under the
National Programme for IT contract prompt for
justification when access is requested to a record
outside the current caseload.
141
Section
Board accountability
(R245)
Board level member for information
Quality accounts (R246-251) see R37 above
Access to data (252) Appropriate steps must be taken to
enable properly anonymised data to be
used for managerial and regulatory
purposes.
Deployment of TPP SystmOne will allow the
establishment of robust information sharing
arrangements between care providers, as well as
allow patients to access their own electronic record
The director of finance, performance and corporate
resources, is accountable for the business
intelligence, performance and analytics
function of the Trust.
Although compliant with the Health and Social Care
Information Centre anonymisation standards further
work is underway to put in place systematic control to
strengthen our compliance.
Board Lead(s)
performance and
corporate resources
performance and
corporate resources
Information governance training is mandatory for all
CLCH staff.
The Trust has implemented a pseudonymisation tool
which can be used to send data without identifying an
individual. This is currently up and running with the
Trusts Information team and a training programme is
to be delivered to other corporate services to enable
the use of the tool.
Using patients’
feedback (R255)
Following up
patients (R256)
Results and analysis of patient
feedback need to be made available to
stakeholder in as ‘real time’ as possible
A proactive system for follow-up after
discharge
Results from patient reported experience measures
(PREMS) and the friends and family test (FFT) are
available to both commissioners and Board members.
The Trust has engaged Picker to undertake telephone
surveys of patients in support of PREMS and gaining
feedback on services provided.
Chief nurse and
director of quality
governance
Chief nurse and
director of quality
governance
142
Section
Enhancing the use,
analysis and
dissemination of
healthcare
information (R262)
Systems to provide effective real-time
information on performance of services
The Trust has implemented QlikView, self-service
access to up to date business intelligence and clinical
dashboards for all staff.
Board Lead(s)
performance and
corporate resources
143
Keogh, 2013
Relevant
Ambitions for improvement
To tackle some of the underlying
causes of poor care
Board Lead(s)
2
The boards and leadership of provider
and commissioning organisations will
be confidently and competently using
data and other intelligence for the
forensic pursuit of quality improvement.
They, along with patients and the
public, will have rapid access to
accurate, insightful and easy to use
data about quality at service line level.
Patients, carers and members of the
public will increasingly feel like they are
being treated as vital and equal
partners in the design and assessment
of their local NHS. They should also be
confident that their feedback is being
listened to and see how this is
impacting on their own care and the
care of others.
Patients and clinicians will have
confidence in the quality assessments
made by the Care Quality Commission,
not least because they will have been
active participants in inspections.
To content and presentation of data is a high priority
for the Trust. Funnel charts have been introduced
(showing outliers) and the use of standard variation
charts (SVC) is being explored.
Chief Nurse and
Director of Quality
Governance with
Director of Finance,
Performance and
Corporate
Resources
We have an agreed engagement strategy which
covers the engagement of patients, carers, the public,
members and stakeholders. Listening events are
planned in every borough (twice annually).
Chief Nurse and
Director of Quality
Governance
A number of CLCH staff have participated in CQC
inspections of other trusts. The Trust is piloting mock
CQC inspections of its own sites. In the future these
mock inspections will include our members.
Chief Nurse and
Director of Quality
Governance
Nurse staffing levels and skill mix will
appropriately reflect the caseload and
the severity of illness of the patients
A monthly nurse staffing report is made to the Board,
this is based on agreed, appropriate staffing levels for
all areas.
Chief Nurse and
Director of Quality
Governance
3
4
6
The most recent listening event was held on the day
of the annual general meeting (18.09.14)
144
they are caring for and be transparently
reported by trust boards.
8
All NHS organisations will understand
the positive impact that happy and
engaged staff have on patient
outcomes, including mortality rates, and
will be making this a key part of their
quality improvement strategy.
The Trust’s engagement strategy includes staff
engagement and staff engagement is a high priority
for 2014/15. Fit for the future events commenced in
September to support the direct engagement of staff.
performance and
corporate resources
Berwick, 2013
Relevant
A promise to learn, a commitment to
act
Board Lead(s)
1
The NHS should continually and forever The quality team have been instrumental in creating a
reduce patient harm by embracing
learning culture. The Trust has a regular CLIP
wholeheartedly an ethic of learning.
(Complaints, litigation, complaints (C), litigation (L),
incidents (I) PALS (P) Serious Incidents (S) (CLIPS)
newsletter for staff. By learning from experiences we
will be better able to continually improve the safety
and quality of the services that we provide (see R44
above)
All leaders concerned with NHS
Our values include “putting quality at the heart of
healthcare – political, regulatory,
everything we do”.
governance, executive, clinical and
advocacy – should place quality of care We have established a quality team, associate
in general, and patient safety in
directors of quality and clinical directors are linked to
particular, at the top of their priorities for every CBU / division.
investment, inquiry, improvement,
regular reporting, encouragement and
support.
2
Chief Nurse and
Director of Quality
Governance
Chief Nurse and
Director of Quality
Governance
145
3
Patients and their carers should be
present, powerful and involved at all
levels of healthcare organisations from
wards to the boards of Trusts.
Our engagement strategy ensures each division and
CBU has a clear strategy for engaging staff, patients
and stakeholders. Board meetings are held in public.
The quality stakeholder reference group (QSRG)
feeds directly into the Quality Committee.
Members have been invited to participate in the 15
steps challenge and patient led assessments of the
care environment (PLACE).
The Trust has been involved with the development of
community education provider networks (CEPNs)
across all networks. The Chief Nurse works with
Health Education England and we are contributing to
the identification of workforce development / needs.
The Board
4
Government, Health Education England
and NHS England should assure that
sufficient staff are available to meet the
NHS’s needs now and in the future.
Healthcare organisations should ensure
that staff are present in appropriate
numbers to provide safe care at all
times and are well-supported.
5
Mastery of quality and patient safety
sciences and practices should be part
of initial preparation and lifelong
education of all health care
professionals, including managers and
executives.
The Trust has launched a continuous improvement
education programme.
Medical Director
6
The NHS should become a learning
organisation. Its leaders should create
and support the capability for learning,
and therefore change, at scale, within
the NHS.
See 5 above and Francis R44 above.
Medical Director
Transparency should be complete,
All 48 hour meetings discuss the duty of candour and
7
Chief Nurse and
Director of Quality
Governance
Reflective time has been incorporated into the working
week for ELT (meeting without a planned agenda) and
this is being encouraged across the organisation.
Chief Nurse and
146
timely and unequivocal. All data on
quality and safety, whether assembled
by government, organisations, or
professional societies, should be
shared in a timely fashion with all
parties who want it, including, in
accessible form, with the public.
unless there are very specific / exceptional
circumstances, the family / patient are informed of any
errors.
8
All organisations should seek out the
patient and carer voice as an essential
asset in monitoring the safety and
quality of care.
9
Supervisory and regulatory systems
should be simple and clear. They
should avoid diffusion of responsibility.
They should be respectful of the
goodwill and sound intention of the vast
majority of staff. All incentives should
point in the same direction.
The Trust collects up to 1500 patient reported
experience measure (PREMs) forms across the
organisation each month, together with patient stories
and localised patient satisfaction data. This is
analysed through the patient experience group lead by
the director of patient experience. The Trust has
appointed 4 new patient experience facilitators to work
within each division to improve the uptake and
analysis of patient data. This will enable the divisions
to work on demonstrating direct improvements in care.
There is a clear management structure within the
Trust. The new clinical business unity (CBU) structure
ensures that clinical staff are managed by clinical
staff. All staff have access to clinical supervision and
are actively encouraged to use this facility.
There are policies and procedures in place to support
staff development and a very clear performance
management strategy.
Staff are rewarded in their day to day practice and at
events such as the annual staff awards ceremony.
Director of Quality
Governance
Serious incident reports are published together with
the quality scorecard and other performance
information.
Chief Nurse and
Director of Quality
Governance
Deputy Chief
Executive
Director of Finance,
Performance and
Corporate
Resources
147
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title:
Board governance memorandum – updated action plan
Agenda item number:
3.3
Report of:
Chief Executive
Contact Officer:
Trust Secretary
1 Embody the best of the NHS for our patients: delivering great
Can be published
Status
Executive Summary:
Having agreed the board governance memorandum in July 2014, an action plan to achieve best
practice was prepared and agreed at the Board meeting of 30.09.14. Since this date, the Trust has
received the findings of the external assessment by Grant Thornton, including some 14
recommendations (5 high priority), attached. These actions have been incorporated into the action
plan (shown in red text). Updates on the original action plan are also tracked (shown in blue text).
The action plan is aligned and referenced to the DH framework, thus there is some repetition which
cannot be avoided.
A copy of Grant Thornton’s report has been circulated to members of the Board.
Key observations included in their report are listed below:
1. The board governance memorandum is thorough and generally supported by the four case
studies and evidence provided by the Trust. Ratings in ten of the fifteen categories have been
endorsed, five scores have however been reduced.
2. Overall, by far the most common rating is 'amber/green'. This characterises accurately the Trust's
overall position, namely the great majority of good practice requirements are either present or
planned to be implemented in the near future. From the work performed, the Trust appears to
be on track with its FT application timetable and has time to address those areas where
improvements are required.
3. Fourteen recommendations that relate to specific ways in which the Trust can adopt more of the
good practices have been made.
4. There is a good balance of skills, experience and knowledge amongst board members, with the
NEDs providing good challenge during board and committee discussions
5. Three of the six NED terms are due to end on 31 March 2015, and the chair is having ongoing
discussions with the TDA to try and resolve this issue. To ensure board stability and prevent a
148
significant loss of expertise, Grant Thornton believe it is important that this issue is fully resolved
as soon as possible to prevent it impacting on the effectiveness of the board.
6. Feedback from the Trust's lead tri-borough commissioners indicates that, although there has been
some improvement in the relationship over the last year, further work is required to further
develop an effective and constructive relationship. The development of a clear stakeholder
engagement plan and supporting key account plans is a recognised development action for the
Trust, and as part of this process we would recommend that the board confirms with its key
external stakeholders the best methods to ensure effective and constructive relationships.
7. The Trust's plans for future engagement with FT governors are consistent with its FT application
timetable. The consideration of detailed plans relating to the future governors of the Trust postauthorisation as an NHSFT should be undertaken by the FT steering group in the coming months.
8. The Trust has spent time considering board performance reporting over the last year, and
feedback from board member interviews indicates that the KPIs included in the integrated
performance and finance report balanced scorecard enable the board to effectively measure
performance against the Trust's six strategic goals. The Trust is planning further development of
the integrated finance and performance report for reporting to the board and Finance, Resources
and Investment Committee (FRIC) in October 2014 and in our view, as part of this development
process, the board should reflect upon the effectiveness of the key performance indicators used
to monitor performance against four of the six strategic goals.
The recommendation in relation to this final observation was contested by the Chief Executive and
since receipt of the report; clarity regarding specific improvements that the Trust might consider has
been requested.
Report provenance:
Actions identified to achieve ‘good’ practice were included in the board governance memorandum
approved by the Board on 31.07.14 and the initial action plan was agreed on 30.09.14. The updated
action plan has been discussed with ELT and is shared for Board comment.
Discussion
Information
Recommendation: To discuss.
149
Grant Thornton recommendations, ref 08.10.14
Section
Recommendation
BGAF 1.1
and 2.3
The Trust should continue negotiating with the TDA over the staggering
of the three NED terms coming to an end on 31 March 2015. The Trust
should consider what contingency actions it can take to prevent the
risk of such an imbalance in board composition.
The Trust should review how the new arrangements to ensure regular
attendance by board members at board and committee meetings are
working after six months.
The board should engage in a comprehensive, independent board
evaluation process in 2015.
The board should ensure that the current work to gather stakeholder
perspectives on the effectiveness of the board is given full consideration
and acted upon. Stakeholder perspectives should then be gathered
and analysed at regular intervals, moving through the foundation trust
application process and beyond.
We recommend that a formal and long-term board development plan /
programme is put in place to ensure that the direction, workings and
supporting governance arrangements of the board are
appropriate both before and following foundation trust authorisation.
The Trust should put an action plan in place to ensure that when the
time comes, governor involvement in the chairman's and NEDs'
appraisal processes is fully considered.
As part of the Trust actions to improve the IPFR, the board should
reflect upon the effectiveness of the KPI
used to monitor the performance against the following four strategic
goals:
‒ deliver better value than competitors in our selected markets;
‒ be responsive to our patients' and partners' needs;
‒ employ only the best staff, and;
‒ be innovation and technology pioneers.
In further developing the form and content of the IPFR over the coming
months, the Trust should ensure:
‒ greater emphasis is placed on providing insightful explanations for
adverse variances and trends and stating what actions have been taken
to bring the variance back into line with plan;
‒ forecast outturn information is provided for non-financial KPIs;
‒ service line reporting information includes a quality perspective and is
presented more clearly; and,
‒ comparable data (comparable organisations or between different
service lines) is included.
We recommend that when committee chairs provide verbal updates to
the board, written updates are also provided or the minutes of board
meetings note the key points made by the committee chairs.
In reporting CIP performance to the FRIC, we recommend that analysis
of major CIP schemes is provided to highlight where performance is not
in line with plan.
We recommend that the chairman and chief executive meet with their
peers in the tri-borough commissioners to confirm the best method to
ensure effective and constructive relationships; and follow
BGAF 1.3
BGAF 2.1
BGAF 2.1
BGAF 2.2
BGAF 2.4
BGAF 3.1
BGAF 3.1
BGAF 3.1
BGAF 3.2
BGAF 4.1
Priority (High,
Medium, Low)
High
Medium
Medium
High
Medium
Low
High
High
Medium
Medium
High
150
BGAF 4.2
BGAF 4.3
BGAF 4.4
this up with the development of key account plans.
The Trust should seek feedback from staff on the effectiveness of its
internal communication methods, particularly the impact of regular email
communications and the effectiveness of the intranet hub, to
ensure that they are appropriate and efficient.
The Trust should set up a process for monitoring attendance at key
external stakeholder events and meetings, in particular those that
involve important commissioner meetings, and ensure regular
attendance by key account owners.
The consideration of the roles, responsibilities, method of selection,
numbers and designations and all other matters relating to the future
governors of the Trust post-authorisation as an NHSFT should be
directed and overseen by the FT steering group once the Trust is within
a year of its planned authorisation
as an FT.
Medium
Medium
Medium
151
Board Governance Memorandum (BGM) Action Plan, v8 October 20141
The action plan, agreed by the Board on 30.09.14, has been updated as planned to reflect the findings of the independent
review by Grant Thornton, 6 Oct 2014. It is confirmed that of the 15 categories, the self-assessment score for 5 has been
reduced (2.4, 3.3, 4.1, 4.3 and 4.4) – see status below. These relate to areas where it is considered that evidence has not
been provided to demonstrate good practice and action plans in place to achieve good practice. Two new sections have
been added to the action plan in relation to 3.3 environmental and strategic focus and 4.3 Board profile and visibility.
Ref
Good practice
question
and
Grant Thornton
recommendation
1.1
Board positions and size
High turnover of Board
membership in previous
2 years
(red flag)
Where necessary, the
appointment term of
NEDs is staggered so
they are not all due for
re-appointment or leave
the Board within a short
space of time.
1
Action
Lead(s)
Action 1.1, good practice
statement 2
Board development programme
supports rapid assimilation. The
most recently appointed Board
members all have previous Board
experience.
P Chesters
statement 7
The Chairman has brought this
problem to the attention of
Christine Beasley and the Head
of the TDA Appointments Section
who have promised to review this
phasing which is an issue
affecting all community trusts.
P Chesters
Position, status and comments
Amber / Green
Open
We have had some significant turnover
of the Board in the previous 2 years.
This has strengthened the Board by
increasing the level of skill and
experience held by Directors to match
the requirements of foundation trust
status.
A succession plan is in place for all
Board positions.
Open
The TDA advised in January 2014 that
their NED development team were
looking at staggering end terms for
community trusts.
Target date
/ deadline
n/a
March 2015
In October, the TDA confirmed that
Director for Delivery and Development
supports the re-appointments of the
Author – Jayne Walbridge, Trust Secretary
1
152
Ref
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
Target date
/ deadline
three NEDs and have asked the
Chairman for a recommendation on the
length of terms (up to four years).
1.3
Grant Thornton BGAF
An action in relation to this issue
1.1 and 2.3
has already been agreed.
The Trust should
continue negotiating with
the TDA over the
staggering of the three
NED terms coming to an
end on 31 March 2015.
The Trust should
consider what
contingency actions it
can take to prevent the
risk of such an
imbalance in board
composition.
Board member commitment
Board members have a
statement 1
good attendance record
This has been reviewed recently
at all formal Board and
and arrangements to ensure that
Committee meetings
‘operational’ staff are routinely
and at Board events
represented at the Quality
Committee are will be confirmed.
This will be reflected in the
revised terms of reference for
Board approval.
Grant Thornton BGAF
Committee and board attendance
1.3
to be reviewed to ensure regular
The Trust should review
attendance by members.
how the new
J Reilly /
L Ashley /
R Milner
J Walbridge
Amber / Green
Complete
Since August 2014, the Deputy CEO
has attended each meeting and this
arrangement has been confirmed,
therefore no changes to the
membership will be required.
Open
Planned for February 2015.
September
2014
March 2015
2
153
Ref
2
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
arrangements to ensure
regular attendance by
board members at board
and committee meetings
are working after six
months.
Effective Board level evaluation
Formal evaluations of
statement 1a
the Board and
The Quality Committee selfCommittees have been
assessment in 2014 has been
undertaken within the
deferred in order to arrange a
previous 12 months
more comprehensive, facilitated,
consistent with the FT
self-assessment with Stephen
Code of Governance.
Ramsden, a former NHS CEO.
The Board can clearly
The output of this review will be
identify a number of
available in September. The
changes/improvements
in Board and Committee Remuneration Committee selfeffectiveness as a result assessment is planned for
of the formal evaluations October 2014 and the Charitable
Funds Committee will be
that have been
concluded in September 2014.
undertaken.
The Board has not
undertaken an
independent evaluation
of effectiveness within
the last 2 years.
(red flag)
statement 1b
The Board’s current focus is on
Development and the Unitary
Board, independent evaluation of
effectiveness will be arranged in
2015.
J Walbridge
/ J Reilly / P
Chesters
Amber / Red
Open
The Code requirement is for the “board
of directors should undertake a formal
and rigorous annual evaluation of its
own performance and that of its
committees and individual directors”.
Target date
/ deadline
Tbc in liaison
with TDA
guidance.
Board and committee programmes
include this requirement. External
evaluation of the Quality Committee has
now been received and the Charitable
Funds Committee have also concluded
their review. The People and
Remuneration Committee review is
complete and will be reported to the
Remuneration Committee on 22.10.14.
P Chesters/
J Reilly
Committee chairs will consider whether
a more formal assessment process is
required in 2015.
Open
Excellence in Leadership will be
conducting a stakeholder survey of the
Board in early 2015. The outcome of
this will shape the next phase of the
Board’s development programme.
June 2015
June 2015
3
154
Ref
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
Target date
/ deadline
The need for independent evaluation of
effectiveness has been discussed by
ELT, it is concluded that this is integral
to the work Excellence in Leadership
and that any gaps, specific to
effectiveness, should be considered
after this work has been concluded.
Previous Board evaluation has included
Deloitte and the TDA.
The Board has had an
independent evaluation
of its effectiveness and
committee structure
within the last 2 years by
a third party that has a
good track record in
undertaking Board
effectiveness
evaluations
Grant Thornton BGAF
2.1
The board should
engage in a
comprehensive,
independent board
evaluation process in
2015.
The perspectives of staff
and commissioners has
not informed Board
evaluation.
statement 2
To arrange further independent
evaluation of the Board (hard and
soft dimensions) and committee
structure during 2015 to ensure
that evaluation within the
previous 12 months can be
demonstrated on application to
Monitor.
Timing of independent evaluation
to be confirmed.
P Chesters
Open
This will be conducted towards the end
of 2015 when the work with Excellence
in Leadership and the current internal
review of Committees/Board work and
reporting has been embedded.
Nov 2015
J Reilly
Guidance from the TDA on the timing
and format of further Board evaluation,
including the status of the recent
assessments by Grant Thornton and
Niche Consultancy has been sought.
April 2015
statement 3
As part of the Board’s
development programme with
P Chesters /
J Reilly
Open
Excellence in Leadership will be
conducting a stakeholder survey of the
Board in early 2015. The outcome of
April 2015
4
155
Ref
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
Excellence in Leadership, internal
stakeholder perspectives will be
obtained later in 2014 and
external perspectives in 2015.
2.2
Grant Thornton BGAF
2.1
The board should
ensure that the current
work to gather
stakeholder perspectives
on the effectiveness of
the board is given full
consideration and acted
upon. Stakeholder
Analysis of stakeholder feedback
perspectives should then at regular intervals throughout the
be gathered
FT process and beyond to be
and analysed at regular
incorporated into stakeholder
intervals, moving
engagement plans.
through the foundation
trust application process
and beyond.
Whole Board Development Programme
… understanding what
statement 1
FT status means;
The Board will consider the
development specific to
requirements of the ‘Well-led’
the Trust’s FT
framework in support of future
application…
Board evaluation plans
Target date
/ deadline
this will shape the next phase of the
Board’s development programme.
I McMillan
for I Millar
Open
The Board has agreed an engagement
strategy.
April 2015
The Board has discussed the
development of the commercial strategy
which is due to be considered for
approval in November 2014.
The Trust will use customer relations
management (CRM) software to gather
and analyse information from
stakeholders.
L Ashley /
J Walbridge
J Walbridge
Amber Green
Open
Reference to Well-led framework,
included in this action plan
Well-led framework for governance
reviews:
As an FT the Trust will be expected (by
Monitor) to commission an external
review of governance arrangements
every 3 years. The framework is built
along the lines of the existing quality
governance framework and is intended
November
2014
At
authorisation
5
156
Ref
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
Target date
/ deadline
as a guide for trusts and assessors in
considering whether the processes and
overall organisational culture in these
areas are fit for purpose. It is proposed
that between the external assessments,
ie year 1 and 2, an internal review of 2
of the 4 domains is undertaken. This
will inform the development programme
for the Board.
P Chesters/
J Reilly
Grant Thornton BGAF
2.2
We recommend that a
formal and long-term
board development plan
/ programme is put in
place to ensure that the
direction, workings and
supporting governance
arrangements of the
board are appropriate
both before and
following foundation trust
Development plan post April
2015 (when Excellence in
Leadership plan concludes), to
be prepared.
P Chesters/
J Reilly/
J Walbridge
A Board development programme
specific to the FT curriculum /
application process to be updated post
April 2015 on completion of the
Excellence in Leadership plan. This will
include how the Board discussion on
how the Board will communicate and
engage with governors and how
governors will be involved in strategic
development, service change and
quality issues.
Open
To be discussed.
May 2015
April 2015
Template from the Good Governance
Institute sourced for long-term plan /
programme.
6
157
Ref
Good practice
question
and
Grant Thornton
recommendation
authorisation.
Members have an
appreciation of how they
will be regulated as an
FT and the role of the
board and NEDS in an
FT environment.
… The Board has been
engaged in the
development of the IBP
and LTFM and in selfassessing the Trust’s
QGAF
… The Board has been
engaged in the
development of the IBP
and LTFM and in selfassessing the Trust’s
QGAF
…. Whether the Board’s
Committees are
operating effectively and
providing sufficient
assurances to the Board.
Action
Lead(s)
Target date
/ deadline
statement 2
A comparison with Monitor’s code
of governance will be repeated in
2014/15.
J Walbridge
Open
Scheduled for December 2014 for report
in January 2015.
March 2015
statement 3a
Board to review progress against
QGF and BGAF quarterly.
L Ashley /
J Walbridge
Open
BGAF action plan considered in
September and October 2014.
Quarterly
review from
September
2014
The Board approved the QGAF in July
2014. The initial action plan was
considered in September 2014.
statement 3b
Implementation of the
commercial strategy (including
external stakeholder
engagement) which is managed
by the Director of strategy and
business development.
statement 4
As Board Committees have
become much more effective in
their role, the Board is actively
considering how best to avoid
repetitive discussion with items
that are considered by the
Iain
McMillan for
I Millar
P Chesters /
J Reilly / J
Walbridge
Recommendations made by the external
assessor (Niche) are expected to be
received in October 2014.
Open
A commercial strategy, including
external (commissioner) engagement
will be developed in 2014. Proposal
considered at Board seminar on
30.09.14. Strategy to be considered for
agreement by Board on 27.11.14.
Open
This has been discussed at the Board
seminar in July and a revised approach
is being introduced, together with
refreshed reporting formats. Once
established they will be reviewed in
2015 to check the effectiveness and
whether the revised arrangements have
January 2015
April 2015
7
158
Ref
Good practice
question
and
Grant Thornton
recommendation
The Board has
considered, at a highlevel, the potential
development needs of
the Board post
authorisation as an FT.
2.3
2.4
Lead(s)
Committees.
statement 6
‘First 100 days’ post FT
authorisation plan to be prepared
and implemented in 2015/16
Board induction, succession and contingency planning
Action 2.3
NED appointment terms
are not sufficient
The second term for 3 of our
staggered.
NEDs will conclude at the same
(red flag)
time (April 2015). The Chairman
has raised this formally with the
TDA and also with the NEDs to
advise that
Board member appraisal and personal development
Grant Thornton 2.4
The Trust should put an
2
Action
P Chesters /
J Walbridge
P Chesters
been appropriately embedded.
Open
Development needs will be addressed
through the Board’s development
programme. At the appropriate time, the
curriculum will include, for example the
FT regulatory regime and the role of
governor.
When the authorisation date is known,
the 100 day plan will be prepared by the
Trust Secretary to ensure that at
authorisation, necessary governance
arrangements can be implemented
immediately, for example confirmation of
governors, the constitution and
establishment of the council of
governors nomination and remuneration
committee.
Amber / Green
Open
In October, the TDA confirmed that
Director for Delivery and Development
supports the re-appointments of the
three NEDs and have asked the
Chairman for a recommendation on the
length of terms (up to four years). See
1.1 above.
Green
2
Amber / Green
Target date
/ deadline
n/a
n/a
has already been agreed
GT assessment score, Oct 2014
8
159
Ref
3.1
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
action plan in place to
ensure that when the
time comes, governor
involvement in the
chairman's and NEDs'
appraisal processes is
fully considered.
Board Performance Reporting
The Board receives a
statement 1 and 2
fully integrated
Internal performance priorities for
performance dashboard
which enables the Board 2014 include:
to consider the
• Gaining a better
performance of the Trust
understanding of any outliers
against a range of
at clinical business unit
metrics, including quality,
(CBU) level and in some
performance, activity and
areas, team level
finance and enables
• More frequent forward
links to be made, eg
looking indicators
financial variances are
• More triangulation of key
linked to activity.
performance metrics
Variances from plan are
examining the impacts of
clearly highlighted and
change in workforce, activity,
explained.
quality and finance have on
one another.
statement 2b
Briefing to be prepared
demonstrating how issues arising
at the front line are identified and
escalated, building on funnel
charts and clinical business units.
Mike Fox for
I Millar
C Sheldon
for L Ashley
Amber / Green
Open
The FRIC have discussed improved
reporting processes which will be
implemented from October 2014.
Open
The serious incident reporting policy
was updated in August 2014 and
includes a clear escalation process from
floor to Board. Whistleblowing for all
staff and further guidance for clinical
staff has been issued. A flow diagram is
also being prepared showing all routes
for whistleblowing (raising concerns
Target date
/ deadline
December
2014
November
2014
9
160
Ref
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
statement 2c
Survey of Qlikview usage to be
arranged towards the end of
2014.
Mike Fox for
I Millar
Grant Thornton 3.1
As part of the Trust
actions to improve the
IPFR, the board should
reflect upon the
effectiveness of the KPI
used to monitor the
performance against the
following four strategic
goals:
‒ deliver better value
than competitors in our
selected markets;
‒ be responsive to our
patients' and partners'
needs;
‒ employ only the best
staff, and;
‒ be innovation and
technology pioneers.
Grant Thornton 3.1
In further developing the
form and content of the
IPFR over the coming
months, the Trust should
ensure:
about staff, clinicians and fraud).
Open
A Tyler has been asked to prepare
report on usage for ELT to consider in
late November.
Target date
/ deadline
November
2014
Mike Fox for
I Millar
J Reilly has written to the Board to state
that he has requested further
clarification regarding Grant Thornton’s
recommendations in relation to the
integrated performance and finance
report.
November
2014
Mike Fox for
I Millar
J Reilly has written to the Board to state
that he has requested further
clarification regarding Grant Thornton’s
recommendations in relation to the
integrated performance and finance
report.
November
2014
10
161
Ref
3.2
Good practice
question
and
Grant Thornton
recommendation
Action
‒ greater emphasis is
placed on providing
insightful explanations
for adverse variances
and trends and stating
what actions have been
taken to bring the
variance back into line
with plan;
‒ forecast outturn
information is provided
for non-financial KPIs;
‒ service line reporting
information includes a
quality perspective and
is presented more
clearly; and,
‒ comparable data
(comparable
organisations or
between different
service lines) is
included.
Grant Thornton 3.1
When committee chairs
provide verbal updates
to the board, written
updates are also
provided or the minutes
of board meetings note
the key points made by
the committee chairs.
Efficiency and Productivity
Lead(s)
Target date
/ deadline
J Walbridge
with
Committee
Chairs
Open
This process is now established for the
Audit Committee and FRIC Committee.
With the exception of FRIC, J Walbridge
to prepare draft for all Committee
Chairs. With the agreement of the Trust
Chairman, such updates will be tabled if
necessary.
January 2015
Amber / Green
11
162
Ref
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
Target date
/ deadline
The Board is assured
that there is a robust
process for prospectively
assessing the risks to
care quality and the
potential knock-on
impact of the wider
health and social care
community of
implementing CIPs. This
process requires the
Medical, Nursing and
Operations Directors to
all sign-off each major
CIP to ensure patient
safety is not
compromised.
statement 1
New CIP review arrangements to
discussed at Quality Committee.
L Ashley /
J Medhurst
Complete
A more robust impact assessment
process has been introduced.
October 2014
The Board receives
information on all major
CIPs/QIPP plans on a
regular basis, including
how other organisations
in the local health
economy are performing
against QIPP. Schemes
are allocated to lead
Directors and are RAG
rated to highlight where
performance is not in line
with plan. The risks to
non-achievement of
Divisional directors of operations are
involved in the agreement and
monitoring of CIP plans.
statement 1
Some corporate CIP quality
impact assessments have not yet
been received for assessment
and are due to be considered in
August 2014.
statement 3a
The Quality Committee and FRIC
have agreed that post
implementation reviews should
be conducted on all significant
CIP schemes to ensure that they
have not led to an unacceptable
level of increased risk to quality.
Timetable for 2014/15 to be
prepared and agreed by the Chief
Nurse and Medical Director.
statement 3b
L Ashley /
J Medhurst
The Medical Director and Chief Nurse
have personally signed off all CIP quality
impact assessments and review CIPs
with Divisions every two months. All
CIP risks are on the Trust’s risk register.
Open
It is planned that all corporate CIPs will
be signed off by mid October 2014.
October
2014.
L Ashley /
J Medhurst
Open
As above, the Medical Director and
Chief Nurse meet every two months with
all Divisions to review quality key
performance indicators for all schemes.
October 2014
Mike Fox for
I Millar
Open
The process to capture information on
October 2014
12
163
Ref
3.3
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
each major CIP is clearly
stated and contingency
measures are
articulated.
To consider process to capture
information on how other
organisations in the local health
economy are performing against
their QIPP schemes.
ELT to consider the level of detail
provided in report to FRIC.
Grant Thornton BGAF
3.2
In reporting CIP
performance to the
FRIC, we recommend
that analysis of major
CIP schemes is provided
to highlight where
performance is not in
line with plan.
Environmental and strategic focus
Mike Fox for
I Millar
other organisations will be considered
but it is likely that this level of detail will
not be published – the resources to
achieve will be considered against any
benefits.
Open
Exception reports to highlight where
performance is not in line with plan.
Target date
/ deadline
Dec 2014
Green
3
Amber / Green
4
3.4
3
4
Note - Grant Thornton
commented that, while
market opportunities and
threats in relation to
services provided have
been considered, the
commercial strategy and
related stakeholder
engagement plans are
not yet confirmed.
Quality of Board papers and timeliness of information
Board papers outline the Action 3.4, good practice
statement 5
decisions or proposals
that Executive Directors
To review the effectiveness of the
R Milner
Amber / Green
Open
To be incorporated into the Board
development plan.
February
2015
This was not a recommendation, but was a key finding
13
164
Ref
Good practice
question
and
Grant Thornton
recommendation
Action
have made or propose.
This is supported, where
appropriate, by: an
appraisal of the relevant
alternative options; the
rationale for choosing
the preferred option; and
a clear outline of the
process undertaken to
arrive at the preferred
option, include the
degree of scrutiny that
the paper has already
been through.
The Board is routinely
provided with data
quality updates (eg IG
toolkit scores). These
updates include external
assurance reports that
data quality is being
upheld in practice and
are underpinned by a
programme of clinical
and/or internal audit to
test the controls that are
in place.
new board writing guidance,
specifically improvement in the
assessment of alternatives and
the rationale for the proposed
option.
The Board does not
routinely receive
assurances in relation to
data quality
(red flag)
statement 6
An independent review in 2014
has informed the Board of the
current status of assurance and
has generated action plans that
are being delivered through the
year.
- a single data warehouse ("one
version of the truth")
- automated report generation,
minimising manual intervention,
to maintain that "one version of
the truth" philosophy,
- easier access for managers to
dashboard information that allows
them to good practice statement
any data issues early.
Lead(s)
Target date
/ deadline
Mike Fox for
I Millar
Open
The agreed internal audit programme for
2014/15 includes data quality.
November
2014
The Audit Committee has a specific
objective (64) for a second year - “To
continue to monitor progress against the
implementation of the Data Quality
Strategy to gain assurance on the
accuracy, timeliness and relevance of
key performance data sets”.
At the Audit Committee in September
2014 data quality in relation to all KPIs
was considered which was interesting
and helpful. Areas of concern have
been referred to the respective
committees (FRIC, Quality and
Workforce).
14
165
Ref
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
Target date
/ deadline
A data quality forum has also
been established and meets
regularly to improve data quality.
It provides reports for assurance
to the Board through the Audit
Committee, including the results
of data audits scheduled through
the year to test the quality of
data.
New for 2014/15 an extra Board
level KPI is also being developed
that will be reviewed regularly at
FRIC and Board tracking overall
data quality confidence levels as
measured by the data quality
assurance framework.
4.1
External Stakeholders
The Board has an
engagement plan that
clearly describes the
Trust’s key existing and
emerging external
stakeholders, their
relative priority and the
tailored methods used to
involve each stakeholder
group (stakeholders
include CCGs, LA and
Wellbeing Boards).
statement 1
External stakeholder plans to be
reviewed and refreshed in 2014,
including confirmation of leads for
various stakeholder groups.
For inclusion in Board
programme, 2014/15.
Iain
McMillan for
Ian Millar
Amber / Green
Amber / Red
Open
At the seminar meeting on 30.09.14, the
Board considered the development of
the Trust’s commercial strategy –
encompassing stakeholders,
partnerships, competition and
marketing.
An external stakeholder engagement
plan specific to FT status is being
prepared for ELT to consider in
November 2014, longer term plans will
be developed as part of the commercial
December
2014
January 2015
15
166
Ref
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
Target date
/ deadline
strategy implementation.
5
Note - Grant Thornton
has commented that
further work is required
to further develop an
effective and
constructive relationship
and that the
development of a clear
stakeholder engagement
plan and supporting key
account plans is
required.
A variety of methods are
used by the Trust to
enable the board and
senior management to
listen to the views of
patients, carers,
commissioners and the
wider public, including
hard to reach groups like
non-English speakers
and service users with a
learning disability. The
Board has ensured that
various processes are in
place and effectively and
efficiently respond to
these views and can
5
statement 2a
Implementation of the learning
disability protocol
L Ashley
Joe Mills for
Open
The learning disability protocol is being
prepared and will be discussed at the
Quality Committee in October 2014.
In liaison with NHS England, the Trust
has developed an iPad based App for
people with learning disabilities to
be supported to answer the
NHS Friends and Family Test. A short
film about the Project has been
produced for service users and
families/carers - which will be available
to be viewed on YouTube My Health, My
Say films with captioning to increase
accessibility.
Complete
December
2014
April 2015
This was not a recommendation, but was a key finding
16
167
Ref
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
provide evidence of
these processes
operating in practice.
statement 2b
Summary IBP to be completed
and distributed to stakeholders.
Relationship with CCGs
The TDA have expressed a view
that CCG relationships is the
biggest challenge to the Trust’s
FT application.
I Millar
A summary IBP has not been prepared,
however, the two-year plan has been
published here.
Open
Monthly chairs meetings
Improved quality meetings with
commissioners
Board meetings with CCGs held
where/when possible
Commercial strategy in development for
approval in November.
Whole systems work progressing to
plan.
J Reilly
Further work is required to
strengthen the confidence of
North West London CCG and a
plan to strengthen relationships
will be prepared by ELT.
Grant Thornton 4.1
We recommend that the
chairman and chief
executive meet with their
peers in the tri-borough
commissioners to
confirm the best method
to ensure effective and
constructive
relationships; and follow
this up with the
development of key
account plans.
ELT will also fully engage and
consult with commissioners and
other key stakeholder in the
production of the 2015/16 IBP,
including key service
developments.
Chairman and Chief Executive to
raise this issue at their meetings
with all commissioning
equivalents, including those in
the tri-borough.
Target date
/ deadline
December
2014
See also 4.1, above (external
stakeholder plan).
J Reilly /
P Chesters
Open
Chairman and Chief Executive to
discuss.
Tbc
17
168
Ref
Good practice
question
and
Grant Thornton
recommendation
4.2
Internal Stakeholders
A variety of methods are
used by the Trust to
enable the Board and
senior managers to listen
to the views of staff,
including ‘hard to reach’
groups like night staff
and weekend workers.
The Board has ensured
that various processes
are in place to effectively
and efficiently respond to
these views and can
provide evidence of
these processes
operating in practice.
Grant Thornton BGAF
4.2
The Trust should seek
feedback from staff on
the effectiveness of its
internal communication
methods, particularly the
impact of regular email
communications and the
effectiveness of the
intranet hub, to
ensure that they are
appropriate and efficient.
Action
Lead(s)
statement 1a
ELT to review staff engagement
plans and processes to further
develop wider and structured
staff engagement opportunities.
ELT will consider whether the
group commissioned to develop
the Trust’s leadership strategy
can support staff engagement
plans.
J Reilly
Effectiveness of internal
communications to be tested.
L McGeehan
for I Millar
Open
To be discussed with Head of
Communications.
February
2015
statement 1b
Staff engagement to be reviewed
to ensure that the views of ‘hard
S Graham
for I Millar
Open
To be discussed with Head of
Communications
December
2014
Amber / Green
Open
Staff engagement events commenced
on 29.09.14.
Target date
/ deadline
December
2014
While a target date of December is
included, this work will be on-going.
A report on the staff communications
and engagement was received by the
Board on 30.09.14 showing some
progress.
18
169
Ref
Good practice
question
and
Grant Thornton
recommendation
The Board can evidence
how staff have been
engaged in the
development of their 5
year strategy for the
Trust and provide
examples of where their
views have been
included and not
included in the IBP.
The Board has
communicated a clear
set of values/behaviours
and how staff that do not
behave consistent with
these values will be
managed. Examples
can be provided of how
management have
responded to staff that
have not behaved
consistent with the
Trust’s stated
Action
to reach’ groups are pro-actively
sought. Divisional Directors of
Operations to be consulted in
identifying robust communication
channels for staff who may only
work at night and weekends.
statement 2
Continued involvement of frontline staff at CBU level in
developing the IBP.
Lead(s)
Target date
/ deadline
Joe Mills for
I Millar
Complete / underway
The 2013/14 business planning process
was used to inform the IBP, this
included discussion with divisional
teams, for example planning away days,
and at the senior management forum.
January 2015
The Trust’s whole planning process for
2015/16 will be built bottom-up by the
CBUs and each manager will have a
planning document which will describe
their future plans for the CBU. This
information will be integral to the
development of the IBP.
statement 5
Improved communication and
engagement with staff through
the ‘Fit for the Future’ initiative.
J Reilly
Open
A series of staff engagement events
(CLCH Fit for the Future) have been
scheduled across all divisions, led by
ELT between 29 September and 19
November 2014. The focus of these
events is to share details of the Trust’s
future strategy and listen to the views of
staff about how teams can work together
to ensure the trust is ‘Fit for the Future’.
December
2014
19
170
Ref
Good practice
question
and
Grant Thornton
recommendation
values/behaviours.
The Board can
demonstrate that
clinicians play a key role
in management and
decision making within
the Trust.
Action
Lead(s)
Target date
/ deadline
statement 7
Establishment of permanent parttime Deputy Medical Director
post
J Medhurst
Complete
New divisional structures include clinical
directors
Assistant directors of quality identified
Medical director forum established and
Deputy Medical Director has been
appointed and is now in post (October
2014).
November
2014
4.3
Board profile and visibility
4.4
Grant Thornton BGAF
Implementation of CRM software
4.3
The Trust should set up
a process for monitoring
attendance at key
events and meetings, in
particular those that
involve important
commissioner meetings,
and ensure regular
attendance by key
account owners.
Future engagement with FT Governors
There are robust plans in
place to elect, induct and
develop governors once
6
statement 3a
A communications plan will be
I McMillan
for I Millar
J Walbridge
P Chesters
Green
6
Amber / Green
Open
The Trust will use CRM software to
capture and act upon commissioner
information.
Amber / Green
Amber / Red
Open
The election and communication plan
(scoping our approach) for the Council
December
2014
June 2015
February2015
20
171
Ref
Good practice
question
and
Grant Thornton
recommendation
Action
Lead(s)
the Trust is authorized.
developed to support our election
plan, including early identification
of a wide range of members who
might be interested in standing
for election.
Target date
/ deadline
of Governors will be prepared for
consideration by the FT steering group
in October 2014.
The draft Governor handbook, including
the role of Governors in the Chairman’s
and NED’s appraisal will be prepared for
in November 2014.
The draft Governor induction
programme will be prepared for
in December 2014.
We have commenced the identification
of governors and the FT team led
engagement events in late autumn early
2015 will help us progress this initiative,
particularly for staff governors.
statement 3b
The Chairman will write to
stakeholders seeking
confirmation of appointed
governors in a timely fashion at
the same time as we move
towards holding elections for
elected members.
P Chesters
Plans to recruit governors will include a
promotional film, to be scoped before
December; however filming will not
commence until after April 2015.
Open
The constitution includes details of our
appointed members.
April 2015
Feb 2015
A letter confirming the Trust’s progress
in achieving FT status will be sent to
organisations who have agreed to
appoint a governor in February 2015.
21
172
Ref
Good practice
question
and
Grant Thornton
recommendation
Grant Thornton BGAF
4.4
The consideration of the
roles, responsibilities,
method of selection,
numbers and
designations and all
other matters relating to
the future governors of
the Trust postauthorisation as an
NHSFT should be
directed and overseen
by the FT steering group
once the Trust is within a
year of its planned
authorisation
as an FT.
Action
Lead(s)
statement 3c
The Trust’s guide for governors
and proposed governor
development plan will be
prepared in 2014. We will ensure
that governors have access to
the Foundation Trust Network
GovernWell national governor
training programme.
J Walbridge
Open
The membership strategy will be
updated in January 2015 and will
include more up-to-date plans specific to
the elections and governor induction.
The handbook for governors will be
drafted in November 2014 and will be
considered by the FT Steering group.
See also 4.4, 3a above
See 4.4, 3a above.
.
Target date
/ deadline
Feb 2015
February
2015
February
2015
22
173
TRUST BOARD PAPER
October 2014
Report title:
FT timeline update
Agenda item number:
3.4
Report of:
Contact Officer:
Foundation Trust Project Manager
3 Deliver better value than competitors in our selected markets:
securing our sustainability by providing effective and efficient services
integration and partnership by demonstrating our capacity, character
and competence
6 Be innovation and technology pioneers: leading transformation of
out of hospital services to empower staff and improve patient health
No
Status
Executive Summary: A foundation trust trajectory was agreed with the Trust Development Authority
(TDA) in July 2014. In light of recent confirmation that the Care Quality Commission (CQC) inspection
will take place in April 2015, rather than March (which was indicative only), dates in the TDA stage of
the Trust’s application have been revised accordingly.
The result is that the timing of the TDA Board to Board meeting is likely to be affected with some
knock-on effect of up to two months on sign-off of the TDA stage. Previously, it was indicated as July
2015 but will now move to either 20 August or 3 September. The earlier date is advisable given that it
will avoid delays to the TDA Board sign-off and the beginning of the Monitor stage; however, the Trust
Board will need to decide whether it would be preferable to hold the Board to Board in August or
early September. It should be notes that the Board to Board will require a considerable amount of
preparation by Board members in advance.
This report also highlights that the introduction of the new Independent Financial Review (IFR) is
delayed and there is still no launch date. Before CLCH can proceed to the Readiness Review, an
external financial assessment will need to have been completed. Consequently, the TDA has asked the
Trust to carry the out the assessments under the old framework, HDD 1 and 2.
174
Assurance provided: The timeline and trajectory for foundation trust (FT) authorisation are regularly
reviewed by the FT Project Manager in conjunction with the TDA.
Report provenance: This paper has been seen by ELT.
Discussion
Information
Recommendation: The Board is asked to note the contents of this paper and, in addition, to decide
whether August 20 or September 3 would be most suitable for the Board to Board meeting with the
TDA.
175
1.
Purpose
1.1
This is a quarterly update report on the foundation trust (FT) timeline. The Board
is asked to note its contents.
In addition, the Board needs to consider whether it wants the Board to Board
(B2B) meeting with the TDA in August or September 2015.
1.2
2.
Introduction
The TDA has issued a new draft timeline in light of recent confirmation that the
Trust’s CQC inspection will take place in April 2015. This is one month later than
in the previous version of the timeline (July 2014), however the timing was
indicative only. Although only one month later, there is an impact on some of the
key milestones, shown below:
• The Quality Summit (date is set by CQC) cannot take place until after the
Chief Inspector of Hospitals’ draft report is issued
• The meeting of the TDA Medical Director and CLCH Chief Nurse is flexible to
an extent but must take place before the B2B
• The B2B with the TDA can only take place after the Quality Summit, optional
dates being August 20th or September 3rd. (B2B meetings are held either
on the first or third Thursday of every month). By agreeing to go with the
earlier date CLCH would minimise delays in the subsequent formal signoff by the TDA Executive and (one month later) by the TDA Board, which
meets every two months, although it may be possible to request earlier
sign-off at an extraordinary Board meeting. The whole Board is required
for the B2B meeting, therefore the possible impact of any annual leave
dates will need to be taken into consideration. It must be emphasised that
the B2B will require considerable preparation beforehand by executive
and non-executive directors
IFR/HDD
There are continued delays to the introduction of the new IFR assessments,
which will not now be introduced during the current calendar year as
originally planned. However, the Trust will still need to undergo external
financial assessments as it did for BGAF and QGF before the Readiness Review
(May 2015) can take place. The TDA has asked CLCH to use the previous
Historic Due Diligence (HDD) framework, parts 1 and 2. The Trust will not be
required to carry out IFR when it is introduced, although a bridge between the
two assessments may be required. In part, this will be fulfilled by the mock IFR
assessment recently carried out by the Trust.
176
3.
Proposal
The draft timeline below revises the milestone dates in the remainder of the TDA
stage of the Trust’s FT application.
4.
There are no implications.
5.
There are no implications.
6.
7.
Delays to key milestones in the timeline may result in a delay to the Trust
becoming authorised as a FT. As mitigation, the FT Project Manager and
Commercial Director review the timeline on a regular basis to ensure that all
milestones are being met in a timely fashion. Close contact is maintained with the
TDA to ensure the programme is on track.
8.
No consultation with partner organisations was required.
9.
The FT timeline is subject to change; however, it is regularly monitored by the FT
Project Manager (in conjunction with the TDA) and the FT Working Group.
177
Appendix 1:
Draft FT trajectory
178
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title:
Safeguarding Children and Adults Report
Agenda item number:
3.5
Report of:
Contact Officer:
Chief Nurse
Head of Safeguarding
3 Deliver better value than competitors in our selected markets:
integration and partnership by demonstrating our capacity,
character and competence
6 Be innovation and technology pioneers: leading transformation of
Status
Executive Summary:
The CLCH Safeguarding Children and Adult Services continue to report on safeguarding activity
quarterly internally to CLCH Safeguarding Committee and externally to commissioners. In addition the
CLCH PSRG receives a Safeguarding report (last report September 2014).
The post of CLCH Head of Safeguarding, Safeguarding Children and Adult professionals is now
managed within the Quality Division. The Looked After Children Services remain within Children
Health and Development Division.
The target for safeguarding training compliance is now 90% however training compliance remains
below this.
CLCH does not have a Named Doctor for Child Protection although an interim arrangement is in place
to offer some basic cover for this statutory role.
CLCH continues to be well represented and an active partner at both the Local Safeguarding Children
Board (LSCB) and Safeguarding Adults Board (SAB). Both the Children Section 11 Audit and the
Safeguarding Adult Risk Tool (SART) have been submitted and accepted by the respective
Safeguarding Boards.
179
Assurance provided:
Safeguarding Children & Adults Service risks / incidents reported to PSRG (quarterly)
Quarterly reports received at the CLCH Safeguarding Committee and Quality Committee.
Report provenance: Safeguarding Reports & Declaration approved at CLCH Safeguarding Committee
and Quality Committee.
Discussion
Information
Recommendation:
The CLCH Board supports the development of a CLCH Named Doctor Child Protection.
The CLCH Board monitors the CLCH Safeguarding training and progress to the 90% target.
1.
Introduction:
1.1 This report seeks to provide a mid-year update to the CLCH Board on the
performance and activities of the CLCH Safeguarding Children and Adults services.
The annual report 13/14 has been received by the CLCH Board (July 2014).
1.2 This report will inform the CLCH Board of the following metrics in regard to
safeguarding children; training, supervision, referrals to children’s social care (CSC)
and partnership working (case conference and multi-agency panel attendance).
1.3 This report will inform the CLCH Board of the following metrics in regard to
safeguarding adults; training including PREVENT and partnership working.
1.4 In addition the report will include an update on CLCH involvement in serious case
reviews (SCR) and domestic homicide reviews (DHR).
1.5 Safeguarding Children and Safeguarding Adult Services are now managed within the
Quality Division (1st August 2014). Looked after Children Services remain in the
Children Health and Development Division.
2.
Safeguarding Children Services
2.1 Safeguarding children training compliance (September 2014) is as follows: Level 1
85.6% Level 2 82.4% Level 3 89.7%.
2.2 All safeguarding children professionals are trained at level 4 and above and
compliance is 100%.
2.3 The 2014/15 target set by commissioners is 90% and so at present training
compliance is below target, however progress toward compliance with this target
will be met through access to an e –learning module (level 1), bespoke level 2
training and to LSCB training (level 3).
2.4 Safeguarding supervision compliance across CLCH for health visitors and school
180
nurses in Q1 exceeded 90% compliance however in Q2 compliance levels have
dipped in Barnet (78%) and H&F (85%). This dip is attributable staffing issues –
sickness, work pressures, work patterns and for one member of staff jury service.
Where practitioners have not accessed safeguarding supervision in Q2 a session in
early Q3 has been arranged.
2.5 Attendance at child protection conferences by CLCH practitioner (initial and review)
in both Q1 and Q2 exceeds 90%. Where a CLCH practitioner has not attended a
child protection conference in Q2 a report has been submitted.
2.6 Referrals to Children Social Care in Q2 by CLCH practitioners numbered 8. This is a
slight decrease on Q1.
2.7 Children subject to a child protection plan in Q2 numbered 584 – Inner boroughs
362 and Barnet 222. The number of children reported subject to a child protection
plan has not shown any significant change in Q1 and Q2.
2.8 CLCH participation in multi-agency panels Multi Agency Risk Assessment
Conference (MARAC), Multi Agency Sexual Exploitation Panel (MASE) in Q1 and Q2
has been 100% compliance. In addition a Barnet Multi Agency Public protection
Arrangements Panel (MAPPA) has been attended by the Barnet Named Nurse for
Child Protection.
2.9 CLCH is represented at both the Local Safeguarding Children Boards (LSCB) and
subgroups – 100% compliance attendance at LSCB Board meetings.
2.10CLCH is currently contributing to a Serious case Review (SCR) commissioned by the
Tri Borough LSCB which has been presented to the LSCB and will be submitted to
the DfE for approval.
2.11Improving the response of partner agencies to cases of child neglect is an objective
of both the Barnet and Tri B LSCBs. Notably Harrow LSCB have released a video
capturing the learning from a serious case review which focusses on how partner
agencies can improve their understanding and response the issues of neglect. This
is available on the CLCH Safeguarding Children team pages and is featured in CLCH
bespoke training updates.
2.12Safeguarding Children Named Doctor Function the CBU transformation of Children
Health and Development Division has not lead to the identification of a resource for
this statutory post. At present CLCH has no Named Doctor function which is a
weakness in regard to safeguarding arrangements. To mitigate this CLCH has in
place is an arrangement with the Designate Doctor to provide as required advice
and support on complex cases.
3. Safeguarding Adults Services
3.1 Safeguarding adult training compliance (September 2014) is as follows: Level 1 87%
Level 2 88 %.
3.2 All CLCH Safeguarding Adult Champions (28) have received training at Level 3.
3.3 All Safeguarding Adult Professionals are trained at level 4 and above and compliance is
100%.
3.4 PREVENT training is part of the HM Government counter terrorism strategy and from
April 2014 has been included in mandatory training for all staff. Prior to this (from
2012) this training was delivered as part of induction training to clinical staff and
181
bespoke training to specific services.
3.5 PREVENT Q2 (July - September) 328 CLCH staff were trained.
3.6 The new updated version of PREVENT has been launched by the Home Office and this
will be embedded in CLCH training by Q4.
3.7 The Safeguarding Adult Service is now producing a quarterly newsletter for staff and
learning event for Safeguarding Champions. The learning event in Q2 focussed on
domestic abuse and the learning from Domestic Homicide Reviews (DHRs). There are
three DHRs in progress across Barnet and the Inner Boroughs. It should be noted that
CLCH involvement with the victim was in all cases minimal and as such the CLCH DHR
action plan is directed towards raising awareness and ensuring CLCH staff have access
to information and support when managing case where domestic abuse is a feature.
3.8 The Safeguarding Adult at Risk Tool (SART) has been submitted to both Barnet and Tri
Borough CCG Safeguarding Leads.
3.9 The CLCH Safeguarding Committee reviews the progress of the Winterbourne Plan.
The Learning Disabilities Service have progressed an innovative technology – tablet
devices - to help patients with learning disabilities give feedback on their experiences
of NHS care and treatment.
4. Looked After Children Services Q1.
4.1 The CLCH Looked after Children Service (LAC) continues to deliver a high quality
service exceeding national and local targets regard to Health Assessments
(compliance with timeframes exceeds 90%).
4.2 The LAC team now have a LAC page on the CLCH intranet which will include a
library of LAC Annual Reports and relevant documents and guidance. This page is
linked to the Safeguarding pages and will continue to be managed and updated by
Safeguarding.
4.3 ‘The Story So Far’ which a compilation stories, poems and pictures from LAC
children and young people has been published.
4.4 The LAC team won a CLCH Award for ‘Team of the Year’ 2014.
4.5 Each Borough LAC team has been involved in an Achievement Event celebrating the
successes of the LAC children and Young People.
4.6 A Domestic Homicide Review (DHR) has been published (Essex) relating to the
death of a 17 year old female who was murdered by her boyfriend who was known
to Leaving Care Services and attended a college with in a London Borough. The
learning from this case has been discussed at the Tri B LSCB and the report is
available on the CLCH Safeguarding Children Team pages. What is of note is the
application of the amended definition of domestic abuse to include violence
between young people 16 years and over who are in a relationship (2013) so
leading to the commissioning of the DHR.
5. Safeguarding Risks
5.1 Safeguarding risks are reported on at the Patient Safety and Risk Group. Reported
on in September 2014.
182
6. Recommendations
6.1 The CLCH Board supports the development of a CLCH Named Doctor Child
Protection.
6.2 CLCH Board receives updates on the progress towards meeting the safeguarding
training target of 90%
183
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title:
Medical Director’s Quarterly Report
Agenda item number:
3.6
Report of:
Medical Director
Contact Officer:
Deputy Medical Director
2. Support people safely out of hospital: providing safe, high quality
3. Deliver better value than competitors in our selected markets:
Status
4. Be responsive to our patients and partners’ needs: promoting
integration and partnership by demonstrating our capacity, character
and competence
5. Be innovation and technology pioneers: leading transformation of
Yes
Executive Summary: This paper summarises some of the work occurring throughout the medical
directorate. The paper includes updates on:
• Ebola outbreak
• Winter planning
• Flu vaccination programme
• Clinical Directors
• Caldicott Guardian Update
• Update on clinical framework
• Update on infection prevention
Assurance provided: The paper provides assurance to the board for the integrated action being taken
across the directorate to ensure engagement of staff, patients and key stakeholders.
Report provenance: None
Discussion
Information
1
184
Ebola Virus
The Infection Prevention team continue to work with clinical teams to ensure that they are prepared
for the possibility of contact with patients at risk of Ebola. A trust Ebola plan is being complied which
will be available to all staff on the Hub. To date, three patients who meet the risk criteria for Ebola
have been seen at CLCH walk in centres and urgent care centres. These patients were managed
appropriately following the risk assessment algorithm and were transferred to the nearest acute
trust. Ebola was ruled out in each case.
On October 7th 2014, the DH sent around a central alerting system email. The outbreak of Ebola
virus disease (EVD) continues in three countries: Sierra Leone, Guinea, and Liberia. In addition to
these countries which are experiencing widespread and intense transmission, other countries have
experienced importation of cases (Nigeria, Senegal, USA), and limited local transmission has
occurred (Nigeria and Spain). The outbreak became a Public Health Emergency of International
Concern (PHEIC) on 8 August 2014.
Winter Planning
The Tri-borough Urgent Care Board undertook an analysis of the current provisions within INWL for
intermediate care beds to support step down of acute patients and step up for community patients
from the community which demonstrated a need for a non-acute provision. Using the knowledge
gained from last year, the aim of the Intermediate Care Ward is to provide effective intermediate
care in a ward environment outside an acute clinical model with strong pathways to other
Community Independence Services.
Local partners believe the scheme will deliver benefits to acute, primary care and social care:
- Reduction of Length of stays
- Decreased DTOC for suitable cohort of patients
- Reduced excess bed days
The model
Since the end of July we have been scoping the project with local partners including Imperial College
Healthcare, Chelsea & Westminster Hospital, CWWH and Tri-Borough Adult & Social Care
The model was initially developed with findings identified in the Boundary less Patient Flow
Programme (shortlisted for HSJ award – awaiting outcome) and Chelsea & Westminster Hospital
data of care audit which identified 30% of patient in acute beds would better cared for in a nonacute environment.
This proposal aims to explore how the registered GP and a community unit can work in partnership
to deliver effective care to this cohort of patients.
The GP had a duty of care that spans the patent journey as set out in recent legislation. The medical
director of CLCH has a responsibility for ensuring appropriate medical care for patients being treated
for pathways defined in contracts between the commissioner and the provider. Jointly with partners
we agreed three principles for the 18 bedded intermediate care clinical model:
1. Integrates clinical responsibility into the primary care environment
2. Re-balances step up and step down access
2
185
3. To align to the thinking of whole systems early adopters to allow the GP/multi-disciplinary
team to manage against the care plan more effectively.
Funding for the project was agreed on 27th August and since then CLCH’s Senior Clinical Working
Group identified the following cohort of patients as medically suitable for an intermediate ward:
•
•
•
•
•
Short term rehabilitation
Post insult e.g. post falls, post-acute recovery/IV therapy
Mobility or confusion related issues resulting in delaying discharge
Social care related delay in discharge
General frailty
These beds would be aligned with the Community Independence Service (CIS) which operates in
each INWL CCG providing home-based intermediate health care and with integration (full or partial)
with social care, and primary care under each CCG’s out of hospital care model. This would enable
the intermediate care provision to become in future an embedded part of community services in line
with the objectives of the SAHF programme.
Flu Vaccination
Flu season is now beginning and the CLCH seasonal flu campaign went live in October 2014. Health
or social care worker are eligible for vaccination by NHS providers, (the target this year has been set
at 75% of staff working in Healthcare).
Having reviewed national best practice the employee health team have worked with the medical
directorate to redesign the local programme. This year, CLCH will be using a peer vaccination
approach to staff immunisation – the idea is that this approach empowers staff to immunise each
other and is better suited to our large geographic spread of staff.
There is an expectation that CBU managers will encourage staff to receive the seasonal influenza
inoculation so that we ensure maximum protection of our patient groups and sickness due to
influenza is reduced. Two weekly immunisation rates will be published at CBU level to encourage
discussion and to drive wider uptake.
Clinical Directors
The four Divisions have either appointed or are looking to appoint a Clinical Director. They will be
accountable to the Divisional Directors of Operations but have a professional accountability to the
Medical Director. Duties will include:
•
•
•
•
•
Clinical leadership within the divisions and support the development of medical staff
Acting as the professional lead for medical staff
Assisting the Medical Director into enquiries with respect to performance and conduct of
medical staff
Ensuring appropriate systems are in place for the effective delivery of patient care
Being responsible for the integration of operational management with the clinical
governance agenda.
3
186
•
Preparing strategic and annual plans for the division alongside the annual objectives.
Division of Allied Primary Care Service
There is a Clinical Director in post one day a week. He has been supporting the two GP practices in
transition, helping recruit Bank GPs for the Finchley and Edgware Walk-In Centres and upcoming
work includes the recruitment of a new doctors to areas within the directorate.
Division of Barnet Community &Specialist Nursing Service
This role will be advertised the week commencing 13th October 2014 and preliminary discussions are
being held with GPs.
Division of Children’s Health & Development Service
This role is currently being designed. The work will focus around health prevention and will feature a
large public health element.
Division of Networked Community Nursing &Rehab Service
This role is currently being advertised for recruitment. There is one day available within the adult
specialist services and one day within the adult community services.
Caldicott Guardian update
1. Introduction
In early July 2014 the Caldicott Work plan was submitted to the Information Governance Group
(IGG) detailing the work to be undertaking in line with the IG Toolkit. It was agreed that the
Caldicott Guardian would work with the IG Team to ensure delivery of tasks by 31st March 2015. The
Caldicott Work plan focuses on the following areas:






Confidentiality
Data Protection Assurance
Guidance for staff on consent issues
Incident Management
Data Protection Audit compliance
Information Sharing agreements
2. Key Areas of Progress
Data Protection Assurance:
The Caldicott has remained a focal point for issues relating to confidentiality and gaining Data
Protection assurances. The IG Team launched the data protection audit compliance programme
which included the Caldicott with other Directors visiting sites unannounced. The results of the
4
187
audits were encouraging with clear themes arising for most sites. The Caldicott has carried out work
to raise the profile 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.
Incident Management:
Incidents are managed via 48hr panel meetings which are chaired by Caldicott Guardian or SIRO.
The IG team carried out a deep dive of incidents between 2012/13-2013/14 which demonstrated
incident reported had increased Trust wide.
Incident Themes:
There have been 49 IG incidents since the beginning of April 2014. The following table provides the
five highest categories and incident themes for the organisation between April 2014 – July 20141.
Category
Accidental
disclosure of
information
Incident Themes
No. of
incidents
reported
Email being sent to the wrong
email address with patient
information.
CLCH has rolled out a new encrypted
email solution (Egress) and staff
awareness is now on the increase to
ensure that patient identifiable Data
(PID) is sent via encrypted means.
Where information is received into
the organisation via insecure methods
the sending organisation is notified by
the IG Department and both parties
are required to incident report.
Patient information being
received in a non nhs.net
account
Posting information to the
wrong person
Patient information left at home
visit
Documents left on printers
Actions
12
The IG Training materials have been
revised with a focus on ensuring
records are kept secure, ensuring
information is limited when sending
via any medium, verifying the
recipient and tracking records while
posting or transferring to another site.
The IG Team have launched
unannounced data protection
compliance audits on sites with
5
188
Directors attending the visits.
Recommendations are stipulated to
the audited services with feedback
being submitted to the Information
Governance Group. Any urgent
matter that arises during a site visit is
rectified immediately.
Accidental loss
of information
Information not recorded not
on RIO
Records left in a non-secure
environment
11
Records lost in transaction
Breakdown in
lines of
communication
Incorrect text messages sent to
patients
6
The Clinical Effectiveness team carry
out clinical record keeping audits and
online training has been mandated for
clinical staff. A Records Management
Facilitator has now been recruited to
aid services with safe records
management and ensure that
processes are put in place to
safeguard records and transfer them
safely.
Records Keeping training materials for
non-clinical (admin) are currently
being created to ensure that all staff
are aware of their roles and
responsibilities for checking the
accuracy of data and updating the
systems at point of contact with the
patient.
Incorrect phone numbers taken
from patients
Services that have waiting areas are
now putting up notices to remind
patients to update their details if they
have changed.
6
189
Loss or theft of
Smartcard
Rio cards lost outside the UK
Misplaced Rio card
14
Once Smartcard is reported misplaced
or stolen the card is disabled and the
member of staff must present
themselves to the Clinical systems
team to be authenticated before
another Smartcard is provided.
Rio card stolen with other
belongings
Records
unavailable
when needed
Records not being filed correctly
6
Information missing from files
Grand total
The newly appointed records
management facilitator is working
with high risk areas as a priority to
ensure that records are managed and
filed appropriately. There is an
Electronic Document Management
System (EDMS) project running to
move paper records that are at the
stage to be archived and scan them to
remove the risk of paper loss or
mislaid records.
49
Since April 2014 there has been 2 serious incidents (SI) reported externally to Hammersmith
& Fulham CCG which related to Community health and Dental services which will have been
previously reported to Board. (Reports relating to August and September and October will
be available in November).
Guidance for staff on consent:
There has been an increase in consent queries Trust wide in particular from clinical services. The
queries have arisen due to some services moving to SystmOne for integrated care allowing for one
record for a patient between Community and GP.
It has been assessed that system functionality and clinical risk remain high on the agenda for the
organisation with regard to SystmOne. The Caldicott is currently working with teams to ensure that
the correct guidance is available to staff during this process and that clinical risk is minimised. This
issue is monitored via the IGG and SystmOne Project Board.
3. Conclusion
7
190
In summary IG remains high on the Trusts agenda with support from Director level to gain
assurances of Data Protection and Confidentiality. There is 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. It is expected that the delivery of the IG Toolkit will be assessed as
compliant at a minimum level 2 with a robust evidence base submitted.
Update on the clinical framework
The clinical framework has now been published on CLCH’s website under clinical policy and
guidelines. The stakeholder reference group requested an easy read version which has now
been designed and can be found at this site;
http://www.clch.nhs.uk/about-us/our-publications.aspx
Update on infection prevention
Eye infections
The infection prevention team have been alerted to five cases of eye infections on Marjory Warren
ward. The first case presented on 16/09/14 with four subsequent cases presenting. Investigation
indicates that transmission may be due to poor infection control practices and as a result the ward
has been deep cleaned. The most recent hand hygiene audit also identifies a decrease in hand
hygiene compliance and measures are being put in place to combat this. The local health protection
team (PHE) have been made aware and are in agreement with action put in place.
Clostridium Difficile
There was one case of C difficile identified more than 72 hours after admission to Marjory Warren
Ward in September. No lapses in care were identified.
Hand Hygiene
Hand hygiene compliance across the bedded areas is at 93.75% for quarter 2.
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191
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title: Medicines Management Annual Report 2013/14
Agenda item number: 3.7
Report of: Medical Director
Contact Officer: Head of Medicines Management
Supporting people safely out of hospital
Executive Summary:
This report highlights the medicines management activities undertaken in CLCH during 2013/14,
providing assurance that systems are in place for medicines management in line with CQC
Regulations, Outcome 9 and Controlled Drugs Regulations 2013.
In 2013/14 the Medicines Management Team has supported CLCH by:
•
•
•
•
•
•
•
•
•
•
•
Advising community health services staff on medicines related issues.
Ensuring all policies, protocol and procedures are current and up to date.
Ensuring all patient group directions and processes are current and up to date.
Undertaking clinical audit in key areas and highlighted areas for further work, e.g. omitted
doses, cold chain and safe and secure handling.
Ensuring safer management and use of controlled drugs.
Ensuring all medicine incidents are reviewed at the Medicines Management Group (MMG) on
a quarterly basis and the risk register updated.
Assessing and responding to 33 medicines alerts.
Providing information under Freedom of Information Act.
Providing education, training and health promotion to healthcare professionals.
Ensuring systems are in place to promote patient safety in relation to medicines, including
bedded services.
Embedding the new in-house clinical pharmacy service post re-tendering of the three
pharmacy SLAs.
2013/14 has seen a number of achievements in medicines management including:
•
•
Increasing capacity of the team has allowed them to be more responsive to queries from CLCH
staff e.g. same day responses to cold chain breaks allowing continuity of service and
preventing loss of vaccines.
Re-tendering of the 3 pharmacy SLAs resulted in a review of the services, all clinical and
community health services have been brought in-house thereby developing a greater
intelligence and quality of service provided.
192
•
•
The medicines optimisation service which was developed as part of the NWL integrated care
pilot and CLCH were the first provider to win a bid as part of the ‘out of hospital’ innovation
funding, came to a conclusion in December 2013. It successfully demonstrated a viable
business case for long-term commissioning.
Raised profile of the team as 4 members of the team were acknowledged in the CLCH
recognition awards, with one winner for Patient safety- Preventing Harm and one highly
commended for innovation for smart effective care from Medicines Optimisation Pharmacists
(MOPs).
Assurance provided: The Medicines Management Annual Report provides assurance to the Board
that there are systems in place to meet the requirements of CQC Regulations, Outcome 9 and
Controlled Drugs Regulations 2013.
Report provenance: The Medicines Management Annual Report was discussed at the Medicines
Management Group (MMG) in September. Comments raised have been incorporated and the
report will be virtually ratified by the Medicines Management Group in October.
Discussion
X
Information X
1.
Purpose
This report highlights the medicines management activities undertaken in CLCH during 2013/14, ensuring
systems are in place for medicines management in line with CQC Regulations, Outcome 9 and Controlled
Drugs Regulations 2013. The report supports the CLCH Clinical Framework 2014-2017.
2.
2.1
Introduction
Medicines management optimises the use of medicines both by patients and the NHS,
protecting against the risks associated with the unsafe use and handling of medicines. It
supports safe, appropriate and cost-effective prescribing, as well as helping patients to have
their medicines at the times they need them, in a safe way and have information about their
medicines made available to them. Good medicines management can help reduce the
likelihood of medication incidents and hence patient harm.
2.2
The CQC has identified the management of medicines as one of its core quality and safety
standards (Outcome 9). The Medicines Management Team provided an effective and
responsive service in 2013/14 to ensure medicines were handled safely, securely and
appropriately; prescribed and given by staff safely and kept up to date with published
guidance on medicines safety so that best practice is implemented within the Trust.
2.3
The Medicines Management Team supports the Controlled Drugs Accountable Officer (CDAO)
to ensure compliance with the Controlled Drugs Regulations 2013.
3.
Proposal
193
Not applicable
4.
4.1
The full Medicines Management annual report which underpins this Board report is available on
request from the medicines management team. The key areas of work highlighted below provide
an overview of achievements in 2013/14 and plans for 2014/15.
4.2 Key areas of work in 2013/14 have included:
• Clinical audits, reported to the Clinical Effectiveness Steering Group and the Quality Committee,
have been undertaken. These led to improvements in clinical practice and compliance with
regulations, where required, in relation to prescribing and safe and secure handling of medicines.
• Omitted Doses audit results showed 5% (850 out of 16861 doses) of omissions recorded compared
to 9.6% in 2012/13. Of the 850 omitted doses, 170 were for critical list medicines (20%). 77% of the
omitted doses had an omission code recorded, an improvement from last year's 66%. A high
number of omissions (71%) were due to patient refusal. This area will be further investigated in the
2014/15 audit. Omitted doses remain an area of concern and Clinical pharmacists monitor these on
a daily basis.
• Antimicrobial audit showed areas of improvement were required in documentation of allergy
status, clinical indication and review/stop date in patient notes.
• Safe and secure handling of medicines audits were carried out by the SLA provider for the Inner
boroughs until the end of September 2013 but the audit was rudimentary. A baseline audit of 11
Inner borough sites in December 2013 found many areas of poor practice. The tools and processes
used by the SLA provider did not meet CQC Outcome 9 standards. No audits had been carried out
in Barnet. To address the gaps, there was a fundamental review of the audit tool, audit process and
the competences of the audit staff, who were TUPE-ed to CLCH. An audit programme commenced
in June 2014 in all sites (Inner borough = 130, Barnet = 55)
• Cold Chain audits conducted by the SLA provider as above did not provide assurance. The CLCH
audits also look at cold chain management commenced in June 2014 (Inner boroughs = 42 sites,
Barnet = 16).
• Controlled Drugs audits were carried out quarterly at all bedded units and day surgery. Areas for
improvement include appropriate use of controlled drugs registers, CD balance checks, security of
keys and timely destruction of unwanted or expired CDs. A gap was identified in audits of non
bedded services that used CDs. These were completed in September 2014.
• There are 266 CLCH non-medical prescribers (NMPs) registered with the Prescription Pricing
Division. The Medicines Management Team maintains a database of NMPs and monitors their
prescribing quarterly.
• The total drug expenditure for CLCH is £1.86m (FP10 budget held by CCGs on behalf of CLCH =
£361k, NMP = £652k and SLA drugs = £849K).
• There are 26 medicines related policies, protocols and procedures reviewed and approved by the
MMG. Four were reviewed or approved in 2013/14. The MMG contribute to the development of 3
other Trust policies. All policies are up to date.
• There are 101 Patient Group Directions (PGDs) managed by the Medicines management Team. All
are up to date.
• The MMG receives quarterly incident reports. There were 724 medicines related incidents reported
on Datix in 2013/14 (compared to 587 in 2012/13). The rise in medicines incidents was mainly due
to the increased presence of clinical pharmacists on the wards in Barnet who identified poor
practice at the wards. Lessons learned and recommendations were discussed at the MMG.
• There were 87 Datix incidents involving controlled drugs. Main areas identified were syringe driver
equipment problems, missing or insufficient supply of CDs, poor management of patches, incorrect
storage and dosage errors. Management of CD incidents occurs day to day and is reported
194
•
•
•
•
•
•
•
quarterly to the MMG.
The CQC self-assessment tool score for CLCH was 73%; CQC's interpretation of this score is "Overall,
your organisation's CD governance appears to be good but you may want to improve by looking at
best practice". An area for improvement was the sharing of information with partners in the local
intelligence network (LIN). There have been no LIN meetings held in the last 12months due to the
restructuring of the NHS. However, quarterly occurrence reports sharing any unresolved CD
incidents and/or matters of concerns were submitted to the London Area CD Accountable Officer at
NHS England.
Medicines Management offers clinical pharmacy expertise to all bedded services. Each service has
an agreed level of pharmacy input. As we move forward, there may be a need to explore the needs
of a clinical pharmacy service versus technical pharmacy support to each of the bedded areas.
The Medicines Optimisation Service (MOPs), a pilot funded by the ICP concluded in December
2013. This service provided a full clinical medication review for housebound patients. The
outcomes included 1799 interventions for 387 patients, 80% of pharmacist interventions accepted
by GPs and potential £56k cost avoidance for non-elective hospital admissions. A full report is
available on request. The Medicines Management Team has successfully bid for commissioning of
this service. From April 2015, Medicines Management will provide a housebound MOPs service to
patients from the West London Clinical Commissioning Group.
A second MOPs service in Care Homes commenced in December 2013.
A comprehensive training programme was delivered at training events, classroom induction,
refresher and e-learning.
Effective risk management led to a number of risks being closed. There were 18 open risks on the
medicines management risk register at the end of 2013/14.
The review and re-tendering of the pharmacy clinical and supply services posed a huge challenge as
it involved changes to services that had been in place for close to 20 years. This transition has been
successfully delivered.
4.3 2013/14 has seen a number of achievements in medicines management including:
• Completion of the medicines optimisation service which was developed as part of the NWL
integrated care pilot and CLCH were the first provider to win a bid as part of the ‘out of hospital’
innovation funding.
• Raised profile of the team as 4 members of the team were acknowledged in the CLCH recognition
awards, with one winner for Patient safety- Preventing Harm and one highly commended for
innovation for smart effective care from Medicines Optimisation Pharmacists (MOPs).
4.4 Priorities identified for 2014/15:
• Embed new in-house services to deliver a high quality, safe and effective patient care.
• Support Controlled Drugs Accountable Officer to comply with Controlled Drugs (CD) Regulations
2013.
• Close monitoring of the 2 new pharmacy contracts.
• Processes to support NICE Technical Appraisals (TAs).
• Ensuring robust processes in place to register non-medical prescribers and monitor their
prescribing.
• Exploring the benefits and mechanisms for having a CLCH drugs budget.
• Ensuring robust and consistent audit of safe & secure handling of medicines across all 4 boroughs.
• Develop a medicines management strategy
• Build relationships with the newly formed CCGs to manage medicines across the interface
5.
195
No implications noted.
6.
Not applicable.
7.
The medicines management annual report provides assurance to the Board that actions are being
taken to reduce the likelihood of medication incidents and hence patient harm. Effective risk
management led to a reduction in the number and ratings of medicines management risks by year
end, as action plans were completed.
Currently there are 10 open risks on the medicines management risk register.
ID
Description
977
974
688
779
994
778
980
978
971
956
Development of transcribing policy
Inaccurate information on discharge summary
NMP financial risk of devolved budget
Cold chain
Discharge of patients from CLCH with inaccurate information
Omitted doses
Self-medication not being assessed
Risk of admitting patients with insufficient medicine supply
Numeracy e-learning package
Cost of Pharmacy SLA
Current
Rating
15
12
12
12
9
9
9
9
9
8
8.
8.1 Collaborative working with the Medicines Management teams of local acute trusts, CCGs and
Pharmacy networks continues to ensure greater understanding and response to medicines
management and patient safety issues.
9.
Quarterly reporting to the MMG:
• Policy and PGD dashboards.
• Controlled drugs and medicines incidents.
• CD Occurrence reports.
• Drugs and SLA expenditure.
10. Recommendations
10.1 The Board is asked to note the content of the report and the work being undertaken by the
Medicines Management Team, along with CLCH staff and managers to protect patients from
medicines related harm.
196
197
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title:
Health and Safety Annual Report Update
Agenda item number:
3.8
Report of:
Contact Officer
Fire, Health and Safety Manager
• Be responsive to our patients and partners’ needs.
• Embody the best of the NHS for our patients.
• Support people safely out of Hospital.
Can be published
Status
Executive Summary: This paper provides a summary of the following topics:
• Key health and safety risks across the Trust and includes comments on aspects of the Workforce
Survey relating to safety.
• A list of Policies and an overview of actions, all of which have been and are being addressed as a
work backlog project.
• A snap-shop of Violence and Abuse across the Trust domain.
• Health and safety objectives for 2014 were not formalised, this was in the main due to changes in
H&S management. Consequently the recently appointed Fire, Health & Safety Manager is
working towards Health and Safety Executive (HSE) requirements; achieving standards set in the
Trust Health and Safety Policy; through compliance with the Health and Safety Committee Terms
of Reference and through the governance arrangements whether through the Patient Safety
Review Group and Quality Committee or directly to the Board.
Assurance provided: The information provided in this summary highlights the key H&S related risks
across the Trust, and gives an outline of the proposals for improvement. It also is evidence of the
work carried out to improve policy production since the arrival of the Trust Fire, Health and Safety
Manager in June 2014. Finally it shows a reduction in the V&A incidents in the first two quarters of
the 2014 reporting year compare with 2013.
Report provenance: The key H&S risks, V&A and Security issues were discussed at the 2nd June 2014
H&S Committee. The Policies were discussed at the 2nd October Health and Safety Committee
Meeting and the initial report was presented to the Board in July 2014.
198
Discussion
Information
1.
1.1
Purpose
To advise Board members of the work being undertaken and respond to questions at the
July Board meeting emanating from the Health and Safety quarterly update.
2.
Introduction
This report updates the Board on the progress of Health & Safety matters over the first 6
months of 2014/15. This is the first such report since the Board agreed the new H&S reporting
governance in July. Going forward the Board will receive a similar report on the activities of the
Health & Safety Committee on a quarterly basis.
1. A summary of current Health and Safety risks.
2. Progress on Policy and review dates.
3. A review of Violence and Abuse Data, including Security issues.
3 Progress
3.1 A summary of current Health and Safety Risks.
The following Health and Safety Risks are taken from the Health and Safety Risk Register Review to the
PRG for 21st October 2014.
Telephony lines for security alarms, fire alarms and lift alarms for CLCH sites across are at risk
of being disconnected by NWL Telephony team.
Initial Risk Rating - 20; Current Risk Rating – 12.
Estates Operational Managers are progressing this matter with NHS PS. Following a recent
discussion NHS PS have agreed to not disconnect any lines without first conducting exhaustive
communications with Trust E&F management.
a.
Auto diallers (Ad) for the fire alarms at the following sites are not active. Parsons Green,
Hammersmith Bridge Road, Falkland House, Stamford Brook and Richford Gate.
Activation of an Ad is a landlords decision, however such a decision can be overridden by the Trust
if we feel such a provision is necessary. This will incur costs, which on balance are considered
minimal in comparison to costs if we had to close services due to fire damage.
• NHS PS have been instructed to activate the Ad at Parsons Green Centre.
• The Practice Manager at Richford Gate is progressing the reconnection of the Ad on said
premises.
• We are still awaiting a response from the GP’s at Hammersmith Bridge Road.
• Stamford Brook is an NHS PS property, they have decided it is not viable to reconnect the
Ad, however as a Trust we believe the low cost of connecting the Ad far outweighs any
adverse service, relocation or reputational impacts on the Trust, thus instructions to
reconnect are being processed.
• The Ad at Falkland House is not being reactivated because the premises are being vacated
in early 2015 by the Trust.
b.
Lack of documented workplace risk assessments in place.
The Trust is working on the premise of there being three categories of building from which we
c.
199
deliver services:
• Category 1 are those buildings for which there is a freehold or leasehold.
• Category 2 are those buildings where the tenure is such that a lease should be in place.
• Category 3 are those buildings where there is need for a licence to deliver services.
To date all category 1 and 2 buildings have been assessed using a ‘Global Non-Compliance
Assessment process. This work along with the recent awarding of the Category 3 premises
assessments to ‘Oakleaf Group’, will lead to the creation of a consolidated set of Site information
Packs to be uploaded on to ‘Technology Forge’ the Trusts Estates & Facilities database by the
beginning of December 2014.
Lack of a robust system of Fire Risk Assessment, Resulting in lack of compliance of Regulatory
Reform (Fire Safety) Order. Leading to a risk to life, property.
A comprehensive review and work plan of sites, Fire Risk Assessments and Fire Safety Action plans
is being conducted by the Fire Health and Safety Team. A full report which will include a work
programme and training requirements is being prepared for the December 2014 Health and Safety
Committee and will be shared with the Board in January 2015.
d.
There is a lack of Health and Safety Representatives across the Trust domain, thus H&S issues
are generally only addressed after a visit from the FH&S Team.
Initial Risk Rating - 20; Current Risk Rating – 12
The lack of Union Trained safety representatives across the Trust means there is extremely limited
access to local advice and support on health and safety matters for staff. In a bid to reverse this
problem the Fire, Health and Safety Manager (FH&SM) is proposing a campaign to encourage
more involvement of Non-Union members in conjunction the ‘Consultation with Employees
Regulations 1996’, the aim being to train volunteers either on a bespoke course or to use the
Institute of Occupational Safety and Health (IOSH) Managing Safely Course as the basis for their
training. The aim will be to run a course in the early months of 2015.
e.
In addition to encouraging non-union members to become safety representatives, the FH&SM is
proposing to run IOSH Managing Safely Courses that should be made available to Band 5, 6 and 7
Managers and E&F managers. This will ensure safety issues are identified and acted upon in a
more timely and effective manner. Costs for the course will be kept to a minimum because the
Trust will only need to fund registration, materials and certification, rather than trainers fees. The
FH&SM is an approved provider of this training hence low costs of courses.
3.2 Progress on policies, documents and review dates
On first of June 2014, only six H&S related policies had been reviewed and approved in accordance
with Trust policy since June 2013. Following the appointment of the FH&SM 3 policies have been
ratified and posted on the HUB, a further 6 policies are awaiting approval by the PRG and 11 are either
in production or under review. The breakdown is as follows, 4 policies produced by the FH&S Team
have been given tacit approval by members of the H&SC subject to there only being minor
amendments; 1 policy produced by HR has been given tacit approval by members of the H&SC subject
to there only being minor amendments and 1 Policy by Occupational Health is currently with the Head
of HR for comments before being sent to the H&SC for comments. Upon approval all policies will then
be progressed through the PRG and subsequently launched on the HUB. The intention is to have all
remaining policies adopted by 31st March 2015.
200
Serial
a
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
29
30
31
32
Document
b
Health and Safety General Policy.
Water Safety and Quality Policy
(including Potable water).
Electricity at Work Policy.
Personal Protective Equipment Policy.
Workplace Safety Policy.
Fire Policy.
Control of Substances Hazardous to
Health Policy.
Display Screen Equipment Policy.
Environmental Strategy.
Control of Contractors Policy.
Asbestos Policy.
Occupational Health Policy.
First Aid Policy (May require input from
HR)
Moving and Handling Policy,
incorporating LOLER and PUWER.
Ionising Radiation Policy.
Medical Devices Policy.
General Waste Policy.
Pest Control Policy.
Transport Policy.
Young Persons at Work Policy.
Violence and Aggression Policy.
Lone Workers Policy.
Maternity and New Parents Policy
Food Hygiene Policy
Stress Policy
Risk Assessment Policy
Noise at Work Policy
Infection, Prevention and Control Policy
Equality and Diversity
No Smoking Policy
Accident, Incident and RIDDOR Policy
Patient and Non-Patient Slips, Trips &
Falls Policies
Introduced
Date
c
Dec 2013
Oct 2014 AA*
Review Date
Owner
d
Dec 2015
Oct 2016
e
H&S
H&S
Oct 2014 AA*
In production
Oct 2014 AA*
Oct 2014 AA*
In production
Oct 2016
May 2014
Oct 2016
Oct 2016
Dec 2014
H&S
H&S
H&S
H&S
H&S
Under review
Jun 2014
Jul 2014
Jul 2014
Oct 2014 AA*
Dec 2012
Dec 2014
Jun 2016
Jul 2016
Jul 2016
Oct 2014
Dec 2014
Dec 2012
Dec 2014
H&S
H&S/E&F
H&S
H&S AB
Emp Hlth
Emp
Hlth/HR
L&D/H&S
Under review
Jan 2016
Under review
Under review
Under review
Under review
Dec 2013
Dec 2013
Oct 2014 AA*
Under review
May 2014
In Production
In production
Jan 2014
May 2014
May 2014
Under review
Sep 2014
Jan 2016
May 2016
Jun 2014
Sep 2014
Sep 2014
Dec 2015
Dec 2015
Oct 2106
Jan 2015
Apr 2017
Jan 2015
Aug 2014
Jan 2016
Apr 2017
Apr 2017
Apr 2014
Nov 2011
Nov 2014
Resilience
Med Dev
E&F
E&F
E&F
HR
Resilience
Resilience
HR
H&S
Emp Hlth
H&S
H&S
IP
HR
HR
H&S/
Resilience
H&S/Q&A
The main proposal following this update report is to ‘develop clear access to centralised Health and
Safety Policies using the HUB as the primary instrument for searches’. The priority of policy work is all
‘Amber’ rated policies in the table above. A quick glance at the table shows there is a significant
volume of work to be carried out in the coming months. This matter has been addressed at the recent
2nd October 2014 H&S Committee meeting.
In support of key the H&S policies we are developing a series of ‘Aide memoires’ (one page
précises) of document that will be downloadable to an iPad, Smart phone or printable to fit in a
diary, they will advise and if necessary direct staff to the full versions of the respective policy.
These will be easily accessible and can be carried by staff at all times.
3.3 Review of Violence and Abuse Incidents first 6 months 2014.
The key point to note from the figures below is they represent the first 6 months of this years’
reporting evidence on Violence and Abuse issues in the Trust.
The bottom line figures in the table below are particularly encouraging, especially in terms of
201
‘Minor’ and ‘Moderate’ incidents. The comparison of incidents to date shows numbers equating
to less than half of those reported in the first 6 months of 2013, and which if the level of reporting
remains on the same trajectory throughout 2014, to the end of the reporting year will be less than
half of those reported last year.
The key area of concern relating to violence and abuse is that 41 incidents have been reported to
date, 29 are ‘No Harm’ incidents, e.g. verbal abuse; 10 are ‘Minor’ in nature, e.g threats, being
grabbed by clothing and limbs, there have also been 2 Moderate events, e.g. slapped or punched
but with no injuries sustained.
To give staff greater confidence when entering domiciliary premises a lone worker communications
device is being procured and will be in service imminently.
Twenty one of the violence and abuse incidents reported have occurred in bedded units and the
Prison, this figure added to the 41 incidents in patients’ homes accounts for 62 of 97 incidents to
date (63.9%).
Violence & Abuse by Site first 6 months of
2014
No
Harm
Minor
Moderate
Major
Catastrophic
2
0
0
0
0
Charing Cross Hospital
1
0
0
0
0
Diabetes Centre, 4b Maida Vale
2
0
0
0
0
Edgware Community Hospital
9
8
0
0
0
Farm Lane Nursing Home
1
0
0
0
0
Finchley Memorial Hospital
8
4
0
0
0
Hammersmith Bridge Road Surgery
0
1
0
0
0
Health @ The Stowe
6
1
0
0
0
HMP Wormwood Scrubs
5
4
2
0
0
Holbrook House
1
0
0
0
0
Lisson Grove Health Centre
1
0
0
0
0
Mill Hill Clinic
0
1
0
0
0
Other
11
3
1
0
0
Parsons Green Health Centre
4
1
0
0
0
Patient's Home
29
10
2
0
0
1
0
1
0
0
Queens Park Health Centre
1
0
0
0
0
Richford Gate Health Centre
1
0
0
0
0
Soho Centre for Health and Care
3
3
0
0
0
St Charles Centre for Health and Wellbeing
5
3
0
0
0
Stamford Brook Centre
0
1
0
0
0
The Medical Centre, Woodfield Road
2
0
0
0
0
Vale Drive Clinic
1
0
0
0
0
Violet Melchett Clinic
1
1
0
0
0
Walmer Road Clinic
0
1
0
0
0
Worlds End Health Centre
2
1
0
0
0
Totals first 6 months 2014
97
43
6
0
0
Totals for 12 months 2013
168
202
25
2
1
202
3. Quality Implications and Clinical Input
The changes outlined in this report will not have any affect upon the clinical quality of
services provided by the Trust. Indeed they will improve access to H&S Policies for ALL staff,
thus reducing time spent in.
4.
4.1
5.
5.1
The Divisional Director – Resources and Performance has reviewed this paper.
There are limited implications of this change in terms of the equality impact.
6.
6.1 The main risk of not having a full suite of policies or aide memoires is that staff could conduct
unsafe activities and possibly suffer injuries or cause damage to Trust property because they
have not been unable to access policies.
6.2 Unaddressed risks present hazards to staff, patients and visitors alike, they must therefore be
adequately funded and properly managed.
7.
7.1 Consultation in respect of the Annual Health and Safety Report; Health and Safety Risks; and
Violence, Aggression and Security is undertaken at the Health and Safety Committee, the
meeting is attended by senior managers, CBU managers specialist advisors, staff side union
representative and non-union staff safety representatives.
7.2 Overlap of Health & Safety and Infection Prevention issues is addressed by the Fire, Health
and Safety Manager, and the Senior Infection Prevention Nurse attending the respective
specialist committees. Additionally there is joint attendance at Strategic Estates & Facilities
Meetings; Capital Project Groups and Joint Planning Meetings. Compliance reporting along
with joint audits and inspections tie the two services neatly together, and where joint visits
are not possible, the specialties share information and are committed to identifying issues
related to both services.
8.
8.1 The issues identified by the Board at the July meeting are all regular agenda items at the
Trust Health and Safety Committee.
9.
Recommendations
9.1 The Board is asked to note the contents of this report.
9.2 To note that the FH&SM will liaise closely with each of the divisions and their heads or
nominated leads on health and safety matters as a means of further enhancing their
understanding and management of health and safety risks and thus improving all round
health and safety compliance across the Trust .
203
A summary of Health and Safety Risks.
The following Health and Safety Risks are taken from the Health and Safety Risk Register
Review to the PRG for 21st October 2014.
1. Telephoney lines for security alarms, fire alarms and lift alarms for CLCH sites
across are at risk of being disconnected by NWL Telephony team.
Estates Operational Managers are progressing this matter with NHS PS. Following a
recent discussion NHS PS have agreed to not disconnect any lines without first
conducting exhaustive communications with Trust E&F management.
2. Auto diallers (Ad) for the fire alarms at the following sites are not active. Parsons
Green, Hammersmith Bridge Road, Falkland House, Stamford Brook and
Richford Gate.
NHS PS have been instructed to activate the Ad at Parsons Green Centre. The Practice
Manager at Richford Gate is progressing the reconnection of the Ad on said premises.
We are still awaiting a response from the GP’s at Hammersmith Bridge Road. Stamford
Brook is an NHS PS property and they have decided it is not viable to reconnect the Ad,
and finally the Ad at Falkland House is not being reactivated because the premises are
being vacated imminently by the Trust.
3. Lack of a robust system of Fire Risk Assessment, Resulting in lack of compliance
of RRO. Leading to a risk to life, property.
A comprehensive review and work plan of sites, Fire Risk Assessments and Fire Safety
Action plans is being conducted by the Fire Health and Safety Team. A full report which
will include a work programme and training requirements is being prepared for the
December 2014 Health and Safety Committee and will be shared with the Board in
January 2015
4. Lack of documented workplace risk assessments in place.
Work place risk assessments are being tendered for and contracts will be awarded by
the end of October 2014. The contents of the reports being commissioned will be
developed into an action plan and shall be linked to CQC compliance requirements.
5. There is a lack of Health and Safety Representatives across the Trust domain, thus H&S
issues are generally only addressed after a visit from the FH&S Team.
The FH&S Manager is proposing to run Institute of Occupational Safety and Health
(IOSH) Managing Safely Course that should be made available to Band 5, 6 and 7
Managers and E&F managers. This will ensure safety issues are identified and acted
upon in a more timely and effective manner. Costs for the course will be kept to a
minimum because the Trust will only need to fund registration, materials and certification,
rather than trainers fees. The FH&SM is an approved provider of this training hence low
costs of courses.
204
A list of H&S Related Policies and Review Dates.
The table below shows policies the Fire, Health and Safety Manager has identified as either being needed in, or that
are available in the Trust. A quick glance at the table shows there is a significant volume of work to be carried out in
the coming months. This matter has been addressed at the recent 2nd October 2014 H&S Committee meeting.
Since the appointment of the current FH&SM in June 2014 3 policies have been ratified; 4 policies produced by the
FH&S Team have been given tacit approval by members of the H&SC subject to there only being minor amendments;
1 policy produced by HR has been passed been given tacit approval by members of the H&SC subject to there only
being minor amendments and 1 Policy By Occupational Health is currently with the Head of HR for comments before
being sent to the H&SC for comments. Upon approval all policies will then be progressed through the PRG and
subsequently launched on the HUB.
An action plan for the remaining policies is being developed and will be sent virtually to all members of the H&SC for
comments.
Serial
Policy
a
1
2
b
Health and Safety General Policy.
Water Safety and Quality Policy (including
Potable water).
Electricity at Work Policy.
Personal Protective Equipment Policy.
Workplace Safety Policy.
Fire Policy.
Control of Substances Hazardous to Health
Policy.
Display Screen Equipment Policy.
Environmental Policy.
Control of Contractors Policy.
Asbestos Policy.
Occupational Health Policy.
First Aid Policy (May require input from HR)
Moving and Handling Policy, incorporating
LOLER and PUWER.
Ionising Radiation Policy.
Medical Devices Policy.
General Waste Policy.
Pest Control Policy.
Transport Policy.
Young Persons at Work Policy.
Violence and Aggression Policy.
Lone Workers Policy.
Maternity and New Parents Policy
Food Hygiene Policy
Stress Policy
Risk Assessment Policy
Noise at Work Policy
Infection, Prevention and Control Policy
Disabled Persons
No Smoking Policy
Accident, Incident and RIDDOR Policy
Patient and Non-Patient Slips, Trips & Falls P
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
29
30
31
32
Introduced
Date
c
Dec 2013
Oct 2013 AA*
Oct 2013 AA*
Oct 2013 AA*
Oct 2013 AA*
July 2014
July 2014
Oct 2014 AA*
Review Date
Owner
d
Dec 2015
e
AB
BC/AB
May 2014
Aug 2014
Dec 2014
Dec 2013
Dec 2014
Dec 2014
Jan 2016
Oct 2014 AA*
Date not known
Jan 2014
Date not known
Date not known
Sep 2014
Jan 2016
May 2016
Jun 2014
Sep 2014
Sep 2014
Dec 2015
Dec 2015
BC/AB
BC/AB
BC/AB
BC/AB
AB/+
AB/+
AB/JC
ABB
AB
CH
CH/SG
MP/AB
Apr 2014
LW
JH/RGA
LB/LC/JC
LB/LC/JC
LB/LC/JC
SG
TL
TL
LL
Tbc
Tbc
Aug 2014
Jan 2016
AB/BC
JR
Apr 2014
Apr 2014
AA* = Awaiting Approval
205
Names Key:
Andrew Basham
Julie Chase
Martin Pendry
Joanna Hill
Lesley Burns
Steve Graham
Liz Lubbock
=
=
=
=
=
=
=
AB
JC
MP
JH
LB
SG
LL
Bill Cooke
Christine Hunter
Laura Williams
Roveena Gata-Aura
Lee Codrington
Terry Leonard
Joanne Rutter
=
=
=
=
=
=
=
BC
CH
LW
RGA
LC
TL
JR
206
A Breakdown of Violence and Abuse issues by site
The key points to note out of the graphical evidence on Violence and Abuse issues in the Trust are:
1. The majority of incidents are occurring in bedded units, the prison setting, walk-in centres and patients’ homes. The Trust Local Security Management
Specialist (LSMS) is visiting sites on a planned basis and where necessary will attend homes in support of staff. The main point to note when conducting
domiciliary visits is that the LSMS has to be invited in by the resident or their family, he cannot force entry or take unnecessary intervention action with
anything other than reasonable force. To mitigate against the risk of abduction and to assist staff when entering domiciliary settings the LSMS has
secured funding for 600 ‘Sky Guard’, Lone Worker safety devices. They are GPS tracked, provide live contact with a controller and can be activated and
deactivated on entering and exiting premises. The devices are due into service imminently.
2. Aside from domiciliary V&A statistics, all other ‘like for like’ Q1 and Q2, 2013 and 2014 figures are down, particularly in bedded units and walk-in
centres. In respect of domiciliary statistics the figures are virtually the same after 2 quarters of reporting.
3. In respect of Security incidents there has been a significant turnaround at Parsons Green Centre, and a slight increase in sites classified as ‘Other’. The
LSMS is producing detailed analysis of this date for the December 2014 H&S Committee Meeting, the information will be shared with the Board in the
January 2015 Q3 report by the FH&SM
207
Violence & Abuse Incidents by Location
01/04/2013 - 31/03/2014
90
80
70
60
50
40
30
20
Data
Mean
10
0
208
Violence & Abuse Incidents by Location
01/04/2014 - 30/09/2014
45
40
35
30
25
20
15
10
Data
Mean
5
0
209
Security Incidents by Location
01/04/2013 - 31/03/2014
60
50
40
30
20
Data
Mean
10
0
210
Worlds End Health Centre
West Hendon
Walmer Road Clinic
Violet Melchett Clinic
Victoria Street
Vale Drive Clinic
Torrington Park Health Centre
Stamford Brook Centre
St Charles Centre for Health and Wellbeing
South Westminster Centre
Soho Centre for Health and Care
School Premises
Patient's Home
Parsons Green Health Centre
Other
Oak Lane Clinic
Milson Road Health Centre
Mill Hill Clinic
In Transit
HMP Wormwood Scrubs
Health @ The Stowe
Garside House Nursing Home
Finchley Memorial Hospital
Edgware Community Hospital
Diabetes Centre, 4b Maida Vale
Connection at St Martins
Childs Hill Clinic
Charing Cross Hospital
Bessborough Street Clinic
Athlone House Rehab Unit - Cluster 4
Athlone House - general - inside
Abingdon Health Centre
145 King Street
Security Incidents by Location
01/04/2014 - 30/09/2014
16
14
12
10
8
6
4
2
Data
0
Mean
211
BOARD OF DIRECTORS
28 October 2014
Report title:
Board self-certifications
Agenda item number:
3.9
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
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. Changes since the last return are tracked in red.
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 and governance rating for
September 2014, for submission to the TDA.
212
Monitor Provider License Conditions and Board Statements – September 2014 data for Board review on 28.10.14 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
(implementation postponed from 1.10.14 to
mid-November for NHS Trusts) will require 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 will include all directors, ie not just NED
and executive directors.
213
Condition
Responsible
officer
Trust position
I McMillan for
I Millar
This condition relates to the power of Monitor
in setting regulations in relation to price,
configuration and continuation of services.
(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.
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
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 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.
The Trust is registered with the CQC.
Note
The CQC’s consultation on guidance for
providers on meeting the fundamental
standards and CQC enforcement powers
ended on 17.10.14.
I McMillan for
I Millar
Eligibility criteria for all services (where this is
available) now published on the web site at
http://www.clch.nhs.uk/media/143682/eligibility
_criteria_for_services_-_clch_nj_dec_2013.pdf
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
214
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
215
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”.
216
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.
217
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
218
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.
Commercial and strategy managers will be
attending 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
1, 2 or 3 of this Condition.
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.
219
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
undertakes monthly monitoring
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
Committee receive reports
regarding CQC compliance;
details of inspection visits are
routinely included in the CEO
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
220
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.
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
J Medhurst
Y
I Millar
Y
Finance report to board of
directors
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
For Finance that:
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.
For Governance that:
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.
221
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
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
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.
The statement is compiled in
line with most recent guidance
annually, agreed by the audit
committee and included in the
annual report
Trust integrated performance
report and balanced scorecard
The Board KPI report includes:
• Milestones met for
222
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
developing and submitting
IBP/LTFM ahead of key
assessments (auditors,
NTDA)
• Milestones met for
completion of action plans
for external assessments
by February 2014 – to be
restated in line FT timeline
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
arrangements for existing and
future vacancies.
There are no Board vacancies.
The NED vacancy has been
filled; the successful applicant
will join the Trust on 1 August
2014.
223
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
A new NED appointment will
be made in April 2014.
The Remuneration Committee
terms of reference include
approval 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
documentation
224
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title:
Quality Committee terms of reference
Agenda item number:
3.10.1
Report of:
Chief Executive
Contact Officer:
Trust Secretary
Status
Executive Summary:
The annual review of the Quality Committee’s terms of reference was postponed from June to
October 2014. This enabled the findings from the external assessment of the Committee’s
effectiveness [reference Ramsden, Transforming Health Ltd, September 2014] to be considered.
Membership of the Committee has also been reviewed; no changes are proposed. Clinical leads are,
however, welcome to attend as observers and there are a number of other regular attendees.
Proposed changes are shown tracked for the Board to approve, including for the first time,
revalidation and monitoring the delivery of the Trust’s engagement plans.
The Committee’s role in relation to risk has been clarified to avoid confusion with the role of the Audit
Committee (to review the establishment and maintenance of an effective system of
integrated governance, risk management and internal control, across the whole of the organisation’s
activities (both clinical and non-clinical), that supports the achievement of the organisation’s
objectives). The risk categories are also updated in line with the Risk Management Strategy approved
by the Trust Board on 30.09.14.
Following approval, a supporting annual programme will be prepared, commencing in January 2015.
This will show how the Committee will deliver against each responsibility and will include the lead
director and form of assurance to be provided.
Assurance provided: The terms of reference have been approved by the Board and compared to the
2nd edition of the foundations of good governance, compendium of best practice published by the
Foundation Trust Network and DACbeachcroft in October 2013.
Report provenance: The Trust Board approved the terms of reference in June 2013 and the Quality
Committee agreed proposed changes at the meeting of 22.10.14.
225
Discussion
Information
Recommendation: For the Board to approvel.
226
QUALITY COMMITTEE TERMS OF REFERENCE
Role
The role of the Quality Committee is to focus on quality and risk issues including the
clinical agenda to ensure that appropriate governance structures, systems and
processes are in place across the Trust.
Definitions
“the Trust” means Central London Community Healthcare NHS Trust
“the committee” means the Quality Committee
“the Directors” means the Trust’s Board of Directors.
1
1.1
Membership
Members of the committee shall be appointed by the Board of Directors. The
committee shall be made up of 7 members. Non Executive Directors shall be
in the majority. Members may appoint a deputy to represent them at a
committee meeting. Members of the Quality Committee are as follows:
 4 x Non-Executive Directors
 Chief Nurse and Director of Quality Governance
 Deputy Chief Executive (Operations)
 Executive Medical Director
1.2
1.3
The Chief Executive shall attend at least quarterly.
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 Non
Executive Director to chair the meeting.
1.4
2
2.1
Secretary
The Trust Secretary or their nominee shall act as the secretary of the
committee.
3
3.1
Quorum
The quorum necessary for the transaction of business shall be one Non
Executive Director and one Executive Director. A duly 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
4.1
Frequency of meetings and attendance requirements
The committee will normally meet ten times a year at appropriate times in the
reporting cycle and otherwise as required;
Committee members should aim to attend all scheduled meetings but must
attend a minimum of seven meetings unless otherwise agreed with the Chair.
The Secretary of the committee shall maintain a register of attendance which
will normally be published in the Trust’s annual report.
4.2
227
5
5.1
5.2
6
6.1
6.2
6.3
Notice of meetings
Meetings of the committee may be called by the secretary of the committee at
the request of any of its members.
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 5 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.
Minutes of meetings
The secretary, or nominated deputy, 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 and the
secretary should minute them accordingly.
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.
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:
8.1
Quality
8.1.1 To review implementation of all elements of the quality strategy. In particular,
obtaining assurance that the measures for success are implemented within
the appropriate time scales.
8.1.2 To gain assurance over the full range of quality performance via the quality
report, quality dashboard, minutes (including unconfirmed minutes if
necessary) and summary reports from the quality stakeholder reference group
and the quality campaign groups, namely the patient safety and risk, clinical
effectiveness and patient experience and the provision of any other quality
related information that the committee may request, including receipt of an
annual report from each of these groups.
8.1.3 To receive reports as appropriate and as the committee may request from any
of the work groups that feed into the quality campaign groups.
8.1.4 To monitor the production of the quality account; ensuring they are produced
annually and in accordance with the relevant guidance.
8.1.5 To receive regular reports on delivery of annual objectives as defined within
the quality account;
228
PATIENT SAFETY AND RISK
8.2
Risk
8.2.1 To receive the quality committee sections of the corporate risk register at least
quarterly –risk categories: clinical, environmental, fire, health and safety,
information governance and workforce. To scrutinise and review risks rated
15 and above for the following risk categories: clinical, environmental and
information governance.
8.2.2 To receive a regular update on new, removed and changes in scoring of risks
on the added to the corporate risk register as they pertain to the above risk
categories, for example risks added, taken off and movements in scoring .
8.2.3 To obtain assurance that risks are being managed appropriately and to
escalate any particular concerns to the board or relevant directors.
8.2.4 To obtain assurance that the Trust has effective mechanisms for managing
risk and improving service user safety, learning from incidents, and taking
action to reduce risks.
8.3
Care Quality Commission (CQC) - Essential Standards
8.3.1 To monitor compliance against the CQC’s Essential Standards and obtain
assurance that standards are being met and that improvement reviews are
implemented.
A POSITIVE PATIENT EXPERIENCE
8.4
Involving and learning from service users
8.4.1 To obtain assurance that the experience of users, carers and voluntary
groups are central to the Trust’s work.
8.4.2 To obtain assurance that the implementation and maintenance of
programmes for measuring, monitoring and improving the experience of
service users and carers is appropriate and relevant.
8.4.3 To obtain assurance that lessons learned learnt from involving service users
are used to improve the quality of service provided.
8.4.4 To monitor the delivery of the Trust’s engagement plan, including the
programme of listening events in each of our four key boroughs.
SMART EFFECTIVE CARE
8.5
Monitoring and improving clinical performance
8.5.1 To approve the annual programme of Trust-wide clinical audits.
8.5.2 To obtain assurance that clinical recommendations resulting from complaints
investigated by the Parliamentary and Health Service Ombudsman; the
implementation of NICE Guidelines and Technology Appraisals and
recommendations for improving clinical performance resulting from national
reviews and other external inquiries are appropriately managed.
229
8.5.3 To receive, at least annually, the log in relation to Caldicott approval of
requests for information.
8.5.4 To assure that the statutory duty of revalidation for doctors is delivered
effectively and for other professionals as this is mandated.
8.6
Clinical Governance
8.6.1 To obtain assurance that appropriate clinical governance structures groups,
systems, and processes are in place, and developed in line with national,
regional and commissioning expectations.
9
9.1
9.2
9.3
9.4
9.5
Reporting responsibilities
The committee will report to the Board of Directors on its proceedings after
each meeting.
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.
The committee will produce an annual report to the Board of Directors.
To identify any control issues and bring these to the attention of the Audit
Committee
To identify any new risks and issues arising during meetings and to agree
action required.
See also 8.1.2 above.
10
10.1
10.2
10.3
10.4
11
11.1
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.
Authority
The committee is a committee of the Board of Directors and has no powers,
other than those specifically delegated in these Terms of Reference. 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.
230
12
12.1
12.2
12.3
12.5
12.6
Monitoring and Review:
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.
The secretary will assess agenda items to confirm they comply with the
Committee’s responsibilities.
Terms of reference reviewed and considered by quality committee 20.10.14.
Terms of reference approved to be approved by trust board 28.10.14.
Date of next review September 2015.
231
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title:
Update following Quality Committee meeting of 22.10.14
Agenda item number:
4.11.2
Report of:
Quality Committee Chair
Contact Officer:
Trust Secretary
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 22.10.14.
Discussion
Information
Recommendation: To note.
232
Highlights:
QUALITY IMPROVEMENT
1
Quality report, Q2
1.1
It was confirmed that a cluster of outliers had been identified. Quality Action Teams will be
appointed to work with the services/teams identified to help implement improvement plans.
1.2
A substantive complaints and claims manager is now in post and training for CBU staff has been
planned to help resolve complaints in a more timely manner. A status update will be reported
back to the Quality Committee in Q, 2015.
2
2.1
There has been positive feedback following the unannounced inspection at Garside Nursing
Home.
2.2
The Chief Executive confirmed that the Trust’s CQC inspection is likely to take place in April
2015.
3
3.1
Quality governance assurance framework (QGAF)
Niche Consulting have provided verbal, positive feedback following the QGAF assessment.
The summary and final report will be shared with the Board. Chair thanked and congratulated all
involved.
4
4.1
Risk register review
The risk in relation to the nursing homes was discussed at length; delays in the transfer to
Sanctuary Housing cited by commissioners included: TUPE and pension arrangements together
with estate issues. Senior representatives from the current health service providers continue to
press for an early transfer date; in the meantime NHS Trusts would continue to manage the risks
to the provision of high quality care.
A new risk (1108) was added to the register with a scoring of 20 (although it is anticipated this
will be lowered to 16 after the patient safety and risk group meeting on 27.10.14). Discussion
took place as to how a risk can enter the register at such a high level without prior “sighting”.
A POSITIVE PATIENT EXPERIENCE
5
Achieving excellence together
5.1
Members welcomed a report on the ‘achieving excellence together’ campaign focussed on
improving the quality of care and morale of staff within district nursing services, in partnership
with New Buckinghamshire University. It was agreed that a quarterly update on this initiative
would go to the Workforce Committee.
6
6.1
Quarterly waiting times report
Members discussed the waiting times report in detail, noting actions planned to consider the
redirection of resources from services which were ‘over-performing’ against contract and more
challenged services. The importance of contract negotiations for 2015/16 was recognised,
including whether a move to activity or performance based contracts could be achieved. It was
also agreed that greater insight into average versus static times would be beneficial. Importantly,
the committee received assurance that any extended waiting times were not putting patients at
risk.
7
7.1
Learning disability protocol
A draft protocol was considered and a number of helpful additions agreed to broaden and
improve access to services for people with a learning disability.
233
PREVENTING HARM
8
Patient safety – serious incident report
8.1
The Committee received assurance that as much as possible was being done to prevent and
manage pressure ulcers. It was noted that the management of level 3 and 4 pressure ulcers
remained a significant challenge, both locally and nationally.
See also 1.1 above regarding action in response to confirmed outliers.
9
9.1
Short record keeping audit
A report triangulating record keeping in relation to pressure ulcer assessments, falls, nutritional
assessments and safeguarding had been prepared and shared with divisions. It was confirmed
that the record keeping steering group would review the results and determine a specific action
plan for improvement.
9.2
It was agreed that the full record keeping audit would be postponed from November to enable an
improved process which is better understood by staff – for report to the Quality Committee in
January 2015.
10
Child health information hub
10.1 The remedial action plan was noted to be progressing well. Executive directors were asked to
confirm the process for electronic notifications and how these would continue to be accessible to
staff.
SMART, EFFECTIVE CARE
11
Falls report
11.1 The comprehensive report, which had been well received by commissioners, comparing the
number and severity of falls in each of the Trust’s bedded units (including those managed by
Care UK for which the Trust provides therapy staff) was considered. It was noted that
Pembridge had achieved a zero falls in September and was commended for having
implemented actions to address the service challenges.
OTHER ITEMS
12
Quality Committee terms of reference
12.1 The revised terms of reference, which had been postponed to enable recommendations from the
external assessment to be considered, were agreed for Board approval on 28.10.14.
234
BOARD OF DIRECTORS
28 OCTOBER 2014
Report title:
Update following Remuneration Committee meeting 22.10.14
Agenda item number:
Report of:
3.10.3
Remuneration Committee Chair
Contact Officer:
Trust Secretary
Status
Report provenance: The Remuneration Committee discussed these issues in full on 22.10.14, a copy
of papers has been provided to all Non-Executive Directors.
Recommendation: To note.
1
Discussion
Information
Highlights
Outstanding issues from the former people and remuneration committee
It was agreed that a comprehensive interim usage report, governance arrangements
for the appointment of interim staff and a table capturing the totality of temporary
posts, highlighting those in excess of 6, 12 and 24 months would be provided to
Workforce Committee members no later than the end of November.
2
2.1
Update on VSM remuneration and terms of service
Members were informed that the Medical Director had a temporary variation to
contract, working 4 days per week for an approximately 8 week period and that a parttime, Deputy Medical Director (Dr Dharini Shanmugabavan) had been appointed.
2.2
J Reilly reported that the Head of Communications and External Relations had
resigned.
3
3.1
People and Remuneration Committee – performance review
The findings of the former Committee’s performance review were noted – no specific
recommendations had been made.
4
4.1
Remuneration Committee - programme
The programme was agreed, subject to the inclusion of pensions and a mid-year
update on progress against VSM objectives. A copy of the programme will be
included with Board papers for 27.11.14.
5
5.1
Remuneration Committee – terms of reference
The terms of reference were agreed, subject to inclusion of a mid-year review of VSM
objectives and the attendance of the Director of HR (or equivalent), for Board approval
on 27.11.14.
1
235
Quality Committee
Minutes of the meeting held on Tuesday 16 September 2014
In the Boardroom, Westminster City Hall, Victoria Street, London
Present
Louise Ashley
Julia Bond
Pamela Chesters
Carol Cole
Joanne Medhurst
Richard Milner
David Sines
Non-Executive Director (Committee Chair)
Non-Executive Director (Trust Chairman) (part)
Medical Director
Deputy Chief Executive Officer
In attendance
Judith Barlow
James Benson
Nick Caley
Jo Davis
Steve Graham
Clare Gray
Joanne Howard
Janet Lewis
Jean Lewis
Esther Palmer
Sheila Pearce
Tony Pritchard
James Reilly
Sharon Slack
Rachel Stoukas
Paul Thomas
Jayne Walbridge
Associate Director of Quality (part)
Divisional Director of Operations
Grant Thornton LLP (observer)
Clinical Specialist OT (observer)
Head of HR and OD
Clinical Lead Physiotherapist Learning Disabilities (observer)
NICHE Patient Safety (observer)
Divisional Director, Children’s Health and Development
Professional Lead Adult Nursing (part)
Clinical Lead Physiotherapist (observer)
Head of Patient Safety
Deputy Chief Nurse (Director of Patient Experience)
Chief Executive
Niche Health and Social Care Consulting (observer)
Committee Administrator
Head of Quality Improvement
Trust Secretary
QC/187/14
187.1
187.2
Welcome, Introduction and Apologies
All members were present.
J Bond welcomed C Cole to the committee.
QC/188/14
188.1
Declarations of Interest
There were no interests declared.
QC/189/14
189.1
Minutes of the meeting held on 7 August 2014
The minutes of the meeting held on the 7 August 2014 were agreed as an accurate
record.
QC/190/14
190.1
Action Log
The action log was reviewed and it was agreed that all completed actions could be
closed.
190.2
Action QC/11/14 (Quality Report) – L Ashley reported that the balanced scorecard
was being migrated onto Qlikview and it was expected that by the end of
September service levels would be able to view data quality sets, however there
were currently some data quality issues. It was agreed a short update paper would
be prepared for the next meeting.
Action QC/83/14 L Ashley
1
236
It was agreed this action would be closed.
190.3
Action QC/60/14 (Terms of Reference Review) – J Bond reported she had received
the report following the external committee review in August. It was agreed an
action plan would be devised and presented to the Board in October.1 The report
would also inform potential revisions to the Terms of Reference.
190.4
Action QC/76/14 (Dental recall audit NICE) - This action would be closed however
it was agreed that R Milner would ask S Yadin to share the audit results with
committee members.
Action QC/84/14 R Milner
190.5
Action QC/81/14 (Statutory and Mandatory Training) - This action would be closed
however it was agreed that an updated position by division would be circulated to
the Board the following week.
Action QC/85/14 L Ashley & T Pritchard
QC/191/14
191.1
Matters Arising
On reflection of the minutes of the meeting held on 7 August, J Bond queried if an
action should have arose regarding encouraging staff to share their concerns via
the internal Trust whistleblowing procedures (ref QC/170/14 / 170.4). J Reilly
assured the committee that ‘Your Trust News’ and ‘CLCH Today’ have regular
bulletins referencing the correct avenues for whistleblowing.
QC/192/14
192.1
Quality Presentation
J Lewis presented on the prevention and management of pressure ulcers
highlighting that training for clinical staff throughout the Trust had developed to
focus on prevention, classification, risk assessment and wound management for
nursing and therapy staff. Competency assessments were also being undertaken.
NHS safety thermometer data showed a reduction in incidence of CLCH acquired
pressure ulcers from April to August.
192.2
A demonstration was provided about the educational smartphone and tablet app
that had been developed for patients and carers. The committee were particularly
impressed and it was agreed that J Medhurst would look into how the body of work
being conducted by CLCH on pressure ulcers could be leveraged further through
the Innovation committee.
Action QC/86/14 J Medhurst
192.4
Members had a useful discussion regarding patient pathways and carer
intervention. J Bond was particularly pleased to note the reduction in pressure
ulcers and it was agreed J Reilly would discuss with L Ashley and J Medhurst the
most appropriate forum to thank staff for their efforts.
Action QC/87/14 J Reilly/L Ashley/J Medhurst
192.3
J Bond stressed the importance of communicating this important work to the
commissioners which L Ashley noted was routinely shared at the clinical quality
groups.
192.4
Resolved
Members thanked J Lewis for her excellent presentation and all the effort being
undertaken to reduce the number of pressure ulcers affecting patients.
J Bond would consider the most appropriate route to ensure all non-executive
colleagues were sighted on this important work.
1
Following the meeting it was decided the action plan would be presented to the Board on 30 September.
2
237
Action QC/88/14 J Bond
QC/193/14
193.1
Quality Improvement Plan – Sign up to Safety
L Ashley updated members on the Sign Up to Safety campaign highlighting the
plan for the Trust was to focus on a safety programme related to organisational
safety culture. Impressively CLCH was one of the first trusts and the first
community trust to join the campaign.
193.2
Resolved
Members noted the Sign up to Safety update and how it would work alongside
existing initiatives.
QC/194/14
194.1
Quality balanced scorecard (August Performance)
Throughout August thirteen KPIs were RAG rated green, six amber and six red.
The areas of concern remained the number of falls with harm and pressure ulcers.
194.2
The proportion of complaints responded to within 25 days
Members discussed the year to date average of 64%. Concern was noted that the
year-end target of 90% was now unachievable which was disappointing given the
low volume of complaints received per month. T Pritchard sought to provide
assurance that whilst not all complaints were resolved within 25 days, they were
resolved within an agreed timeframe. It was anticipated there would be a
significant improvement now that a permanent complaints manager was in post and
culture change workshops were being held for staff.
194.3
10% reduction in falls that cause harm
The year to date average was reported at 16. Whilst the decline in falls was
acknowledged it was agreed a detailed falls analysis would be prepared for the next
meeting highlighting the outliers and mitigations in place.
Action QC/89/14 L Ashley
194.4
Proportion of services capturing clinical outcomes
Although RAG rated red at the moment, J Medhurst assured the committee there
would be a step change at the end of September as work had been intensified by
the continuous improvement manager to work closely with services to record their
clinical outcomes.
194.5
Resolved
The Quality Balanced Scorecard was noted.
QC/195/14
195.1
Engagement Strategy
T Pritchard introduced the strategy highlighting the Trust’s plans for ensuring
effective engagement with patients, the public and key stakeholders.
195.2
Members discussed the strategy in detail emphasising the importance of direct
involvement with divisional directors and CBU managers. J Reilly noted that initial
accountability for engaging stakeholders lies with CBUs and the current planning
round included a focus on stakeholder engagement.
195.3
In response to members’ queries, T Pritchard confirmed further equality impact
assessment work was being considered on how to include hard to reach groups
and following further discussion agreed it would be useful to have more specific
measurements in some areas of the strategy. For example metrics against what
success looked like and how assurance could be provided.
195.4
It was also decided it would be important to evidence engagement of the Board of
Directors and J Walbridge agreed to prepare a section for inclusion in the strategy.
3
238
Action QC/90/14 J Walbridge
195.5
Resolved
The committee endorsed approval of the Engagement Strategy by the Board
subject to amendments. It was agreed the maturity matrix would be considered on
a quarterly basis by the committee.
QC/196/14
196.1
Patient and Public engagement update
T Pritchard highlighted key updates on the patient and public engagement work
streams through April to June 2014;
• There were now four patient experience facilitators in post aligned to each
division and a new permanent head of patient experience had been
appointed
• PREMS coverage had expanded to include a monthly walk around of
services to collect data
• Tablets and kiosks were being used in some bedded areas and wards
• Divisional engagement plans had been drawn up
• The 15 steps challenge had been implemented on Jade ward, Marjory
Warren ward, the Pembridge Unit, Athlone House and Alexandra rehab unit.
196.2
Members were particularly pleased with the ‘you said / we did’ updates and L
Ashley confirmed these were communicated back to the services on a regular basis
as well as on a quarterly basis to the commissioners.
196.3
In response to P Chesters’ query, L Ashley explained it was important for the
Qlikview data to be reviewed at a team level quarterly to enable progress against
action plans.
196.4
Resolved
The Patient and Public engagement update was noted. The committee welcomed
the future plans to develop staff and carers stories and re-introduce ‘mystery
shopping’ to follow the pathway of care / the patient journey.
QC/197/14
197.1
Volunteer Service Update
Members discussed the current volunteer services provided within the Trust noting
the high number of volunteers in Barnet and the low numbers within the tri borough.
A key aim for the remainder of 2014 was to expand the service within the inner
boroughs with one idea focused around recruiting younger people with the aim of
advancing to apprenticeships.
197.2
J Reilly highlighted the Charitable Funds Committee had discussed the volunteer
service with a view to supporting plans to expand provisions. It was agreed it would
be useful to have a proposal and discussion at the next Charitable Funds meeting.
Action QC/91/14 T Pritchard
197.3
Resolved
Members noted the volunteer update and were supportive of the plans to increase
the numbers. It was agreed J Medhurst would ensure there were robust systems in
place with employee health regarding the immunisation status of current and future
volunteers.
QC/198/14
198.1
Patient safety – serious incident report
S Pearce reported on the serious incident cases to end of August 2014. Of
concern there were twelve new pressure ulcer cases and five confidential
information governance leaks.
4
239
198.2
In response to concerns raised regarding the delays in reporting some pressure
ulcer cases, S Pearce highlighted that although there were delays in reporting
cases on STEIS due to staffing issues, there was no delay in the investigation of
each case.
198.3
The table charting the number of pressure ulcers reported to NWL CSU since April
2013 was discussed in detail. Given the substantial range month on month,
members queried if there were any particular themes / outliers and any correlation
with the use of agency nurses / incidents occurring within patient’s homes. J
Medhurst noted a standard variation chart would be a useful tool to capture this
data and would arrange a meeting between S Pearce and J Ramazanoglu who
would be able to assist.
198.4
Resolved
Members noted the Serious Incident Report and welcomed an update in the next
report against the actions generated in the lessons learned section.
QC/199/14
199.1
Record Keeping Audit
J Barlow introduced the results of the short record keeping audit that took place in
July 2014. An overall compliance rate of 76% was recorded. Whilst there was
improvement around safeguarding, reporting on resuscitation and medication and
care planning, there were several areas of concern where questions were poorly
answered around pressure ulcer and falls risk assessments, nutritional
assessments and medication deficits.
199.2
The audit findings were discussed and members acknowledged the effort needed
to achieve the 90% target in the annual audit due to take place in November. J
Barlow provided assurance that the Record Keeping Steering group were providing
extra support to those services identified the previous year as having poor
recording keeping performance. However members were still concerned regarding
the percentage of non-compliant services. It was agreed that an update report
would be prepared for the next meeting focusing on service outliers and their KPIs
for falls, pressure ulcer management and safeguarding.
Action QC/94/14 J Barlow / L Ashley
199.3
In addition J Medhurst would review the audit questionnaire focusing on the issues
around the questions that were not answered correctly.
199.4
Resolved
The Record Keeping audit report was noted.
J Bond expressed her concern that the tone of the paper was more positive than
suggested when looking at the detail.
QC/200/14
200.1
Quality Impact of Cost Improvement Programme update
L Ashley updated the committee on the quality impact assessments undertaken for
the 2014 /15 cost improvement programme highlighting a more collaborative
process with the divisions this year. Whilst no CIP schemes were declined, J
Medhurst and L Ashley worked closely with services to revise proposed schemes
and ensure robust quality assessments were in place. Full assurance was also
given around all schemes as the full project plans including patient experience data
were reviewed as part of the assessments.
5
240
200.2
Resolved
Members noted the report and were assured the CIPs were being appropriately
managed and monitored to prevent adverse impact on the quality of service
delivery.
QC/201/14
Update on progress with delivery of remedial action plans for Child Health
Information Hub records management process
J Lewis informed members that the two satellite centres had been set up to deal
with the backlog. This had ensured the CHIH could continue to run business as
usual. All the red and amber rated notifications had been processed. L Ashley
assured the committee that there were no children within the records that were of
immediate safeguarding concern as these cases would have been dealt with at the
time under the serious incident reporting process.
201.1
201.2
In response to queries, J Lewis suggested an estimated completion date of the end
of November, however stressed there were currently problems with ensuring
continuity of bank staff and recruitment processes. It was agreed J Lewis and S
Graham would urgently discuss ways of recruiting to and sustaining bank admin
staff.
Action QC/96/14 J Lewis / S Graham
J Bond also stressed that appropriate financial resources / incentives should be
allocated to ensure sustainability for the satellite centres.
201.3
Resolved
Members noted the update on progress with delivery of the action plan for CHIH
records management. It was suggested the next iteration of the report should
sensibly manage expectations and include timeframes.
In response to J Bond’s suggestion of an external review, J Reilly recommended
awaiting the findings of the internal investigation and internal audit to be picked up
at the Audit Committee.
QC/202/14
202.1
Dementia Update
Resolved
Members noted the update on initiatives to support the development of dementia
care across the organisation in particular noting the e-learning specialist dementia
training module that had been set up and the links with the End of Life strategy and
Carer’s strategy.
QC/203/14
203.1
Committee effectiveness review
Resolved
J Bond informed members she had received the feedback following the
committees’ external assessment and shared some of the high level output. An
action plan would be prepared by J Bond and L Ashley and shared with the Board.
QC/204/14
204.1
Risks and issues arising for which further assurance is required
A risk in relation to the non-compliance with the record keeping audit in particular
pressure ulcer risk assessments and falls risk assessments was identified during
the meeting and J Bond requested that a paper come back to the committee which
cross-referenced these areas against other reporting metrics.
QC/205/14
205.1
Grid of all meeting dates
Members noted the list of meeting dates for groups reporting to the Quality
Committee.
205.2
J Bond reiterated the need for consistency with the groups reporting to the
committee and noted her disappointment that minutes were still not being received
6
241
in a timely manner. She urged the Chairs of the groups to ensure minutes were
provided emphasising draft minutes were acceptable. J Bond also suggested the
Chairs of each group might want to review memberships to ensure more consistent
attendance.
QC/206/14
206.1
Clinical Effectiveness Group Minutes
The minutes of the Clinical Effectiveness group held on 9 July 2014 were noted.
QC/207/14
207.1
Patient Safety and Risk Group Minutes
The minutes from the Patient Safety and Risk Group held on the 30 June 2014 and
the 28 July 2014 were noted.
QC/208/14
208.1
Update of key issues from Clinical Commissioning Group Quality Meetings
Members noted updates from the Barnet CCG and combined inner London CCG
following the meetings held in August 2014.
QC/209/14
209.1
Update on new regulation and guidance
Resolved
The committee noted the update on regulation and guidance issued since July
2014.
QC/210/14
210.1
Any other business
L Ashley reported that the Achieving Excellence Together programme had been
successful in receiving a bid with the value of £340,000 from LETB.
210.2
J Medhurst informed members that a Deputy Medical Director had been appointed
and would take up post in October.
186.1
Date and time of next meeting
20 October 2014, 1400 Boardroom, Victoria Street
The meeting closed at 1655 hours.
Signed ………………………………………………….. Julia Bond, Committee Chair
Date ……………………………………………………..
7
242
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
243
LETB
LTC
MAU
NHS
NHSLA
NICE
NRLS
NTDA
OBD
OD
OOH
ORSA
PASA
PID
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
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
Organisational Development
‘Out of Hospital’ agenda or Out of Hours
Organisational Readiness Self-Assessment
Purchasing and Supply Agency
Project Initiation Document
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
244
KEY PERFORMANCE INDICATOR SCORECARD
Key Performance Indicator Description
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.
Support people safely out of hospital
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.
Deliver better value than competitors in our selected markets
Net new business won - annualised figure of committed changes to income
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.
Be responsive to our patients and partners needs
Complaints resolved within 25 days of receipt
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.
245
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.
Percentage of Appointments cancelled by CLCH
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.
Employ only the best staff
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.
Staff appraisal rates
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.
Sickness absence rate
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.
Be innovation and technology pioneers
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.
246

Board of Directors - Central London Community Healthcare NHS Trust

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