4th november 2015 - hgs.uhb.nhs.uk … · 04-11-2015 · on 4 november 2015 4.00 – 6.00pm a g e...

Agenda ApologiesDeclarations of Interest

Chief Executive’s

Report

Integrated Performance

Report

Improvement Plan

Infection Control Report

Minutes of previous

Matters Arising

Attendance Record

Any other Business

Date of Next

Meeting

Council of Governors 4th November 2015

4.00pm

St Johns Hotel, Warwick Road, Solihull, B911AT


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Council of GovernorsNov 2015

Notice is hereby given that a meeting of the Council of Governors of Heart of England NHS Foundation Trust

will be held at St Johns Hotel, Warwick Road, Solihull on 4 November 2015 4.00 – 6.00pm

A G E N D A

Indicative Timings

(minutes) Presenter

1. Introduction

5 Les Lawrence

2. Apologies

1 Kevin Smith

3. Declarations of Interest - Governors - Directors

1 Les Lawrence (Enclosure)

Strategy

4. Chief Executive’s Report

10 Julie Moore

(Oral)

Quality & Performance

5. Integrated Performance Report (Inc. Financial Recovery Plan)

40 Jonathan Brotherton/ Sam Foster/ Hazel Gunter/ Andrew Catto/ Darren Cattell

(Enclosure)

6. Integrated Improvement Plan

10 Andrew Catto (Enclosure)

Matters for Report

7. Annual Infection Control Report

10 Abid Hussain (Enclosure)

Governance & Administration

8. Minutes of previous meetings – 8 September 2015


9. Matters Arising/ Recommendations Tracker

5 Kevin Smith (Enclosure)

10. Attendance Record


For Information

11. Any Other Business Previously Advised to the Chair

12. Date of Next Meeting

6 January 2016 – Venue to be confirmed Light refreshments will be available from 3.30pm Kevin Smith Company Secretary 28 October 2015


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Apologies


Chief Executive’s

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Matters Arising

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Declarations of Interest


Chief Executive’s

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COUNCIL OF GOVERNORS

REGISTER OF INTERESTS

NAME INTEREST DECLARED DATE DECLARED

DATE CEASED

Cllr Mohammed Aikhlaq

Member of Overview & Scrutiny Committee : Health & Social Care May 2015

Arshad Begum Nothing to declare 21 Nov 2011

Kath Bell Company Secretary - Succeed Services Ltd 21 Nov 2011

Nicola Burgess Assistant Professor of Operations Management, Warwick Business School, Warwick University and honorary contract with HEFT to conduct research.

2 Jun 2015

Elaine Coulthard Nothing to declare 21 Nov 2011

Dr Olivia Craig Various roles associated with the British Psychological Society

2 Jun 2015

Carol Doyle Awaiting information

Helen Griffiths Awaiting information

Emma Hale Nothing to declare 27 May 2014 Ron Handsaker 1. Shareholder – Santander

2. Director – 24/7 Industrial Services UK Ltd 2000 20 Oct 2014

Albert Fletcher Director – Aquarius (unpaid). A charity that specialises in helping and treating those with drink and/or drug issues.

28 May 2013

Richard Hughes 1.Chairman – Homestart (Tamworth) 2.Chairman – Tamworth Credit Union Ltd 3.Director – The Pathway Project 4.Director – Tamworth Community Advice Network CIC 5.Chairman – Tamworth Talking Newspaper Ltd 6.TrusteeChairman – The Rawlett Trust 7.Vice Chairman – Standards Committee, Tamworth Borough Council 8.Divisional President – St John’s Ambulance President Tamworth and Wilnecote St John’s Ambulance. 9.Member – Appeal Committee, St Giles Hospice 10.Retired CEO & President Secretary, Tamworth Cooperative Society 11.Mr Hughes’ son holds a very senior managerial position with Barclays Bank 12.Chairman – Tamworth Community Advice Network CIC 13. Independent Member – Tamworth Borough Council Nominations Committee 14. Member – Conservation Advisory Committee, Tamworth Borough Council 15. President – Tamworth Male Voice Choir 16. Treasurer – St Andrew’s Methodist Church, Tamworth 17. Shareholder – BP

21 Nov 2011

Amended 1 Sep 2013 Amended 2 Sep 2015 Amended 23 Oct 2012 16 Feb 2012 23 Oct 2012 23 Oct 2012 23 Oct 2012 23 Oct 2012 23 Oct 2012 23 Oct 2012 23 Oct 2012

23 Oct 2012 4 Mar 2014 23 Oct 2012 23 Oct 2012 23 Oct 2012


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18. Shareholder – Santander 19. Trustee – Spirit of Tamworth Trust

23 Oct 2012 May 2014

Michael Hutchby Nothing to declare 16 Aug 2013

Sue Hutchings Shareholder in Lloyds TSB 19 Sept 2013

Phillip Johnson Nothing to declare 21 Nov 2011

Michael Kelly Nothing to declare 21 Nov 2011

Attiqa Khan Nothing to declare 16 Aug 2013

Marek Kibilski Nothing to declare 15 June 2015

Heidi Lane 1. Member of Church – Renewal Christian Centre 2. Husband is an Elder of the Church. 3. Trust uses Christian Renewal Centre for

conferences & meetings

21 Nov 2011

Andrew Lydon Nothing to declare 16 Aug 2013

Anne McGeever 1. Registered with Therapy Bank in Worcestershire to provide services to BMI Droitwich Spa Hospital.

2. Unite Professionals Limited (Occupational Therapists) – ad hoc employment.

12 Sep 2014

14 Apr 2015

Margaret Meixner Awaiting information

Catherine Needham

Nothing to declare 13 May 2014

Barry Orriss Nothing to declare 21 Nov 2011

Mark Pearson Member of Green Party

21 Jan 2015

Liz Steventon Friends of Solihull Hospital 21 Nov 2011

Jean Thomas Nothing to declare

David Treadwell 1. Shareholder - Lloyds TSB 2. Shareholder - STW 3. Shareholder - National Grid

21 Nov 2011

Matthew Trotter

1. HEFT Employee 2. Director - Specialist Health Partnership 3. Director - Specialist ENT Care Ltd

12 Sep 13 15 Dec 14

David Wallis 1. Knowle, Dorridge & Bentley Heath Neighbourhood Plan Ltd – Director

2. Prospect (Trade Union) - Member

16 Sept 2015 16 Sept 2015


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REGISTER OF DIRECTORS and REGISTER OF DIRECTORS’ INTERESTS

VOTING DIRECTORS

NAME DATE OF APPOINTMENT INTEREST (if any) DATE OF

NOTIFICATION DATE OF

TERMINATION OF INTEREST

Mr Jonathan Brotherton

04.03.15 Nothing to declare 04.03.15

Mr Darren Cattell 19.01.15 Director & Shareholder - Mill Street Consultancy Limited.

19.01.15

Dr Andrew Catto 01.03.14 (Interim CEO -

14.11.14 to 16.02.15)

Nothing to declare. 01.03.14

Mr Andrew Edwards

01.10.14 1. Couch Perry & Wilkes. In receipt of annuity following business sale until May 2019.

01.10.14

Mrs Sam Foster 01.09.13 Nothing to declare. 01.09.13

Prof Jon Glasby 01.10.15 1. Professor / Head of School, University of Birmingham

2. Senior Fellow, NIHR School for Social Care Research

3. Member of Birmingham Health Partners Executive Group

01.10.15

01.10.15

01.10.15

Ms Hazel Gunter 04.03.15

Nothing to declare. 04.03.15

Mrs Karen Kneller 01.10.14 1. CEO of Criminal Cases Review Commission

2. Part time judge Social Entitlement Chamber Fitness to Practise

3. Member for General Dental Council 4. Director (unremunerated) of BRAP, an

equalities think tank.

01.10.14

01.10.14

01.10.14 01.10.14

Mr Les Lawrence 01.04.12 (Chair –

01.06.14)

1. Trustee for the National Institute for Conductive Education.

2. Governor of City of Birmingham School.

3. Director of Lindridge Enterprises Limited.

4. Director (unremunerated) of Bordesley Birmingham Trust Limited (since 7 July 2011).

5. Chairman of the Birmingham Special Educational Needs & Disability Information, Advice and Support Service (SENDIASS).

Mar 2013

Mar 2013

Mar 2014

July 2014

Mar 2015


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Mr David Lock 01.07.13 1. Practising barrister and a member of Landmark chambers. Providing legal advice and representation to a wide range of individuals, NHS organisations, local authorities, charities and commercial organisations mainly on public law issues. These frequently involve issues concerning the rights of patients to NHS treatment as well as structural and management issues involving NHS bodies.

2. Member of Amnesty International. 3. Member of the BMA Ethics Committee

(unremunerated). 4. Member of the Labour Party and

occasional legal advice to Labour Party and elected Members of Parliament on NHS policy issues.

5. Mr Lock’s wife, Dr Bernadette Gregory, is a medical doctor employed by Redditch and Bromsgrove Clinical Commissioning Group and is Clinical Lead for the Worcestershire Integrated Care Project.

6. Chairman of Innovation Birmingham Limited.

7. Representing NHS England in relation to specialised services.

8. Receives instructions from the CQC from time to time.

9. Receives instructions from NHS England from time to time

Updated Jan 14

01.07.13 01.07.13

01.07.13

01.07.13

05.11.13

06.01.14

04.07.14

07.10.15

Oct 2015

Oct 2015

Ms Alison Lord 01.05.13 1. CEO and Shareholder of Allegra Ltd. 2. Voluntary role as a business mentor

for the Prince's Trust. 3. In her professional capacity as a

'turnaround executive' Ms Lord has relationships from time to time with major accountancy firms, legal firms, banks and venture capital providers.

4. Company Secretary - Adente Limited (unremunerated).

01.05.13

22.01.14

13.05.14

Dame Julie Moore 26.10.2015 1. Birmingham Systems Ltd (DBu has confirmed this)

2. Innovating Global Health China Ltd (DBu has confirmed this)

3. Member of Birmingham Business School Advisory Board

4. Court of the University of Birmingham

5. Governor – Birmingham City University

6. Non-Executive Director – Precision Medicine Catapult (PMC)

7. CEO – University Hospitals Birmingham NHS Foundation Trust


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Dr Jammi Rao 01.07.13 1. Sole director of Gorway Global Ltd. a private company and owning 50% of its share capital. A consulting company offering management support, training and bespoke public health analytical support to public sector organisations involved in health, well-being and health care.

2. Board Director of Welcome CIC - a Community Interest Company supporting minority and disadvantaged communities by working with statutory and other agencies.

3. Trustee of the Faculty of Public Health as an elected General Board Member. Term of office from 2010 to July 2013.

4. Visiting Professorship in Public Health in the School of Health, Staffordshire University.

01.07.13

01.07.13

01.07.13

01.07.13

Jul 2013

Mr Adrian Stokes 01.07.08 1. Director of Heartlands Education Centre Ltd.

2. Pfizer Virtual Customer programme.

01.07.08

20.06.11


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Integrated Performance Report (Inc. Financial Recovery Plan)


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Integrated Performance Report

(Inc. Financial Recovery Plan)

Title: Integrated Performance Report (IPR) Reporting Month – September 2015

Attachments: 1

From: Executive Directors To: Trust Board and Council of Governors The Report is being provided for: Decision Y/N Discussion Y/N Assurance Y/N Endorsement Y/N The Committee is being asked to: Consider the IPR summary of progress against delivering Trust Safety, Quality, Performance Standards, Workforce priorities and Finances and outlines plans to remedy late and/or non delivery. Key points/Summary: This document describes the summary of progress against the IPR, summary performance which is described in detail in the attached summary is as follows: QUALITY and SAFETY Infection Control There were no new cases of MRSA bacteremia in September. There have been five cases of post 48 hour toxin positive Clostridium Difficle (C.Diff) against the monthly target of five or less. The 2015/16 target is 64. The total number of cases of reportable C.Diff YTD is 23 against an YTD target of 32. There was one patient identified with CPE in September. Pressure Ulcers The Trust has reported a total of 90 avoidable grade 2-pressure ulcers to date against a maximum threshold of no more than 185 for the year, and 26 avoidable grade 3-pressure ulcers against a threshold of 29. Therefore these trajectories are not on target and both are likely to breach before year-end. Review of current reporting and changes to Performance Framework commences in November 2015 when all divisions will formally present incidence of PU and lessons learnt. In addition to this the 13 hot spot areas at BHH have commenced daily KPI monitoring and a weekly report will be produced and analysed by the Head Nurse for rectification. Falls The Trust falls rate per 1,000 occupied bed days has fallen significantly since March 2015 and remains low. This drop in falls rate co-incides with the Trust's open visiting hours, which commenced in April 2015 and may have had an impact on the number of inpatient falls. The CCG have undertaken a falls themed review at GHH and SOL have plans to undertake the BHH review this month. Patient Experience The delivery of the patient experience improvement plan sees all actions complete this month with exception of a single point of access on the website for patient experience. Scheduled to complete end December 2015: • Inpatient FFT – positive responders 94% (2% below national score).

• ED FFT – positive responders – 80% (8% below national).

Ward to Board assurance requires embedding at pace – this is highlighted in the Board Assurance Framework to Trust Board


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MORTALITY The HSMR continues to show a better position with the 2015/16 first quarter results currently recording a HSMR of 91 which is the lowest it has been for 3 years. The SHMI January to December 2014 is also below 1 “within the expected” band 2 however it should be noted that this period includes some inaccurate data due to the previous PMS 2 input errors. There is one CQC mortality outlier alert which the Trust is reviewing in relation to gastrointestinal haemorrhage.

OPERATIONAL PERFORMANCE The latest months headline operational performance standards showed improvements and solid progress in a number of areas although progress against the 4hr standard reached a plateau. RTT Admitted backlog reduction on trajectory for September. There is an emergent risk to the backlog

trajectory for October which is being quantified.

Incomplete pathway is at 87.64% for September. Specialty recovery plans are under review by the Director of Operations.

Diagnostics saw an improvement at 94.10%, continuing the trend of a consistent improvement in performance over the last 6 months. This is expected to continue.

Cancer 2 week wait performance was 90.15%, which is an improvement on previous month and best

performance year to date. Further improvement projected for September but slightly below recovery trajectory. More than 10% up on last year despite over 15% growth.

62 day performance deteriorated to 76.36% as projected owing to the backlog reduction. September performance projected to be similar as backlog reduction continues. Focussed 62 day pathway improvement projects in Urology, Lung, Upper GI and Head and Neck continue. The remedial action plan is being signed off with CCGs.

Urgent Care 90.9% for September, which is around 3% below the agreed “best case trajectory” for 4 hour

performance.

ED activity is above assumed levels in the trajectory and the 3.5% DTOC target of maximum 49 cases across the Trust is running at 73 (49% above target).

Close management of the HEFT Urgent Care Programme continues to ensure all the high impact changes are fully embedded and sustainable. The new BHH ED and GHH AMU are examples of this with both to open late October / early November.

The “best case” recovery trajectory is unlikely to deliver if the activity increases and discharge delays persist at current rates.

HEFT is therefore working with the CCG to support the necessary actions to ensure we continue to deliver safe patient care.


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WORKFORCE The main focus of the workforce directorate in recent weeks has been on helping drive down the financial deficit. One of our main areas for doing this is ensuring the large scale recruitment campaigns reach fruition with regard to starters. We are expecting circa 160 qualified nurses to join the organisation over the next 6 weeks. Large cohorts of new starters are now joining us and pastoral support to help them settle in their early weeks and months is in place. We are also supporting the Medical Efficiency Programme which is being led by Andrew Catto and Clive Ryder which reports in to the Financial Recovery Programme Board. Time to hire has been affected by the large numbers of newly qualified nurses awaiting pin numbers and also our overseas recruitment.

Overall performance against workforce KPIs this month has been positive with sickness reducing again to an in month position of 4.03%, compared to last September when we were at 4.71%. Nursing sickness is the lowest it has been for 18 months. The moving annual average is now 4.56% against a target 4.46%. All of our Divisions are compliant with their overall mandatory training targets. However, focussed effort is being given to some individual subjects to raise compliance. An area of focus needs to be on our appraisal rates which have reduced again this month. Each Divisional HR Business Partner is pushing this focus within the Divisions.

Our priority is to continue to support the improvement in our financial position by ensuring we are utilising our resources efficiently and effectively.

FINANCE We have received draft Monitor enforcement undertakings under section 106 and 111 following the completion of the investigation into the Trust’s deteriorating financial position. The Trust Financial Sustainabilty risk rating is currently 2. Financial performance in month 6 has shown a marginal improvement with a movement from a £7m overspend in month 5 to £6.4m overspend in month 6. We have seen the Nursing Efficiency programme deliver to improvement trajectory in month but the Medical Staff efficiency programme has got off to a slower start with catch up required. The Month 6 year to date results show a £35.9m loss and a £29.6m variance to plan. Patient safety is an absolute given whilst the Trust remains committed to improving performance and maintaining quality of services, however the current run rate on expenditure is unaffordable. This places significant and unacceptable financial risk upon the organisation. A financial recovery plan has been developed, agreed by the Trust Board and Monitor and implementation of this plan has started. Ernst & Young have commenced within the Trust to support the implementation of the recovery plan. This plan projects a revised deficit of £32.8m at the end of 2015/16 when compared to the planned deficit of £9.9m. Whilst not where we would like it to be it does demonstrate a considerable improvement in results when compared to the Month 6 year to date result of £29.6m. Quality Impact Assessments on any financial recovery actions will be undertaken and signed off by the Medical Director and the Chief Nurse, Performance Impact Assessments will be signed off by the Director of Operations.


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Recommendation(s): That Trust Board notes the current delivery of Trust Performance within the IPR and approves/supports any recommendations to improve performance. Assurance Implications: Strategic Risk Register

Y/N Performance KPIs year to date Y/N

Resource/Assurance Implications (e.g. Financial/HR)

Y/N Information Exempt from Disclosure

Y/N

Which other Committees has this paper been to? (e.g. F & PC, QRC etc) EMB, F&PC, Quality Committee, Workforce Committee


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Integrated Performance Report - September 2015

Integrated Performance Report (IPR)

Month 6 - September 2015

1


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Operational Lead: Diane Povey

IPR - ContentsSeptember 2015

Section Page NumberPerformance Indicator

Effective

Well-led: Workforce & Well-being

Recruitment

Vacancies

Executive Lead: Darren Cattell

Executive Directors Summary

Referral to Treatment (RTT)

Diagnostics

19

22

23

Caring

20

20

21CQUINs

Patient Experience Metrics (Friends & Family Test - FFT)

Patient Complaints

Mandatory Training

Turnover

7

8

9

10

12

Theatre Utilisation & Cancelled Operations

Cancer Performance

Infection Control

Pressure Ulcers

Falls

Summary

Urgent Care Pathway (A&E) 5

19

20

3

Quality & Risk

Mortality 16

SUI 18

13

14

15Nursing Workforce

Appraisals

2


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IPR - Executive Directors SummarySeptember 2015

Operational Lead: Executive DirectorsExecutive Lead: Executive Directors

QUALITY and SAFETY Infection Control There were no new cases of MRSA bacteremia in September. There have been five cases of post 48 hour toxin positive Clostridium Difficle (C.Diff) against the monthly target of five or less. The 2015/16 target is 64. The total number of cases of reportable C.Diff YTD is 23 against an YTD target of 32.There was one patient identified with CPE in September. Pressure Ulcers The Trust has reported a total of 90 avoidable grade 2-pressure ulcers to date against a maximum threshold ofno more than 185 for the year, and 26 avoidable grade 3-pressure ulcers against a threshold of 29. Therefore these trajectories are not on target and both are likely to breach before year -end. Review of current reporting and changes to Performance Framework commences in November 2015 when all divisions will formally present incidence of PU and lessons learnt. In addition to this the 13 hot spot areas at BHH have commenced daily K PI monitoring and a weekly report will be produced and analysed by the Head Nurse for rectification. Falls The Trust falls rate per 1,000 occupied bed days has fallen significantly since March 2015 and remains low. This drop in fall s rate co-incides with the Trust's open visiting hours, which commenced in April 2015 and may have had an impact on the number of inpatient falls. The CCG have undertaken a falls themed review at GHH and SOL have pl ans to undertake the BHH review this month. Patient Experience The delivery of the patient experience improvement plan sees all actions complete this month with exception of a single point of access on the website for patient experience. Scheduled to complete end December 2015: • Inpatient FFT – positive responders 94% (2% below national score). • ED FFT – positive responders – 80% (8% below national). • Ward to Board assurance requires embedding at pace – this is highlighted in the Board Assurance Framework to Trust Board MORTALITY The HSMR continues to show a better position with the 2015/16 first quarter results currently recording a HSMR of 91 which is the lowest it has been for 3 years. The SHMI January to December 2014 is also below 1 “within the expected” band 2 however it should be noted that this period includes some inaccurate data due to the previous PMS 2 input errors. There is one CQC mortality outlier alert which the Trust is reviewing in relation to gastrointestinal haemorrhage. OPERATIONAL PERFORMANCE The latest months headline operational performance standards showed improvements and solid progress in a number of areas alth ough progress against the 4hr standard reached a plateau. RTT • Admitted backlog reduction on trajectory for September. There is an emergent risk to the backlog trajectory for October which is being quantified. • Incomplete pathway is at 87.64% for September. Specialty recovery plans are under review by the Director of Operations. • Diagnostics saw an improvement at 94.10%, continuing the trend of a consistent improvement in performance over the last 6 mon ths. This is expected to continue.

3


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Operational Lead: Executive DirectorsExecutive Lead: Executive Directors

IPR - Executive Directors Summary ContinuedSeptember 2015

OPERATIONAL PERFORMANCE contiuned Cancer • 2 week wait performance was 90.15%, which is an improvement on previous month and best performance year to date. Further impr ovement projected for September but slightly below recovery trajectory. More

than 10% up on last year despite over 15% growth. • 62 day performance deteriorated to 76.36% as projected owing to the backlog reduction. September performance projected to be similar as backlog reduction continues. Focussed 62 day pathway improvement

projects in Urology, Lung, Upper GI and Head and Neck continue. The remedial action plan is being signed off with CCGs. Urgent Care • 90.9% for September, which is around 3% below the agreed “best case trajectory” for 4 hour performance. • ED activity is above assumed levels in the trajectory and the 3.5% DTOC target of maximum 49 cases across the Trust is runnin g at 73 (49% above target). • Close management of the HEFT Urgent Care Programme continues to ensure all the high impact changes are fully embedded and sus tainable. The new BHH ED and GHH AMU are examples of this with both to

open late October / early November. • The “best case” recovery trajectory is unlikely to deliver if the activity increases and discharge delays persist at current rates. • HEFT is therefore working with the CCG to support the necessary actions to ensure we continue to deliver safe patient care. WORFORCE The main focus of the workforce directorate in recent weeks has been on helping drive down the financial deficit. One of our main areas for doing this is ensuring the large scale recruitment campaigns reach fruition with regard to starters. We are expecting circa 160 qualified nurses to join the organisation over the next 6 weeks. Large cohorts of new starters are now joining us and pastoral support to help them settle in their early weeks and months is in place. We are also supporting the Medical Efficiency Programme which is being led by Andrew Catto and Clive Ryder which reports in to the Financial Recovery Programme Board. Time to hire has been affected by the large numbers of newly qualified nurses awaiting pin numbers and also our overseas recruitme nt. Overall performance against workforce KPIs this month has been positive with sickness reducing again to an in month position of 4.03%, compared to last September when we were at 4.71%. Nursing sickness is the lowest it has been for 18 months. . The moving annual average is now 4.56% against a target 4.46%. All of our Divisions are compliant with their overall mandatory training targets. However, focussed effort is being given to some individual subjects to raise compliance. An area of focus needs to be on our appraisal rates which have reduced again this month. Each Divisional HR Business Partner is pushing this focus within the Divisions. Our priority is to continue to support the improvement in our financial position by ensuring we are utilising our resources e fficiently and effectively. FINANCE We have received draft Monitor enforcement undertakings under section 106 and 111 following the completion of the investigati on into the Trust’s deteriorating financial position. The Trust Financial Sustainabilty risk rating is currently 2. Financial performance in month 6 has shown a marginal improveme nt with a movement from a £7m overspend in month 5 to £6.4m overspend in month 6. We have seen the Nursing Efficiency programme deliver to improvement trajectory in month but the Medical Staff efficiency pro gramme has got off to a slower start with catch up required. The Month 6 year to date results show a £35.9m loss and a £29.6m variance to plan. Patient safety is an absolute given whilst the Trust remains commit ted to improving performance and maintaining quality of services, however the current run rate on expenditure is unaffordable. This places significant and unacceptable financial risk upon the organisation. A fin ancial recovery plan has been developed, agreed by the Trust Board and Monitor and implementation of this plan has started. Ernst & Young have commenced within the Trust to support the implementation of the r ecovery plan. This plan projects a revised deficit of £32.8m at the end of 2015/16 when compared to the planned deficit of £9.9m. Whilst not where we would like it to be it does demonstrate a considerable imp rovement in results when compared to the Month 6 year to date result of £29.6m. Quality Impact Assessments on any financial recovery actions will be undertaken and signed off by the Medical Director and th e Chief Nurse, Performance Impact Assessments will be signed off by the Director of Operations.

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Effective: Urgent Care Pathway (A&E)September 2015

Operational Lead: Carl Holland Data Quality Kitemark:Executive Lead: Jonathan Brotherton Information Analyst: Dileepa Nathavitharana

Current Situation As of the start of October Heft were 3.6% off the “Best Case” trajectory, with a downward trend for the past 6 to 8 weeks. The outlook for October remains below trajectory.

The caveats associated with the above “Best Case” 4hour A&E trajectory forecast were:- Attendance Levels to reduce by 0.45% against the previous year Seasonality profile remaining the same as previous years Urgent Care Improvement Programme Delivery Solihull Hospital to maintain a stretch A&E target of 98%

79.2% 79.7

%81.7

%86.1

%84.6

%86.8

%84.2

%79.4

% 80.4%

84.9% 85.8

% 86.7%

79.8%

81.4% 82.1

%87.4

%92.4

%87.1

% 88.0%

86.4%

92.0%

88.9%

86.1%

91.9%

90.7%

95.3%

87.2%

94.9%

93.3%

96.0%

93.5%

87.5%

93.5%

91.7%

90.4% 90.8

%

88.6%

92.2%

90.2%

93.8%

91.2%

89.1%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

04/01/20

15

18/01/20

15

01/02/20

15

15/02/20

15

01/03/20

15

15/03/20

15

29/03/20

15

12/04/20

15

26/04/20

15

10/05/20

15

24/05/20

15

07/06/20

15

21/06/20

15

05/07/20

15

19/07/20

15

02/08/20

15

16/08/20

15

30/08/20

15

13/09/20

15

27/09/20

15

11/10/20

15

25/10/20

15

08/11/20

15

22/11/20

15

06/12/20

15

20/12/20

15

03/01/20

16

17/01/20

16

31/01/20

16

14/02/20

16

28/02/20

16

13/03/20

16

27/03/20

16

4hr Perfor

mance %

Heart of England NHS Foundation Trust4hr A&E Performance Trajectory - updated 18/09/2015

95% Target Actual Best Case Probable Case Worst Case

1,900

2,000

2,100

2,200

2,300

2,400

2,500

2,600

2,700

WK

1

WK

3

WK

5

WK

7

WK

9

WK

11

WK

13

WK

15

WK

17

WK

19

WK

21

WK

23

WK

25

WK

27

WK

29

WK

31

WK

33

WK

35

WK

37

WK

39

WK

41

WK

43

WK

45

WK

47

WK

49

WK

51

Pati

ents

per

Wee

k

BHH Weekly Attendances 2014 v 2015

2014

2015

1,200

1,300

1,400

1,500

1,600

1,700

1,800

1,900

WK

1

WK

3

WK

5

WK

7

WK

9

WK

11

WK

13

WK

15

WK

17

WK

19

WK

21

WK

23

WK

25

WK

27

WK

29

WK

31

WK

33

WK

35

WK

37

WK

39

WK

41

WK

43

WK

45

WK

47

WK

49

WK

51

Pati

ents

per

Wee

k

GHH Weekly Attendances 2014 v 2015

2014

2015

Year to date Attendance comparison 2014 v 2015:- BHH - up by 2.9% year to date – Going from 96,131 to 98,943. GHH – up by 3.7% year to date – Going from 66,500 to 68,967 There has been a significant uplift in attendance over the last 5 weeks at both BHH and GHH

Admission Levels are up The increases in attendance have also had a material impact upon base ward and assessment area admissions.

400

450

500

550

600

650

700

750

800

8500

1/0

4/2

01

21

3/0

5/2

01

22

4/0

6/2

01

20

5/0

8/2

01

21

6/0

9/2

01

22

8/1

0/2

01

20

9/1

2/2

01

22

0/0

1/2

01

30

3/0

3/2

01

31

4/0

4/2

01

32

6/0

5/2

01

30

7/0

7/2

01

31

8/0

8/2

01

32

9/0

9/2

01

31

0/1

1/2

01

32

2/1

2/2

01

30

2/0

2/2

01

41

6/0

3/2

01

42

7/0

4/2

01

40

8/0

6/2

01

42

0/0

7/2

01

43

1/0

8/2

01

41

2/1

0/2

01

42

3/1

1/2

01

40

4/0

1/2

01

51

5/0

2/2

01

52

9/0

3/2

01

51

0/0

5/2

01

52

1/0

6/2

01

50

2/0

8/2

01

51

3/0

9/2

01

5

Nu

mb

er

of

Ad

mis

sio

ns

fro

m E

D

BHH Admissions from ED to Base Wards and Assessment Areas

Value

300

350

400

450

500

550

01

/04

/20

12

13

/05

/20

12

24

/06

/20

12

05

/08

/20

12

16

/09

/20

12

28

/10

/20

12

09

/12

/20

12

20

/01

/20

13

03

/03

/20

13

14

/04

/20

13

26

/05

/20

13

07

/07

/20

13

18

/08

/20

13

29

/09

/20

13

10

/11

/20

13

22

/12

/20

13

02

/02

/20

14

16

/03

/20

14

27

/04

/20

14

08

/06

/20

14

20

/07

/20

14

31

/08

/20

14

12

/10

/20

14

23

/11

/20

14

04

/01

/20

15

15

/02

/20

15

29

/03

/20

15

10

/05

/20

15

21

/06

/20

15

02

/08

/20

15

13

/09

/20

15

Nu

mb

er

of

Ad

mis

sio

ns

fro

m E

D

GHH Admissions from ED to Base Wards and Assessment Areas

Value

Seasonality – Increases in Volume year on year The peaks and troughs associated with the seasonality have been generally in line over past 3 years, but with increased volumes from year to year. However a significant shift has taken place over the past 5 to 6 weeks.

1,900

2,000

2,100

2,200

2,300

2,400

2,500

2,600

2,700

WK

1

WK

3

WK

5

WK

7

WK

9

WK

11

WK

13

WK

15

WK

17

WK

19

WK

21

WK

23

WK

25

WK

27

WK

29

WK

31

WK

33

WK

35

WK

37

WK

39

WK

41

WK

43

WK

45

WK

47

WK

49

WK

51

Pati

ents

per

Wee

k

BHH Weekly Attendances 2014 v 2015

2014

2013

2015

1,200

1,300

1,400

1,500

1,600

1,700

1,800

1,900

WK

1

WK

3

WK

5

WK

7

WK

9

WK

11

WK

13

WK

15

WK

17

WK

19

WK

21

WK

23

WK

25

WK

27

WK

29

WK

31

WK

33

WK

35

WK

37

WK

39

WK

41

WK

43

WK

45

WK

47

WK

49

WK

51

Pati

ents

per

Wee

k

GHH Weekly Attendances 2014 v 2015

2014

2013

2015

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78

10 20.40% 92 4.10% 105 10.20% 12

32 65.30% 1349 100% 14

151616171717181920

Data Quality Kitemark:Information Analyst: Dileepa Nathavitharana

Operational Lead: Carl HollandExecutive Lead: Jonathan Brotherton

Effective: Urgent Care Pathway (A&E) ContinuedSeptember 2015

1st April 2015 to 1st Oct 2015 (programme end date 31st march 2016)Urgent Care Improvement Programme IIP Milestones Status

Qty %

Completed on TimeCompleted LateWork in Progress - Currently OverdueWork in Progress - Currently on Target

Total

Urgent Care Improvement Programme –Milestones and Actions

Urgent Care Improvement Programme –Milestones and Actions The programme has and is continuing to deliver significant improvement progress in the areas of: - Emergency (A&E) and Ambulatory Emergency Care (AEC) Departments

• Expanded Majors and Minors areas at BHH to support increased demand. • New AEC departments to manage the ambulatory patients more efficiently. • New Medical Rotas to better match patient demand profiles. • Extended opening hours to support demand profiles. • New escalation processes to communicate site status pro-actively.

Dedicated Clinical Site Management (CSM) teams introduced to manage flow and capacity. Introduction of the Safer Patient Placement process, to aid flow through the Hospital. Increased focus and emphasis on the morning Jonah Board/Ward Rounds: -

• Length of Stay Reduction • Daily Discharge Targets • Earlier Discharge before 1pm

Delayed Transfer of Care - DTOC However, the increasing attendance figures along with increases in delayed transfers of care are squeezing the acute activity and increasing the pressures on our resources. The following graphs indicate the increases in Health Care and Social Care delays at both BHH and GHH for 2014 to 2015 The overall Trust DTOC target is set at 3.5% / 49 DTOC’s (24 at BHH, 16 at GHH and 9 at SOL) with the current performance reported at 73, which is 49% above target.

0

10

20

30

40

50

60

07/0

2/20

1428

/02/

2014

21/0

3/20

1411

/04/

2014

02/0

5/20

1423

/05/

2014

13/0

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1404

/07/

2014

25/0

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1415

/08/

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1426

/09/

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1407

/11/

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1419

/12/

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1530

/01/

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/03/

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/04/

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/06/

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/10/

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Num

ber

of D

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Date

BHH Delayed Transfer of Care - DTOC

BHH_Social

BHH_Health

BHH_Target

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5

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/12/

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/03/

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/06/

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/07/

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/10/

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GHH Delayed Transfer of Care - DTOC

GHH_Social

GHH_Health

GHH_Target

Solihull Hospital’s Performance against the A&E stretch Target of 98%

95.0%

99.02%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

102.0%

04/01/

2015

25/01/

2015

15/02/

2015

08/03/

2015

29/03/

2015

19/04/

2015

10/05/

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31/05/

2015

21/06/

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12/07/

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02/08/

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13/09/

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04/10/

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25/10/

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15/11/

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06/12/

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27/12/

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17/01/

2016

07/02/

2016

28/02/

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20/03/

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06/11/

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27/11/

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18/12/

2016

% Achi

eved

SOL 4hr A&E Performance Trajectory

95% Target Stretch Target Sol Actual

Summary Micro management of the Urgent Care Improvement Programme of work will be required to ensure that all of the high impact changes required are fully embedded and sustainable. The recovery trajectory is likely to track between the “Probable” and “Worst Case” trajectories, if the Front Door activity and Back Door delays remain at their current levels. To help mitigate this HEFT are working with the CCG to support the necessary resolution actions to ensure we continue to deliver Safe Patient Care, although it has to be recognised that this requires a whole system response beyond the control of HEFT.

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/1690% 82.90% 82.64% 83.60% 85.08% 84.09% 85.00% 83.79%95% 91.02% 93.41% 93.28% 91.38% 91.85% 90.61% 91.89%92% 89.61% 91.23% 90.38% 89.95% 88.55% 87.64% 89.55%

0 8 6 2 26 4 2 2

% ≤ 18 wks 52 wks % ≤ 18 wks 52 wks % ≤ 18 wks 52 wks

0 73.77% 1 76.39% 1

0 89.49% 0

85.00% 0 90.61% 2 87.64% 2

77.73% 0 89.83% 0 88.76% 0

Overall

General Surgery

85.34% 0 74.87%

85.55% 0 93.73%

87.93% 0 91.96%

81.12% 0 87.30%

Trauma & Orthopaedics

ENT

Ophthalmology

Gastroenterology

Urology 1 80.51% 1

Data Quality Kitemark:Information Analyst: Nathan Atkins

Dermatology

0 90.71% 0

83.33% 0 95.53% 0 91.14% 0

0 93.63% 0

80.68%

Effective: Referral to Treatment (RTT)September 2015

Performance Indicator/ MetricAdmitted patients Treated ≤ 18 weeks of ReferralNon- Admitted patients Treated ≤ 18 weeks of Referral18 week incomplete pathways

18 weeks Backlog (Gastroenterology as proportion of total backlog)

High risk Specialties against the Overall RTT Performance (September 2015)Admitted Non-admitted Incomplete

Specialty

No. of 52 week breaches (Incomplete Pathway)

Operational Lead: Executive Lead: Jonathan Brotherton

Headlines September performance for RTT was slightly lower than the previous month for both Incomplete pathways and non-admitted stops, however, admitted stops showed a slightly improved position. The number of patients waiting over 52 weeks at the end of September was two. Performance Analysis The number of patients in the backlog at the end of September was 1,204 against the planned 1,207 backlog trajectory, three less than the plan. The main specialties that are furthest from their individual committed trajectories (as of weekending 18/10/2015) are: • Dermatology - 30 on the IPWL (+15 from trajectory) • ENT - 114 (+78 from trajectory) • General Surgery - 198 (+61 from trajectory) • Urology - 125 (+27 from trajectory) There are no 52 week breaches at the week ending 18/10/2015.

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/1699% 90.63% 90.31% 90.50% 91.30% 93.57% 94.10% 94.10%

No. > 6wk % in 6 wk No. > 6wk % in 6 wkMagnetic Resonance Imaging 18 99.29% 55 97.95%Computed Tomography 15 99.02% 1 99.93%Non- obstetric Ultrasound 23 99.46% 12 99.70%Barium Enema 0 0DEXA Scan 3 99.23% 1 99.73%Audiology 1 83.33% 0 100.00%Cardiology - echocardiography 27 96.77% 2 99.79%Cardiology - electrocardiography 0 0Neurophysiology 0 0Respiratory Physiology - Sleep Studies 1 98.25% 0 100.00%Urodynamics - Pressures & flows 8 86.67% 14 75.44%Colonoscopy 298 54.64% 305 48.39%Flexi sigmoidoscopy 124 61.13% 113 63.55%Cystoscopy 24 88.73% 71 75.93%Gastroscopy 198 66.72% 89 77.47%

740 93.57% 663 94.10%

Diagnostic Tests within 6 weeks - Summary by Test

Test

Imaging

Physiological Measurement

Effective: DiagnosticsSeptember 2015

Performance Indicator/ MetricDiagnostic waiting times < 6 weeks

Endoscopy

Aug-15 Sep-15

Operational Lead: Data Quality Kitemark:Executive Lead: Jonathan Brotherton Information Analyst: Nathan Atkins

Total

Diagnostic Tests within 6 weeksHeadlines Radiology have now been authorised to procure recurrent outsourced mobile MRI scanning capacity (currently 4 days per month). This should rectify the position in the coming weeks and reduce the backlog of 55 patients waiting for imaging for over 6 weeks. Gastroscopy position continues to improve with the throughput of high numbers of OGD (Upper GI scopes) via the Vanguard endoscopy unit. It is expected that there will be no Gastroscopy backlog by end of October. There are currently 300 patients awaiting colonoscopy, pre-pod and ready to be dated. It is planned to put colonoscopies through the Vanguard unit from 1st November. The anticipated throughput is 48 per week. Once this has begun it will free up capacity in the main Endoscopy suites to bring flexible sigmoidoscopy patients in. Consultant sickness and prioritisation of cover for the theatre lists meant the Cystoscopy lists in September could not be covered. The consultant is now back so extra capacity will be diverted to pick these up in order to get back on track. Performance Analysis In September: • Demand was lower than forecast (-158) • Activity was lower than forecast (-721) • Net Activity was 168 cases higher than demand, meaning the total waiting list fell in month The number waiting 6+wks at month end was: • 128 cases higher than anticipated • 66 cases lower than last month’s position Performance in month vs trajectory was: • Endoscopy (-5.77%) • Diagnostics Total (-1.89%) • GHH Endoscopy activity fell by nearly 300 cases in September, compared to the two months previous due to the loss

of Medinet and the initial impact in the loss of weekend lists due to nurse enhance pay withdrawal. • BHH Endoscopy activity overall fell by 150 cases compared to last month, but was higher than it had been prior to last

month. Vanguard saw more cases than it had during any previous month, however, activity in the BHH Endoscopy Unit fell by nearly a third compared to the previous two months

• SH Endoscopy activity was similar to level in the previous two months The key variance against the model in relation to this month’s Endoscopy performance was activity. It which was expected to be 798 cases above the normal baseline activity level for September, however in reality, was only 77 cases above the baseline. Of the 664 6 week breaches in month, the Trust had 69 Imaging breaches (55 MRI), and 17 Physiological measure breaches (14 Urodynamics). The Audiology section of the Diagnostics return is currently being updated. If this position has been historically under-reported, as is currently anticipated, there may be some breaches sitting within this Diagnostic test reporting line that

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/16≥97% 96.99% 96.97% 98.25% 97.50% 96.57% 93.52% 97.28%≥90% 90.88% 89.24% 88.64% 90.75% 88.02% 89.48% 89.50%

0 2 2 1 1 0 0 60 2 1 3 3 1 0 10

September 2015Performance Indicator/ Metric

List Utilisation (%)Sessions Time Utilisation (%)

Operational Lead: Erica Loftus Data Quality Kitemark:

Cancelled operations not offered another date within 28 days

Effective: Theatre Utilisation & Cancelled Operations

No urgent operation cancelled for 2nd time

Vanguard Unit Utilisation

All Hospital-led Cancelled Operations on the day

Executive Lead: Jonathan Brotherton Information Analyst: John Cunningham

Headlines The number of in-hospital operations has reduced year-to-date (533) by 4% when compared with April - September 2014. Theatre list utilisation has been below the Trust target for the past two months. Analysis The list utilisation has reduced from 98.03% between April and September-14 (107 cancelled sessions) to 96.64% between April and September-15 (185 cancelled sessions). 61 sessions were cancelled in September-15, 35 (57%) of these were due to no surgeon and 19 (31%) because of no Theatre staff. The three lowest performing specialties for list utilisation (target 97%) in September were: • General Surgery - 88.78%, 23 sessions were cancelled (with 19 due to no surgeon) • Gynaecology - 86.21%, 12 sessions cancelled (7 due to no surgeon) • ENT - 90.32%, 8 of the 9 cancelled sessions were stopped due to no staff available. The three lowest performing specialties for session time utilisation (target 90%) in September were: • Ophthalmology - 84.08% • Plastic Surgery - 86.61% • Urology - 86.99% There were 66 hospital led cancelled operation on the day in September and 395 YTD. The number of hospital led cancelled operations on the day reduced by 21%, 102 when compared with April - September 2014 (497). In 2015/16, the cases cancelled due to lack of time (session time ran out or list overbooked) account for approximately 35% (137) of cancelled operations on the day. Activity on the Vanguard Unit has been split between Orthopaedics and Urology in September. Orthopaedics (who has the most activity on the unit) had their lowest session time utilisation this month at 57.45% in 2015/16. 14 sessions were cancelled in month (100 - YTD), 13 due to no surgeon (100 - YTD).

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/16≥93% 89.22% 88.67% 89.55% 84.64% 90.15% 89.15%≥93% 84.39% 89.32% 80.92% 88.89% 95.77% 84.60%≥95% 98.40% 98.91% 98.97% 97.70% 97.61% 98.75%≥95% 95.45% 97.81% 100.00% 98.53% 97.83% 97.70%≥95% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Operational Lead: Elly McFayden Data Quality Kitemark:Executive Lead: Jonathan Brotherton Information Analyst: Robert Watkins/ Louise Spencer

Statistical Process Chart of two-week wait referrals

Effective: Cancer Performance (Month in Arrears)September 2015

Performance Indicator/ MetricTwo-week wait referrals seen by a specialistBreast Symptomatic (Two-week wait)31-day Decision to Treatment31-day Decision to Treat (Surgery Modality)31-day Decision to Treat (Anti Cancer Drug)

Two Week Waits: Breach Analysis

Headlines Two Week Waits (2WW) in Aug-15 have improved for both indicators to the highest performance of 2015/16. Breast Symptomatic has achieving >93% for the first time this year. 31 Day decision to treatment - all indicators related to 31-days are being achieved 62 Day Urgent Referral - Aug-15 performance is the lowest recorded in 2015/16 Analysis There were 56 capacity breaches and 125 patient choice breaches in August 2015. Patient choice breaches reduced in August to 125 breaches from 220 in July; consisting of 61 patient cancellations, 19 patients declined 45 patients unavailable for appointments offered within 14 days. The main specialties with capacity breaches were Lower GI (20), Upper GI (18) and Urology (11). Although Urology performance was above trajectory, these three specialties fell below 93% performance, capacity breaches were not the main delay reasons. The only other specialty to fall below 93% was skin, which had 38 breaches (24 patients cancelled, 1 patient declined, 8 patients unavailable, 4 outpatient appointment capacity inadequate, 1 other). Median Wait times for a 2WW appointment in August were ahead of trajectory at 10 days (trajectory 13 days)

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/16≥85% 85.44% 82.75% 79.55% 77.48% 76.36% 82.74%≥85% 100.00% 85.71% 92.86% 100.00% 100.00% 91.49%

Total ≤62 Days

483 359468 356453 333433 318426 353426 372421 352420 305419 338

33,806 27,713

Executive Lead: Jonathan Brotherton Information Analyst: Robert Watkins/ Louise Spencer

Quarter 2 2015/16 (Quarter-to-date) Performance by Cancer Type

HEFT 62 Day Performance vs. Peer Trust - Quarter 1 2015/16

62-day Urgent Referral for first definitive Treatment62-day Urgent Referral for first definitive Treatment from Screening

Operational Lead: Elly McFayden Data Quality Kitemark:

Effective: Cancer Performance (Month in Arrears)September 2015

Performance Indicator/ Metric

Breast 96.36% 98.78% 87.72%

Cancer Type Two week waits 31 days 62 days

Gynaecology 93.04% 95.65% 75.76%Haematology 85.11% 100.00% 90.91%Lower GI 77.01% 100.00% 75.47%Head & Neck 91.34% 100.00% 55.56%Lung 97.12% 99.05% 66.67%Skin 88.08% 100.00% 98.06%Upper GI 80.47% 97.73% 47.37%Urology 86.11% 94.15% 66.67%

Total 87.25% 97.66% 76.86%

All English Providers 82.0%

Heart of England NHS FT 82.7%University Hospital Southhampton NHS FT 87.3%

Sheffield Teaching Hospitals NHS FT 83.6%United Lincolnshire Hospitals NHS Trust 72.5%

Plymouth Hospitals NHS Trust 80.7%

62-Day Performance % 62 DaysEast Kent University Hospitals NHS FT 74.3%

Norfolk & Norwich University Hospitals NHS FT 76.0%University Hospitals of North Midlands NHS Trust 73.5%

Royal Devon & Exeter NHS FT 73.4%

Headlines 62 Day Standard August performance is the lowest achieved in 2015/16 Quarter 1 was not achieved at 82.8% and is expected to fail Quarter 2 Analysis 62 day standard performance deteriorated again in August. There was a high volume of breaches (39 patients) in August with performance at 76.36%. The worst performing site by far was Urology. There are 22 breaches for Urology as they continue to clear the backlog of patients that have passed their target date, partly as a result of delays to first seen since April's endoscopy flood and this is projected to continue into September. Other areas that fell below 85% minimum standard had the following number of breaches: Upper GI 5, Gymea 2.5, Head and Neck 0.5, Lung 2 (Lung performance improved from 54.5% in July to 80% in August). 62 day standard for September is predicted to be similar, with a high level of Urology breaches as a result of ensuring backlog patients are treated and recovering performance.

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/160 0 0 1 0 1 0 2

<64 2 5 2 6 3 5 23<64 1 0 1 1 0 2 590% 89.66% 88.71% 90.38% 90.83% 91.18% 91.04% 90.32%90% 82.64% 85.08% 85.28% 85.77% 82.01% 84.12% 84.16%

Quality And Risk: Infection Control

Performance Indicator/ Metric

September 2015MRSA Bacteraemia Cases

Number of C.Difficile post-48 hr. toxin positive cases - Avoidable

Trust Wide Avoidable/ Unavoidable Toxin Positive Post 48 hr. C.Diff cases

MRSA Emergency Screening

MRSA Emergency Screening (%)

Number of C.Difficile post-48 hr. toxin positive cases

MRSA Elective Screening (%)

Operational Lead: Gill AbbottExecutive Lead: Sam Foster

Data Quality Kitemark:Information Analyst: Dileepa Nathavitharana

Headlines There were no new cases of MRSA bacteraemia in September. There have been five cases of post 48 hour toxin positive Clostridium Difficile (C.Diff) against the monthly target of five or less. The 2015/16 target is 64. The total number of cases of reportable C.Diff YTD is 23 against an YTD target of 32. There was one patient identified with CPE in September and no cases of Ebola. Analysis Two of the five post 48 hour toxin positive C.Diff cases in September were deemed to be avoidable. These were due to: • Inappropriate antibiotic prescribing by locum doctors who were possibly unfamiliar with the Trust antibiotic prescribing guidelines • Known C.Diff patient having a repeat stool sample sent within 28 days of the initial result and whilst still an inpatient Compliance with MRSA screening has persistently failed to achieve a satisfactory score of 90%. Although the majority of patients admitted as an emergency are screened for MRSA, this often occurs later than seven days after admission and these patients are classed as a missed screen. Due to historic Data Quality issues with the ADT datasets, which are still being addressed, this information is still subject to change.

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/16≥95% 94% 92% 92% 93% 92% 93%≥90% 93% 89% 92% 92% 92% 89%

89

101213141516161717171819

Operational Lead: Maria McKenzie/ Julie Tunney Data Quality Kitemark:

Quality And Risk: Pressure UlcersSeptember 2015

Performance Indicator/ MetricOverall tissue viability assessment scoreDaily skin inspection

Executive Lead: Sam Foster Information Analyst: Ruth Thacker

Avoidable hospital acquired grade 2 pressure ulcers

Avoidable hospital acquired grade 3 and necrotic pressure ulcers

Performance Analysis The Trust has reported a total of 90 avoidable grade 2 pressure ulcers to date against a maximum threshold of no more than 185 for the year. There are 50 RCAs still awaiting an outcome for August and September which will potentially alter the finalised figures for the last two months. In addition there have been 26 avoidable grade 3 pressure ulcers to date against a maximum threshold of 29. Therefore these trajectories are not on target and both are likely to breach before year end. The overall Trust score for tissue viability assessment is still below the 95% target, with the daily skin inspection and repositioning frequency elements of the SSKIN bundle falling consistently below the 90% target. In order to address the poor performance, a twelve month re-energising campaign commenced in September with each of the month's work representing a theme for improvement and improving the SSKIN bundle documentation and the review of care plans. New nursing documentation will be launched through the campaign with additions to help to improve compliance. Locally the sites have set trajectories and are examining the KPIs by hospital each month. Peer audits have commenced and unannounced audits of compliance with documentation started in September. The Heartlands site has a rectification action plan for performance for which the Deputy Chief Nurse requests an update at each of the monthly meetings and takes appropriate action. Wards with the highest number of avoidable pressure ulcers to date are as follows: 2 BHH (13), 18 AMU GHH (11), 24 BHH (8), and 9 GHH (7).

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/16<6.36 6.51 5.65 6.59 6.15 6.09 6.16

10 5 9 4 2 10 40≥95% 95% 93% 95% 94% 92% 94%

Number of injurious falls (falls resulting in fracture or head injury)

HEFT Falls rate per 1,000 occupied bed days (OBD)

Overall falls assessment score


Falls rate per 1,000 occupied bed days

Nursing Metrics Falls Assessment: Exception Areas

Quality And Risk: Falls

Operational Lead: Maria McKenzie/ Julie Tunney Data Quality Kitemark:Executive Lead: Sam Foster Information Analyst: Ruth Thacker

Headlines The Trust falls rate per 1,000 occupied bed days has fallen significantly since Mar-15 and remains significantly low. The number of injurious falls for September has increased to 10. The overall trust score for the falls assessment element of the nursing metrics remains below the target of 95%. The drop in falls rate co-incided with the Trust's open visiting hours which commenced in April which appears to have had a positive impact on the number of inpatient falls. The number of injurious falls for September increased to 10, however this still falls within the normal limits for the Trust. The Wards with the highest falls rates for September are as follows: 9 BHH (21.9), 21 GHH (23.0), 17 GHH (15.4), AMU Short Stay SH (14.5), 3 GHH (13.1). Wards with the highest number of repeat fallers during September are as follows: 24 BHH (4), 29 BHH (4), 12 AMU Short Stay GHH (3), 23 ASU BHH (2), 9 GHH (2), 24 GHH (2), AMU Short Stay SH (2). The overall trust score for the falls assessment remains below the target of 95%. Weekly assessments is the only indicator within the falls bundle that is falling below the individual target of 90% for Sep-15. Wards not achieving the overall 95% target for the falls assessment are for September: BHH: 27, 22 AMU 2, 4 , 7, 12, 29, 1, 8, and 2. GHH: 11, 16, 18 AMU, 10, 14, and 23 CCU. SH: 14, 15, 8, and 20B.

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/16<4.25 4.49 4.58 4.85 4.27 4.01<4.25 6.40 7.18 6.06 6.31 6.25≥95% 99% 101% 101% 100% 97% 98%≥95% 108% 111% 109% 108% 108% 106%

Executive Lead: Sam Foster Information Analyst: Ruth Thacker

Temporary nurse staffing % (Qualified)Temporary nurse staffing % (HCA)

Sickness rates - Qualified and Non-Qualified Nursing

Nursing Workforce - Qualified Nurse Staffing (WTEs)

Operational Lead: Andrea Field Data Quality Kitemark:


Nursing staff sickness (Qualified)Nursing staff sickness (HCA)

Quality And Risk: Nursing Workforce

UNIFY Staffing Return (Qualified)UNIFY Staffing Return (HCA)

Headlines The Trust measures its compliance with safe staffing levels through weekly surveillance and submission of the monthly UNIFY return to NHS England. Areas of non compliance where actual qualified nurse staffing levels fell below 90% of their agreed safe staffing levels during Sep-15 were Ward 10 GHH, Ward 18 AMU Assessment GHH, NIV / ICU / HDU on all sites, and Ward 1 BHH. Ward 10 GHH has a rolling recruitment programme in place and staffing is now reported as safe by the Site Head Nurse. Ward 18 AMU Assessment GHH is increasing staffing in readiness for the new unit opening later in the year and staffing is reported as safe for the current number and acuity of patients. NIV / ICU / HDU staffing is flexed across all sites to meet acuity levels. Ward 1 BHH is staffed according to patient numbers which fluctuate with planned reductions in capacity over the weekends and all shifts are reported as being safely staffed by the Head Nurse. The Trust has a robust mechanism to assess and assure safe staffing levels and can provide actions and risk mitigation where actual staffing levels fall below established numbers. There is a schedule of nursing workforce reviews in place across all areas and specialties that is compliant with Section 5.2.4 of the NHS Standard Contract (to undertake a detailed review of staffing requirements every 6 months). The current review carried out during Sep-15 indicates that staffing levels by unit are at a safe level. A further review will be undertaken in six months' time for any areas that have had service changes or acuity / quality triggers during this period.

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2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 Q1 Q2 Q3 Q498 98 108 109 100 90 2012/13 100 104 105 12198 101 110 114 110 100 2013/14 117 110 114 97

102 98 108 107 99 85 2014/15 103 96* 98* 103*93 93 104 101 83 74 2015/16 91 Source: HMSR taken from Dr Foster QI

Heartlands HospitalGood Hope HospitalSolihull Hospital

SiteTrustwide

Operational Lead: Ann Keogh Data Quality Kitemark:Executive Lead: Clive Ryder Information Analyst: Dylan Gibbons

Quality And Risk: MortalitySeptember 2015

HSMR QUARTERLY DATA The HSMR of 91 for Apr-Jun 15 is significantly low. The HSMR may change/increase after the next quarterly rebase but not to above 100. (* shows unreliable data)

HSMR YEARLY FIGURES, 2010/11 TO APR - JUL 2015 HSMR in 10/11 and 11/12 was around 100, in 12/13 and 13/14 HSMR was nearer 110. The 14/15 figure is unreliable. The current Apr - Jul 15 figure is significantly low.

HSMR MONTHLY DATA There was a highly significant correlation between HEFT monthly deaths and deaths at other West Mids acute Trusts between Apr 07 - Jun 15 and statistically, three quarters of the variability in HEFT monthly deaths can be explained from the pattern of West Mids Trusts' deaths.

HSMR MONTHLY DATA The HSMR for the July 2014 - March 2015 period is not reliable, due to PMS2 input errors. The April - July 2015 HSMR is 90,but subject to upward revision to below 100.

DR FOSTER UNIT AND CQC MORTALITY OUTLLIER ALERTS A new alert from both Dr Foster Unit and CQC has been received in relation to GI haemorrhage Dec 14- May 15. There is also an alert from Dr Foster Unit in relation to Mar 2014/Feb 2015 higher than expected mortality rates for upper GI therapeutic endoscopy. Both are being reviewed. CQC IMR June 15: one elevated risk and four risks.

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Data Quality Kitemark:Executive Lead: Clive Ryder Information Analyst: Dylan GibbonsOperational Lead: Ann Keogh

Quality And Risk: MortalitySeptember 2015

WEEKLY ADULT EMERGENCY DEATHS There has been a gradual shift from around 52 deaths in the summer to 58 deaths per week now.

SHMI INDEX The Jan- Dec 14 SHMI is 0.986, the HSCIC ‘within expected’ Band 2. It may be affected by HEFT's data quality issues and likely to be subject to upward revisions if the data was corrected.

CRAB SURGICAL 30 DAY RISK ADJUSTED MORTALITY RATIO Until August 2015, the O/E ratio has shown a low level. However, in September 2015 the ratio rose to the national average of 1. Further work is being undertaken to explore this.

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Operational Lead: Andrea Field Data Quality Kitemark:Executive Lead: Sam Foster Information Analyst:

Quality And Risk: SUISeptember 2015

No SUIs in September to Report

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/16≥85% 73.29% 72.26% 71.10% 70.85% 69.50% 66.40% 70.85%≥85% 88.51% 88.20% 88.32% 88.26% 88.58% 88.26%

BHH GHH SOL CSS W&C FACIL CORP TRUST

53.76% 55.28% 65.14% 61.53% 53.40% 56.61% 77.115 59.92%56.77% 62.36% 65.46% 63.16% 55.50% 77.92% 70.76% 62.71%60.39% 60.93% 66.47% 63.23% 76.40% 63.16% 64.89%

Appraisal Completion - areas by exception

Operational Lead: Andrew McMenemy & Claire Whittle Data Quality Kitemark:Executive Lead: Hazel Gunter Workforce Information Analyst: Jeanette Bullock

Sickness - Areas with the highest moving annual averages

Division DirectorateBHH Admissions & DischargesSOL Admissions & DischargesGHH Acute MedicineW&C Gynaecology

Sep-15 MAA11.15%

Division Directorates Time to Hire

Mandatory Training Compliance - areas by exception

4.66% 4.63% 4.56%Trust Sickness (MAA - Moving annual average)4.25% by Mar-15

4.71% 4.71% 4.71%

Well Led Workforce & Well-being: Appraisals & Mandatory TrainingSeptember 2015

Performance Indicator/ MetricNumber of Appraisals CompletedMandatory Training (MIA - month in arrears)

4.71%

Equality & DiversityFire Safety

Clinical Resus

Module

51.46%

63.13% 73.35% 54.97% 61.86% 75.90% 31.94% 65.95%

Blood Transfusion (Collecting)

Blood Transfusion (Administering)

55.56% 54.55% 25.00% 82.76%

BHH A&E 48.99%46.48%34.33%44.65%

CSS Theatres/ DSU, SSU

8.15%7.15%7.19%

9.46%15.09%3.06%2.38%

SOL Ophthalmology

W&C Paediatrics

Mandatory Training At the end of September 2015 using August data the overall compliance for the Trust is 88.58%. The Trust has maintained an overall compliance >85% for all of its divisions but some specific modules have quite low completion. Actions: The Resuscitation Team will remain responsible for resuscitation training However, there are on-going issues regarding the resources to support this training. A decision has been taken to use a British Heart Foundation DVD for Resus. We are now in line with West Midlands Streamlining Requirements for 10 core mandatory training topics. Equality and Diversity workbooks are now available and the module is also on Moodle so improvement expected. DNA and Cancellation reports have been escalated to divisional level and the HR Director. A report has been compiled for EMB with recommendations to align with Skills for Health and the core skills training framework. Appraisals The appraisal rate for the period 1st October 2014 to 30th September 2015 is 66.4%. Actions: The Faculty with support from colleagues in the Workforce Directorate have initiated additional communication to staff and managers to encourage greater engagement with the appraisal process. In addition, more dates for appraisal training are being provided. Human Resource Business Partner's (HRBPs) receive reports and work with divisions to encourage all managers to have sufficient plans in place to ensure appraisal is a priority. Monthly reports to managers now contain all appraisal data including those in date, upcoming in the next three months and appraisals out of date. Discussion at Delivery Unit Meetings, particularly Heartlands and Women's and Children’s Divisions to ensure focus on completing appraisal is intensified. Sickness Sickness for the month of September was 4.03% which compares with 4.71% last September and the moving annual average has now reduced to 4.56% against target 4.46% Actions: Focused management of sickness absence facilitated by the Operational HR Team take place to ensure consistent and fair application of the process. It is expected that the launch of the new sickness policy in September 2015 will contribute to further reductions of the absence rates.

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/1611 weeks 14.00 14.80 13.80 13.70 14.99 14.32 14.26

64.47 65.55 62.98 73.63 87.88 79.34 7 70.913.45 46.77 22.74 18.98 65.74 97.11 8 33.54

N/a 54.00% 910

13

5.82% 1600.00% 13.44% 11.98% 13.19% 14.43%9.20% 1600.00% 12.03% 13.40% 14.24% 13.93%

12.88% 1700.00% 22.68% 14.58% 14.46% 13.60%10.37% 1700.00% 7.85% 18.39% 17.41% 15.60%15.14% 1700.00% 16.21% 15.46% 13.99% 14.22%15.26% 1800.00% 16.58% 15.34% 15.09% 14.68%17.48% 1900.00% 17.73% 17.49% 16.13% 16.12%

- 20 - 19.66% 15.97% 14.87%

Well Led Workforce & Well-being: Turnover, Recruitment, VacanciesSeptember 2015

Executive Lead: Hazel Gunter Information Analyst: Jeanette Bullock

Performance Indicator/ MetricTime to RecruitVacancies (WTE) - MedicalVacancies (WTE) - NursingStaff Engagement - Friends & Family Recommender

Division Directorate Apr-15 Jan-00 Jun-15

CSSW&C

Pharmacy

Directorates with the highest turnover (2015/16)

Time to Recruit - Directorates with long Time to Hire

Operational Lead: Andrew McMenemy, Alex Covey & Ray Reynolds Data Quality Kitemark:

Gynaecology

Division Directorates Time to Hire

SOL Children's Health 28.43

Jul-15 Aug-15 Sep-15

BHH

SOL

GHH

Gastroenterology

Acute MedicineGeneral Medicine

Child HealthOut of Hospital

Therapies

22.71

19.2

17.43

SOL Dermatology

W&C Obstetrics & Gynaecology

BHH Gastroenterology

Turnover There has been a slight increase to 9.41% this month but still remains fairly stable. Actions: A new exit information analysis tool will be initiated by November and provide detailed analysis on the reasons for staff leaving and associated trends. Operational HR Staff continue to work with Divisions to identify issues, hotspots and problems and look for solutions. Some of the issues are directly related to on-going employee relations matters and the impact this can have on staff. New starters are being more closely supported in order provide a positive experience in their formative months and to reduce the risk of them leaving early. Time to Hire There has been a reduction this month from 14.99 weeks to 14.32 weeks. Action: The Recruitment team continue to work with mangers and meet monthly with HRBPs to identify areas within their control which can be improved. Vacancies Vacancies are based on current staff in post against funded establishments. There has been a decrease in Medical Vacancies this month. There has been an increase in Nursing Vacancies through leavers but there are a large number of new starters due in October as newly qualified Nurses become available. Actions: Medical staff establishments are being reviewed in conjunction with Associate Medical Directors. Nursing staff vacancies will be revised for additional cover allowances to show a clearer picture of vacancies. In the meantime, extensive recruitment plans for Nurses and Medical Staff are continuing. Engagement This figure is based on the friends and family test which is produced quarterly. The latest figure (for quarter 2) shows 54%. Following a significant increase in engagement from Q3 2014/15 through to Q1 2015/16, engagement was maintained in Q2. Action: There has been a significant increase in the ‘Influence’ measure, which reflects the work on this around the large scale engagement events and the involvement of staff across the Trust. Engagement activities are planned to continue.

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Value Status Value Status Value Status Value Status1 £0.00m N/A £0.26m £0.26m £0.53m

2a £0.00m N/A £0.11m £0.11m £0.21m

2b £0.00m N/A £0.11m £0.21m £0.21m

3a £0.06mNot

Achieved£0.19m £0.19m £0.19m

3b £0.03m Achieved £0.03m £0.03m £0.03m

3c £0.08m Pending £0.08m £0.08m £0.08m

4a £0.04m Achieved £0.04m £0.04m £0.30m

4b £0.04m Achieved £0.04m £0.04m £0.30m

4c £0.05m Achieved £0.05m £0.05m £0.05m

5 £0.26m Achieved £0.26m £0.26m £0.26m

6 £0.21m Achieved £0.21m £0.42m £0.21m

7a £0.00m N/A £0.00m N/A £0.00m N/A £2.75m

7c £0.00m N/A £0.00m N/A £0.00m N/A £0.92m

Caring: Commissioning for Quality and Innovations (CQUINs)September 2015

Operational Lead: Dawn Carty Data Quality Kitemark:Executive Lead: Darren Cattell Information Analyst: Ruth Thacker

Acute Kidney Injury

Sepsis: Screening

CQUIN Total ValueQuarter 1 Quarter 2 Quarter 3

Dementia and Delirium: Supporting Carers

Sepsis: Antibiotic Administration

Dementia and Delirium: Staff Training

£0.42m

£0.42m

£0.21m

Reducing the Proportion of Avoidable Emergency Admissions to Hospital (AEC)

Safer Care Bundle: Improve Patient Experience by Reducing Number who are in hospital for over 14 days

COPD: Implementation of the COPD Discharge Bundle

£1.05m

£1.05m

£2.75m

£0.92m

Total value achieved

Dementia and Delirium: Find, Assess, Investigate, Refer and Inform (FAIRI)

COPD: Specialist Respiratory Review

COPD: Education and TrainingMaternity Safety Thermometer

Cancer Survivorship Framework: Health and Well-being Clinics (Gynae Cancer)

Quarter 4

£1.05m

£0.53m

£0.53m

£0.63m

£638,140.80

£0.11m

£0.32m

Headlines Confirmation of CQUIN status for Quarter 1 has been confirmed by the Commissioners. All requirements for Quarter 1 were achieved, with the exception of the Dementia CQUIN part 3a (Find, Assess, Investigate, Refer, and Inform). The Trust must achieve 90% in each element of the Find, Assess, and Refer elements for this national CQUIN for the quarter, however the scores for the Find and Refer elements were 86.1% and 61.2% respectively meaning that the Trust failed this milestone and will not receive the associated value of £63,287 for Quarter 1. The status of CQUIN 3c which relates to the Dementia Carers Survey is pending awaiting confirmation of achievement from the Commissioners. This CQUIN was agreed late and extra time was granted to submit the Quarter 1 milestone, however it is anticipated that this will be achieved.

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/1624.91% 35.54% 28.33% 35.57% 27.50% 51.32% 31.53%92.20% 93.76% 93.38% 92.29% 93.86% 94.37% 93.10%16.53% 15.86% 14.93% 14.85% 16.65% 15.30% 15.48%79.01% 80.52% 78.30% 79.88% 81.62% 79.80% 79.88%

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1012131415161617171718

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Caring: Patient Experience Metrics (Friends & Family Test - FFT)September 2015

Operational Lead: Jamie Emery Data Quality Kitemark:Executive Lead: Sam Foster Information Analyst: Sue Kewell

Performance Indicator/ MetricFFT Inpatient - response rate (%)FFT Inpatient - Percentage of patients providing a Positive ResponseFFT A&E - response rate (%)FFT A&E - Percentage of patients providing a Positive Response

Inpatient FFT Performance, Positive vs Negative responders

A&E FFT Performance, Positive vs Negative responders

Headlines The delivery of the patient experience work stream - all actions complete, with exception of a single point of access on the website for patient experience. Scheduled to complete end December 2015: • Inpatient FFT – positive responders 94% (2% below national score) • ED FFT – positive responders – 80% (8% below national) • ED FFT – trend of gradual and continuous improvement in positive responder score (6 month average April –

September is 80% positive, 5% above the previous 6 month average) • The % response rate for complaints was 26% of complaints responded to within 25 working days. • Complaints handling escalation process devised launch October • Complaints handling remains on the Trust Risk Register (amber 12) • Complaints policy away day, policy redraft commenced • Main themes of complaints remain consistent. Details shared with divisional teams to address and consider

mitigation plans • The PHSO partially upheld two complaints in September. One case was not upheld • 74% of comments posted on Patient Opinion and NHS Choices were positive • Terms of Reference for Patient Community Panels are agreed

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Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 2015/160.09% 0.08% 0.11% 0.10% 0.09% 0.10%

1 5 0 0 7 80 0 0 0 0 2

Caring: Patient ComplaintsSeptember 2015

Executive Lead: Sam Foster Information Analyst: Sue Kewell

Performance Indicator/ MetricComplaints Rate as a proportion of total activity (Distinct Patients)Number of Re-opened Complaints

Operational Lead: Jamie Emery Data Quality Kitemark:

Number of Complaints upheld by Ombudsman

Complaints - Number of Complaints (including Ombudsman involvement)

Headlines

The key achievements against the peer review action plan to date are

• Purchase of up updated complaints management database

• Established reporting cycle to Commissioners and Quality Committee (QC)

• Quarterly complaint dip-sampling by CCG

• Complainants are routinely advised of their right to refer complaint to the Parliamentary Health Service Ombudsman (PHSO)

• Weekly complaints review of performance and monthly with Head of Nursing (HoNs)

• Business case development to support devolved complaint handling

• Data cleansing, complaints performance data management and monitoring

Imminent actions against the plan are:

• Completion and re-launch of an updated complaints handling policy

• Decision regarding service funding to support devolved complaint handling

• Implementation of Datix web complaints handling module

• Complaints data available locally via the performance dashboard

• Delayed complaints escalation process implementation

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EXECUTIVE SUMMARY We have received draft Monitor enforcement undertakings under section 106 and 111 following the completion of the investigation into the Trust’s deteriorating financial position. The Trust Financial Sustainabilty risk rating is currently 2. Financial performance in month 6 has shown a marginal improvement with a movement from a £7m overspend in Month 5 to £6.4m overspend in Month 6. We have seen the Nursing efficiency programme deliver to improvement trajectory in month but the Medical Staff efficiency programme has got off to a slower start with catch up required. The Month 6 year to date results show a £35.9m loss and a £29.6m variance to plan. Patient safety is an absolute given whilst the Trust remains committed to improving performance and maintaining quality of services, however the current run rate on expenditure is unaffordable. This places significant and unacceptable financial risk upon the organisation. A financial recovery plan has been developed, agreed by the Trust Board and Monitor and implementation of this plan has started. Ernst & Young (EY) have started within the Trust to support the implementation of the recovery plan. This plan projects a revised deficit of £32.8m at the end of 2015/16 when compared to the planned deficit of £9.9m. This is clearly not where we would like it to be, it does demonstrate a challenging improvement in results when compared to the Month 6 year to date result of £29.6m deficit against plan. Quality Impact Assessments on any financial recovery actions will be undertaken and signed off by the Medical Director and the Chief Nurse, Performance Impact Assessments will be signed off by the Director of Operations. SEPTEMBER POSITION The Trust had a larger I&E loss in September than planned. Our planned deficit in 2015/16 partly reflects the investment required during the year to improve our performance and significantly reduce our performance fines going into 2016/17, but it also reflects our current lack of rigourous financial control over how we comitt our funds. Financial recovery alongside improved Performance are now key priorities and whilst we remain on trajectory for 18 weeks backlog we are currently off trajectory against A&E, as demonstrated below and as explained within the Integrated Performance Report.

FINANCE EXECUTIVE SUMMARY & KEY PERFORMANCE INDICATORS

Month 6 to 30th September 2015

Darren Cattell, Interim Director of Finance & Performance


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In summary, for a year to date position, the Trust continues to see a higher than expected level of expenditure whilst seeing a level of activity broadly similar or in case of some of our services, slightly higher than last year.


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The Trust’s income and expenditure position in September was a £6.4m loss versus a planned loss of £0.4m. The Trust’s year to date income and expenditure position is a £35.9m loss versus a planned loss of £9.0m this is worse than planned due in part to the cost of improved performance being higher than expected alongside an overspending pay bill and also costs being incurred outside approval and control processes. Planned inpatient activity for September was above last year and emergency inpatient activity was slightly lower than last year. However activity was below the Month 6 plan for the month for both elective and emergency inpatients. Outpatients and critical care were also below both last September’s activity level and plan whilst A&E continues to be busier than last year and is also above the planned level. Non pay costs remain constant including significant expenditure for additional capacity to ensure continued performance along our improvement trajectory for 18 week RTT. The outstanding CQUINs for the Acute contract have now been agreed and the Specialsied Services Conditions Precendent are nearing completion also. A figure of 82% achievement has been agreed with CCGs for the Quarter 1 CQUIN figures. (£639k from a total of £780k). Quarter 2 is being worked on now. The table below shows the key issues influencing the in month financial position, in terms of actuals against plan: 1 FINANCE

Category Plan Sept Variance Headlines £m £m £m

Income 53.7 53.0 (0.7)

£0.4m upside for maternity pathways

and £0.3m for Palliative Care in month. An underlying under performance in

month against plan. This is expected to recover.

Expenditure (54.1) (59.4) (5.3)

Unsuccessful Business Cases through

BCRG Underlying pay control

PMO and other interims above plan Independent sector

£2.8m Penalities YTD

Overall Position (0.4) (6.4) (6.0) Pay costs reduced slightly overall, notably Nursing costs, but remain at an unaffordable level and of most concern.


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When we add a proxy WTE adjustment for temporary staff on top of our vacancy position, we report WTE or volume variances against budget in certain staff groups as well as price variances against budget across all staff groups. The high level analysis of our September pay variance is shown below:

£m Budget Actual Variance

Additional Measures to

Improve Performance

BCRG 0.9 0.9 -

WLI

Winter - 0.2 (0.2)

PMO * 0.1 0.2 (0.1)

Further Initiatives

Additional Bank Rates 0.2 0.2 -

Local Flex - 0.2 (0.2) Underlying Pay / Control 33.2 35.0 (1.8)

Total 34.4 36.7 (2.4)

*n.b. reported in non pay expenditure. Further analysis regarding the pay position is available and is provided to the Finance and Performance Committee but is summarised below for major staff groups; 1.1 Medical Staffing – Total medical expenditure has increased by 10% over this time last

year. We report a WTE volume variance in certain specialties within certain Divisions when we add in the proxy for Locum costs on top of our current vacancy position. This is in addition to our price variance for the cost of Locum staff. Within the Finanical recovery plan, the Medical Director has instigated a Medical Staff Efficiency Programme which reduces the volume and price variance of Locum staff along side a number of other initiatives. This information has been passed to Divisions to work on.

1.2 Nursing & Midwifery – Nursing expenditure has increased by 11% over this time last year, we report a WTE volume variance in unqualified staff within certain Divisions when we add in the proxy for temporary costs on top of our current vacancy position. This is in addition to our price variance for the cost of temporary staff. Within the Finanical recovery plan, the Chief Nurse has instigated a Nursing Efficiency Programme which reduces the volume and price variance of Temporary staff along side a number of other initiatives. This information has been passed to Divisions to work on.

1.3 Non–Pay – A critical increase year on year has been our planned use of the Independent Sector and in sourced capacity, this is overspent by £3.0m year to date. This use is being reviewed in line with the Trust being ahead of our 18 week performance improvement trajectory.

1.4 SIEP – Actual delivery in month was £1.2m against the plan of £2.1m. Ongoing delivery

and closure of the residual planning gap with early implementation is required to mitigate remaining risk in 2015/16. EY are reviewing the elevated risk in relation to the SIEP programme.


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1.5 Cash Deposits – The cash balance at the end of September 2015 was £34.1m, £37.5m lower than plan. £21m was held on short term deposits with the National Loans Fund at the end of the month attracting rates of around 40bp. Funds remaining in the main GBS current accounts earn 25bp interest All deposits will be returned to the main GBS current accounts by the end of October. A plan to “protect our cash balances” has been developed and many items have been put in place by mid October.

1.6 Monitor Targets – The Trust’s Financial Sustainability rating remains at level 2 in

September. Three of the four criteria are scored as 1 due to the large I&E deficit position and dropping cash levels.

1.7 Capital – The original planned capital expenditure in the year was £50.4m, including carry forwards. Spend year to date was £12.5m against a YTD plan of £12.0m. A capital reforecasting exercise is currently being undertaken with an indicative value of a maximum of £25m to reduce our cash exposure.

1.8 Risk Register – The current risk register shows £47m of risk all of which is within the

forecast position.

2 CONTRACTING The conditions precedent relating to the sign off of the CCG contract have been met in relation to CQUINs and we expect to achieve the outstanding NHSE conditions precedent by the 31st October deadline. The first Finance Subgroup (FSG) meeting took place on 9th October to discuss and progress the M1 to 4 payment challenges. There are currently no issues to escalate to the Executive CRM however all issued that have been raised are still live. The Income team is currently reviewing the legitimacy of these challenges and will use the FSG and contract process to mitigate and resolve these issues. 3 FORECAST AND FINANCIAL RECOVERY

The Trust has reforecast its financial position for 2015/16 which demonstrates a £63m deficit before Financial recovery, the current forecast presented and agreed at the Trust Board including financial recovery is a c£32.8m deficit after in year financial recovery actions are completed. Whilst not where we would like it to be it does demonstrate a considerable challenge in results when compared to the Month 6 year to date result of a £29.6m deficit against plan. The Financial Recovery plan has been agreed by the Trust Board. This plan is currently being validated by EY and then by the new leadership team in conjunction with Monitor. This will include a phasing plan and clear accountability arrangements. This will be presented to the Finance and Performance Committee and will be presented to the Finance and Strategic Planning Sub-Committee of the Council of Governors for assurance.


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Finance and Performance Committee Assurance Actions The Trust Finance and Performance Committee (F&PC) met in September and October where the following six areas of focus previously identified were discussed. All are issues that Trust staff continue to work on as part of Trust Financial Recovery. An update is provided below, quantification of the impact is being worked on with EY support; Controls and Financial Governance within the Trust

The actions can be summarised into four categories; 1. Financial Control or Governance actions, examples include;

a. Creditors – stretching creditor payments, reduced payment runs, letter to suppliers, renegotiate others

b. Debtors - Increased chasing of debtor payment, £small compromise, escalation of aged debt

c. CAPEX – Immediate review of CAPEX d. Purchasing - lock out of catalogue items e. No Purchase Order, no payment.

2. Divisional “just do it” actions, examples include;

a. Increasing payment authorisation controls b. Stopping of non essential expenditure c. Review and elimination of interims (non-clinical).

3. Divisional actions where approval is required, examples include;

a. Bank and agency (medical) – review and improve current policy. WLIs – commitment to significantly reduce WLIs, need to understand the impact on performance

b. Outpatients – overbook to DNA rate

4. Executive led actions with Trust wide impact, examples include; a. Corporate staff – minimum of 1 clinical shift per week.. b. Clinical audit days – no clinical activity to be cancelled on clinical audit days

from 1 November c. Rapid introduction of payment for Trust mobiles / reduction in device numbers

(iPad, mobile, desktop, laptops)

Messages to all Stakeholders including staff and how they can help

A Trust wide multi level and multi channel communications plan has been developed that is being reviewed by the new leadership team.

Greater financial information availability and transparency

Simplified monitoring to demonstrate success or where improvement is required is in development. Leading indicators on a more real time basis are being developed with Divisions. Appendix A outlines an example of such monitoring information. A roll out plan for Service Line Reporting has been prepared.


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Job Planning (demand and capacity)

F&PC received an update on this project with an in depth review at the November meeting

Staff Terms and Conditions – how do we maximise staff effectiveness and efficiency

A workforce update will be available to the meeting

Transition to PbR – getting paid for all activity performed

This project is already part of the Financial Recovery Plan and will be reviewed in depth at the November F&PC meeting

Further review work has also started on;

1. Identifying the financial risk relating to existing SIEP plans 2. Identifying unfunded cost pressures with little or no link to service quality or

performance improvement and stopping them 3. Identifying unfunded cost pressures with an evidenced link to service quality or

performance improvement and reviewing the impact of stopping them

Monitoring To demonstrate success or where improvement is required is in development. Leading indicators are also being developed. Appendix A outlines an example of such monitoring information. Progress In high level terms the Trust is slightly behind the Financial Recovery trajectory for the Month 6 results due to the slow start on the Medical Staff Efficiency Programme and a lower than expected income month in September. Both indicators are expected to catch up from Month 7 onwards. Governance A Governance structure has been agreed within the Trust with the Finanical Recovery plan being overseen by the Executive and Divisional AMDs, this is led by the Financial Recovery Programme Board which meets weekly. This group reports into the EMB and onward to the Finance and Performance Committee for assurance. A further update will be available when EY have reviewed the Financial Recovery Plan and the new leadership team has had sufficient time to review and agree the plan.


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4 CONCLUSION

Whilst the Trust remains committed to improving performance and maintaining quality of services, the current run rate on expenditure is unaffordable. This places significant and unacceptable financial risk upon the organisation. Financial recovery, alongside improving performance, is key to the Trust moving successfully into 2016/17. The Plan contains a number of actions. These can be summarised into increasing the internal capacity of the Trust to improve quality and reduce cost. A fully worked up plan is being validated by EY and the new leadership team for future presentation. Quality Impact Assessments on any financial recovery plans will be undertaken and signed off by the Medical Director and the Chief Nurse. 5 RECOMMENDATIONS The below actions are recommended:

1. Actions are outlined in the report. 2. Critically controls and compliance with controls is the important first step. Following

this extensive efficiency programmes will be further developed which will be clinically led.

3. Divisional recovery plans have been developed. Further work on these is being completed with support from EY.. A progress report is included within the papers and the Chair of the F&PC is asked to provide an assurance statement.

4. As these plans further develop and are challenged by EY and the new leadership team they will be summarised and presented to the next F&PC for further assurance.

Darren Cattell Interim Director of Finance & Performance October 2015


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Integrated Improvement Plan


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Title: Integrated Improvement Plan (IIP) Reporting Month - September

Attachments: 1

From: Dr Andrew Catto To: Trust Board and Board of Governors The Report is being provided for: Decision Y/N Discussion Y/N Assurance Y/N Endorsement Y/N The Committee is being asked to: Consider the IIP summary of progress against delivering the plan which highlights delivery of all Programmes forming the IIP and outlines plans to remedy late and/or non delivery Key points/Summary: This document describes the summary of progress against the IIP, summary performance which is described in detail in the attached summary is as follows:

Recommendation(s): That Trust Board notes the current delivery of this plan and approves/supports any recommendations to improve programme performance. Assurance Implications: Strategic Risk Register

Y/N Performance KPIs year to date Y/N

Resource/Assurance Implications (e.g. Financial/HR)

Y/N Information Exempt from Disclosure

Y/N

Which other Committees has this paper been to? (e.g. F & PC, QRC etc) IIP, EMB

1. SUMMARY The attached document summarises in a narrative format the IIP;

It describes the summary progress against the plan Summary of each programme performance Performance improvements Summary of red rated milestones.

2. BACKGROUND

The Trust has commenced delivery of the IIP, all programmes are now live, this report summarises delivery and actions to mitigate any recognised issues

3. ACTION

The Trust Board and the Board of Governors are asked to review and endorse the attached documents and issue the necessary instruction to implement any recommended actions.

4. RECOMMENDATION(S)

Note the attached and approve delivery of actions and note that Scheduled Care and Urgent Care programmes are transferred to Business as Usual.

5. NEXT STEPS - See the action plans in the attached document


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Executive Summary for Integrated Improvement Plan (IIP)

Reporting Month: September 2015 Portfolio update – progress against plan

The Integrated Improvement Plan (IIP) Programme Board met on 15th October 2015.

Members of the IIP Programme Board noted that four of the six programmes are Green rated; two are Red Rated (Urgent Care and Culture & Engagement). The Programme Board is reminded that both Scheduled and Urgent Care are operating as Business as Usual. Please note that on Tuesday 20th October the Trust Board approved the decision to pause the Surgical Reconfiguration Programme until further notice, the Board also agreed at this point to remove the programme from the IIP.

Assurance for the view above is provided from:

Programme reporting via Programme Status Reports (PRSR’s) submitted to the PMO by all Programme

Directors at midday on 14th October, see appendix 1. Programme and Project data held on the IIP Cross Programme SharePoint site. Programme Directors statements as recorded in the Programme Status Reports.

Milestone Reported by Exception

Count of Red Milestones* RED Programme Related to Programme/Project Culture and Engagement Leadership 1 Mortality Governance 1 Scheduled Care Cancer Pathways 1 Urgent Care A&E 1

Appendix 2 – Reports risk of delivery against milestones, this in line with Monitor guidance*. Appendix 3 – Reports milestones by exception, note this contains only those milestones rated Red in line with the BRAG reporting structure. These are not to be confused with specific actions to deliver project outcomes which are captured and managed separately by each project and may be referenced in each a programme’s status report. *Red milestones are derived from those with progress rated as Red and either a static or degrading trend.

During September, 4 milestones were reported as Red, The programmes report a proportion of those red rated milestones are in part related to the Trust financial position and the impact this will have around capacity and resources to deliver milestones in the near future. The summaries below and appendix three


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contains further detail of mitigation and the programme’s response to these red rated milestones. The IIP Programme Director is in receipt of draft transition to service plans which are under review with feedback to be provided to each of the programmes where submitted. As stated in the last Executive Summary the IIP Programme Director has completed a draft business case for a substantive Programme Management/Assurance Office which at this time is pending further review and consideration by the Financial Recovery Programme Board. A decision around which option to pursue is expected imminently. The section below outlines current Programme Status Report rating and a rating of future performance (based on, but not seen in the PSR).

The Board is asked to note the ratings are defined as follows:

Green – Milestone on track with a high level of assurance around delivery. Red – Milestone reported off track and programme unable to mitigate at programme level without

assistance and support from the PMO and escalation to the IIP Programme Board or above (summary seen at Appendix 2).

The Board is asked to note the ratings are as reported on the 14th October 2015. Following this date the reports are locked down. It is acknowledged post this date further work will continue. Summary Position

Programme Against Our Plan Future Position Mortality Green Green Governance Recovery Green Green Urgent Care Red

Red

IM&T Green Green Culture and Engagement Red

Red

Scheduled Care Green Green


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“Business as Usual” Performance

Scheduled Care Planned Care/RTT Implement series of initiatives to comply with nationally mandated

scheduled care targets.

Cancer Implement series of initiatives to comply with nationally mandated cancer targets.

Scheduled Care

Progress has continued to have been made in September and the programme has been assessed as “green”. Of a total of 45 Milestones, only 18 remain outstanding and all but 3 are on schedule and are “green”. The 3 milestones that are behind schedule are “When systems are in place to ensure all patients on an 18 week pathway are managed transparently and data quality provides assurance.”, "When job descriptions for medical secretaries are standardised, reflect proactive patient management and are aligned to the Patient Access Policy." and "When new best practice pathways in Urology and Lung have been implemented and progress reviewed." The data quality milestone is regarding delays with mapping of electronic and manual systems and confirmation of IT project timescales. A plan has been put in place to standardise job descriptions for medical secretaries so this milestone is complete but will remain on the system for monitoring purposes until October. The backlog trajectory for the admitted pathway pre-validation at the end of September is likely to be 1,212 versus a trajectory of 1,207.


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Urgent Care BHH Urgent Care Implement series of initiatives to improve compliance with the national

emergency care 4 hr standard.

SOL Urgent care Implement series of initiatives to maintain compliance with the national emergency care 4 hr standard.

GHH Urgent Care Implement series of initiatives to improve compliance with the national emergency care 4 hr standard.

Length of Spell Length of Spell (LOS) Reduction for Patients on site for 14 days or more Median Time to Treatment in A&E

Performance to 60 minute target

Admitted patients Time in ED (95th Percentile) Non- Admitted patients

Time in ED (95th Percentile)

Urgent Care It has been a challenging month for both Heartlands (BHH) and Good Hope (GHH) Hospitals with the Programme Status Report being rated red for September, based upon the under performance against the:- 4hr A&E trajectory and 14 day+ Length of Spell Metrics. Both BHH and GHH remain focused upon high impact interventions to help improve this situation - specifically around the escalation activities that support the: A&E departments in times of increased pressure; and the base wards where the focus is upon the reduction in patient length of stay, which will help aid hospital flow. It should be noted that the New Majors and Minors building development and supporting departmental moves are still having a slight detrimental impact on capacity but the works will be completed in October. The key interventions being:- 1. Both BHH and GHH have increased their AEC capacity with increased cover from the new medical rota, at BHH and extended opening hours at GHH. 2. BHH has re-launched the Safer Patient Placement (SPP) process along with increased engagement with ward MDT's around the Bronze ward rounds process to support improved flow and increased discharge. 3. GHH are also focusing upon the medical ADAT meeting process to challenge patients who have a length of stay greater r-than 14 days, as well as revised Bronze ward rounds. GHH are aloes targeting the improvement in the escalation process within the A&E dept. 4. BHH have new leadership in the Discharge Hub which will now focus upon the reduction in the constraints that hold patients in site for longer than necessary, therefore reducing the overall Length of Spell on site. All triumvirates are focused upon the recovery of the situation and confirm and challenge meetings are being held to closely monitor progress and generate recovery actions.


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IIP Programme Performance Programme Summary of Performance IIP

Assurance Mortality

Mortality Governance Process

Refine and implement revised process and supporting mechanisms to capture and review mortality data with supporting governance process

Mortality Education Develop and roll out education programme to improve Executive and Clinical understanding with regards to mortality information

Future Information Requirements

Research best practice and define Trust vision for mortality analytics

Coding Improve clinical engagement and understanding of clinical coding Mortality

Red rated milestones, with external dependencies to delivery. Pilot progressing well with good clinical buy-in. Mapping of end to end Mortality review process taking place to reflect framework in place at present. All other milestone are delivered or in progress. Given the overall status of plans for this Programme the current assurance rating is Green.


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Governance Recovery Programme Patient Experience A refreshed patient experience dashboard and systems to ensure

learning and remediation are in place

Governor Engagement

To assess, refresh and implement governor engagement arrangements Complete

Management of Risk and BAF

Implement revised Board Assurance Framework to strengthen the understanding of key strategic risks. Develop committee reporting structure to Trust Board.

Kennedy Review Assess residual work and transfer to PMO; determine executive lead and map in to action plan

Complete

Strategy Development and Planning

Develop Trust strategy , Annual planning process and Stakeholder Engagement process

CQC Delivery of CQC action plans Improving Performance Management and Data Quality

Implement a Performance Management Framework, associated reporting data quality and governance strategies and processes

Governance Recovery Programme

The Programme has largely delivered milestones due by the end September target date but there are some notable exceptions; On the positive side, the GRP Board has formally closed the completed Kennedy and Governor Engagement projects with arrangements in place for effective transfers to business as usual; After a challenging start the CQC project is now on track and additional work (supplementary to scope of this project) has now been resourced to progress readiness preparation for the next CQC visit including a mock visit being planned for November; The Patient Experience project is complete except for the web site patient feedback functionality milestone which is on track to be delivered by the end of December; the Trust Board has now signed off the Trust Strategy agreeing that supporting strategies will continue to be developed for consideration in the New Year and the Strategy project's next major milestone for delivery of a refreshed planning cycle is not due until the end of March; The Performance project is virtually complete with residual work on track to embed changes by the end of March next year. On the negative side, despite the good work and achievements of the Risk and BAF project which is largely complete, disappointingly the Board has not yet been able to sign off the BAF Committee terms of reference, breaching a significant milestone and these are now due to be re-presented to the Board in November. This project has also missed milestones for addressing the IR1 backlog and implementation of the new reporting framework caused by the diversion of resource to deliver the competing Trust priority of Duty of Candour; following escalation resource has now been re-instated and work to recover the IR1 position is expected to get this back on track; A request will be processed to alter the IR1 milestones to mid-November to reflect this change; these milestones are expected to improve following assurances


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from director and heads of service. The GRP Board has considered shortlisted benefits for benefits realisation and it is anticipated that the SRO will sign these off ahead of the next GRP Board at the end of October; The Transition to Service template has been completed with clear arrangements for seamless transition documented.


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IM & T PMS2 Recovery Review of PMS2 to ensure fit for purpose and reliable and subsequent

remediation of issues identified.

Competence Review of competence and capability of the ICT Function to support the Trusts needs and subsequent remediation of issues identified.

Strategy and Market Review

Develop a Trust IM&T strategy to support the Trust Corporate strategy.

Information Management and Technology

Planning aligned to requirements to support IM&T from the status of IIP to Business As Usual (BAU) has resulted in the requirement for the development of Transition Planning. This planning is made up of three individual plans which identify tolerances within the specific scopes. It is intended that delivery against the projects will create a robust management around demand vs capacity within ICT Services. The Transition to Service (TTS) plans below have been submitted for approval: TTS Project 1 : IIP Workstream ICT Enablers Programme of Works TTS Project 2 : ICT Demand Management TTS Project 3 : ICT Programme of Works Governance Development Project For the next Reporting period (November 2015) the three TTS Plans (with identified milestones) above will replace the four modules identified within in the Programme Summary.


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Culture and Engagement Engagement This stream is focused on step changing Staff Engagement across all

areas of the workforce

Values/Culture To strengthen the Trust’s values-led culture Leadership Seeking to systematically improve leadership capability across the Trust Culture and Engagement (CE)

The progression of the leadership development stream still requires some senior level leadership expertise at this stage, to complete the mappings, to put structure and governance around the current silo-ed approach to leadership development, to gain stakeholder buy-in, to meet with providers, design leadership material, check quality of existing provision, and systemise the approach to leadership development within the Trust from its current local and sporadic approach. Original planning included funding for a band 8 post to continue and embed this new stream of work once the initial work was completed by the interim Leadership Specialist post. The lack of decision on the OD cost schedule means funding for the post remains uncommitted, the interim has left, and there is a lack of resource to carry the work forward with pace. It is proposed that, pending the outcomes of initial conversations with new senior leadership, a three-month deferment of the milestones relating to mid-term Leadership Development activities is applied through change control. This will also allow for existing financial and resource constraints to be resolved. An immediate conversation around the forward-looking approach to leadership development will be a helpful next step in terms of action planning around outstanding milestones. There are however a number of other resource and financial constraints which will shortly have an impact on connected aspects of the Culture & Engagement plan, most notably the Staff Engagement work-stream which also require attention. In large part a number of the issues arising stem from the long-standing lack of decision on the OD cost schedule, which has meant that the Culture & Engagement work-stream, planned on the basis of four band 8 resources, has been running with only one in place, and financial commitment for two of the roles has not progressed. By the end of December this will be reduced to the Head of OD, a band 6 OD Advisor and a band 4 Administrator, as the current Staff Engagement Lead will be on maternity leave.


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Surgical Reconfiguration Surgical Reconfiguration

Delivery of the Surgical Reconfiguration Programme including, public consultation, Estates, HR, Elective Orthopaedics and Theatres

Surgical Reconfiguration

On Tuesday 20th October 2015 the Trust Board approved the decision to pause the Surgical Reconfiguration Programme until further notice, at this point the Trust Board also approved removing the reporting of Surgical Reconfiguration from the Integrated Improvement Plan.

Paused until further notice


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IIP Portfolio Update, Risks and Issues

Governance – There are no significant issues around PMO reporting and governance, all live projects continue to report via the IIP SharePoint site. To note Scheduled Care and Urgent Care are operating under Business as Usual following operational reporting processes. A summary report relating to Transition to Service is submitted to the IIP Programme Board to provide an update.

Benefits Realisation – Since last update the Surgical Reconfiguration Programme has held a series of benefits realisation workshops which were resourced and supported by the PMO. Given the decision to pause the programme and remove from the IIP it is expected that benefits will be included in any subsequent work by the team directly and referenced in programme documentation such lessons learned etc.

A formal update of the benefits realisation by programme will be provided at November ’s IIP programme board.

Development of SharePoint – The roll out of a new SharePoint system is complete with all programmes using the new system. A draft business case submitted to the Financial Recovery Board includes a small IT investment requirement to enable cross programme reporting from the SharePoint sites. PMO Business Case – A Business Case was presented to the Finance Recovery Board on 30th September which sets out the requirements and justification for the establishment of a permanent Programme Management Function for the Trust and the roles and responsibilities for the staff that would be employed by the PAO/PMO. Following “Transition to Service” of the IIP, the case puts forwards two options to move the PMO to:

Programme Assurance Office (PAO) ; or Programme management office that has the capability to lead and deliver major

transformation initiatives The Interim Director of Finance and Performance advised the October IIP Programme Board that the Finance Recovery Board has opted for a light touch assurance PMO (with project resource provided by directorates on a case by case basis). Further details will be available as the Financial Recovery Board ratifies the organisation’s requirements for programme and project management.


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Portfolio Risk and Issues – The Programme continues to notes risks relating to transition to service and the impact of demobilising interim support in some IIP Programmes. The PMO is in part mitigating this through the provision of the Transition to Service templates. These templates aim to do this by:

confirming handover plans from the project to the business confirm day to day arrangements of services responsible for the continued delivery of the

projects benefits post project closure to capture resources (pay/non pay) required to do this.

IIP Board Members have noted the current financial position of the Trust and the possible impact this may have on delivering improvements as originally intended. The board noted this concern and that some activities may lose focus, the Deputy CEO has requested that where any issues are noted that these are escalated to IIP Programme Board members for immediate review and mitigation.


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Appendix 2

IIP Scoring Ratings

Summary

Please read for a summary of how scorings below are derived


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Appendix 3


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Annual Infection Control Report


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From: Director of Infection Prevention and Control Title: Infection Prevention and Control Annual Report 2014 - 15 This report provides a comprehensive summary of the Infection Control work Programme across the Trust during the last financial Year The report is provided to the Board for: Decision: (Approx 10 mins) Discussion: (Approx 15 mins) Assurance: (Approx 5 mins) Endorsement: (Approx 5 mins) Summary/Key Points:

The report details activity against the 9 criteria outlined in the Health and Social Care Act (2008) to demonstrate how the Trust has maintained compliance throughout 2014-15.

Resource Implications (e.g. Financial, HR):

The Initial estimate of 5000 screens per year for carbapenemase-resistant Enterobacteraiacae (CPE) has been overestimated. The screening programme, in-line with Public Health England guidelines is on-going.

Assurance Implications:

The Health and Social Care Act 2008: Code of Practice for the Prevention and Control of Healthcare associated infections.

NHSLA Compliance CQC Registration Standards.

Information Exempt from Disclosure:

Nil


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Infection Prevention and Control

Annual Report

2014-15

June 2015 Compiled by the Infection Prevention and Control Team


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CONTENTS Summary Page 1 Introduction

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2 Compliance Criterion 1: Effective management systems for the prevention and control of HCAI informed by risk assessments and analysis of infection incidents. Committee structures and assurance processes Compliance assessment and assurance Surveillance of Healthcare Associated Infection (HCAI) Audit programme to ensure key policies are implemented Research activity and contribution to national agenda to enhance practice Post Infection Reviews (PIR) for post-48 hour MRSA bacteraemias Root Cause Analysis (RCA) for C difficile Staff training, information and supervision Policy on admission, transfer, discharge and movement of patients

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3 Compliance Criterion 2: A clean and appropriate environment for healthcare. Committee structures and monitoring processes PEAT inspection Uniform standards Hand hygiene initiative

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4 Compliance Criterion 3: Provide information to patients, the public and between service providers on HCAI. Communications programme Trust website and information leaflets Providing information when patients move between providers

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5 Compliance Criterion 4: Promptly identify, manage and treat infected patients MRSA screening Managing outbreaks of infection

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6 Compliance Criterion 5: Co-operation within and between healthcare providers Health Economy Working Internal co-operation External contractors

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7 Compliance Criterion 6: Provide adequate isolation facilities

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8 Compliance Criterion 7: Ensure adequate laboratory support

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9 Compliance Criterion 8: Policies and protocols

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10 Compliance Criterion 9: HCAI prevention among healthcare workers

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11 Conclusion 31 Appendix 1: programme of work for 2015/6

Annual PoW 2015-16.xls


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1. Introduction This report summarises the activities of the Infection Prevention and Control Team (IPCT) at the Heart of England NHS Foundation Trust (HEFT) during 2014-2015. The report also demonstrates how the Trust has systems in place for compliance with the Health and Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance. The Trust continues the commitment to improve performance in infection prevention and control practice. The prevention and control of healthcare associated infections (HCAI) remained high on the Trust’s agenda. There was no inspection from the Care Quality Commission throughout this period for infection prevention, although an unannounced breach inspection took place between 08 and 11 December 2014. This inspection did highlight relevant issues that are described below. The work of the IPCT maintained efforts to reduce HCAIs in relation to MRSA bacteraemias and Clostridium difficile infections (CDI) in particular. The number of post-48 hour MRSA bacteraemias was 1 in comparison to the 8 in 2013-2014. Using the new Post Infection Review system, the case was identified as avoidable. HEFT had a MRSA bacteraemia rate of 0.2/100 000 bed days; the range for 10 Trusts in the Midlands was 0.0 to 2.3/100 000 bed days. CDI infections in 2013-14 were 75 in comparison to 82 cases in 2013-14. HEFT had a post 48 hour Cdiff toxin rate of 17/100 000 bed days; the range for 10 Trusts in the Midlands was 10 to 21/100 000 bed days). Table 1: Comparative data for Clostridium difficile infection (CDI) and MRSA bacteraemia rates (per 100,000 bed days) for certain West Midlands and East Midlands Trusts for 2011-2015.

CDI MRSA Bacteraemia Location 11/12 12/13 13/14 14/15 11/12 12/13 13/14 14/15 HEFT 24.4 17.1 16.7 16.9 1.6 1.3 1.6 0.2 UHCW 23.8 20.1 12.7 10.7 0.3 0.5 0.5 2.3 UHNM 21.9 20.1 19.1 19.9 1.8 0.0 1.5 1.0 UHB 24.6 20.9 21.9 17.7 1.4 1.5 0.8 0.8 SWBH 33.0 15.2 16.1 11.8 0.7 0.4 0.4 0.8 WAH 24.5 28.9 14.8 13.9 1.1 1.1 0.4 0.4 TRW 34.1 15.4 14.6 18.1 0.0 0.4 0.0 0.7 GEH 43.3 15.2 9.6 10.3 0.9 1.9 0.0 0.0 NUH 23.3 27.4 17.5 21.3 1.7 1.0 0.4 0.8 UHL 21.3 18.1 12.7 14.1 1.8 0.4 0.6 1.2

Key:

HEFT: Heart of England Foundation Trust UHCW: University Hospitals Coventry and Warwickshire UHNM: University Hospitals of North Midlands UHB: University Hospitals of Birmingham SWBH: Sandwell and West Birmingham Hospitals WAH: Worcestershire Acute Hospitals TRW: The Royal Wolverhampton


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GEH: George Elliot Hospital NUH: Nottingham University Hospitals UHL: University Hospitals of Leicester

The key objectives of the service during 2014-15 were to:

Improve the quality of patient care by preventing and controlling healthcare-associated infections.

Ensure effective assurance and reporting processes from Board to Ward. Reduce MRSA bacteraemia and Clostridium difficile infection (CDI) rates. To introduce targeted CPE screening in-line with the national Public Health England

toolkit To conduct an RCA for each post-48 hour toxin positive case of Clostridium difficile,

in conjunction with the CCG, and determine if cases were avoidable or unavoidable. Continue the mandatory surveillance of Escherichia coli and MSSA bacteraemias Coordinate overall management to significantly reduce the incidence of norovirus

outbreaks. Improve infection prevention and control knowledge and skills of all staff, patients

and public. Ensure completion of the programme of work and audit programme. Ensure compliance with the Health and Social Care Act 2008.

2. Compliance Criterion 1: Effective management systems for the prevention and control of HCAI informed by risk assessments and analysis of infection incidents. 2.1 Committee structures and assurance processes As required by the Health and Social Care Act (2008), HEFT ensured throughout 2014-15 that the Trust Board had a collective agreement recognising its responsibilities for the infection prevention and control agenda. The Chief Executive has overall responsibility for the control of infection within the Heart of England Foundation Trust. Dr Abid Hussain is currently the Trust’s designated Director of Infection Prevention and Control (DIPC), Consultant PHE Microbiologist, accountable to the Chief Executive and Trust Board. The Lead nurse for IPC is Gill Abbott. In addition to quarterly TIPC meetings, the DIPC attends Trust Executive Management Board meetings quarterly with updates on infection prevention and control matters. The Chief Nurse is the Executive Lead for Infection Prevention & Control (IPC) and is the Chair of the Trust Infection Prevention Committee (TIPC). The CEO maintained the contact with the DIPC via Executive Director (EMB) Meetings. The DIPC and Associate DIPC had regular one-to-one meetings with the Chief Nurse. Trust Executive team job descriptions incorporate a statement detailing their responsibility for infection control issues The TIPC continues to report to Clinical Governance and EMB, and this report reviews the output of the Infection Prevention Control team, through the quarterly TIPC meetings, where the DIPC quarterly report is tabled, which is used as the basis of the DIPC report to EMB. The annual report for 2014-15 was reported to the Trust Board in August 2015.

The Trust’s Decontamination (Chaired by Dr Alexandra Daley, Consultant Gastroenterologist) and the Water Management Committee (chaired by Dr Grace Smith, Consultant Microbiologist) report regularly to TIPC in addition to their reporting pathway for assurance, and to highlight IPC issues for resolution.


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The Infection Prevention and Control service is provided through a structured annual programme of teaching, audit, policy development & review, advice on service development and 24 hour access to expert advice and support. The annual program for 2015-2016 has been embedded in this document on page 4. Infection Prevention and Control Team The organisation structure for the team is demonstrated below (Figure 1). Specialist support is provided by the Consultant Microbiologists and Virologists of the Public Health (England) Microbiology laboratory. The IPC nurses are allocated responsibility for specific ward /departmental areas. All nurses have specific Trust projects e.g. hand hygiene, decontamination, MRSA screening, and sharps safety. Dr Itisha Gupta has a specific role for Lead Infection Control Doctor for Good Hope and Solihull Hospitals, and Dr Susan Alleyne is the Lead Infection Control Doctor for the Heartlands sites. These roles were developed a year ago to support the operational function on-site and also have input in strategic issues. The senior IPC nurses were also given site-specific responsibilities to develop links with the site-teams and oversee the continuity management of the site IPC issues. The DIPC and the Lead IPC nurse maintained the corporate view of the service whilst supporting each site. The data analytical work which involves performance reporting and mandatory data return requirements, as well as supporting the analysis of surveillance data, is performed by officers in Performance. The DIPC has monthly meeting with these officers to review the monthly returns for HEFT performance, KPI, and MESS data.


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Fig 1: IPCT structure. 2.2 Compliance Assessment and Assurance During 2014-2015 the Trust had an on-going process to evaluate its compliance with the Health and Social Care Act (2008) Code of Practice on Healthcare Associated Infections. Gap analysis was done and actions put in place. The Chief Nurse established regular Care Quality Commission Regulations’ meetings, where reviews were discussed.


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2.3 Surveillance of Healthcare Associated Infection (HCAI) 2.3.1 Post 48 hour MRSA Bacteraemias In 2014-2015, the Trust MRSA bacteraemia threshold “allocation” was 0 post-48 hour cases. The table below shows monthly data for pre- and post-48 hour cases by site. The total number of post-48 hour cases was one, seven fewer than the previous year. Pre 48 hour Post 48 hour BHH GHH SHH BHH GHH SHH Apr-14 May-14 1 Jun-14 1 Jul-14 1 1 Aug-14 Sep-14 1 Oct-14 1 2 Nov-14 1 Dec-14 2 1 Jan-15 1 Feb-15 1 1 Mar-15 Site Totals 4 7 3 1 0 0 HEFT Total 14 1

The graph shows the MRSA bacteraemias cases for each site, and total HEFT cases for 2013-2014. The 2012-2013 information is included for information.

The post-48 hour MRSA bacteraemia-free period, to the end of March 2015 was: BHH: 74 days; GHH: 579 days; SHH: 1107 days.


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2.3.2 Clostridium difficile infection (CDI) The total number of post-48 hour CDI cases reported for 2014/15 was 75, which was below the target of 78 cases. The table below shows monthly data for pre- and post-48 hour cases by site, and is graphically presented below. Pre 48 hour Post 48 hour Post 48 hrs

Target Community BHH GHH SHH BHH GHH SHH Apr-14 2 1 1 3 1 6 1 May-14 7 6 1 2 7 5 Jun-14 3 2 1 2 4 2 6 5 Jul-14 3 1 1 4 2 1 7 4 Aug-14 2 3 1 2 2 6 3 Sep-14 8 3 1 3 3 1 7 9 Oct-14 5 1 1 3 3 6 7 Nov-14 1 1 1 7 4 Dec-14 5 1 8 2 6 1 Jan-15 6 2 7 6 Feb-15 2 2 1 6 2 Mar-15 2 1 1 3 2 3 7 3 Site Totals 40 12 9 41 22 12 78 50

HEFT Total 61 75 50

The graph shows C. difficile toxin-positive post-48 hour cases for 2014-2015, with the annual threshold (78) and the 2012-2013 actual (75) shown too.

Using the Key Point Feedback (KPF) and antibiotic review data, the collated information on each case is fed back to the nursing and clinical team. Where there are periods of increased incidence (PII), with 2 or more CDI in a 28 day period on a ward, a PII Infection Control and Antibiotic Audit is done. This information is also fed back to nursing and medical staff.


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2.3.3. Human Probiotic Infusion as a treatment for C diff infections. In total 13 patients were treated with HPI between March 2014 and March 2015 at Heart of England NHS Foundation Trust. Administration of screened donor stool is performed on a case-by-case basis. Broad criteria for inclusion include either patients who have suffered from >3 episodes of Clostridium difficile infection (CDI) or those patients who are classified as non-responders who are transplanted on compassionate grounds only. An audit done for the Novel Therapy Committee requirements shows overall compliance with the donor and clinical SOPs to be 100% in terms of donor screening being in date, patient consent being sought and provided, and patients meeting the clinical inclusion criteria of multiple recurrence or non-responder. The delivery of a local HPI service is rapid, targeted and clinically led as PHE and Infectious disease work together to deliver the service. This service represents not only a major achievement in improving patient care, but also represents a significant cost saving for the Trust, when comparing HPI with conventional pharmacological methods. As the numbers of hospital attributed numbers begin to decrease over time, there are substantial staffing and treatment costs to be achieved by deploying HPI earlier in the CDI treatment cycle. In October 2014 we moved from using freshly prepared HPIs to frozen HPIs. Nine of the 13 HPIs were carried out with fresh and four with frozen material. The move to frozen material has allowed us to provide a more secure supply of material and ensure that all screening of donors is always complete before donation. Initial response to HPI treatment has been extremely good with demand for the service outside the region. No adverse events were reported which were directly attributable to the HPI treatment and side effects reported by patients treated at HEFT are consistent with those reported in the literature. I have been particularly impressed with the immediate response of patients, in most cases after a single treatment. 2.3.4 Meticillin sensitive Staphylococcus aureus bacteraemia (MSSA) mandatory surveillance Monthly returns through the MESS database were submitted. In 2014-15 there were 144 MSSA bacteraemias cases, of which 44 were post 48 hour cases (definition is the same as for MRSA bacteraemia); 8 of these cases were considered to be device related. This equates to a rate of 18%, which is slightly higher than 2013-14, which was 16%. All of the devices implicated in the MSSA device-related bacteraemias were vascular catheters, and the majority of those were peripheral catheters. There has been increasing vigilance from IPCT when reviewing ward metrics and also increased education for staff responsible for cannulation.


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2.3.5 Escherichia coli bacteraemias mandatory surveillance There were a total of 535 E. coli bacteraemias in 2014-14, of which 100 were post-48 hour cases. This equates to 18.7%, which is in keeping with the 2013-14 figure of 19.4%. The majority of the pre-48 hour cases, essentially community cases, reflect the burden of urinary tract infection in the community. Although the post 48 hour cases are not formally assessed a proportion are due to instrumentation or gut translocation.

2.3.7 Antibiotic Stewardship Antibiotic stewardship has been driven and maintained by the Trust Antibiotic Committee (TAC) which is chaired by a PHE consultant microbiologist. TAC activities have been promoted through the smartphone app called eTAG, information updated on the intranet site http://pharmacy/?page_id=922 and use of Trust Communications. A band 8a antibiotic pharmacist Rashmeet Bhogal, has taken up post as the lead antimicrobial pharmacist, and will be supported in antimicrobial stewardship by three rotational band 7 pharmacists (part-time, one at each Trust site). C.diff antibiotic reviews continue to be conducted for all patients diagnosed with post 48 hour C.diff toxin positive infection. As part of the review all antibiotic prescriptions during the admission are examined. Each antibiotic prescribed is assessed for documentation of


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stop/review date, indication and appropriateness (i.e. was it prescribed in accordance to Trust guidelines or following micro/ID advice). From the results observed it would suggest inappropriate antibiotic prescribing is not a significant contributor to HCAI C.diff at HEFT. The antibiotic initiatives by the TAC has won the 2014 Trust Patient Safety Award and more recently received recognition at the Trust’s quality summit. The in-house developments have helped electronic prescribing wards to increase antibiotic stop date performance, and this has gone up by 28 % compared to that of the same period last year. IV STAT antibiotic administration within one hour has improved in the past 2 years from 56% to 71%. Introduction of an antibiotic bleep has helped drive further improvements in some of our admission areas for urgent administration of antibiotics in patients with sepsis and a ‘live’ antibiotic dashboard (unique in the NHS) is available for wards to maintain vigilance to avert delays in STAT antibiotic dose administration. A podcast was used to promote the importance of antibiotic prescribing and avoiding missed/delayed doses, the video is available here. The TAC has developed 2 important lessons of the month, which is a large Trust forum for communication (Carbapenemase Producing Enterobacteriacae-CPE (March 2015 ) and Improving Antibiotic Safety at HEFT (February 2015), that went out to all staff with their payslips in 2014/5. Several important antibiotic audits were conducted and action plans developed: ertapenem, audit of antibiotic use in Elderly Care at Heartlands hospital, fidaxomicin and daptomycin. The TAC has developed and approved a number of new guidelines: Diagnosis and Treatment of Endocarditis, Prescribing and Administration of Intravenous Tobramycin in Adult Bronchiectatic (non - Cystic Fibrosis) Patients, Gentamicin use in Endocarditis patients. The TAC has approved with the contents of the amoxicillin and flucloxacillin PGD’s for A/E. In order to meet the current Trusts medicine management piperacillin/tazobactam KPI ALQR35 we are carrying out weekly band 7 rotational pharmacist-led piperacillin/tazobactam audits at all three sites and we are currently reviewing piperacillin/tazobactam patients on the microbiology-led antibiotic ward rounds. We have updated the primary care antibiotic guidelines in partnership with XCity, Solihull and Sandwell and West Birmingham CCGs. We have driven this initiative to now have a uniform primary care guideline for the catchment area of HEFT, QE and City/Sandwell hospitals. The TAC inaugurated in 2014 (and Chairs) the Birmingham Area Prescribing Committee. The group consists of antibiotic pharmacists from UHB, HEFT, Birmingham hospitals and CCG’s (Solihull and Birmingham). It also includes GP’s and Microbiologists from the region. This group was set-up to discuss the RED list (restricted drugs) in readiness for the Area Prescribing Committee (APC). The primary aim of BAAG is to create a uniform formulary across hospitals in Birmingham and collaborate with the CCG’s. The final BNF Chapter 5 RAG recommendations of BAAG are due to be tabled soon at the APC. The BAAG and clinicians have started to develop a new guideline for lower limb cellulitis across Birmingham. The aim of this guideline is to ensure that patients will receive similar treatment whether they are in any of the emergency departments or acute medical units cross the city or being assessed by a community advanced nurse practitioner. European Antibiotic Awareness day was marked on 18th November 2014 by a numbers of activities at HEFT including general COMMs, twitter messages and posters.


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The TAC has started an information bulletin aimed specifically for Trust prescribers. The first one went one in Feb 2015 with the subject “Oral Fosfomycin.in Primary Care” PHE currently manages a strong antibiotic stewardship program at HEFT, which supports the efficient use of antimicrobials and limits the selective pressure on antimicrobial resistance. CPE and the soon to be published NICE guideline on antimicrobial stewardship, this is likely to pose significant new organizational challenges. 2.4 Audit Programme to ensure key policies are implemented The annual audit program for 2014-15 was completed in line with the agreed schedule. 2.4.1 Audits of Commode Cleanliness Results are published in league table format and circulated to senior nursing staff and site teams for follow up action. Site Head Nurses escalate any wards not achieving 100% on commode cleanliness and action plans are set by those wards. The Infection Prevention and Control met with ward managers to support the development and implementation of individual action plans for improvement in failing areas. Overall there had been improvement in the cleanliness of commodes by the end of the year.

Quarterly Commode Audit Results in HEFT (2013-14)

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2.4.2 Audits of Hand Hygiene Practice Hand hygiene remains a central aspect of the audit programme. The results for 2014/15 are shown in the graph below and indicate Trust compliance as continuing to be above 90%.

2.4.3 Saving Lives Audits Saving lives High Impact Intervention Audit Programme The Trust has conducted monthly audits of the following Saving Lives High Impact Intervention audits. These are:

CVC ongoing care. PVC insertion. PVC on-going care Renal dialysis catheters Surgical site peri-operative care Ongoing care of ventilated patients Urinary catheter ongoing care.

These have been carried out as detailed in the 2014/15 programme. Clinical staff inputted data and downloaded results via the locally developed web based system with the support of the Infection Prevention and Control Team when required. The Infection Prevention and Control Nursing Team undertook peer review of the Saving Lives audits in clinical areas where infection control issues or incidents were identified such as outbreaks of infection. This allowed for targeted actions for improvement to be identified and instigated.

Quarterly Hand Hygiene Audit Results in HEFT (2013-14)

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Catheter Care The urinary catheter passport continued to be issued by hospital and community staff to patients with long term urinary catheters. This patient held document allows for continuity of patient care and improves communication between healthcare workers.

Essential Steps audits for Solihull community services The Essential Steps audit programme continued to be undertaken by community staff. Improvements were made to the infection prevention and control audit process with community teams being audited annually and clinic environments audited every two years. 2.5 Research activity and contribution to national agenda to enhance practice

1. Two of the infection prevention and control nurses successfully completed the infection prevention and control degree programme at Birmingham City University.

2. Two members of the infection prevention and control team attended national training programme for ebola personal protective equipment. This supported the Trust wide ebola PPE training programme.

3. A project was commenced to review the effectiveness of ultraviolet light for environmental decontamination.

4. A joint surgical site surveillance project with the surgical directorate and infection prevention and control team was established. This will continue throughout 2015/16.

Quarterly PVC Insertions Audit Results in HEFT (2013-14)

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Quarterly Catheter Ongoing Audit Results in HEFT (2013-14)

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2.6 Post-Infection Reviews (PIR) for post 48 hour MRSA bacteraemias. The new Post-Infection Review (PIR) system was used for the MRSA bacteraemias. In addition to the clinical team and Infection Control being present, officers from the CCG Infection Control team were present too. A summary of the case for the year is given below:

Jan BHH: The source of the MRSA bacteraemia was related to the insertion of a central line. No deviations were found in Trust policy. The CCG were asked to follow up with care providers chronic care as to practice and protocols particularly with regard to PPE, urinary catheter management and hand hygiene.

2.7 Root Cause Analysis (RCA) for C difficile The HEFT DIPC and Lead Nurse Infection Control have reviewed all 75 post-48 hour C diff cases with the ICT of the relevant CCG. Using the Infection Control key point feedback and the antibiotic review done for each C diff case, an avoidable/unavoidable categorisation was used. It is worth noting that out of the 75 post 48 hrs C diff cases, only 25 were classed as avoidable. Post 48 hour Cdiff toxin positives cases in 2014-2015, classed as avoidable or unavoidable.

Clinical review of all of the post 48 hour C difficle cases are performed jointly with representatives from the CCG. 25 out of the 75 cases were deemed to be avoidable, with the rest labelled as unavoidable. This process entailed a detailed review of antibiotic prescriptions, laboratory data as well as the electronic patient record. Patients notes were also referred to as needed. The IPCT have received positive feedback from the CCG and we have been working closely with the community pharmacists to feedback prescribing data. The avoidable/unavoidable review process applies in the year 2014-2015 year in relation to financial penalties. National directives have allocated HEFT 64 cases for the 2015-16 financial year.


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C difficile Key Point Feedback RCAs 2.8 Risk assessment and action As part of the root cause analysis for all post 48 hour C diff cases, key point feedback is sent to the senior nursing and medical teams. This highlights areas of good practice and management and clinical staff are requested to comment upon and address any areas where patient management could have been improved. A total of 145 Cdiff key point feedback RCAs were issued by the Infection Prevention and Control Team in 2014 – 15. 2.9 Staff training, information and supervision 2.9.1 Staff information

Reports to Sites and TIPC: Site Reports continued to be produced as an assurance framework to include feedback of data on MRSA bacteraemia, RCA findings and follow up of actions, CDI, MSSA and device-related infections, outbreaks of infection, audit results and other current information relevant to each site. These are presented to TIPC by Head Nurses.

Ward Reports: Monthly reporting of ward-based surveillance information on MRSA and CDI to wards and clinical departments continued in 2014-15. Cleaning scores and commode cleaning results are included on these reports. Wards were able to download results of their high impact intervention (HII) scores to display to the public in their clinical area on the infection control notice boards, enabling staff to review their own performance and readily track their routine infection control tasks to complete.

Infection Prevention and Control Promotional Activities: Events were held throughout the year promoting infection prevention and control activities and good practice, targeted at both staff and visitors to the Trust.

Infection Prevention and Control Study Day: This event was held in October 2014 ad focused on new and emerging infection prevention and control issues including ebola and CPE. Representation from companies and networking space helped to support the day.

Intranet: Infection prevention and control team continued to update and improve their intranet site for staff with an easy access portal for information, policy guidance and team contact details.

Link Nurse Scheme: The Infection Prevention and Control Team continued to support the link nurses, with every ward area having at least one designated link member of staff.

Mandatory updates for consultants: The DIPC and infection control doctors continued to deliver joint sessions with the IPCNs for the mandatory updates for senior medical staff. This provided more medical focus and helped to engage staff, using the opportunity to discuss antibiotic prescribing, as well as infection control practices.

Posters: The IPCT worked with the communication team to produced key messages

for both staff and visitors particularly around norovirus, flu and hand hygiene.


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2.9.2 Staff training The Team continued to have a strong training role within the Trust during the year. Infection control training and education programmes during 2014-15 included a programme of mandatory sessions and presence on staff induction days. Other sessions included, mask fit testing, HCA education, hand hygiene and ebola PPE training. Training was recorded on either the national standard module “OLM” on the Electronic Staff Record or the infection prevention and control databases with training attendance being reported to the mandatory training committee. 2.9.3 Staff supervision The Infection Prevention and Control nursing team were deployed to provide training and expert advice to staff as well as monitoring compliance by wards and departments with expected standards. In this way, the work of staff in the Trust was subject to scrutiny and supervision. 2.9.4 Infection Prevention and Control Team Personal Development and Training During 2014-15 all nurses in the Infection Prevention and Control Team attended required mandatory training. The wider team attended national and local study days/seminars and conferences. All staff participated in the annual appraisal process. In-house training occurred monthly to update specialist skills and knowledge. 2.10 Policy on Admission, Transfer, Discharge and Movement of Patients The Trust bed management policy addresses the admission, transfer and discharge of patients within and between healthcare facilities. The IPCT liaises with bed management staff and operational managers on a regular basis to support compliance with this policy. 3. Compliance Criterion 2: A clean and appropriate environment for healthcare 3.1 Committee structures and monitoring processes The TIPC has a designated sub-committee to oversee environment issues with IPCT representation in attendance. The Water Management and Decontamination groups report to TIPC. There is a designated lead manager for cleaning and an identified decontamination lead. There is a project manager for waste disposal who reports through the patient environment operational group. 3.1.1 Water Management Group The Water Management Group for HEFT, meets quarterly and is chaired by Dr Grace Smith, Consultant Medical Microbiologist. Policies: The Water Management Policy is currently undergoing review, and will include technical elements relating to Pseudomonas aeruginosa sampling and control. Temperature monitoring: There have continued to be problems with the cold water temperature in the Good Hope treatment centre, the addition of automatic flushing taps did not correct the problems. Plans are now being drawn up for a long term solution. Copper and Silver Ions: From February 1st 2013, the use of copper as a biocide was no longer allowed under the European Biocidal Products Directive and the Biocidal Products Regulations 2001. However, the HSE applied for essential use derogation for the use of copper in legionella control and this has been granted within the UK. Copper and silver ion


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treatment is still in use across Heartlands, Solihull and Good Hope sites and monitoring has demonstrated that all have achieved satisfactory levels. Legionella: All three hospital sites have water outlets routinely monitored for Legionella, and any legionella isolates from these water supplies are investigated and preventative action taken. The sites for monitoring of Legionella have been rotated in January to ensure widespread coverage. During 2014/15 Legionella pneumophilia was only isolated from Mallory Residential block on the Solihull site following completion of pipework alterations. This area and other non-clinical areas on the Solihull site are not covered by the silver and copper ion treatment. The problem was resolved with chlorination of the system and introduction of regular flushing. The issue highlighted the control on non-clinical areas across the Trust and the need for flushing records for these areas to be maintained. Pseudomonas: The Trust has been involved in a Department of Health funded multi-centre research project to investigate the extent of P. aeruginosa acquisition in adults caused by transmission from water in the non-outbreak augmented care setting, using whole genome sequencing to study relatedness of clinical and water isolates. P. aeruginosa was isolated in small numbers from augmented care areas at both Heartlands and Good Hope, measures were introduced following results and all areas tested negative subsequently. In addition to the DoH funded study, sampling of all augmented care areas was undertaken by the Trust, with again P. aeruginosa being isolated from a small number of outlets. The number of patients with P. aeruginosa in augmented care is monitored and there have been low numbers, with no clusters of cases. Following review of all of the data collated from the study and through routine sampling a risk based sampling protocol is currently being drafted. Flushing: There still remains some gaps in maintaining flushing records across the Trust, but is improving overall. These are reviewed at the Health and Safety Forums and a check of records is also undertaken as part of the infection Control nurses annual audit. There is an audit of compliance taking place in June 2015. Staff and Training: A compliance manager is now in post for Solihull Community and a community compliance officer is soon to be appointed. A complete list of occupied community buildings has been compiled and these will be reviewed once the compliance officer is in post. This will ensure that the group will have clarification of responsibilities and risk assessments for all Trust premises. All APs have received training this year and is now a regular fixture on the training schedule for staff across all sites. 3.1.2 Decontamination Committee The Trust is required as far as reasonably practicable to ensure that all reusable medical devices are properly decontaminated prior to use in accordance with published, national standards and that the risks associated with decontamination facilities and processes are appropriately managed. Current Decontamination Standards:-

Choice Framework for local Policy and Procedures 01-06 (CFPP0106), which replaced the NHS Estate’s Health Technical Memorandum (HTM 2030) in 2012.

Management responsibility for ensuring the Trust’s continued compliance with local decontamination standards is held by the Trust Decontamination Committee and the Medical Devices & Decontamination Manager.

The Decontamination Committee meets bi-monthly and has been chaired by Consultant Gastroenterologist, Dr Alexandra Daley, since January 2013.


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The Trust has access, when required, to the services of an external Authorised Engineer (Decontamination), to provide an expert opinion and external audit of local decontamination practice. Further assurance and expert advice is also available to us from the Trust DIPC, Dr Abid Hussain, and Consultant Medical Microbiologist, Dr Kathy Nye. Through their work with PHE (Public Health England), they also have direct access to other local & national experts Surgical Instruments Decontamination of surgical instruments is outsourced to B.Braun Sterilog and the Scantrack IMS system is currently used to track instruments through the various stages of the decontamination process. Traceability of instrument sets used on individual patients is assured, currently, by the manual insertion of instrument set production labels into patient notes. However, this information is difficult and time-consuming to retrieve in the event of a look-back exercise or audit. Following an options appraisal, it was decided to incorporate an instrument traceability module into the new, electronic Theatre Management Information System (TMIS) which is being developed within the Trust. This will enable rapid & accurate tracing of instruments & the patients on whom they were used. No date has yet been set for this module to be introduced by Theatres Management. Local Decontamination All decontamination of heat sensitive items is undertaken in strict adherence to the Trust Decontamination and Infection Control Policies and with the guidance of the Infection Control Team. Historically there has been a poor understanding of the guidelines and regulations surrounding the decontamination of endoscopes, particularly amongst non-specialist staff. In some part this is due to the lack of clarity within the guidelines themselves, but it has not been improved by the introduction of the more complex CFPP 0106. To address this issue key staff have been designated with lead responsibility for decontamination in their areas and have completed a programme of external training in decontamination. An Endoscope Users Group was established in 2011; this operates as a sub-group reporting in to the Decontamination Committee and provides an opportunity to run specialist training sessions and share best practice across the different specialist teams involved in decontamination. Local decontamination is focussed on the reprocessing of flexible endoscopes in Automated Endoscope Reprocessors (AERs), which is carried out in the following specialist units across the Trust:-

Urology, Ward 10 at Heartlands Main Theatres at Heartlands Endoscopy on all 3 sites

Scope decontamination facilities on both Solihull & Good Hope sites operate as a centralised decontamination facility for the respective sites and are operated by trained endoscopy staff. It is proposed that this model will be introduced at Heartlands during 2015 and decontamination within Theatres at BHH will become the remit of specialised Endoscopy staff as on the other two sites. This plan is being progressed jointly by Theatre and Endoscopy Managers. Future plans to incorporate Urology scope reprocessing in a central endoscopy unit at Heartlands are being considered by the Surgery Directorate. Capacity within the existing units is limited by the clinical space available; however the new equipment now in place will


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assist with patient flow until a new larger unit can be created. In Urology scope reprocessing is also benefitting from a new AER to replace the old obsolete machine. External testing & maintenance contracts for Trust AER machines, and drying cabinets, Trust wide have been combined to facilitate better management and to provide economies of scale across Endoscopy, Urology & Theatre Directorates. Decontamination using Tristel disinfectant wipes is carried out in two clinical specialities listed below:-

Ear Nose & Throat, Out Patients Dept. on all 3 sites (Nasendoscopes (TNE)) Cardiology on all 3 sites (Trans Oesophageal Echo (TOE probes))

A regular & robust audit process continues to be in operation to confirm that the required testing is completed for all AERs and to confirm efficacy of TNE & TOE probe decontamination. These audit results are reported on a bi-monthly basis to the Decontamination Committee where they are reviewed and assurance is also provided to the Medical Devices Committee. 3.2 Patient Led Assessments of the Care Environment (PLACE) Infection Prevention and Control team members continued to participate in patient led assessments of the care environment (PLACE visits/inspections). SITE NAME 2013 - 14

Cleanliness Score

Food Score

Privacy and Dignity Score

Heartlands Hospital

96.78% 87.14% 85.91%

Good Hope Hospital

96.72% 84.93% 87.49%

Solihull Hospital

92.72% 89.6% 77.07%

National Average Score

95.74% 84.98% 88.87%

3.3 Examples of IPCT work to support environmental duties:

Regular meetings occurred between the IPCT and the Housekeeping Manager throughout the year to resolve operational issues.

Infection Control attendance at service development meetings including upgrade and new build projects.

A robust environmental audit programme was followed during 2013 - 14 involving IPCT, Head nurses and the Hotel Services department.

3.4 Uniform Standards The Trust continues to provide uniforms for medical staff to encourage compliance with the bare below the elbow policy (BBTE). 3.5 Hand hygiene initiative Throughout the year the IPCT continued to promote the WHO initiative “The Five Moments” template which demonstrates and promotes effective hand decontamination in the patient environment. Monthly hand hygiene audits continued to be carried out, providing statistics on hand hygiene and decontamination.


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Link nurses were regularly encouraged to promote hand hygiene in their areas of work, giving ongoing education to staff by using the glow-boxes, reiterating the six step technique and the Trust requirement for “ bare below the elbow “. A chain reaction process to teach the “Five Moments” and good technique developed by a link nurse in 2011 has continued to be used across the Trust. The IPCT and HEFT media department designed posters for hand hygiene; these were well received by staff and visitors. 4. Compliance Criterion 3: Provide information to patients, the public and between service providers on HCAI

4.1 Communications Programme Information to patients and the public continued to be provided in order to raise awareness of infection control issues. Highlights include:

Visitors stand manned by IPCT in particular to promote the urinary catheter passport and the introduction of Octenisan anti-microbial hair and body wash.

Use of the Intranet Use of leaflets produced to highlight specific issues e.g. Norovirus Further development of patient-held urinary catheter passport project

4.2 Trust website and information leaflets

The Trust website promotes infection control issues. A range of information leaflets are available for patients, public and staff archived on the trust patient information database. The visitor information linked to ward closures is on the Internet website to inform visitors and relatives regarding specific ward closures at all sites during outbreaks of norovirus.

4.3 Providing information when patients move between providers During 2014-15 the IPCT continued with automatic generation of clinical letters for patients with a known CDI or MRSA positive result. CDI alert cards for patients were sent on


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discharge, thereby complying with the requirements to provide effective communication between healthcare providers

5. Compliance Criterion 4: Promptly identify, manage and treat infected patients There are daily lists from the lab on infection prevention alert organisms which are reviewed and followed up by the team. There is a weekly Infection Prevention and Control operations meeting which is a multidisciplinary group comprising medical, nursing, science, analytical and managerial staff. The meeting reviews the current position of the Trust in terms of infected patient caseload and locations, and the steps being taken to respond to the Trust’s situation. This was well attended during 2013-14 with an improved teleconferencing system across the 3 sites. 5.1 MRSA screening MRSA Emergency Screening – monitoring of conventional techniques Following the discussions in 2013-14, Infection Control teams introduced a dual-swab (nose and groin) direct culture system for screening. There is underperformance on screening across all of the sites, with significant geographical variations. MRSA Elective Screening The Department of Health introduced the mandatory screening of elective patients from April 2009. This was launched in the Trust in March 2009. For quality purposes the Trust have been monitoring the patient-to-screen rates data, aiming for 90% compliance. This patient match screening compliance has been consistently below 90% during 2014-15, which has been a finding for the last 6 quarters.


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MRSA Emergency Screening This was introduced in the Trust in June 2008, ahead of the national guidance which came into force in December 2010. The target for emergency screening was set at 90% for 2013-14 and this has mostly been achieved throughout the year. Compliance with emergency screening has also been consistently below 90% for the financial year.

The methodology for the production of these reports has not changed now for a number of years. The data quality of these figures doesn’t appear to be reflection of the pathology dataset but rather the ADT (admission, discharge, transfer) dataset that this links to. Essentially, the MRSA screening data looks at every admission on to the Trust PAS system, and, if it meets the reporting criteria, looks for a corresponding screen within the required timescale for that admission. The admissions’ details source for MRSA screening is updated daily, but only for the past 7 days, so any system updates that occur more than 7 days after the day they are recorded will not be reflected in the final reported figures for that month. The Trust moved from using ‘HISS’ to ‘PMS2’ as its PAS system back in July 2014, and since this date, there have been data quality problems around the dataset produced by PMS2. The majority of these result from routine user errors, particularly around the ‘cold’ admission of elective or daycase patients (ie. not from a waiting list), resulting in elective patients being recorded as emergencies. This impacts on the distribution of cases on the MRSA Screening reports between electives and emergencies, and thus the reported Screening figures (as well as all of our other activity / performance reports). The Trust has invested in a ‘validation team’ to correct all of the data ‘anomalies’ retrospectively, concentrating first on the most recent data (to enable us to return to external reporting asap), and so far, they have been able to correct April 15-June 15, and are nearly complete with January 15-March 15 data. They will shortly be looking at correcting September 14-December 14 data, and once complete the screening figures will be reanalysed. 5.2 HEFT response to Ebola In August 2014, with the repatriation of the first UK case, the local Ebola Action Group (EAG) was formed and tasked with the development, regular updating and implementation of the HEFT response to the threat of Ebola virus disease (EVD). Members of this group include representation from IPCT, DIPC, Virology, Emergency planning, Hotel Management, Blood Sciences, ID (adult and paediatric), HEFT communications. This group is chaired by Dr Sowsan Atabani, Consultant Medical Virologist. The remit of the group was to oversee and manage the health and safely aspects of EVD, especially infection control and prevention. In particular, EAG works to ensure that all suspected and confirmed cases are provided with a safe and high level clinical service, with the prevention of the development of secondary cases by training in the use and disposal of personal protective equipment (PPE). A video illustrating the correct procedures for the donning and doffing of PPE has been created by the Infection Control Team and is available on the local HEFT intranet. To date


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the IPCT has trained individuals to act as trainers. Clear communication strategies for sharing and dissemination of unified public health guidance have been established for internal use among HEFT staff and external healthcare providers and agencies in the region. The EAG meets weekly to discuss all information, from Public Health England, WHO and CDC, as it becomes available and agree required actions and dissemination. To date, a total of 7 patients from HEFT have been tested for EVD, all being negative. Following each case, a full formal debrief was carried out to ensure that all stakeholders involved in the case were given the opportunity to comment and address any concerns raised in the management of the case, and all protocols and policies were reviewed and amended to reflect the new or additional findings. 5.2 Managing outbreaks of infection Responses to Incidents and Outbreaks The Infection Prevention and Control Team were involved in the management of outbreaks and incidents over the year 2014-15, as detailed below: Outbreak of MRSA on ward 24 at GHH A patient who was previously known to be MRSA positive but was screen negative on this admission, became MRSA positive during the admission. Screening identified other patients who were likely to have acquired MRSA. Molecular typing showed that the organism in the index patient was the same as two other patients on the ward. Staff screening identified 5 MRSA positive staff members, 3 of whom, had the same molecular type. Although a PAT dog was regularly visiting the ward, screening showed this pet to be MRSA negative. A SUI was called and several outbreaks meetings convened with the CCG. The whole process of equipment and environmental cleaning, staff compliance with hand hygiene was reviewed. The issue of MRSA acquisition on wards is discussed in more detail in the Conclusion. Outbreak of Clostridium difficile infection (CDI) declared as SUI 3 cases on BHH 4 of CDI cases were reviewed in February 2015, all of which were found to be type O27. The index case was known to previous suffer from CDI, with a positive sample from October 2014. Transmission was thought to have occurred through a common sluice as timelines did not demonstrate patient crossover in the same bay. It was noted that one of the affected patients was not isolated in a timely fashion, which may have been a contributory factor. A robust action plan of deep cleaning, as well as refurbishment of furnishings has prevented any further outbreaks on Ward 4. Outbreaks due to diarrhoea and vomiting Norovirus continued to have a significant effect of the activities if the Trust, and in terms of the numbers of patients and staff affected, this is shown graphically in the figure below. Graphical presentation of the affect that norovirus has in the Trust is shown below with the distribution of the incidents reflecting what was occurring in the community.


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The number of patients and staff, by month, affected by confirmed norovirus outbreaks in the 2014-15 year.

The total number of days (bays and wards) closed, and total bed days lost in confirmed norovirus outbreaks in the 2014-15 year.

The number of days of bed closures (bays and wards) was 268, 179 patients and 47 staff were affected, and a total of 1003 bed days lost. Norovirus Major Outbreak at SHH in February 2014 SHH site experienced an increase in activity of diarrhoea and vomiting on wards in February. This coincided with the rise in norovirus activity in the community. A total of 5 wards (including one surgical) were closed, and a major outbreak was declared. Daily site outbreak meetings were held which included members from the external organisations. The Communications team at HEFT, and Solihull CCG team jointly issued GP information to minimise patient referral to that absolutely necessary. The Health Protection Unit kept the Trust updated about the activity position in the region especially with regards to nursing home and schools affected.


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In spite of these measures and declaration of major outbreak, one further ward (surgical) was closed when it impacted on elective surgical activity which had to be cancelled. Due to the outbreak, full visiting restrictions on the SHH site were in place for 3 days, and additional locum junior doctors were employed to provide segregation of medical staff, and limit spread. A large number of staff were affected which made the outbreak difficult to manage. Total length of this outbreak was 9 days. This incident was declared as a Serious Incident and an RCA meeting was held after the outbreak. No major issues were highlighted in the RCA meeting in identification and management of the outbreak. Salmonella enteritidis O9g Outbreak at the BHH site This is a brief summary of the salmonella outbreak that occurred at the BHH site. More detailed information will be provided in the RCA that has been set up to review this major outbreak.. Clinical cases presented from late May, and laboratory-proven cases identified from 1st to 19th June. In all there were a total of 42 cases. Of the 20 patients, 10 were on Beech/Rowan wards, and the other 10 on wards across the main site (3 on BHH19, 3 on BHH7, and 1 each on BHH 2, 8, 11, 22). Five patients died, one with the salmonella infection cited as a primary cause of death, and a Coroner’s inquest is to be held on 15th September. Bacteraemias were identified in 6 patients, which is considered a high rate for this organism. Asymptomatic carriage was identified on screening of 3 patients on Beech ward. There were 7 cases associated with staff, of which at least 2 were likely to be community acquired. There were 5 cases in staff associated with Rowan ward. Considering the 12 community cases which occurred at the same time, epidemiological and food history investigations, and microbiological examination of food and water showed no clear source of the organism in relation to the wards, or elsewhere on the BHH site. On Beech ward, a single swab taken from the food regeneration trolley grew the organism. It is possible that one staff member associated with Rowan may have introduced the organism onto that ward, and in view of the ward environment, process, and patient group, it is likely that the organism was acquired by four patients on Rowan ward. However the identification of 6 symptomatic patients (and 3 with asymptomatic carriage) on Beech, confirmed that overall practices were not acceptable. For discussion, Appendix 2 is a diagrammatic summary of the BHH site outbreak, with a layout plan of Rowan ward. Shortly after the first major outbreak meeting on the 6th June, actions were taken for patient safety. Beech ward had been closed, and in addition to a rolling program of cleaning starting on Beech, ward kitchens were emptied of all food items, and deep cleaned with hydrogen peroxide, and restocked. Until water was confirmed as safe, bottled water was provided for patients. The whole process of food handling and serving by staff was reviewed, and staff duties separated into food handling and cleaning. Security of food storage and preparation areas on wards is an ongoing action. 6. Compliance Criterion 5: Co-operation within and between healthcare providers 6.1 Health Economy working There is collaborative working at the operational level between HEFT Infection Prevention and Control team and microbiologists, CCG infection control teams, and the West Midlands East Health Protection Unit (HPU). There were collaborative health economy wide HCAI group meetings throughout 2013-14 attended by the Head IPCN.


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As mentioned previously, the Trust has worked to share root cause analysis findings with CCG partners, The Trust also contributed to the formulation of the health economy strategy and priority actions for the Cluster Group. 6.2 Internal Co-operation In order to achieve the significant reduction in infection rates within the Trust, extensive internal multidisciplinary collaboration was understandably necessary. Engagement with the assurance framework and responsiveness to the needs of the infection control work programme was gained at all levels within the trust with clear leadership from the trust Chief Executive, Chief Nurse and senior clinical and operational personnel. The IPCT continued to meet with head and lead nurse and ward department mangers on a regular basis in order to publicise audit results and encourage further improvements. 6.3 External contractors The IPCT was involved in decisions for External Contracts. 7. Compliance Criterion 6: Provide adequate isolation facilities As part of the Trust’s strategy to manage cases of C difficile and prevent further spread identified beds on BHH 27 (cohort ward) have continued to be used for the care and management of symptomatic patients from across the three sites. The side room tool on electronic patient handover is being promoted to manage the utilisation of side rooms in an effective manner. 8. Compliance Criterion 7: Ensure adequate laboratory support Laboratory services are provided through contractual arrangements with PHE for the Heartlands, Solihull and Good Hope sites. All laboratory services were successfully accredited by Clinical Pathology Accreditation in 2012. Detailed information on laboratory performance for the year can be found in the Annual Report on the PHE Regional Laboratory Service to Heart of England NHS Foundation Trust for Microbiology. 9. Compliance Criterion 8: Policies and protocols The areas of the work programme described in this annual report are relevant to the policy areas listed in the Health and Social Care Act 2008. These are available through the Trust Intranet site. Policies were updated and approved by the Trust Infection Prevention and Control committee according to review dates or changing practices. Policies were compared with peer performance and national guidance to ensure that best practice is promoted. 10. Compliance Criterion 9: HCAI prevention among healthcare workers All job descriptions include infection control responsibility and this message is reiterated during mandatory training. The Infection Prevention and Control team participate in induction training and mandatory updates for all staff groups. Staff training The team continues to have a strong training role. Infection control training and education programmes during 2013-14 included a programme of mandatory sessions and presence on staff induction days. Other sessions included MRSA screening, C difficile awareness,


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outbreak management, flu management and mask fit testing, portering and domestic staff updates, volunteers cascade training and HCA education. Link staff conducted cascade training on hand hygiene. The IPC team provided updates to link staff during the year. Training is recorded on a national standard module “OLM” on the Electronic Staff Record, with training attendance reported to the mandatory training committee. Occupational Health services are provided as required within the Trust. The IPCT worked with the Occupational Health services to support the flu vaccination campaign and undertook staff vaccination along with other trust flu champions. Conclusion The Infection Prevention and Control team has a wide range of activities. These centre on the day-to-day management of the process, which is triggered by calls from a full range of HCP, and by the daily alert lists generated by the laboratory. MRSA, C diff, group A streptococcus, tuberculosis, norovirus and influenza are ongoing and recurrent issues. The weekly Infection Control Operations meeting, usually chaired by the DIPC, and teleconferenced to all 3 sites, enables a detailed review of the infection control status of the Trust, and generates a wide range of actions and plans, which are reviewed and action plans updated each week. The Infection Control team have good working relations with the ward staff in particular, working to make the sites as safe as possible. One area of concern is MRSA acquisition that takes place on wards. This exacts a lot of extra work for the Infection Control team, and laboratory staff too. A key part in addressing this is the ongoing engagement of all staff in the Trust in basic infection control practice. One initiative has been the involvement of consultants in the process. A letter sent by the CEO and Acting Medical Director in February 2014, reinforcing the Trust’s policy about “bare below the elbows”, which generated some negative responses. There is a clear need for the consultant body to peer-review the practice of “BBTE”, and general infection control on the wards, and to challenge non-complaint colleagues, in order to attain the best standards for patient safety. This really needs site-specific engagement of all medical staff. Dr Abid Hussain Director of Infection Prevention and Control July 2015.


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8th Sept 2015


ANNUAL GENERAL MEETING

Minutes of a meeting of the Council of Governors of Heart of England NHS Foundation Trust

held in De Vere Venues Colmore Gate, Birmingham on 8 September 2015

PRESENT: Mr L Lawrence (Chair)

Mrs C Doyle Mr R Hughes Mr M Hutchby Mrs S Hutchings Mr P Johnson Prof H Griffiths Mr R Handsaker Mrs J Thomas

Mr M Kelly Mr A Lydon Mr B Orriss Dr M Pearson Dr C Needham Dr M Trotter Mr D Wallis

In attendance Dr A Catto Mrs S Foster Mr D Cattell Mr A Edwards Ms H Gunter Mrs K Kneller Mr R Bacon (PwC)

Mr A Foster Ms A Lord Mr J Brotherton Dr J Rao Prof L Serrant Mr D Lock Mrs K Eccles

Ms P McLaughlin (Minutes) Mr K Smith (Company Secretary) Members of the public Mr T Webster

The Chair welcomed everyone to the meeting.

15.075 APOLOGIES Apologies for Governors had been received from Mrs Begum, Mrs Bell, Dr Burgess, Mrs Coulthard, Mr Fletcher, Mrs Lane, Mrs McGeever and Mr Kibilski.

Apologies for Directors had been received from Dr Cadigan, Mr Rex, Mr Sellars and Mr Stokes. The Chair noted that Mrs Coulthard had sent apologies due to a fall and recorded best wishes for a speedy recovery.

15.076 DECLARATIONS OF INTERESTS

The Chair referred to the Governors Register of Interests and asked that Governors with any new interests should notify the Company Secretary so that the Register could be updated accordingly. The Directors Register of Interests was noted.


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8th Sept 2015

15.077 ANNUAL REPORT AND ACCOUNTS 2014/15 15.077.1 Annual Report 2014/15

Mr Foster presented an overview of 2014/15 and an insight into the future. The following was noted: 2014/15 had been a busy year with 248,047 patients being seen in A&E; 75,250

surgical operations carried out; 1,166,877 outpatient department appointments, 9,477 births and 96,983 emergency admissions.

Quality improvements had included:

Medication Safety Programme supported by Lisa Everton-Richards; electronic prescribing; medication dashboard piloted; greater use of technology including safety Apps and manuals for nursing and clinical staff.

There had been improvement seen for six trust Quality measures:

SHMI (Summary Hospital Mortality Indicator). HSMR (Hospital Standardised Mortality Indicator). Hospital MRSA, only 1 case compared to 8 in 2013/14 an excellent

improvement. Hospital C Diff, 75 cases compared to 82 in 2014/15. Injurious falls remains the same at 65. Grades 3 and 4 pressure ulcers, a modest reduction had been seen. A&E 4 hour performance had improved. There had been 51,948 ED attendances compared to the previous year. Emergency activity had decreased by 3.74%. Ambulance arrivals had decreased slightly. The trust had commissioned the Deloitte report on governance. Departure of Mark Newbold and other EDs; loss of Sexual Health Services

tender; outbreak of salmonella; steep dip in A&E performance; continuing to miss RTT and cancer targets / Silverman report into mortality.

Consequent regulatory intervention by Monitor. The trust had incurred the first financial loss for many years and ‘required

improvement’ rating from CQC. The Hyper Acute Stroke Unit at Heartlands had opened and had seen

improvements in care and became one of the highest performing units in the region.

Chief Nurse Sam Foster had been given the honour of carrying the ceremonial lamp at the Florence Nightingale service at Westminster Abbey.

International Nurses Day had been celebrated across the trust including the launch of compassion cards that had led to the Kate Granger Award nomination.

The trust launched the open visiting policy making HEFT the biggest trust to undertake such an initiative.

Staff at Good Hope had arranged for critically ill patient Doreen Mooney to be presented with an MBE by the Lord Lieutenant of Birmingham.

The Supported Integrated Discharge team won a HSJ award in the Secondary Care Service Redesign category.

Solihull Hospital achieved Vanguard status from NHS England and its NHS Five Year Forward View partners for its integrated work with partners on the Solihull Together for Better Lives project.

All of our hospitals had been MRSA free for the year. Ambulatory Emergency care and improvement in A&E performance had been

launched. The trust had been the location for several documentaries including the BBC

documentary series ‘Protecting our Parents’ filmed at Heartlands that had been


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8th Sept 2015

nominated for a BAFTA TV award and Dr Christian Jessen visited the Bariatric team to film for the TV series ‘Weighing up the Enemy’ on Channel 4.

Following the appointment of Mr Foster as Interim Chief Executive, a 3 phased action plan had been undertaken to consolidate the Resilience Plan and the pyramid of priorities in the integrated improvement plan (IIP). The trust had a recovery programme setting out clarity, staff engagement and quality for all staff.

Progress so far this year: A&E had improved every month and it was anticipated the 95% A&E 4 hour

would be achieved by the Autumn; 18 weeks and other waiting times had improved. Plans were in place to achieve all targets this Autumn with the exception of endoscopy due by December; 228 IIP milestones – 57 had been completed; 147 were on track to deliver; there were 13 minor issues and 11 behind schedule.

Looking forward to 2015/16 – finance, staff engagement, sustained performance, quality and governance would be the top priorities. The Chair noted that Mr Foster would be leaving the trust at the end of October and recorded thanks to Wrightington, Wigan and Leigh NHS Foundation Trust and to Mr Foster for his work and achievements. In response to a question from Dr Pearson, Mr Foster advised that he believed he had achieved a degree of momentum and was confident that the Directors would continue the work. Mr Foster was returning to Wigan where his family were based.

15.077.2 Audited Accounts 2014/15 Mr Cattell, Interim Finance Director presented an overview of the Audited Accounts and it was noted that: The Annual Report and Accounts had been submitted to Monitor within the

reporting deadline on 29 May 2015 and were presented to Parliament on 25 June 2015, the Quality Report and Annual Governance Statement had been included.

PwC had given a ‘clean’ audit opinion for the Accounts. PwC were unable to satisfy themselves that the trust had made proper

arrangements for securing economy, efficiency and effectiveness in its use of resources.

PwC had given a limited assurance report in respect of the Quality Report. Continuing of services rating (COSR) 4. The trust deficit of £5.6m was in line with the re-forecast made to Monitor in

December 2014 to reflect extra investment made to maintain capacity and address the failure to hit national performance targets.

There was a £2.2m reduction in charges for provisions following a reappraisal of the redundancy provision.

The trust maintained significant provisions in relation to environmental issues (asbestos) and the Kennedy Review related costs.

Capital expenditure for the year was £21m. Cost control remained a major challenge throughout the year. Monitor red risk rating due to continued failure throughout 2014/15 to achieve

the A&E 4 hour 95% target; Q4 other targets were not met – 18 week RTT; 62 day waits for first cancer treatment; 2 week breast cancer; 2 week other cancer. Plans were in place for recovery.

In response to a question from Mr Lydon, Mr Cattell advised that, after discussions with our Commissioners it had been agreed that the trust would opt for PbR


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(Payment by Results); PbR generally supported growth in activity where JMRA (Jointly Managed Risk Agreement) depended on growth being funded up front. PbR gave the trust both opportunities and risks.

15.077.3 Auditors Report 2014/15 Mr Bacon advised that PwC was regulated and its work was scrutinised by the

Institute of Chartered Accountants. PwC had worked with the trust throughout the year and where issues had been identified prompt responses had been received. PwC continued to bring good practice from other trusts and work in partnership with the trust to increase efficiency and effectiveness in the audit process. Following completion of the audit in May 2014 PwC had issued:

An unqualified audit opinion on the 2014/15 Financial Statements. A modified conclusion with regards to the trust’s arrangements for securing

economy, efficiency and effectiveness in the use of trust resources. A qualified limited assurance report with regard to the 2014/15 quality report. Copies of the ISA260 Report were available upon request.

In response to a question from Mr Lydon, Mr Bacon advised that he was unable to

state why the trust had failed on performance and the problems around the use of resources and the financial difficulties the trust was now experiencing. There was a balance to be struck between economy, efficiency and effectiveness. In any year the budget needed to be set to achieve this. With the intervention by Monitor in 2013/14, in terms of economy, efficiency and effectiveness, PwC did not have concerns about value for money. Having been back, PwC issued a ‘modified conclusion’.

In response to a question from Dr Pearson, Mr Bacon advised that he was not

qualified to make a judgement on whether there would have been improvements had the trust spent more money in 2013/14 than it had.

15.078 RECOMMENDATION FOR APPOINTMENT OF NON-EXECUTIVE DIRECTORS The Chair referred to the pre-circulated paper. The CoG Appointments Committee

had interviewed Professor Jon Glasby on 25 August and subject to receipt of satisfactory references, disclosure and barring service checks and occupational health checks the Appointments Committee recommended Professor Jon Glasby as a Non-Executive Director with effect from 1 October 2015.

The Council of Governors unanimously approved the appointment. The Council of Governors Remuneration Committee members had met and been

asked to ratify and approve the proposed standard NED fee of £14,123 per annum in respect of this appointment.

The Chair advised that Professor Serrant would be leaving the trust in September

2015 to take up a new role with NHSE in Leeds. The Chair wished her well and recorded thanks for her contribution at Board and Chairing the Workforce Development and Welfare Committee. Ms Kneller would take up the duties of Chair from 1 October 2015.


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15.079 REPORTS FROM CHAIRS ON THE HIGHLIGHTS OF THE WORK OF THE CoG

COMMITTEES OVER THE LAST YEAR 15.079.1 Appointments Committee The Chair advised that following Mr Edwards and Mrs Kneller appointment as NEDs

last September, it had been agreed that he would work to identify a suitable third candidate. This had been undertaken and the Appointments Committee had met and interviewed and subsequently recommended Professor Jon Glasby as a Non-Executive Director with effect from 1 October 2015.

15.079.2 Finance and Strategic Planning Committee The Chair noted that Mrs Bell had sent apologies and Dr Trotter would present the

report. Dr Trotter recorded his thanks to Mrs Bell who had stepped down as Chair and to Professor Cooke who had presented the 2020 Vision Strategy to the Committee. Dr Trotter noted that most of the updates had already been given by way of Mr Foster and Mr Cattell’s earlier reports. The Committee had experienced a stormy year following a vacant Chair until Mrs Bell had stepped in. The Committee had received several presentations throughout the year. Cancer 2 week wait was improving; PMS2 data issues were hopefully now resolved, although data that was reported to the Committee it was not always robust.

15.079.3 Hospital Environment Committee Mrs Hutchings gave an overview of the work of the Committee for the year on behalf

of Mrs Coulthard, Chair. Two Governors had resigned and Mr O’Leary had passed away, new members included Mr Kibilski and Mr Edwards had joined as the NED representative, Mrs Hutchings had become Vice Chair in March. If anyone was interested in joining they should express their interest to the Company Secretary, Mr Smith.

The Committee as part of the work looked at trust sites and considered

issues/concerns raised at its meetings. At the meeting on 9 October 2014, Mr Treadwell queried whether members were happy with the function and due process of the Committee in order to ensure that members did not feel that they were wasting their time in attending meetings. It was felt that the Committee was well administered and that any actions raised were picked up and resolved. The Committee had received several presentations throughout the year. Good Hope Hospital multi storey car park was currently on hold pending the outcome of the strategic and capital plan reviews following the presentation of a paper to EMB.

Mr Kelly advised that the trust had broken even in terms of parking income and

expenditure. It would cost the trust in the region of £4m if it was free. Mrs Thomas recorded thanks to Mr Webster (Ex-Governor) and Mrs Coulthard for

their recent fundraising event at Tesco that had raised over £600 for the Friends of Good Hope Hospital Charity - the Chair recorded thanks.

15.079.4 Membership and Community Engagement Committee Mrs Thomas on behalf of Mr Fletcher gave an overview of the work of the

Committee for the year. There had been a lack of meetings this year due to holidays, logistics etc. The Committee had received several presentations throughout the year and monthly member seminars had been held. At the member’s seminar held on 15 September 2015 the Chief Executive and Chair had presented an update on the current position of the trust. Community engagement was happening on all three sites and money had been spent on equipment for the trust. More young people were getting involved and a Youth Governor had been appointed; 20 work experience placements had also taken place.


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The Citizens Assembly had gone from strength to strength and the Memorandum of

Understanding had been approved at Trust Board. The Citizens Assembly had received support from Professor Cooke including presentation of the 2020 Vision Strategy. Posters had been made available to promote membership engagement. The Committee had worked closely with Jamie Emery and the Patient Experience Committee and Mrs Thomas recorded thanks to Jamie Emery and Sandra White and their respective teams. Membership was now in excess of 100,000.

Mr Orriss questioned the validity of 100,000 members, in particular to the cost to the

trust associated with the upcoming governor elections in 2016; there was the need for engaged members rather than it being a numbers game. The Chair advised that Mr Fletcher had this in focus and was looking for engaged membership.

In response to a question from Mr Lydon, Mr Smith advised that a review of

membership data was undertaken every year and any deceased or members who had moved out of area were removed. The Chair noted that the trust did see contested elections and that not all trusts did. Mrs Thomas noted that the Committee was working with Sandra White in order to obtain email addresses to keep postage costs down.

15.079.5 Patient and Staff Experience Committee Mr Kelly gave an overview of the work of the Committee for the year and noted that

Mrs Bell had resigned as Chair. Thanks were recorded to Mrs Bell, Mrs Foster, Dr Catto, Bev Bellerby and the Governor’s for their support. The last two meetings had been cancelled in order that an extraordinary meeting could be held to discuss committee structure and patient experience groups in particular. The question of who would be undertaking ward inspections following the suspension of the CHC Committee was raised, with Mr Kelly adding that the restructuring of the committee structure including ward visits had created a great deal of bad feeling and upset.

Mr Lydon expressed the view that the Consultative Health Council should be re-

instated and they should be allowed to resume ward visits to avoid alienation.

The Chair noted that he was working with Dawn Chaplin and Mrs Foster to get the best outcome for patient care and ensure pace and good will.

Mr Kelly noted that the trust had seen an improvement in the number of DNAs. The Chair recorded thanks to Mr Kelly and Governors who had pursued the reduction of DNAs relentlessly, and noted that the Finance and Strategic Planning Committee considered the financial implications.

Mr Kelly referred to 2 June 2015 CoG minutes and noted that Mr Cattell had agreed

to prepare a report for the CoG Finance and Strategic Planning Committee on income and expenditure incurred for car parking. Mr Cattell advised that Mr Sellars had circulated a report to the Hospital Environment Committee on 9 July and would arrange for this to be circulated to all Governors.

15.079.6 Quality and Risk Committee Dr Pearson gave an overview of the work of the Committee for the year and noted

that it was the largest of the CoG Committees and it met bi-monthly. The Terms of Reference had been reviewed. Mrs Bell and Mrs Steventon had resigned due to being dissatisfied with the remit of the Committee. There had been concerns that reports were buried if there was bad news. It was noted that patient complaints went to Patient and Staff Experience Committee (PEC) and staff complaints go to CoG Quality and Risk Committee; there was no triangulation and the complaints process required review in order that the patient’s voice was heard.


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The Chair advised that Mrs Foster had brought a report to Board held that morning

on the complaints process and this would be presented to the CoG Quality and Risk Committee.

Dr Pearson noted that Dr Rao was an excellent NED and Mr Lydon was a credit to

any Committee he served. The Committee now had a good minute secretary and he recorded his thanks.

15.079.7 Remuneration Committee

Mr Hughes noted that the Committee had met only once to discuss NED remuneration and it had been agreed that this would remain unchanged at £14,123 per annum. Mr Kelly recorded the standard of NEDs was excellent for the modest fee they earned.

15.079.8 Kennedy Task Force Dr Pearson noted that this Committee had been set up because of the issues

surrounding Ian Paterson. The review had been commissioned by the Board and the trust had developed an overarching Integrated Improvement Plan (IIP) that had duplicated other Task Force work streams that included: The Whistleblowing Policy – headed up by Ms Gunter. A Freedom to Speak Up

Guardian needed to be appointed by the trust. The process and avenues including the GMC or CQC were now available to staff to raise concerns had been set out. Concerns were now being raised by staff now they felt more comfortable to do so.

Review of Disciplinary Procedures – the policy had been updated and a team now met monthly to review doctors’ disciplinary investigations. There may be a link between doctors in difficulty and a lax approach to taking patient consent.

Behavioural Based Recruitment (BBR) – key behaviours had been identified and tools developed. BBR had been applied from November 2014.

The trust had lost some Executives during 2014/15 including Dr Newbold, Dr Woolley and Mrs Thomson. The trust needed to ensure it was more patient centred and continually vigilante. The more open and transparent it was as an organisation, the more freely patients and staff would report concerns.

Dr Trotter noted that the issues around Mr Paterson had been flagged at an early stage but the organisation did not act quickly enough. The Deloitte Governance report and the Kennedy report had been a big wake up call. The Chair noted that there is still a considerable legal process to follow therefore no comment on the Ian Paterson case could be made in order not to prejudice him. The Chair noted that at the Board meeting held earlier in the day, it had been formally agreed that the Kennedy Task Force Committee would be disestablished. Mr Kelly expressed that he felt ‘whistleblowing’ was an old fashioned name and a more up to date title was required.

The Chair noted the importance of the work of the CoG Committees and their Chairs and Members, and recorded his thanks.


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15.080 GOVERNANCE ARRANGEMENTS 15.080.1 Appraisal of Non-Executive Directors The Chair noted that the process has begun. In response to a question from My Lydon, Mr Smith advised outcomes of the NED

appraisals had been shared with Governor’s. Mr Orriss suggested CoG Committee Chairs were involved in the process in the future; the suggestion was noted.

15.080.2 Governors’ Attendance Record

The report was taken as read.

15.080.3 Governors’ Governance Review The Chair referred to the Governor’s draft Code of Conduct. Mr Lydon questioned the first sentence of question 10; after consideration the Chair proposed to remove the sentence. The Code of Conduct was approved. The Chair referred to the Governor’s Indicative Training Programme October 2015 to June 2017 and sought approval. The meeting approved the training programme.

15.080.4 Directors’ Attendance Record

The report was taken as read. Mr Orriss referred to the table and requested a minor amendment to Dr Cadigan’s data that should read 13 not 138. Chairs Report The Chair noted this had been circulated and published on the trust website late last week in order to ensure that it was as current as possible. The report was taken as read.

15.081 MINUTES OF PREVIOUS COUNCIL OF GOVERNORS MEETING The minutes of the meeting held on 2 June 2015 and 8 July 2015 were approved as a true record. Mr Orriss referred to Page 48, Para 8, of the minutes of the meeting held on 2 June 2015; Dr Catto has not provided this information. In response to a question from Mr Orriss the Chair noted that all media alerts had been circulated to Governors.

15.082 MATTERS ARISING 15.049 Update - Car park history and situation - outstanding.

All other items had been included within the agenda or had been discharged.

15.083 DATE OF NEXT MEETING

The next meeting will be held 7 October 2015 at Good Hope Hospital.

………………………… Chairman


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3 Feb 2015 15.012

Consider Governor attendance at CoG and Committees with Lead Governor

Chair May 2015

Constitution specifies at 8.11: Governor can be removed from office for failure to attend meetings for a consecutive period of six months but may be excused for ‘reasonable cause’.

4 Nov 15

5 May 2015 15.049

Ask J Gould to prepare report for HEC on solution for clinical staff not being able to get a hot meal after 3.00pm (based on F&SP deliberations).

DC Jun 2015

Report on catering taken to Hospital Environment Cttee 9 Jul 15 – circulated to all Governors by e-mail.

14 Sep 15

15.049

Prepare a full paper on the car park history and situation (BHH and GHH) for the next ‘formal’ meeting.

DC/JS Jun 2015

Report on car parking taken to Hospital Environment Cttee 9 Jul 15 – circulated to all Governors by e-mail.

14 Sep 15

2 June 2015 15.058

Prepare a paper on Birmingham City Council explaining the system wide relationship for the discharge process for CoG Finance & Strategic Planning Committee

DC Sept 2015

Process for discharge and inherent complexities explained to CoG (and in greater detail to Breakfast Meeting on 4 Sep 15).

8 Sep 15

15.058

Report back on whether discharge of patients from Solihull Hospital in early hours was normal or exceptional occurrence

JB Nov 2015

15.059 Content of IM&T overview in IIP to be feedback to J Rex

DC Sept 2015 Completed 8 Sep 15

8 Jul 2015 15.071

Report on status of Car Parking machines at GHH on dispensing change following an increase in parking charges.

DC Sept 2015

Report on car parking taken to Hospital Environment Cttee 9 Jul 15 – circulated to all Governors by e-mail.

14 Sep 15

15.071

Report to CoG Quality & risk Committee on Solihull CCG models of care and planned changes

SF Sept 2015

15.071 Action logs to be attached to all CoG sub Committee minutes

KS Sept 2015

Note issued to CoG Committee secretaries. 8 Sep 15

15.072 Strategy Update to be circulated to Governors when available.

MC/ KS

Sept 2015

CoG F&SPC members sent copy by e-mail. 7 Sep 15

15.073 Circulate list of 26 groups to Governors SF/ KS Sept

2015 List circulated by email. August 2015


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15.073

Chairman to attend CHC meeting on 24 July to facilitate further discussion on taking forward suggested changes

LL Sept 2015

Meeting held and chaired by L Lawrence.

24 July 2015

15.073 Ad Hoc Governor meeting to be held LL/KS Sept

2015 Meeting held. 30 July 2015

7 Oct 2015

Provide high level Finance paper to show pre and post mitigation forecast out-turn for 2015/16

DC Nov 2015

Provide split of staff costs (staff, bank, agency) to provide context (YTD)

DC Nov 2015

Arrange meeting between M Kelly, Chair and BHH car parking manager regarding disabled parking at GHH

KS Nov 2015


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Mohammed Aikhlaq Ap- 7 Ab Ap- 7 Ab Ab

Arshad Begum Ap-1 Ap-1 Ap-1 Ab Ab

Kath Bell Ap - 7

Nicola Burgess Ap-1 Ap - 7

Elaine Coulthard Ap - 3

Olivia Craig Ap- 7 Ap - 6

Carol Doyle Ab Ap-1 Ab Ap-1 Ab

Albert Fletcher Ap - 3 Ap - 3 Ap - 3 Ap - 3

Helen Griffiths Ap - 3 Ap - 4 Ap - 3 Ap - 3

Ron Handsaker Ab Ab

Emma Hale Ab Ab Ap - 7

Richard Hughes Ap-1

Michael Hutchby Ap-1

Susan Hutchings

Richard Holt Ab

Phillip Johnson Ap - 2

Michael Kelly

Attiqa Khan Ab Ab Ab Ap-2

Marek Kibilski Ap- 7 Ap- 7 Ap- 7

Heidi Lane Ap-1 Ap- 7 Ap-7

Andrew Lydon

Anne McGeever Ap - 4 Ap - 4 Ap - 4

Margaret Meixner Ap-1 Ap - 3 Ap - 3 Ap - 3

Catherine Needham Ap-1 Ap-4 Ap-3 Ap- 7

David O'Leary

Barry Orriss Ap- 2

Mark Pearson Ap - 2

Jim Ryan Ab

Elizabeth Steventon Ap-1 Ap-4

Jean Thomas

David Treadwell Ab

Matthew Trotter Ap-6 Ap-6

David Wallis

Board 5 8 8 7 7

Public 3 2 3 2

Key: Ap 1 = No reason stated

Ap 2 = Sickness

Ap 3 = Holiday

Ap 4 = Care Cover Obligations (Child/Elderly/Relatives etc)

Ap 5 = Bereavement

Ap 6 = Unavailable due to change of meeting date

Ap 7 = Other (prior engagement etc)

Ab = Absent (no apology received)

07.10.15NAME 14.04.15 05.05.15 02.06.15 08.07.15 08.09.15 04.11.15 Jan-16 Feb-16 Mar-16

O:\Company Secretarial\Shared Data\Governors\CoG Meetings\2015\12 - 4 Nov 15\10 Governor ATTENDANCE RECORD.xlsx

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Date of Next Meeting:6th January 2016 -Venue to be confirmed

4th november 2015 - hgs.uhb.nhs.uk … · 04-11-2015 · on 4 november 2015 4.00 – 6.00pm a g e...

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