5.30-7.30pm, wednesday 20th december 2017 in the … › corporate › ... · in the education...

GENERAL MEETING OF THE COUNCIL OF GOVERNORS

OF BARNSLEY HOSPITAL NHS FOUNDATION TRUST 5.30-7.30PM, WEDNESDAY 20TH DECEMBER 2017

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL AGENDA

PART 1

1. Apologies & Welcome

2. To invite comments from members of the public

3. To receive any declarations for interest ENC 03

4. To approve Minutes of the Annual General & Public Members meeting held on ENC 04.a 13th September and the General Meeting held on 18th October 2016 ENC 04.b

5. To consider any matters arising from the Minutes of the last General Meeting

6. To receive an update and overview on the Accountable Care System Presentation – Mr B Kirton, Director of Strategy & Business Development

7. To introduce and welcome Mrs Grosvenor, Interim Director of HR&OD Verbal

8. To receive and approve the Mid Year Performance report of Enc 08 the Non Executive Directors – Mr S Wragg, Chairman

9. To receive and approve the Mid Year Performance Report of the Chairman To follow and the Annual Review of the Terms & Conditions of Service for the Non Executive Directors (including the Chairman) – Ms A Moody, Lead Governor

10. To receive a report from the Lead Governor, Ms A Moody ENC 10

11. To receive a report from the Trust’s Chairman, Mr S Wragg ENC 11

12. To receive an update report from the Trust’s Chief Executive, Dr R Jenkins ENC 12

13. To receive latest update report from the Council of Governors’ sub-groups ENC 13 – Mr D Brannan (Chair, Finance & Performance) and Mr T Smith (Chair, Quality & Governance)

14. To receive and note reports from the Board of Directors ENC 14 – latest Board agenda and Minutes (meetings held in public) – latest monthly integrated performance report (month 7) – Horizon Scanning report

15. To consider issues raised by Governors – items highlighted in pre-meeting

16. Any other business, including – matters raised by the public – date of the next General Meeting: Wednesday 14th February 2018, 5.30-7.30pm – schedule of meetings 2018 (attached)

17. To resolve that representatives of the press and other members of the public be excluded from this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest in accordance with 8.13.2 and 8.13.3 of the Trust’s Constitution.

Signed: ………………….. CHAIRMAN

COUNCIL OF GOVERNORS GENERAL MEETINGS 2018

(open to public)

5.30-7.30pm, in the Education Centre

14th February 2018

18th April 2018

13th June 2018

15th August 2018

September – Annual General Public Members Meeting (date to be advised)

17th October 2018

19th December 2018

COUNCIL OF GOVERNORS – DECEMBER 2017 REF: CG/17/12/04.a

MINUTES OF THE ANNUAL GENERAL & ANNUAL PUBLIC MEMBERS (AGPMM) MEETING HELD ON 13 SEPTEMBER 2017

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

Present: Governors Ms K Armitage Public Governor, Barnsley Public Constituency

Ms P Buttling Public Governor, Barnsley Public Constituency Mr A Conway Volunteers Governor Ms H Dixon Staff Governor, Clinical Support

Mr A Grierson Public Governor, Barnsley Public Constituency Mr A Higgins Public Governor, Barnsley Public Constituency

Mr M Jackson Partner Governor, Joint Trade Unions Committee (JTUC) Mr C Millington Partner Governor, Barnsley Clinical Commissioning Group

Ms A Moody Public & Lead Governor, Barnsley Public Constituency Cllr J Platts Partner Governor, Barnsley MBCV Mrs C Robb Public Governor, Barnsley Public Constituency Board Ms J Dean Non Executive Director Dr S Enright Interim Medical Director Mrs K Firth Non Executive Director Mr R Kirton Director of Strategy & Business Planning Mr P Hudson Non Executive Director Dr R Jenkins Chief Executive Mrs K Kelly Director of Operations Mr N Mapstone Non Executive Director Mrs H McNair Director of Nursing & Quality Mr F Patton Non Executive Director Mr S Wragg Trust Chairman

Apologies: Mr P Ardron Partner Governor, Sheffield Hallam University Mr P Lleshi Partner Governor, Barnsley Together Mr S Long Public Governor, Barnsley Public Constituency Ms R Moore Non Executive Director Mrs J O’Brien Public Governor, Barnsley Public Constituency Mr H Patel Public Governor, Barnsley Public Constituency Mr L Pryor Partner Governor, Barnsley College Mr R Raychaudhuri Staff Governors, Medical & Dental Mr R Slater Public Governor, Barnsley Public Constituency Mr T Smith Public Governor, Barnsley Public Constituency

1. WELCOME & INTRODUCTION The Chairman welcomed all attendees: Governors, Directors, patients, members of the public and staff to the Annual General & Public Members Meeting. The meeting was an opportunity to present the Trust’s Annual Report & Accounts for 2016/17, report on progress to date in 2017/18, highlight plans for the year ahead and respond to questions anyone may have of the Board. He also recorded sincere thanks to all the staff who had worked so hard and provided such fantastic care for the hospital’s patients throughout the year.

04.a

CoG: Dec 2017 – 04(a) AGPMM Mins 2017 / page 1 of 5 Pack pg 1

The Chairman emphasised that 2016/17 had been a good year in many aspects. The Trust had achieved its Control Target (CT) – in effect the Trust’s budget, delivered nearly all of its quality targets and, thanks to work led by the teams in the Emergency Department (ED), delivered improvements in the <4 hours emergency access target. He appreciated the continued good work in the current year (2017/18) under the leadership of the new Chief Executive, Dr Jenkins, following Ms Wake’s move to Dudley Hospitals.

1. SUMMARY OF 2016/17 – DR RICHARD JENKINS, CHIEF EXECUTIVE

Dr Jenkins welcomed the opportunity to share reports from 2016/17. He expanded on the Chairman’s introduction. The Trust had done welI in 2016/17; the main challenge now would be to build on that progress for the benefit of patients and staff. He introduced a short video, which showed just some of the excellent care provided by the Trust, the great staff who delivered it every day, a patient’s story to illustrate the impact on patients who remained at the centre of the Trust’s work and its aspirations for the future. The patient’s story had been heard by the Board previously; it was a striking story and Dr Jenkins was proud to say that the level of care it showed was evident every day from staff across the hospital. Dr Jenkins gave a brief overview of the Trust’s progress to date, including continued improvements in ED, achievement against cancer waiting times, reductions in cancelled operations, continued good performance in Infection Prevention & Control, achievement against financial targets, delivery of the efficiency programme for the third consecutive year and reduction in agency spend year on year (which was also indicative of good progress in Consultant appointments throughout the year). The Trust’s main aim, however, continued to be improving services for patients and patient experience. He was pleased to report on the Trust’s improved rating from 3 to 4.5 (out of 5) on the NHS Patients’ Choice website and the largely positive feedback on social media in addition to the formal compliments received. It was acknowledged that the Trust also received complaints and negative feedback – all of which was reviewed to both address the concerns raised and identify learning for the Trust, again helping to improve services. Dr Jenkins emphasised the importance of staff feedback too, which was generally positive but which he was keen to improve further so that staff enjoyed working at the hospital, wanted to stay here and would encourage friends to join too.

2. ANNUAL REPORT & ACCOUNTS 2016/17 The Annual Report & Accounts were presented, copies were available at the meeting and on the Trust’s website. Dr Jenkins introduced several members of the Board of Directors, who expanded on key sections of the report: Mrs McNair and Dr Enright gave an overview of the progress and developments around quality, patient safety and clinical improvements. Continued focus on quality and safety had helped to deliver improvements (reductions) in hospital acquired pressure ulcers harm from falls, which many patients – particularly the frail or elderly – were susceptible to. Mrs McNair stressed that the improvements in these two critical areas over the past year had been notable. Other areas in which valued progress had been seen included medication errors (just two incidents above the Trust’s internal target) and infection rates (MRSA Bacteraemia at zero and Clostridium Difficile below target, which was good). Dr Enright emphasised improvements in other aspect of care including Acute Kidney Injury (as highlighted in the patient story featured in the video) and sepsis, with nearly 100% of patients now monitored on admission via the ED – all of which were helped by new tools such as the VitalPAC system, enabling staff to monitor patients more easily and identify deteriorating conditions more quickly. The developments and service improvements built on progress from previous years too, the benefits of which were evidenced in the delivery against national targets, improvements in mortality ratios and feedback from patients. Mrs Kelly focused on the Trust’s performance against key national and internal indicators. Like all hospitals with an ED, the Trust continued to face a huge challenge in terms of demand on services with numbers of non-elective (unplanned) attendances continuing to grow. Nevertheless the Trust had attained 91.5% for the emergency access <4 hours target for 2016/17 and, more recently achieved 95% (national target) on a daily basis. The Trust also consistently performed well on important issues such as the 18 weeks referral to treatment target and cancer services. Mrs Kelly emphasised that it was not a matter of working to deliver targets for their own sake but to deliver better services for patients, ensuring they received the right care at the right time as much as possible.


The Director of Finance, Mr Wright, outlined progress year on year. The Trust had ended in a difficult position in 2015/16 and seen considerable improvement for 2016/17, exceeding its Control Target of -£8.1 million and consequently receiving an additional £1.5 million from the Sustainability & Transformation Fund as a combination of bonus and incentive funding, resulting in a year end final position of -£6.6 million. He outlined some of the key contributors to this success, including clinical income and expenditure controls. The year ahead would be challenging with a deteriorating plan of -£10.1 million, reflecting national changes on tariff and the continuing impact of insurance premia. To meet this challenge, the Trust faced a large cost improvement programme (£7.8 million) and some tough targets from the Sustainability & Transformation Fund, with which it is already making good progress. Mr Kirton gave an overview of the Trust’s strategies that would help to deliver the financial plan and the service improvements in 2017/18. He stressed that the hospital could not deliver this on its own and would be working closely with partners across the local community and the wider South Yorkshire region. Service developments in year had seen an increase in market share of nearly 10%, underpinned by close working with local partners to deliver a better service overall. He highlighted some of the key areas of focus for the Trust in 2017/18 to continue to deliver it vision of better services across Barnsley. These would include changes in intermediate care, primary care support at the hospital’s front door and a new integrated respiratory service going live shortly.

3. GOVERNORS’ REVIEW OF 2015/16 – ANNIE MOODY, LEAD GOVERNOR It was her first year as Lead Governor and Ms Moody was pleased to report on just some of the work of the Council of Governors in 2016/17. Ms Moody reminded attendees of the key roles and responsibilities of the Governors: to hold the Non Executive Directors to account, ensuring they scrutinised, challenged and oversaw delivery of the plans and improvements outlined above. She highlighted some of the work already being progressed in 2017/18 too. Ms Moody also took the opportunity to record a note of thanks to Mr Joe Unsworth, who had been Lead Governor for over eight years before stepping down at the end of December 2017. She urged public and staff members of the Trust to consider putting themselves forward as Governors: it was a vital role, giving valued support to the hospital and a voice to local people. The next annual elections were due to start in October for five public Governors and a number of staff seats.

4. THE YEAR AHEAD 2017/18 – DR RICHARD JENKINS, CHIEF EXECUTIVE 2016/17 had been year three of a five year plan and the Trust was already a considerable way into 2017/18. Dr Jenkins drew attention to the papers distributed on the chairs, showing the strategic objectives for 2017/18 and key areas of focus for the year. He also outlined the good progress in many of these areas to date. The Trust was not complacent and was already working to refresh its plans to look ahead a further five years.

Presentation of the Annual Report & Accounts ended with a video of some of the Trust’s staff who had recently completed the ‘Talent’ programme, an internal training initiative and good example of how the Trust supported and developed its hard working and valued staff – without whom the hospital could not succeed.

5. QUESTIONS Questions and comments were invited from the audience.

• A representative of Barnsley Save our NHS expressed concerns regarding increases in privatisation in the NHS nationally and asked about the Trust’s plans for its subsidiary company – Barnsley Facilities Services Limited (BFS) – and orthopaedic surgery work undertaken, he believed, by a private firm at weekends.

The Chairman assured the meeting that BFS did not represent privatisation in any form. It was a wholly owned subsidiary of the Trust, with staff transferred on the same terms and conditions as those directly employed by the Trust, with the right to retain those terms and conditions whilst they held the same role within the company. New staff joining BFS would have different terms and conditions but they were not intended to create a low paid workforce as had been suggested. As part of the hospital group, BFS’s ability to operate under private sector rules would provide savings and efficiencies that would benefit the Trust overall.


With regard to the work of Orthohealth, Dr Jenkins advised that this organisation was made up almost exclusively by the Trust’s own staff taking on additional work over and above the Trust’s core contracted work and thus helping it to deliver additional services and benefits for patients. He confirmed that it was not providing services for private patients.

• A member of the public referred to the planned service changes in the ED and asked if this might put the town at risk of ending up with an urgent care centre - rather than an A&E - and also how people attending the newly structure unit would be assessed before being directed into either the hospital or an on site GP for care.

The Chairman explained that assessment for GP or hospital treatment was already happening in the ED but whereas the former had previously been delivered by a private organisation, it would be delivered by NHS providers in future. The new system would provide closer working between the ED and GPs and a more comprehensive service for patients. It would not mean any cuts in the ED, on the contrary staffing and services in the ED had grown recently.

• Partner Governor Mr Millington highlighted the progress on Sepsis. The Chairman acknowledged that this had been an area of concern for the Trust previously and was pleased to reiterate the notable and sustainable improvements featured in the presentation and the published Annual Report & Accounts. He stressed that the Trust did not consider the work completed and would continue to embed the improvements achieved to date and look for further developments.

• Public Governor Mr Grierson queried the challenging financial position in view of the recent announcement by the Government of its intent to give pay rises for nurses. He agreed that the pay rises would be fully justified but would add to the pressures.

It was clarified that the Government had announced its intent to relax the current 1% cap on pay rises in 2018/19, which would not impact on the current year but the Chairman advised that the Trust shared Mr Grierson’s concerns about the impact on future funding and would be looking at the implications with care.

• Mr Unsworth, former Lead Governor, thanked the Board for a good annual report & accounts. He had been pleased to see the continued focus on patient safety. He did, however, share the concerns of a lot of local people about the impact on Barnsley of the national plans for the Sustainability & Transformation Programme (STP) and Accountable Care Systems (ACS).

The Chairman stressed that ACSs did not comprise constitutional bodies so decisions for the future remained with the Boards of the varying trusts – all of whom would continue to have the best interests of their patients at the centre of every decision. Dr Jenkins was conscious that Barnsley was an area facing considerable deprivation and high healthcare needs; the Trust supported the aim for more ‘joined up’ care and the changes that could be delivered through the STP and ACS would help to deliver that.

Discussions on the STP and ACS widened. It was acknowledged that the intent was to standardise good quality care across the region: ensuring patients received the right care, in the right place, at the right time. There was a considerable gap in funding across the South Yorkshire & Bassetlaw region – c£570 million. It was anticipated that working within the STP and ACS could help organisations across the patch work together more effectively, using resources more efficiently, delivering a seamless service between primary and secondary care. Dr Balac, Chair of the Barnsley Clinical Commissioning Group, was currently Chair of the local ACS Delivery (shadow) Board. He stated that the opportunity of working together more closely would give the best opportunity for the people of Barnsley to get the best value for the Barnsley £ through closer working across the healthcare services. To do nothing was not an option: the pace would continue nationally.

• Mr Conway, Governor representing the Trust’s volunteers, spoke as both a Governor and a patient. He had experienced very good treatment as a patient but also greatly appreciated the kind word and smile given so freely by the Trust’s staff. He recounted a recent sad experience where a patient had died on a ward; the staff had rushed to give treatment but had also extended care and support for the other patients in the area mindful of the impact on them too. It was often that extra care and attention that Barnsley Hospital staff gave so readily that made a real difference to patients.


6. CLOSE OF MEETING The Chairman thanked everyone for attending and for showing their interest in the Trust. He reiterated heartfelt thanks to the staff, members, governors, members of the Board and volunteers – and the general public – who continued to give so much support to the Trust.

The Chairman asked anyone who wanted to become more involved to become a member of the Trust and consider standing for election themselves, or to think about joining the Trust as a volunteer or working with the Hospital’s charity.

There being no further business, the meeting closed at 11.40am.

Attendees were reminded of the summer fete following the meeting. The stalls had been moved indoors due to the inclement weather.


COUNCIL OF GOVERNORS – DECEMBER 2017 REF: CG/17/12/04.b

04.b

MINUTES OF A GENERAL MEETING OF THE COUNCIL OF GOVERNORS HELD ON 18th OCTOBER 2017, 5.30PM

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL Present: Mr P Ardron Partner Governor, Sheffield Hallam University

Ms K Armitage Public Governor, Barnsley Public Constituency Mr D Brannan Partner Governor, Voluntary Action Barnsley Ms H Dixon Staff Governor, Clinical Support Mr A Grierson Public Governor, Barnsley Public Constituency Mr A Higgins Public Governor, Barnsley Public Constituency Mr M Jackson Partner Governor, Joint Trade Union Committee

Mr P Lleshi Partner Governor, Barnsley Together Mr S Long Public Governor, Barnsley Public Constituency

Mr C Millington Partner Governor, Barnsley Clinical Commissioning Group Ms A Moody Lead & Public Governor, Barnsley Public Constituency Cllr J Platts Partner Governor, Barnsley MBC Mrs C Robb Public Governor, Barnsley Public Constituency Mr F Skorrow Public Governor, Barnsley Public Constituency Mr R Slater Public Governor, Barnsley Public Constituency Mr S Wragg Trust Chairman

In attendance: Dr K Baker Acting Deputy Director of ICT * Ms C Dudley Secretary to the Board & Governors Mrs D Edwards Associate Director of Nursing, CBU1 * ± Mrs K Firth Non Executive Director Mr S Garside Associate Director of Operations, CBU1 * ± Dr R Jenkins Chief Executive (CEO) Ms R Moore Non Executive Director * attended for part of meeting ± CBU = Clinical Business Unit

Apologies: Ms M Bailey Public Governor, Barnsley Public Constituency Mr A Bogg Public Governor, Barnsley Public Constituency Mrs P Buttling Public Governor, Barnsley Public Constituency Mr T Conway Staff Governor, Volunteers Mr T Dobell Public Governor, Barnsley Public Constituency Ms K Kanee Public Governor, Barnsley Public Constituency

Ms G Morritt Staff Governor, Nursing & Midwifery Mr H Patel Public Governor, Barnsley Public Constituency Mr L Pryor Partner Governor, Barnsley College Mr R Raychaudhuri Staff Governor, Medical & Dental

CG 17/72 APOLOGIES AND WELCOME The Chairman welcomed Governors, public and attendees to the meeting. Apologies were noted as above.

ACTION

CG 17/73 COMMENTS FROM THE MEMBERS OF THE PUBLIC None.

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CG 17/74 DECLARATIONS OF INTEREST Mr Higgins had recently been appointed as a Trustee at Barnsley Hospice; this would be added to the Register of Governors’ interests. No other declarations were received.

CG 17/75 MINUTES OF THE PREVIOUS GENERAL MEETING (Enc 04) The Minutes of the General Meeting held on 16th August 2017, were reviewed and accepted as a true record.

CG 17/76 MATTERS ARISING Several matters arising from the previous meetings were noted:

• CG 17/65 – Freedom to Speak Up (FTSU) Guardian It was noted that Mr Nick Mapstone had recently taken on the role of Non Executive lead for FTSU.

• CG 17/66 – Chairman’s Report It was noted that work had continued to address the current system preventing public Governors from also supporting the Trust as volunteers. This could be addressed simply and quickly but the Constitutional implications would be reviewed to ensure the approach was correct.

• CG 17/67 – CEO’s report Dr Jenkins advised that the final outcome from the ongoing review of Hyper Acute Stroke Unit was due to be reported at a meeting for the regional Accountable care System (ACS) shortly and would be reported at a subsequent public meeting shortly thereafter.

CG 17/77 EMERGENCY DEPARTMENT (ED) (Presentations) a) ED Dashboard

Introducing the new ED dashboard, Dr Baker emphasised the value of forecasting and data analysis – helping to ensure the right information, reached the right people at the right time in the right way. This was increasingly vital and the Trust had commenced work on a central resource: a reporting portal, intended to help front line decision making at the right time. Whilst initial focus had concentrated on supporting the ED, the system would be equally useful across the site and would be rolled out shortly to key areas such as the Acute Medical Unit and support services too, including Pharmacy. The portal would link into VitalPAC to assist capture of latest data. Other developments also being progressed included live “Wall Boards”, which could be used in the ED waiting room as well as on wards and clinical areas, options for more mobile reporting - increasing operational efficiencies, and patient accessible data. Dr Baker presented a brief overview of the dashboard. He was pleased to advise that the success of the dashboard had been recognised beyond the hospital, having been shortlisted for a national Health Technology Award. Governors congratulated Dr Baker on the progress and innovative approach and fully endorsed the aim of data sharing to support service delivery. It was agreed that effective IT was both exciting and essential for the future and it provoked a wide range of questions and comments.

CoG Mins Oct 2017/p2 of 10

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• Mr Millington enquired if the Trust’s profitability could be monitored by the new approach as well as its performance. Dr Baker advised that his team was working with the operational teams to look at productivity and explore how it could be measured better, helping to deliver both efficiencies and service improvements – eg improved clinic utilisation in Outpatients.

• Mr Brannan asked if the Trust might be able to sell the some of the innovative developments to other users. Dr Baker advised that the Trust was a leader in several aspects (hence the Award shortlisting) and this would be looked at in the future. At this stage, however, the focus was very much internal, to deliver improvements locally.

• Mr Lleshi welcomed the developments outlined. He asked if future developments would include apps on mobile phones how accountability had been addressed as a consequence of additional data becoming more freely available and if there would be cost efficiencies in comparison with existing systems. Dr Baker affirmed that there would be a structured approach to ensure that both access and accountability were addressed properly with the right data being available to the right people. He also advised that whilst the Trust had the ability internally to build apps, this was time consuming and it would be more practical to look to providers of existing models. In terms of efficiencies and improvements, he referred to new systems within Pharmacy and Medicines Management as good examples.

• In response to Mr Slater, Dr Baker reconfirmed that the system and data sharing was currently aimed at internal uses although the Trust did share some secondary service data and had also given presentations on the dashboard to partner organisations and other interested parties.

• Mrs Armitage was conscious of information already in the public domain, citing recent BBC reports as examples. It was confirmed that these would have been compiled from data submissions required centrally, the outcomes of which were published nationally.

• It was recognised that, as pointed out by Cllr Platts, data would be dependent on accurate inputting, which could be problematic when staff were busy. Dr Baker confirmed that accurate and timely inputting was critical, particularly with the system being refreshed every few minutes.

• From a staff perspective, Ms Dixon highlighted the need for sufficient devices for access; her team had limited access to VitalPAC due to a lack of units. Dr Jenkins undertook to look into this as additional devices had been purchased.

• Mr Jackson expressed his support for the new system; he had recently had direct – and very positive – experience of the dashboard in ED. However, he flagged the need for quality as well as efficiencies to be supported. If a patient needed treatment on ED beyond the national <4 hours target, it would be good to see that featured as a priority on the system rather than being assessed as a performance issue. He was also keen to see the Trust become paperless and asked when this might be achieved. Dr Baker

RJ


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welcomed both points and agreed that they were equally important and were key factors for the development programme. Mr Skorrow reported on his personal experience with a family member being cared for in ED. The patient had needed treatment in the unit beyond the national 4 hours target and he had not seen any pressure to move her out. The Chairman reiterated the Board’s stance that quality of care and patient safety must always be the first priority.

Dr Jenkins echoed the Governors’ views regarding the impressive work being led by Mr Davidson, Director of ICT, Dr Baker and the ICT team. He agreed that further development was needed not just in terms of measurability but driving and delivering performance improvements too. He would also like to see data being used more proactively in terms of planning (clinics and theatre times etc) and was pleased that work was progressing on this as well. The meeting was reminded that IT systems can fail; Ms Moore had seen the impact of this in NHS Scotland when the systems had suffered a total breakdown. It was acknowledged that, despite best efforts, system failure would always remain a possibility but the Chairman and Dr Baker outlined some of the back-up systems in place to maintain data security and support quick recovery. Dr Baker was thanked for a very insightful and informative briefing. Governors reiterated their full support for the progress to date and proposed developments.

b) Primary Care Streaming In their presentation, Mr Garside and Mrs Edwards reminded the meeting of the national drive to meet the 95% target (<4 hours emergency access) by the end of March 2018. This tough target had been supported with some national funding, against which the Trust had successfully submitted a bid and received c£340,000 matched funding. This was being used to develop a new service model at the hospital’s front entrance - providing a single point of access for both ED and primary care. Mr Garside and Mrs Edwards outlined the work undertaken to secure primary care services, with I-Heart Barnsley co-located in the ED alongside the hospital’s own emergency services, giving a broader service for patients. Building works had started at the beginning of October; this had caused some disruption around the entrance but would be largely completed in December. The new service would be operational from 4th December. The plans had required some departments to give up space – with particular thanks to therapy – but co-operative working with other teams had identified some good solutions. It was emphasised that the aim was to provide a streaming/navigation reception: one desk assessing and directing patients to the right area for treatment – primary care or emergency services. Preparation had entailed a lot of hard work from and collaboration with primary care and the Trust’s own staff to develop the right protocols and flowcharts. The outcome will improve the patient pathway, with a single entrance for all needs. Governors asked several questions about the service:


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• Mr Millington assumed learning had been sought from Luton & Dunstable Hospitals (LDH), which were nationally recognised as an exemplar in A&E performance. Mr Garside confirmed that representatives from BHNFT had visited the other trust. LDH offered a GP service (albeit outside the A&E department) and collaborative working between primary and ED care; the Trust’s plans for decision making and streaming reflected some of the learning from the visit.

• In response to a question from Cllr Platts, it was confirmed that patients using the new service would be able to take their prescriptions to an external chemist.

• Mr Long enquired if the reduced space for departments such as physiotherapy would be detrimental to patients using those services. Ms Dixon, a Clinical Lead in therapy services, acknowledged that this had been a concern initially but utilisation of the lesser space had been reviewed and changed, enabling better functionality and improved working systems.

• Mr Ardron appreciated confirmation that there would be a formal evaluation of the new streaming service. Mr Garside explained that a comprehensive assessment of the benefits was required to demonstrate good use of the external funds received in addition to the internal evaluation required by the Trust.

• Mr Grierson was pleased to receive confirmation that the plaster room would be located close to the fracture room.

• In response to a further question from Mr Grierson, it was confirmed that children’s and Adults’ A&E services would remain separate albeit a bid had been submitted to support improvements for this too (outcome awaited).

Ms Moody advised that she had been invited to attend some of the project meetings as a governor representative. She had been impressed by the determination and willingness of everyone to make it work, as illustrated by the feedback from Ms Dixon, and to find a better solution for Barnsley. The Chairman agreed with Mr Lleshi’s observation that there were difficulties in primary care services in the Borough; demands on primary care were huge and there was a growing call for more out of hours services, with many people consequently turning to emergency services for quicker or more timely access. It was anticipated that the new service would bring benefits to the ED, primary care and, most importantly, Barnsley patients. Before leaving the meeting Mr Garside and Mrs Edwards were thanked for attending and providing an informative overview of the planned new service. Governors looked forward to hearing more as the service progressed. Dr Baker left at this juncture too.

CG 17/78 LEAD GOVERNOR’S REPORT (Enc 7) Ms Moody presented and briefly expanded on her report, which gave an overview of her activities as Lead Governor since the last General Meeting. She drew attention to the Talent Management event, which she and Mr Long had attended together with the Chairman. It was a great occasion to


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recognise the achievement of the staff involved with the programme. The only reservation had been the predominance of white female staff; whilst everyone was valued, it would be good to see wider representation from staff. Dr Jenkins confirmed that this had been recognised and work had already commenced to try to attract a more diverse intake. Ms Moody reminded Governors of the annual elections due to start shortly. She would also welcome ideas for the 2018 Annual Development Session. In addition to the items in her report, Ms Moody advised that the Chairman’s mid year performance review would commence shortly. Whilst this would be led jointly by the Senior Independent Director and herself, and reported via the Nominations Committee, input would be welcomed from all Governors. It did not have to be submitted formally, reflecting the ‘light touch’ approach adopted for the mid year review as usual.

ALL

CG 17/79 CHAIRMAN’S REPORT (Enc 8) The Chairman’s report on his actions and items of interest since the last General Meeting was received and reviewed. He too referred to the elections and reiterated his thanks to those Governors whose terms of office would terminate on 31st December. He hoped they would seek re-election and asked all Governors to encourage their friends, families and colleagues to consider standing for election too. The Chairman invited Governors’ interest in: a) the Constitution review group, the first meeting of which would be held on

21st November. More details would be circulated by email shortly b) the Outpatient Steering Group Any Governors interested in either or both of the above were asked to contact Ms Dudley.

CED

ALL

CG 17/80 CHIEF EXECUTIVE (CEO) REPORT (Enc 09) The CEO’s report was received and reviewed. Dr Jenkins highlighted and expanded upon a number of points: • Mrs Kelly’s move to Dudley Hospitals at the end of 2017. The Trust had

appreciated her input since joining in 2014. Dr Jenkins advised that work would commence shortly to review the structure of the Executive Team subsequent to Mrs Kelly’s departure;

• the appointment of Dr Enright as substantive Medical Director following recent interviews. Finalisation of Dr Enright’s appointment would be subject to NHS Improvement (NHSI) opinion;

• the arrival of the Care Quality Commission (CQC) inspection team. The team would be on site for 2-3 days, focussing on A&E, medicine, surgery and paediatric services;

• the Hospital Services Review, with five areas for review to be announced formally on 23rd October: Urgent & Emergency Care, Women’s & Maternity Services, Paediatrics, Stroke services (non hyper acute) and gastro services (including endoscopy). The five streams had been chosen based on quantitative and qualitative assessment and the Trust would be involved with the working groups in each one. Reports from the review(s) were due in March 2018.


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Dr Jenkins outlined the Trust’s position; he was confident that the Trust offered good services in four of the five areas. Governors were aware that Stroke had been adversely impacted by the outcomes from the earlier review of hyper acute services, with most of the other trusts across South Yorkshire similarly placed. Dr Jenkins confirmed that urgent work was ongoing collectively to attract more stroke consultants into the region;

• performance against the <4 hours emergency admissions target, which had been good in quarter 2 but dropped off in October due to a marked increase in demands over the past few weeks and a year on year uplift in admission levels. Other factors had also impacted including the changes in intermediate care services (now located on the BHNFT site but currently managed by another provider) and an outbreak of an antibiotic resistant bacteria, which had been addressed swiftly;

• involvement with the NHSI’s “moving to good” programme, which could provide some useful learning;

• involvement with the national programme for supporting NHS whistle-blowers returning to work;

• relocation of the Patient Advice & Liaison Service desk, back to the front of the hospital before the end of October. This was appreciated by the Governors.

Dr Jenkins also outlined actions being progressed in response to some problems identified in patient pathway reporting recently. He explained that the Trust’s performance against referral to treatment (RTT) times was monitored closely and generally good. Not all pathways were counted as RTTs but a recent review had identified that some patients’ pathways had been coded incorrectly due to a system error and consequently excluded from the RTT count. To date the records of 900 patients affected had been validated, of which most had been verified as correct exceptions; the reminder would not have significantly changed the Trust’s RTT compliance data. More importantly, however, no harm to patients had been identified. Nonetheless the issue had been declared as a serious incident and been reported to the CQC and NHSI. A second issue had also been identified when, through human error, some patient pathways had been closed that should not have been. The review to date had found two patients at 52 weeks, neither of whom had resulted in harm but the Trust would be liaising with them to determine the best way forward and to apologise for the unnecessary delay. Work would continue to validate all patients and systems had been revised to ensure the situation could not recur. The Governors appreciated the information provided. The CEO also responded to a number of issues raised by the Governors, including: • welcome feedback received from Mr Grierson, whose granddaughter had

recently had a baby at BHNFT. Mr Grierson was pleased to share very good reports of the hospital’s services;

• Mr Higgins had attended the ophthalmology service earlier in the month and had noted a lot of very positive comments from other patients in the department. He asked about any problem on the injection room. Dr Jenkins advised that the minor operations room was now open and he undertook to check progress of the other room too.

RJ


Pack pg 12

• Cllr Platts enquired about the rationale for plans to reduce intermediate care beds. Dr Jenkins explained that the decision to do so had been made by the commissioners after careful review, following which a number of changes had been proposed to ensure more care was provided at or nearer to patients’ homes, with services at similar levels to the current provision but via a different structure. Ms Dixon also referred to the planned change from a nurse-led to therapy-led model. Whilst this was making progress, as a member of the therapy services she would appreciate more information on which CBU the new service would be aligned to and under which management team. Dr Jenkins was keen to learn more from Ms Dixon regarding her thoughts on the way forward and it was agreed it would be useful to meet shortly. He emphasised, however, that the CBU alignment should not affect the overall changes or anticipated benefits as the ward should not be seen in isolation to other services and patient flow.

• Mr Slater had recently been able to offer support in the ED and had observed some poor practice around the laundry services, with bags falling to the floor, giving rise to the risk of tripping. Mr Jackson also commented on a deterioration in laundry services overall from the new provider. Mr Higgins was surprised as he had observed the tender exercise for the new services, which had been very clear on the (increased) standards expected. Dr Jenkins undertook to follow up both aspects raised.

Governors’ feedback and comments were appreciated and noted.

RJ/HD

RJ

CG 17/81 SUB GROUP REPORT (Enc 10) The report on the latest activities of the Quality & Governance (QGSG) and Finance & Performance (FPSG) sub-groups was noted. Both sub-groups continued to be very effective and well attended by both Governors and Non Executive Directors. Mr Brannan, Chair of FPSG, highlighted the Trust’s flu vaccination campaign and reminded Governors that they were eligible to take part. The next vaccination session was scheduled for 23rd October; more dates would be announced through the Hospital Buzz. On behalf of its Chair (Mr Smith), Ms Moody expanded on the report from the latest QGSG meeting. Governors had focussed on a presentation from the Director of Nursing & Quality and Deputy Director of Nursing, giving an update on nursing and midwifery developments and leading to a wide ranging debate on pathways and nursing in general. It had been a very interesting meeting.

CG 17/82 BOARD OF DIRECTORS (Enc 11) The latest agenda (October), approved Minutes (September), Integrated Performance Report (IPR) and Horizon Scanning report presented at the Board of Directors meeting held in public in October 2017, were received and noted. With reference to the Minutes, Mr Ardron advised that “Physician Assistants”, should read as Physician Associates (PAs). He also reported that he was involved with some of the related work being led by Health Education England (HEE) and was aware of some concerns shared by universities and employers that people were being trained for these new roles but they were not factored into future workforce plans. Dr Jenkins


Pack pg 13

advised that the Trust would be employing four PAs, rotating across the hospital and community; the Trust would be putting a lot of support in place for the candidates. Mr Millington sought more information on the Trust’s plans for e-prescribing. It was confirmed that the earlier plans had been deferred in order to enable the Trust to look at the needs of its electronic patient record (EPR) system more holistically. The Trust was mindful that the current EPR contract would expire in 2020; it was timely to review the position in readiness. Dr Jenkins assured Governors that the Trust remained sighted on related concerns and advised that a joint audit of D1s (discharge letters) was ongoing with the Clinical Commissioning Group (CCG); the Trust’s response to the outcomes would be led by Dr Enright. Mr Brannan welcomed the new approach to IT, which he hoped would also help to address staff’s continued concerns about the existing system. Mr Jackson and Mr Skorrow agreed that the current system had proved very unpopular with staff and staff believed it had failed to deliver the benefits promised. The Chairman was pleased to highlight the changed approach to IT, led by Mr Davidson, which would ensure greater staff engagement with and input to plans for future changes. Mr Jackson welcomed the open sessions and workshop being hosted by Mr Davidson. The Chairman also reminded members that Mr Davidson was the community-wide lead on IT too, which would help to ensure good alignment with partners too where appropriate. In relation to IT systems, Mr Higgins asked if a decision had yet been made on the preferred system in Ophthalmology. Dr Jenkins undertook to follow this up and respond shortly. In response to a query from Mrs Armitage, Dr Jenkins advised that the Cost improvement programme (CIP) would be subject to further scrutiny at the Finance & Performance Committee meeting on 21st October, as part of the Trust’s six month performance review. Latest data showed the CIP on track, having pulled back from an earlier deficit and ahead of the position at this time in 2016.

RJ

CG 17/83 ISSUES RAISED BY GOVERNORS It was confirmed that all issues had already been covered in earlier discussions.

CG 17/84 ANY OTHER BUSINESS • Comments from Public

No public present • Any other issues

The Chairman advised that tickets were now on sale for the Trust’s Christmas Ball on 1st December 2017. 100% of any profits would go to the Hospital’s Charity. Mr Skorrow advised that, for family reasons he would not be seeking re-election at the end of December and was unlikely to be able to attend another Governors’ meeting before stepping down. He thanked everyone for their support. Speaking for the meeting, the Chairman thanked Mr Skorrow for his contribution to the Council of Governors; it had been greatly valued and he would be missed.


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CG 17/85 PRIVATE AGENDA There being no members of the Public present, the meeting received and reviewed the Minutes from the Council of Governors’ discussions held in private on 16th August 2017. There were accepted as an accurate record. There were no matters arising.

CG 17/86 DATE OF NEXT MEETING The meeting schedule for 2018 was reviewed and accepted. The date of the next General Meeting was confirmed for 20th December 2017, 5.30-7.30pm. Governors were reminded that they were invited to attend and participate in the next meeting of the Board of Directors on 2nd November – public and private sessions. There being no further business the meeting closed at 7.35pm.


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COUNCIL OF GOVERNORS – DECEMBER 2017

REF: COG/17/12/08

NON-EXECUTIVE DIRECTORS’ MID YEAR END APPRAISAL

/ PERFORMANCE REVIEW (2017/18)

1. INTRODUCTION 1.1 Following agreed protocols, and in accord with Monitor’s1 guidance, as Chairman of

the Trust I have led the mid-year appraisals for the Non-Executive Directors (NEDs). 1.2 As the report is intended to give a review on the NEDs’ performance in 2017/18, it

focusses on the NEDs in post during that period who have continued in their appointments this year. Proposed objectives for the NEDs for 2017/18 have not yet been agreed, with the exception of Ros Moore, as they fall out of my objectives, which have only recently been agreed as the process was concluded in October.

1.3 With the refresh of NEDs on the Board we now have a relatively inexperienced team, who nonetheless are performing very well as a team. Although the newest NEDs have settled in very quickly and making excellent contributions to the governance of the Trust. The experience in the team and the corporate knowledge comes from Francis Patton and this is invaluable in steering the team through the issues that will arise in 2017/18.

1.4 This report is based on a fuller briefing shared with and scrutinised by the Nominations Committee at its latest meeting, in November.

2. NED PERFORMANCE 2.1 Mid-Year Review

My mid-year review of the NED team for 2017/18 affirmed that – with no exception – all of the NEDs have continued to work effectively and are making valuable contributions to the Board of Directors and business of the Trust. The NEDs have a diverse range of skills, strengths and experience, which collectively make them a strong, well balanced and effective team. I considered each NED’s performance in governing the Trust against the corporate objectives for the year and confirmed that progress had been good. In terms of development, I continue to urge all of the NEDs to increase their engagement with staff and governors, particularly by greater attendance at Governors’ general and sub-group meetings. In my view this is better than it has ever been and I look forward to this improving again in the coming year.

2.2 An ongoing development need is to increase the local knowledge of the NEDs, regarding the health needs of the community, health inequalities and the culture of the borough as a whole – over and above statistical data provided in the course of their work with the Board. This improved in 2017 with the appointment of a NED who lives in the borough and she and I continue to share our local knowledge as much as possible.

2.3 Fuller reports on the individual performance and progress of each NED were shared with the Nominations Committee in November and were wholeheartedly endorsed. The Committee agreed that all of the NEDs have delivered another strong

1 Monitor now operating as part of NHS Improvement

08

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performance throughout the year to date and that collectively they continue to work extremely well as a team, bringing valuable skills and experience to the Board and the wider Trust.

2.4 Objectives The Non-Executive Directors’ objectives for this financial year will be related to my objectives, now that they are finalised, as agreed by the Council of Governors.

3. RECOMMENDATIONS

The Council of Governors is asked to endorse the outcome of the Non-Executive Directors’ Mid-Year appraisals for 2017/18

Stephen Wragg CHAIRMAN December 2017

COG Dec 2017: NED MYR (p2 of 3)

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LEAD GOVERNOR’S REPORT

1. INTRODUCTION 1.1. This report provides a brief overview of my activities as Lead Governor, on behalf of the

wider Council of Governors. 1.2. I have been Lead Governor at Barnsley Hospital (BHNFT) for twelve months now and

during that time I’ve learned a lot and thoroughly enjoyed an interesting and varied year. I’ve also been a Public Governor for nearly three years and am coming to the end of my first term but would like to continue, provided I am re-elected to the role. We will know the position at our General Meeting, when the election results will be available.

2. ACTIVITIES 2.1. Internal meetings

I have attended a number of meetings of the Council of Governors and Sub Group Meetings:

- annual joint meeting of the Board and Governors on 2nd November This was an interesting meeting, well attended by Governors, giving us a welcome chance to join in the debates and ask questions direct of the Executive Team and Non Executive Directors.

- Finance & Performance sub-group meeting 8th November More information on which is noted in the sub-group report (agenda item 12).

- Governors’ Training Session on 15th November This was a very topical presentation from, and discussion with, Bob Kirton on the Accountable Care System moving forward.

- Quality & Governance sub-group meeting More information shared under agenda item 12.

2.2. With other Governors, I attended a meeting of the Constitution Review Working Group on 21st November, and also the Nominations Committee on 28th November – papers outlining the discussion etc. will be tabled elsewhere on the Agenda.

2.3. Community events It was an honour to attend the Remembrance Day Service on Sunday 12th November at Barnsley Town Hall War Memorial along with our Chief Executive Dr Richard Jenkins, and lay a wreath on behalf of the Hospital.

2.4. Regional events I was pleased to attend a South Yorkshire & Bassetlaw Foundation Trust Governors’ Conference along with several other Governors on 27th October. This was an opportunity to meet and share news and views with Governors from other trusts across our region, and hear more about health and social care working together in South Yorkshire & Bassetlaw in the future.

2.5. This is a time of huge change in the NHS and it was good to hear more about the work to date and plans moving forward. Governors will have an important part to play in communication of this with BHNFT Members and the general public more widely as this work develops.


REF: CG/17/12/10

10

CoG Dec 2017/ Lead Gov (p1 of 2)

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2.6. Inspections As we all know, the Hospital has also recently undergone an inspection from the Care Quality Commission (CQC). Together with a small group of Governors I met with them on 15th November to answer their questions and give our views on how well led we are as an organisation, and we hope the Trust will be rewarded for their hard work and meet the “Good” criteria set out by CQC.

3. And Finally 3.1. This will be the last meeting that Carol Dudley, Secretary to the Board and Governors,

attends before her early retirement. Carol has been an enormous help to me in my first year as Lead Governor. I am sure that you will all agree that we will miss her for her knowledge, her calm and organised presence, her keeping us all on track and in order, but most of all simply for being herself.

3.2. We will miss Carol hugely, but wish her all the best in her future.

4. RECOMMENDATION The Council of Governors is recommended to receive this report.

Annie Moody LEAD GOVERNOR December 2017

CoG Dec 2017/ Lead Gov (p2 of 2)

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COUNCIL OF GOVERNORS – DECEMBER 2017 REF: CG/17/12/11

11

CHAIRMAN’S REPORT

1. INTRODUCTION 1.1 This report is intended to give a brief outline of some of the work and activities undertaken

as Trust Chairman over the past month and highlight a number of items of interest. 1.2 The items reported are not shown in any order of priority.

2. TRUST POSITION 2.1 Our financial position continues to improve through very tight controls of our costs and an

increase in activity. We met our control total for 2016/17, which means we have contributed to the overall NHS savings. Our record on patient safety continues to give confidence to the population of Barnsley and our key stakeholders that care will not be compromised and we will continue to improve our current position. I will continue to reiterate this message as I think it should be constantly in people’s minds. Whilst we are controlling our financial position, we will not compromise on quality of care and patient safety.

2.2 We also continue to give confidence, in continually difficult circumstances, to our staff that the Trust is doing everything it can to improve patient experience and the quality of care our patients receive. Our hospital is very busy and it is important that we continue to recognise this, and the hard work our staff put in on a daily basis, and pay tribute to all our staff for their valued work and their efforts to conceive new ideas to deliver better care.

2.3 We must also continue to be conscious of the continuing pressures on the hospital, particularly the 4 hour emergency standard. It is essential we keep on track to control our finances whilst protecting the quality of our services for our patients and meaningful staff engagement.

3. COUNCIL OF GOVERNORS 3.1 The Finance & Performance sub-group met on 8 November; it was well attended by Non

Executive Director colleagues too. Karen Kelly, Director of Operations, and her Deputy Ben Brewis took Governors through the winter PLACE plan and Francis Patton led the discussion around the Finance & Performance Committee Chair’s Log and the Trust’s Integrated Performance Report.

3.2 The Constitution review working group met on 21 November, which produced a couple of recommendations that are in a paper later in the agenda. My thanks go to the Governors who came along to help with the review.

3.3 Governors’ election are currently taking place for up to 1/3 of our public and staff Governors. Six nominations are on the ballot paper for the five seats in the Barnsley Public Constituency. There are two nominations on the ballot for the seat in the Staff Constituency for Non Clinical Support Staff. The two seats in Nursing and Midwifery were appointed to without contest.

CoG Aug 17: Chairman’s Report (p1)

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3.4 The Nominations Committee of Governors met on 28 November to review the half year appraisals of the Non-Executive Directors and the Chairman.

3.5 Expressions of interest have been received for the following seats: 3.5.1 Council of Governors roles

• Lead & Deputy Lead Governors – Annie Moody and Trevor Smith respectively • Sub-group Chairs and Vice Chair – David Brannan, Trevor Smith and Tony

Dobell I am very pleased to approve these nominations and recommend them to the wider Council of Governors to serve for another year for 2018.

3.5.2 Trust-wide groups: • Tony Conway has been appointed to the R&D Patient Panel as Governors’

representative • Steve Long has been appointed as Governors’ representative for the TNA

(Trainee Nurse Associate) Curriculum and Placement Group Interest in both groups was over subscribed, the R&D had one other interested person who was happy to support Tony’s request For the TNA group it was a case of names in the hat. There was a lot of interest from partner governors and that has been passed on to the group at any rate, who will make a point to follow this up in the new year

• Tony Dobell is the Governors’ representative on the Outpatients’ modernisation steering group (with Non Executive Director Francis Patton), but in view of changes in the CBU, Simon Ainsworth, the Associate Director of Operations has deferred its work into the new year.

4. NEWS & EVENTS 4.1 I was delighted to be able to catch up with Professor Adebajo on his return to work from

long term illness on 1 November and then to pass on his request to Governors for a Governor to become involved with research in the Trust.

4.2 On 3 November along with the Chief Executive I met our counterparts at the Clinical Care Group (CCG) to discuss matters of interest to both parties.

4.3 6 November saw the meeting of the Working Together Partnership, where amongst other things the final touches were put to the Committees in Common decision making structure. Discussions were reported to the November Board and at this month’s Board we will report discussions at the first meeting of Committees in Common, which will take place on 4 December.

4.4 I was pleased to be able to represent the Trust on 7 November, having been invited to the 70th birthday celebrations of the owner of Barnsley Chronicle, Sir Nicholas Hewitt.

4.5 On 10 November I represented the Trust at the annual graduation ceremony of University Centre Barnsley and Barnsley College.

4.6 13th November saw the BHNFT Board meet our counterparts at The Rotherham Foundation Trust, where discussions led to partnership opportunities to assist each other in improving patient care.

4.7 The Care Quality Commission (CQC) visit to the Trust began on 15 November and they were welcomed into the Trust by the CEO, myself and other Director colleagues.

CoG Dec 17: Chairman’s Report (p2)

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4.8 The Infection Prevention & Control Level 2 Certificate Awards took place on 16 November, where I was pleased to be able to meet the learners and present them with their certificates.

4.9 On 17 November I represented the Trust at the Proud of Barnsley Awards, where I presented the Hospital Hero award to Sarah Reynolds who is an Intensive Care Nurse at the Trust.

4.10 I visited Oxspring Brownies on 21 November to receive a giant cheque worth £225 for their sponsored silence. It was a delight to meet the Brownies, who were full of enthusiasm for the Tiny Hearts appeal and full of questions for me.

4.11 On 29 November I presented the long service awards along with the CEO; awards ranged from 20 years right up to 45 years.

4.12 On 8 December the CEO and I hosted a meeting with our four MP’s where we discussed our hospital performance the ACS and ACO, and we answered questions that the MP’s had.

4.13 The annual Christmas visit of the BFC football club took place on 14th December, I can happily say that they were wonderfully received by both patients and staff alike. It was a delight to see the children’s faces light up at the attention of the players.

5. BARNSLEY HOSPITAL CHARITY 5.1 The generosity of local people and the support for our Charity continues unabated. The

work done by the charity team is spreading our message throughout the borough and this has resulted in increasing in donations to the Charity, supporting the hospital to deliver its aims.

5.2 A headline from this month is that the incubator in reception has received over £50,000 in donations in just over 18 months, which emphasises the generosity of Barnsley people. We can’t thank them enough.

5.3 A point to note is that the Tiny Hearts appeal has now reached the £600,000 mark, and our thanks must go to the public and to our terrific Fundraising Manager Lisa Calvert. Total November 2017

Donations excluding Tiny Hearts £6,368.42 Donations Tiny Hearts £9,308.43 November Tiny Hearts Raised £600,923.00 November Tiny Hearts Balance £565,923.00

5.4 Events: Several departments are fundraising in run up to Christmas. The Theatre staff are having a Christmas jumper day, Janet from Volunteers Coffee Shop has a raffle going on until next week. There are also a number of external raffles and collections.

5.5 Next year a Tiny Hearts supporter has a Variety Night organised on 23rd February http://www.barnsleyhospitalcharity.co.uk/event/tiny-hearts-variety-night/

6. RECOMMENDATIONS Governors are asked to receive and note this report and endorse the recommendations for appointments to the Lead and Deputy Governors and Sub-group Chairs and Vice Chair.

Stephen Wragg CHAIRMAN, December 2017

CoG Dec 17: Chairman’s Report (p3)

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http://www.barnsleyhospitalcharity.co.uk/event/tiny-hearts-variety-night/


REF: CG/17/12/12

CHIEF EXECUTIVE’S REPORT

1. STRATEGIC CONTEXT

1.1 This report is intended to give a brief outline of some of the key activities undertaken as Chief Executive since the last meeting and highlight a number of items of interest.

1.2 The items below are not reported in any order of priority

2. BARNSLEY ISSUES 2.1 Care Quality Commission (CQC) Well-Led Review 15-17 November

The well-led component of our annual CQC review took place over three days. 2.2 The CQC held a series of interviews with leaders and groups of staff as well as

comprehensively to examining our governance systems and ward-to-board connectivity. Initial feedback did not highlight any concerns and we anticipate receiving a draft report in mid January 2018.

2.2 Freedom To Speak Up (FTSU) Guardian I have met with Jacqui Pollington twice recently to support her FTSU role. Jacqui had made an excellent start and has recently had some of her work reported in the first annual report of the national FTSU Guardian. At her request, I have agreed an increase in time allowance for the role to one day per week.

2.3 Executive Team Restructure Changes to the executive team have been agreed and are shown in the appendix. This is a cost neutral change which is intended to maintain the successful delivery of key operational targets but to also augment the focus on delivering the 95% emergency care standard.

2.4 Executive Team Timeout The Executive Team had a successful timeout on 6th November. Discussions were helpful and will be used to inform the development of the future Trust strategy, alongside the views of the wider Board and other stakeholders.

2.5 Meeting with Peter Needham, Hospital Chaplain Peter and I had a constructive meeting on 14th November. One important issue that we are working on is to ensure that Muslim patients and visitors have access to appropriate prayer facilities when required. A solution has been identified and will be worked up over the next few weeks.

2.6 Remembrance Service 12th November I attended this moving service of remembrance with Annie Moody, Lead Governor, and placed a wreath on behalf of the hospital and its staff.

2.7 Getting It Right First Time Orthopaedics Review 27th November Professor Tim Briggs met with orthopaedic and management colleagues, including Dr Enright, to follow up his original visit of 2-3 years ago. It was a very helpful meeting that identified a number of ways we could develop the service to improve quality and reduce costs.

12

CoG Dec 17 / CEO report (p1 of 4)

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2.8 Meeting with the Improvement Academy Heather McNair, Dr Simon Enright, Gill Feerick and I met with colleagues from the Improvement Academy and discussed how they could support our quality improvement agenda. A number of areas for joint work were discussed including an offer from the Academy to lead a Board development session in the New Year.

2.9 NHS Improvement (NHSI) Whistleblowing Scheme Natalie Grosvenor and I met with the NHSI lead for this national scheme aimed at supporting staff that have suffered detriment as a result of being whistleblowers. We have agreed that the Trust would be prepared to support this work and potentially to help individuals re-establish their NHS career.

3. SOUTH YORKSHIRE AND BASSETLAW (SYB) ACCOUNTABLE CARE SYSTEM (ACS) ACTIVITIES 3.1 Collaborative Partnership Board 10th November

A range of topics were discussed including the hospital services review and the communications approach that the Accountable Care System will take to ensure its workers understood by local people. Data that compared aggregate ACS footprint performance across the North of England was reviewed.

3.2 Appointment of Stroke Consultants With the recent agreement that there will be two Hyperacute Stroke Units (HASU) in South Yorkshire & Bassetlaw (plus one in Wakefield), I have been asked by the ACS to coordinate provider efforts to recruit consultants to the region. We have developed two split site roles which will be out for recruitment very soon - one split between Barnsley and Doncaster and the second split between Rotherham and Doncaster. The posts are intended to provide local stroke expertise in Barnsley and Rotherham whilst also supporting the Doncaster HASU.

3.3 Provider collaboration to improve access to echocardiography Across the ACS, diagnostic performance is generally good but all Trusts struggle to reliably hit the six weeks diagnostic standard for echocardiography. This is largely driven by national workforce issues but we have decided to take a collaborative approach to finding short and long term solutions to this problem through the ACS. I have agreed to coordinate this work on behalf of the other provider Trusts. An initial workshop for provider echo teams generated a range of actions that we will be implementing.

3.4 Elective and Diagnostic Workstream I attended a number of related meetings as the co-lead for this work. A new programme director has been appointed and a new subgroup set up to focus on echocardiography. Discussions have been ongoing with national teams about how best to use RightCare benchmarking data, Get It Right First Time data and also whether or not to implement a capacity alert system on top of the existing Electronic Referral System for out-patients.

3.5 Radiology Network Management Group I continue to chair this group. The innovative regional Radiographer Academy is now looking to its second cohort of recruits to potentially focus on reporting chest x-rays. We have submitted an expression of interest to be an early adopter region for some national work in this area.

4. PARTNERSHIP WORKING WITH OTHER HEALTH AND SOCIAL CARE PARTNERS 4.1 Board to Board with Rotherham Hospital 13th November

This was a very helpful meeting of the two Trusts at which we discussed developing the BRILS pathology partnership and other areas of mutual interest. A joint workshop of our respiratory teams has been arranged for December and we have been sharing approaches to delivering timely emergency care.


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4.2 Exec to Exec meeting with Barnsley BMBC The executive teams of BMBC and the Trust met on 28th November and explored areas of current and future joint working. This included joint work on tobacco and alcohol harm reduction, accountable care and how we can support patients to access support with staying warm in winter.

4.3 Meeting With Barnsley Clinical Commissioning Group (CCG) Steve Wragg and I met with Dr Nick Balac, CCG Chair, and discussed a range of issues as part of our regular monthly meetings.

4.4 Meeting with Scott Green, Chief Superintendent, South Yorkshire Police I had a quarterly meeting with Chief Superintendent Green. We discussed the interaction of the Trust and local police particularly in the context of how we can effectively work together in the interests of service users with alcohol or mental health conditions. We will also explore whether the Trust could provide an office on site for the police to use.

5. NEW CONSULTANT APPOINTMENTS I would like Governors to note the following Consultant appointment since the last report:

• One Consultant in Urology.

6. TRANSFER OF RESPONSIBLE OFFICER 6.1 Transfer of Responsible Officer Role to Dr Simon Enright, Medical Director

Earlier this year Mr Jeremy Bannister took on the Responsible Officer (RO) role for a six months period whilst the Trust worked with an interim Medical Director. The intention was for this role to transfer back to being held by the Medical Director once a substantive appointment was made. Now that Dr Enright has been offered and accepted the substantive role, and has also completed the required training over recent months, the Trust Board agreed that Dr Enright would become the RO for the Trust.

Dr Richard Jenkins CHIEF EXECUTIVE December 2017


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APPENDIX to CEO report

EXECUTIVE TEAM RESTRUCTURE – CHANGES IN ROLES

1) Chief Delivery Officer (formerly Director of Strategy and Business Development)

New responsibilities: • Line management and performance management of CBUs • Operational performance and delivery of all operational standards • Emergency Preparedness Removed responsibilities: • Cost Improvement Plan • Business Planning

2) Director of Finance

New responsibilities: • Cost Improvement Programme • Business Planning • Management of SLAs between BHNFT and BFS. • Lead finance officer for Accountable Care Shadow Delivery Board

3) Director of Nursing and Quality

New responsibilities • Daily executive leadership of emergency care pathway • Improvement of the emergency care pathway • Professional leadership of Allied Health Professions

4) Medical Director

New responsibilities • Executive lead for Pharmacy • Responsible Officer • Caldicott Guardian (via Deputy Medical Director) • Human Tissue Act Executive Lead • Lead Executive for Healthcare Scientists

5) Director of Communications and Marketing

New responsibilities • Management of the Membership of the Trust

6) Director of ICT

New responsibilities • Director lead for medical records (to align with paperless agenda).


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REF: CG/17/12/13

13

STRATEGIC SUB-GROUPS

1 INTRODUCTION

1.1 This report provides an update on the work and discussions of the Council of Governors’ Finance & Performance sub-group (FPSG) and Quality & Governance sub-group (QGSG).

1.2 The sub-groups meet on alternate months. This report includes notes from the November FPSG meeting and December QGSG meetings.

2 SUB-GROUP LEADERSHIP & MEMBERSHIP 2.1 The sub-group meetings were led by Mr David Brannan, Sub-group Chair of FPSG,

and Mr Tony Dobell, Vice Chair of QGSG respectively taking the Chair in Mr Trevor Smith’s absence (QGSG Chair).

2.2 Membership of the sub-groups remains informal. Governors are welcome to attend the sub-group meetings regularly or on an ad hoc basis if preferred. If any Governor wishes to raise an item through either of the sub-groups, the Chairs would be pleased to hear from you ahead of the next meeting’s agenda setting.

3 WORK OF THE SUB-GROUPS 3.1 One of the primary objectives of the sub-groups is to support the Governors’ role of

holding the Non Executive Directors (NEDs) – and through them, the Board – to account for the Trust’s performance. NED attendance at sub-groups is invaluable and helps the sub-groups to review progress against the strategic aims and objectives underpinning the Trust’s business plan.

3.2 The sub-group meetings also provide a valuable opportunity for Governors to share feedback from their constituencies (public, partners and staff) and members.

3.3 Minutes from the sub-groups are available for all Governors at the meetings and on request and key points from each meeting are reported at General Meetings (see below).

4 REPORT ON SUB-GROUP MEETINGS Finance & Performance Sub-Group (FPSG) 4.1 At the November FPSG, we were joined by four Non Executive Directors, including

the Chairman – Keely Firth, Nick Mapstone, Francis Patton and Steve Wragg, as well as the Director and Deputy Director of Operations, Karen Kelly and Ben Brewis.

4.2 Karen and Ben gave us a useful presentation on the community-wide winter PLACE plan, submitted ahead of the winter pressures - although it was queried when “winter” starts as the Trust has already been facing considerable pressures for some time. The new dashboard for the Emergency Department, which had been

CoG Oct 2017: Sub-groups report

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demonstrated to the Governors at the General Meeting in October, would be a vital tool helping the team to maintain oversight of patient pathways, minimising delays and ensuring that patients continued to received the right care at the right time, with patients’ needs remaining as the priority (ahead of targets). The plan also highlighted the new streaming system being instigated at the hospital’s front door to direct patients to the right service – be it emergency services from the hospital or primary care from GPs.

4.3 Governors were pleased to receive assurance that the additional pressures on staff during the winter period were recognised too. BHNFT was one of only a few trusts nationally with mental health professionals within its Occupational Health team, which illustrated the importance the Trust gave to staff mental as well as physical wellbeing.

4.4 It was reported that the mid year review for 2017/18 had shown the Trust on target but with a tough six months ahead in terms of activity, cash and the Cost Improvement Programme. Performance on workforce indicators was good overall but, as indicated, the Trust was mindful of the pressures ahead.

4.5 Progress against the business plan objectives also showed good progress to date, with green and amber ratings apparent and no “reds”, which Governors were pleased to note.

4.6 The timeline for a refresh of the Trust’s business plan was received and reviewed too. This was currently being progressed with the Clinical Business Units (CBUs) to ensure a “bottom up” approach and would be shared with Governors as the work developed, as usual. Views would be sought from external partners as well, to ensure alignment with their work too.

4.7 The sub-group also welcomed feedback from the Lead Governor and several others who had attended the regional Governors event held in Doncaster at the end of October. They had all found it to be an informative and useful event, giving a valuable overview of the work and aims of the Accountable Care System. One of the key presentations – the King’s Fund video – was scheduled to be shared with Governors at the November training session and December General Meeting.

4.8 Looking ahead, the group also agreed an outline for the Annual Development Session to be held on 24th January. This would be split between discussion of the business plan (as above) and devising the Governors’ training programme for 2018.

Quality & Governance Sub-group (QGSG) 4.9 . At the QGSG meeting held on 13th December, we were pleased to welcome Ros

Moore and Philip Hudson, Non Executive Directors, to the meeting. Governors’ attendance was slightly lower than usual, possibly affected by the season and the weather, but the meeting was still very lively and useful.

4.10 The main focus of our discussions was around Governors’ responsibilities to keep up to date about the Accountable Care System (ACS) as it progresses. As a public member of the Citizen’s Panel for the ACS in our region and Chair of QGSG, I am keen to ensure that we continue to be fully briefed as the work develops and are able to respond to our members and members of the public with any questions they may have of us about the ACS.

4.11 Several Governors attended the regional meeting in October; Annie Moody and I have attended some local public meetings recently, and Alan Higgins will continue to attend the Accountable Care Partnership (shadow) Board meetings when they are open to the public. All of this is over and above the briefings we receive from the Board – the latest one having been from Bob Kirton, Director of Strategy & Business Development, in November, and the next being at our General Meeting this month.

CoG Dec 2017: sub-group report (2)

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4.12 The regional ACS leads will continue to co-ordinate further public engagement sessions. It was agreed that as Governors, we should share any meeting dates and/or information we glean individually or collectively so that we can all remain as up-to-date as possible and can share our information with each other and with the members we represent.

4.13 In a wider context we also agreed that there was a need to boost our engagement with members and the public overall. The Communications team is leading work on this and we look forward to hearing more about their plans in the new year, with a refresh of the Membership Strategy being a key part.

4.14 The regular review of the Chair’s Log from the Board’s Quality & Governance Committee and the quality and safety aspects of the Integrated Performance Report (IPR) was effective. We continue to hold the Non Executive Directors to account for delivery against the business plan and they have undertaken to come back to our next meeting with more information on several aspects of the latest reports and our wider discussions, including any trends in complaints, information on bed occupancy, the Trust’s response to the PLACE (patient-led assessment of care environment) inspection and thoughts about what more can be done to provide sufficient wheelchairs for patients and public coming on site. As this shows, our discussions cover a wide range of topics and we appreciate the Board’s transparency which helps us to continue to do so.

4.15 The sub-group also looked at its work programme for the coming year. In addition to our continued focus on areas already identified in past discussions, we have asked for briefings on Medical Staffing and Medical Education to be added, both of which are vital to the Trust’s performance and continued quality of care.

5 CONCLUSION & RECOMMENDATIONS 5.1 As stated previously, sub-group meetings are intended to supplement and support

the work of the wider Council of Governors. Other information will also continue to be available to Governors via formal and informal updates from the Chairman, Governor attendance at Board meetings held in public, the joint meeting of the Governors and Board, briefings received at General Meetings, private briefing sessions for Governors, and the Board’s responses to any questions raised by Governors.

5.2 These notes above are by no means a full reflection of the meetings’ business. Governors are encouraged to come along to hear more and contribute to the sub-groups’ discussions and work.

5.3 Governors are asked to note and support the continued work of the sub-groups

DAVID BRANNAN TREVOR SMITH Sub-Group Chair Sub-Group Chair FINANCE & PERFORMANCE QUALITY & GOVERNANCE December 2017

CoG Dec 2017: sub-group report (3)

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COUNCIL OF GOVERNORS – DECEMBER 2017 REF: COG/17/12/14

14

BOARD OF DIRECTORS

1 MEETING PAPERS & AGENDA

1.1 The Agenda for the meeting of the Board of Directors held in public on 7th December 2017, is attached for information. The Minutes of the previous meeting, held in November, are also attached.

1.2 Governors have access to all of the papers from the Board meetings held in public but the following two reports are enclosed for your information: 1.2.1 The latest performance report (to end October 2017). These monthly reports

continue to be subject to closer review regularly at Governors’ sub-group meetings. Progress against delivery of the strategic objectives for the Business Plan is monitored through the sub-groups too.

1.2.2 The Horizon Scanning report received in December, which provides insight into national new and future plans, much of which will have a bearing on services at Barnsley.

1.3 Copies of the full reports presented at all Board meetings held in public are available on the Trust’s website (www.barnsleyhospital.nhs.uk) or on request from the Secretary to the Board & Governors.

2 FUTURE MEETINGS 2.1 Governors, staff and members of the public are welcome to come along to observe

any meetings of the Board held in public. Meeting papers will be provided on the Trust’s website and at the meeting.

2.2 The Board of Directors’ meeting schedule is changing for 2018 – with meetings being held on the fourth Thursday of each month (excluding December). Governors are advised to check with the Governors’ Office or on the Trust’s website for further details.

2.3 The first Board of Directors’ meeting to be held in public on the new schedule will be on 25th January 2018, commencing at 9am. Governors and members of the public are very welcome to attend as observers.

3. RECOMMENDATION Governors are asked to receive and note this report.

Stephen Wragg CHAIRMAN December 2017

CoG Oct 2018: BoD reports Pack pg 30

A MEETING OF THE BOARD OF DIRECTORS

WILL TAKE PLACE ON 7TH DECEMBER 2017, 9AM IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL

AGENDA

No Item Sponsor Ref

1. Apologies and Welcome

S Wragg, Chairman

2. Declarations of interests

3. To approve the Minutes of the meeting of the Board of Directors held in public on 2nd November 2017

17/12/P-03

4. To approve the Action Log in relation to progress to date and review any outstanding actions

17/12/P-04

Strategic Aim: Patients will experience safe care

5. To receive and review latest Patient’s Story H McNair, Director of

Nursing & Quality Presentation

6. To receive and approve the Chair’s Log for the Quality & Governance Committee

R Moore, Quality & Governance

Committee Chair

17/12/P-06

7. To receive and review the Chair’s Log on any escalation issues from the Executive Team (ET)

Dr R Jenkins Chief Executive Verbal

8. To review Learning from Deaths and the Mortality Report Dr S Enright, Medical Director 17/12/P-08

Strategic Aim: People will be proud to work for us

9. To endorse the report on Celebrating our People E Parkes

Dir of Comms & Marketing

17/12/P-09

Strategic Aim: People will be proud to work for us

10. To receive and approve the latest Chair’s Log from the Finance & Performance Committee

F Patton Committee Chair 17/12/P-10

11. To review the integrated performance report (month 07) Executive Team 17/12/P-11

12. To note revisions to the Single Oversight Framework Dr R Jenkins Chief Executive

17/12/P-12

13. To receive latest update on the Accountable Care System 17/12/P-13

Strategic Aim: Partnership will be our strength

14. To receive and review the monthly report from the Chairman S Wragg Chairman 17/12/P-14

15. To receive and review the monthly report from the Chief Executive

Dr R Jenkins Chief Executive 17/12/P-15

16. To receive and review the latest Horizon Scanning report E Parkes

Director of Comms & Marketing

17/12/P-16

Cont/…

BoD Dec 2017: Agenda (PUM)

Pack pg 31

No Item Sponsor Ref

17. In accordance with the Trust’s Standing Orders and Constitution, to resolve that

representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted.

Date of next meeting: - 25th January 2018, 9am

Signed: ………..…………………… CHAIRMAN

Please see reference section at back of papers for key to business plan and glossary of terms/acronyms

BoD Dec 2017 Agenda (PUM)

Pack pg 32

REF: 17/11/P-03

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT

MINUTES OF A MEETING OF THE

BOARD OF DIRECTORS HELD ON 2PP

NDPP NOVEMBER 2017

IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL NHSFT PRESENT:

Ms J Dean Non Executive Director Dr S Enright Interim Medical Director Mrs K Firth Non Executive Director Mr P Hudson Non Executive Director Dr R Jenkins Chief Executive Ms K Kelly Director of Operations Mr R Kirton Director of Strategy & Business Development Mr N Mapstone Non Executive Director Mrs H McNair Director of Nursing & Quality Ms R Moore Non Executive Director Mr F Patton Non Executive Director Mr S Wragg Chairman Mr M Wright Director of Finance

IN ATTENDANCE: Mr P Ardron Partner Governor, Sheffield Hallam University Ms K Armitage Public Governor, Barnsley Constituency Mr D Brannan Partner Governor, Voluntary Action Barnsley (VAB) Mrs L Christopher Managing Director, Barnsley Facilities Services Ltd (BFS) Mr T Davidson Director of ICT Mr A Dobell Public Governor, Barnsley Constituency Ms C E Dudley Secretary to the Board & Governors Ms D Gibson Consultant Nurse, Children’s Ambulatory Care * Mrs N Grosvenor Interim Director of HR&OD Mr A Higgins Public Governor, Barnsley Constituency Mr C Millington Partner Governor, Barnsley Clinical Commissioning Group (CCG) Ms A Moody Lead & Public Governor, Barnsley Constituency Ms E Parkes Director of Marketing & Communications Ms J Pell Head of Patient Experience * Councillor J Platts Partner Governor, Barnsley Metropolitan Borough Council (BMBC) Mrs C Robb Public Governor, Barnsley Constituency Ms Z Thomas Respiratory Nurse, Children’s Ambulatory Care * * attended part of meeting as reflected in the Minutes

17/161 APOLOGIES & WELCOME

Members, Governors and attendees were welcomed, with particular welcome extended to Governors attending for the annual joint meeting with the Board of Directors. Ms Gibson, Ms Pell and Ms Thomas were also welcomed, attending to present the Patient’s Story. It was noted that apologies had been received as a courtesy from the Clinical Directors and from a number of Governors unable to attend.

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BoD Dec 2017: Nov Minutes PUM (p2 of 13)

17/162 DECLARATION OF INTERESTS The standing declarations of interest from Mr Patton, Mrs Firth and Mr Kirton as Chair and Directors of Barnsley Facilities Services Limited (BFS), were received and noted. Declarations were also noted for Mrs Christopher, as Managing Director of BFS. No other declarations were received in relation to the meeting’s agenda.

17/163 MINUTES OF LAST MEETING (17/11/P-03)The Minutes of the meeting of the Board of Directors held in public on 5 PP

thPP

October 2017 were reviewed and accepted as an accurate record.

17/164 ACTION LOG (17/11/P-04)The action log showing progress on matters arising from the last and previous meetings held in public was received and noted. Two further updates were received: UU17/157 – Chief Executive’s Report: Accountable Care System websiteUU

Ms Parkes advised that the website was still in development; the link would be shared as soon as it was confirmed that the site was ready.

UU16/171 – Chairman’s Report – Ambassador Packs UU It was agreed that the recently issued Staff Handbooks and daily CQC briefings had served as a useful resource and provided the required information.

Members noted that updates on a number of items on the Log would be reported separately under later agenda items.

17/165 PATIENT’S STORY (Presentation)Mrs McNair introduced Ms Gibson, Ms Thomas and Ms Pell attending to present a patient’s story about an exciting opportunity provided for children facing daily problems due to their health issues. Ms Thomas explained that Dreamflight, which operated as a charity, had evolved some time ago from an idea developed by two British Airways workers. Each year it provided a once in a lifetime trip to a small group of young people with disabilities/life limiting conditions by taking them to the USA for a special experience aimed at changing their lives. The trips started with a party in London and ended with swimming with the dolphins in Florida. Whilst away the children would be under the care of health and social care professionals, all of whom gave their time freely to support them, and the children were encouraged throughout the trip to stretch their own parameters, become more independent and make friends and special memories. Simultaneously the trip would give valuable respite to their families and carers at home. Children could be nominated from across the country; the programme was always heavily oversubscribed and selection was against strict criteria. Nine children from Barnsley had been involved in trips over the last 15 years. Some of the past attendees nationally had gone on to become patrons of the Charity. Ms Gibson and Ms Thomas showed a brief video, which illustrated both the scope of the trips and the benefits to the children involved. They also spoke about each of the Barnsley children who had been involved with the programme and the changes it had made to their lives, helping their confidence to grow, making them better able to cope with their conditions and encouraging them to be more self sufficient.

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The Board thanked Ms Gibson, Ms Thomas and Ms Pell for attending the meeting and for the information shared regarding the Dreamflight trips and the moving stories of and feedback from some of the local children involved. As observed by Ms Moore, the briefing had also illustrated the limitations of medicine, the value of engagement and the need for support for carers. It was acknowledged that the presentation had been a slightly different approach to the Patient Stories usually shared with the Board but, as stated by the Chairman, it had served the same vital purpose of reminding members of the importance of putting patients and their differing needs at the centre of every decision. Ms Pell, Ms Thomas and Ms Gibson were invited to stay for the remainder of the meeting but, due to other commitments, left at 09.25 hrs.

17/166 QUALITY & GOVERNANCE COMMITTEE (Q&G) (17/11/P-06)As Chair of Q&G, Ms Moore presented the Chair’s Log from the Committee’s meeting held in October, highlighting key issues the Committee wished to report to the Board for assurance or escalation. Ms Moore drew particular attention to: the Committee’s action on the three items referred by the Board,

ie agreement to monitor services within the Alliance on behalf of the Board; pursuit and receipt of assurance on weekend consultant cover in obstetrics and across the Trust, and approval of the revised Equality Impact Assessment (EqIA) for the Deteriorating Patients’ Policy following amendment as requested by the Board

assurance on the Trust’s response to the recent Care Quality Commission (CQC) unannounced inspection in October and readiness for the Well Led review due later in the month – with formal thanks recorded to Ms Feerick, Head of Clinical Governance, for the organisation behind both visits

two reports on nursing & midwifery staffing, one of which the Committee had recommended be presented to the Board as a separate item (agenda item 9), to monitor and give assurance on safe staffing levels and planned actions for further reviews

regular review of the Board Assurance Framework (BAF) and Corporate Risk Register (CRR)

the informative presentation and assurance received on management of pressure ulcers in theatres.

Ms Moore affirmed that the Committee also wished to include Dr Orme as a regular attendee, as the lead on the Trust’s work around the new mortality reviews. The Log was noted and Dr Orme’s inclusion as a regular attendee to the Committee was approved.

17/167 AUDIT COMMITTEE (17/11/P-07)Ms Dean, as Chair of the Audit Committee, presented the Log from the Committee’s latest meeting, which summarised the main issues for reporting upwards to the Board. These included progress on compliance with the latest NHS England (NHSE) guidance on Conflict of Interests (all registers extended and published on the Trust’s website and further development ongoing); notice of a routine inspection scheduled in December for Counter Fraud and Bribery services, and feedback on the first regional meeting of Audit Chairs across the South Yorkshire & Bassetlaw Accountable Care System (ACS). The latter had looked at the potential evolution and how/why organisations within the ACS can have confidence in the supporting governance.

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Mr Dobell, as Audit Liaison Governor, commented on the Committee’s efficiency at the meetings led by Ms Dean, who ensured that the wealth of papers was dealt with appropriately and effectively. He had raised concerns regarding one aspect of audit work across the Trust, when the Committee had received reports of poor attendance at audit meetings or some issues deemed no longer relevant. Ms Dean confirmed that this had related to information gleaned from the Clinical Audit annual report and had been followed up by the Audit Committee. Improvements had been effected and would be monitored by the Committee. Ms Dean also drew attention to the request relating to the BAF and CRR. The latter was currently only presented to Q&G regularly and to Board on a quarterly basis. It was the Audit Committee’s recommendation that the CRR be received by the Audit and Finance & Performance (F&P) Committees regularly too. This was considered and approved by the Board. Several issues on the Log were discussed further: Dr Enright gave assurance that the audit feedback on Consultant Job Plans

had been taken into account. The latest planning round had started on 1 PP

stPP

November and was scheduled to be completed in March 2018. He affirmed that job planning was quite strong overall but agreed that it would benefit from being more streamlined.

Ms Moore noted reference to the Workforce Strategy and Workforce Planning audit. Whilst these documents were likely to be addressed through F&P, she asked that they also be shared with Q&G for information to ensure the Committee was kept aware of any outcomes relevant to its remit too. It was agreed that this would be useful.

In response to a query from Mrs Firth, Ms Dean confirmed the Audit Committee’s position that the subsidiary company, BFS, must hold responsibility for management and audit of its own accounts as an independent company. On behalf of BHNFT, as the parent company, the Trust’s Audit Committee would have access/oversight of the BFS accounts as part of the consolidated group accounts. Mr Wright also affirmed that BFS should determine how it managed its audit work – via an audit committee of its own or through its Board. More importantly for BHNFT, as indicated by Ms Dean, the accounts would then come up to BHNFT’s Board and Audit Committee as part of the group’s consolidated accounts.

As a general observation on the outcomes issued for the internal audits, Ms Dean repeated the Committee’s view that the more informed the management responses provided were, the more assured the Committee – and consequently the Board - would be. She encouraged the Executive Team (ET) to ensure that the responsible officers for each action plan provided a full response (ie no blank boxes etc).

The Chairman highlighted the recent launch of the Special Health Authority (SHA) for counter fraud. Mr Wright confirmed that the Trust’s Counter Fraud services were provided by 360 Assurance, who had not indicated that the SHA would cause any significant issues for BHNFT.

The report was noted.

NG

17/168 MEDICAL DIRECTOR’S REPORT (17/11/P-08)The six monthly report to October 2017 was received from Dr Enright as interim Medical Director. He advised that in general work was progressing well, with good progress in particular in terms of effective team working across the disparate areas within the directorate. He highlighted a number of specific developments, including:

Pack pg 36


the patient safety team, which was moving forward under the leadership of the new Patient Safety Lead and taking on responsibility for several key issues including VTE (venous thromboembolism), VitalPAC, sepsis and other complex patient safety matters

mortality ratios, which remained below the national median (ie positive) across all indicators. The Trust was, however, far from complacent taking mortality and learning from mortality extremely seriously. Earlier in the year the Trust had revised its internal review processes to align with new national guidance and was developing an outcomes related process (ie learning from death) under the leadership of Dr Orme

a full report on sepsis was scheduled to go to the Patient Safety & Harms Group shortly, key points from which would show improvements in data collection and review of antibiotics

VTE assessment had been a difficult area for some time; following extensive focussed work, improvements were beginning to be seen. Dr Enright reported an unvalidated figure of 93% for October

following last year’s success on agency spend for medical – and nursing – staff, the Trust had faced a difficult target to achieve the national requirement for a further 15% reduction but it had been delivered to date. Dr Enright emphasised that the controls were not just about spend but also encouraged teams to consider working differently whilst still delivering high quality and safe clinical needs. Consultant appointments continued to make progress well too and Dr Enright was keen to move forward with other doctor appointments as outlined in the report

positive feedback had been received in relation to education for undergraduates. The Trust treated them as well as possible, not only to help develop their careers but also to encourage interest in the hospital as a future employer

the continued progress and development of Research & Development (R&D), under the leadership of Professor Adebajo, was highlighted.

Mr Millington congratulated the Trust on the reported consultant appointments in terms of both numbers and quality. He was also pleased to note the good progress on VTE. Mr Brannan thanked Dr Enright for the progress on sepsis and agency spend too; as a long serving Governor he was conscious of the marked improvements reported in areas that had been of significant concern in the past. Ms Dean was pleased to note the continued developments in R&D and asked how R&D would factor into the ACS proposals in Barnsley and regionally. Dr Enright confirmed that the Trust had R&D links across the region as part of this work already and he was confident that these would continue to develop as part of both the ACS and local Accountable Care Partnership Board (ACPB). The Chairman reminded members that Professor Adebajo had returned to work earlier in the year following an extensive absence for health reasons. He was delighted that Professor Adebajo had been able to re-join the Trust and was pleased to report on his recent meeting with him and the invitation for a Governor representative on the R&D patient panel, which the Chairman would be putting to the Governors shortly.

SW

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17/169 NURSING & MIDWIFERY ACUITY REPORT (17/11/09)Mrs McNair presented the report, which provided a lot of detail regarding the latest acuity assessment on Nursing & Midwifery staffing. The assessment had been carried out in accordance with mandated guidance, aimed at evaluating whether trusts had a sufficiency of staffing in terms of capacity and capability on an annual basis. The tools and guidance varied by teams and areas. The report focussed on core areas and confirmed that the Trust had enough staffing within its establishment to look after its patients, taking account of numbers, needs, professional judgement and (new this year) the Model Hospital criteria. The data showed little change in acuity year on year. It had identified a small number of areas for further review and others which could be seen as overstaffed. The latter enabled some flexibility in staffing. Mrs McNair emphasised, however, that whilst the data confirmed that the Trust had sufficient staff in place overall, this did not mean that staffing was not stretched as it focussed on establishment data and did not account for pressures such as sickness absence, maternity leave or escalation wards. Mrs Firth advised that these aspects had been reviewed further in discussions at Q&G and repeated her concerns regarding how the Board could gain assurance that safe staffing levels would be maintained at all times. Mrs McNair believed that BHNFT was in a better position than many trusts as it carried fewer nursing vacancies than most, which allowed the Trust to be flexible in response to issues such as unplanned absence or escalation but she would not wish to minimise the impact that those additional pressures brought on staff. As mentioned not all areas had been assessed in the same way. The expected guidance for Emergency Departments (ED) had been withdrawn but work was ongoing to deliver a review by other means. The Trust was also working to identify the best tool for assessment of acuity in maternity, with results expected by the financial year end. Mrs McNair also expanded on outcomes from the Model Hospital benchmarking. On first review it showed the Trust as expensive in terms of staff costs. On drill down by ward level, however, the Trust was in line with peers albeit with some anomalies in Critical Care (CCU) and Intensive Treatment Units (ITU) but this might reflect the variable level of patients and acuity. She was also conscious that the information currently in the Model Hospital system was dated; this would improve as it developed. A number of comments and questions were raised by Governors present: Mr Millington referred to the intermediate care services now based within

the hospital (but managed by SWYFPT). He had received an email from Save our NHS Barnsley who had challenged the new environment as poor - having no facilities such as TVs etc. He had received assurance from the CCG’s Chief Nurse that she was satisfied with the current arrangements and asked if BHNFT had any comment. Mrs McNair affirmed that intermediate care services had not been factored into the acuity report as it was not a BHNFT service; she could only comment on what she had seen when attending the ward as a visitor rather than a manager. It had looked well equipped and the area would have options for the same facilities as for all wards at BHNFT. TVs were not permitted on wards at BHNFT other than the Hospicom service; there may have been different arrangements at Mount Vernon. Some things will be changed when the service was managed by the Trust but it would be operated on a very different service. Dr Jenkins advised that similar questions had been raised in recent media reporting, possibly as part of wider concerns regarding the closure of Mount Vernon. The Trust had issued a statement (copies available) which largely refuted the points made and addressed the misinformation presented.

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In reply to Cllr Platts, it was confirmed that the Trust expected to take over the intermediate care services at the start of December.

Mr Brannan enquired if staff costs were impacted by low staff turnover (ie would be higher as staff stayed longer and became more experienced). Mrs McNair acknowledged that this could be a factor but would be common to several other trusts too, including Chesterfield and Rotherham; it had not been considered in the acuity assessment.

In response to a question from Ms Armitage, Mrs McNair confirmed that the costing data for the Model Hospital system would be updated quarterly and would become more accurate and robust as it developed.

Cllr Platts was conscious that maternity services would were being considered as part of the ongoing Hospital Services Review and expressed some concerns that the data and costs currently referenced might be to the Trust’s detriment. Mrs McNair advised that the Trust was mindful of that and had been looking at how this could be presented more accurately. The maternity data was skewed by the Trust’s historical position with NHSLA (now NHS Resolution). Mr Kirton and Dr Jenkins emphasised the need to ensure people looked at the Trust’s current performance and outcomes in maternity, which were widely recognised as good.

In closing this agenda item, Mr Hudson appreciated that the report essentially confirmed that the Trust was well placed generally in terms of staffing and costs, with some positive variations against benchmarking.

17/170 BOARD ASSURANCE FRAMEWORK (BAF) (17/11/P-10)Mrs McNair presented the Q2 BAF and reminded members that it had also been reviewed by the Q&G and F&P Committees. Changes since the last report to Board (Q1) were listed in the executive summary. Some further amends were agreed on further review:

Mrs Firth drew attention to the risk associated with non payment of full CQUIN (Commissioning for Quality and Innovation), as a consequence of which the Trust would be at risk of not achieving the STP target and thus not receiving Sustainability & Transformation Funding (STF). There were inconsistencies in the national messages around CQUIN payments for 2017/18 and this was causing difficulties for executives. Dr Jenkins reiterated that the Trust would continue to take advice from NHSI and the Board acknowledged that this needed to be fully reflected in the BAF.

Ms Moore suggested and it was agreed that the first reference to ‘local’ should be removed from the statement that “Local people may choose to work at other local provider organisations”’. The Trust valued staff from any region; the real aim was to provide the right workforce for local patients.

Ms Moore further suggested and it was agreed that in terms of staffing, reference should be included to the assurance received from the latest acuity review (see above), which would doubtless inform some of the Trust’s future decisions.

HM

17/171 CORPORATE RISK REGISTER (CRR) (17/11/P-11)Mrs McNair presented the CRR, which was closely linked to the BAF. The executive summary listed those risks which had been closed and/or added since it was last presented to the Board. It was clarified that the risks on the CRR were operational; those on the BAF were recognised as more strategic.

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The Chairman reiterated earlier agreement that the CRR should be shared with all of the governance Committees regularly to ensure even fuller review.

17/172 EXECUTIVE TEAM (ET) LOG Dr Jenkins confirmed that most issues to be reported to Board from the ET had been raised in earlier discussions. He briefly outlined two additional matters:

UUET structure and portfolioUU Dr Jenkins advised that this was currently under review. Outcomes would be shared at the next meeting and would go live from 22 PP

ndPP December.

UUCQC initial feedback UU An initial letter had been received from the CQC following the unannounced inspection in October. It was broadly positive, with some areas of improvement included, none of which were considered to be major issues. Nevertheless Dr Jenkins confirmed that the Trust would be working to address them swiftly. A copy of the letter would be shared with Board members shortly.

RJ

RJ

17/173 FINANCE & PERFORMANCE COMMITTEE (F&P) (17/11/P-13)Mr Patton presented the Log, which covered key aspects from the Committee’s latest meeting, which, he reminded members had also served as the Trust’s mid year performance review. Consequently the Log was fuller and more detailed than usual. Mr Patton highlighted key points from the Log, including:

Finance, which was very tight at month 6. Although it had been slightly favourable to plan, it had also exhausted all provisions, reflecting a tighter position than in previous years. The Cost Improvement Programme (CIP) had been c£174k adverse to plan, which added to the challenges ahead albeit a later update received by the Committee had included further schemes and confirmed the forecast at £7.891m (ie above plan) for the year end. It still, however, included a large non recurrent element, which would impact on the 2018/19 run rate. Cash was ahead of plan (after the latest borrowings draw down, as agreed) and clinical income was currently below plan. F&P had concluded that the year end outturn forecast could be achieved but it would be a tough challenge. The Committee had sense checked the underpinning work and requested additional data to be included in future reporting on plans in place by ET to deliver the forecast, to enable better understanding of ongoing risks.

Performance had been good overall, hitting most targets, including those for 18 week referral to treatment/RTT (albeit with work ongoing in two of areas) and cancer services. That said, compliance with the <4 hours emergency access target remained under pressure and was vulnerable for Q3, which would put STF support at risk.

Workforce data showed the Trust in good position for sickness absence, mandatory training and appraisals. It was noted that the data on turnover reflected staff transferred into BFS (hence the apparent spike) but these staff remained within the overall group. Mr Patton confirmed that work was ongoing to develop a separate reporting dashboard for BFS to help maintain tracking.

Winter plans: as requested at the October Board meeting, the Committee had received and commented on the winter PLACE plan for Barnsley. The Committee had requested that its constructive comments be fed back to

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the report’s co-ordinators, including the continuing query on GP capacity over holiday periods, which had not been addressed in the Plan despite comments from last year.

Market share: the continued growth in elective market share had been noted. The Trust would build on this in its plans for the next three years, alongside the agreed aspirations to return to financial balance and gain an “outstanding” CQC rating.

The Committee had also reviewed the BAF and signed off the updated Losses & Special Payments policy. This was supported by the Board.

Mr Mapstone emphasised the challenging position facing the Trust. Delivery throughout the winter period would be critical. Dr Jenkins reported on recent data reviewed when trying to ascertain what, if anything, had changed in terms of demands compared to prior years. The statistics showed that ED activity was not dissimilar year on year but there had been a marked increased in ED attendances in recent weeks (over 300 patients being seen through ED on several days) and an increase in admissions due to the varied needs of the patients. It was the admissions that had impacted most on the Trust’s need for escalation beds. Work was ongoing to try gain a better understanding of the drivers behind the changes. The focus of the weekly improvement group had shifted from ED to acute pathways, reflecting the changes identified to date. Ms Moore expressed disappointment at the drop in outpatient performance despite the significant investment in that area. Dr Jenkins advised that the investment had supported sustainable improvements in aspects such as the reduction in Did Not Attend (DNA) rates. The Trust had also been affected by changes in the community such as GP work on anticoagulation, which required plans for the teams affected to be revised. Mr Hudson enquired about flexibility within revenue. Mr Wright affirmed that September had been one of the lowest income generating months in the year, reflecting a number of variables in month (including levels of uncoded activity and an increase in lengths of stay due to acuity and lack of beds in the community), most of which were expected to improve in October. ET were looking closely at how data could be captured and recorded better. Ms Moore was also conscious of national reporting on discharge planning and would still like to see actions taken internally to deliver further improvements where possible.

17/174 INTEGRATED PERFORMANCE REPORT (IPR) (17/11/P-14)The month 6 IPR was received and reviewed, some of which had already been reviewed in discussion of the F&P and Q&G Chairs’ Logs. Further information was provided on several aspects. UUUQuality UUU Mrs McNair confirmed that the position remained positive overall, with continued improvements in complaint response times and generally good performance in terms of levels of harm from falls and incidents of hospital acquired pressure ulcers. The Serious Incidents listed had been reviewed by Q&G, including the second case of MRSA. In response to a query from Mr Hudson regarding the death following a fall, Mrs Mcnair confirmed that it had been a very unusual and tragic case. Whilst it had not been care related or involved any safeguarding issues, it had still been counted and recorded as a serious incident (SI) and would be subject to full review.

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UUUWorkforceUUU Mrs Grosvenor confirmed that, as reported via F&P, the progress on absence, training and appraisal levels remained good. Further work was ongoing in order to maintain and improve these positions and expand work on quality issues within each aspect. She also flagged that uptake of the flu vaccination programme had increased to over 69% to date (national target was 75%). Work continued on a review of the workforce strategy and people metrics, with the aim of including more qualitative elements too. The latest staff survey had been launched recently. Responses were low at present but the HR team would be working closely with departments to encourage greater participation. The Trust would continue to progress work via the Staff Engagement Plan, built on the 2016/17 survey outcomes. AUUActivityUU Mrs Kelly reconfirmed that Trust remained compliant against most targets. The Trust continued to outperform most other organisations in terms of RTT, with work ongoing in dermatology (including a review of workforce) and general surgery (impacted by additional work taken on to help a partner organisation). She acknowledged that the additional work was not the full reason for the pressures on RTT in general surgery but it had kept the unit’s performance just below target; plans had been developed to return to compliance as soon as possible. Agreement to take on the additional work had been supported by the Board and NHSI, despite the potential adverse impact on RTT levels. In response to a query from Mr Mapstone, Mrs Kelly and Mr Kirton also gave assurance that the additional work had not been taken at the detriment of Barnsley patients; the additional income would be beneficial Barnsley patients in the longer term. In terms of readmissions, Ms Dean had been pleased to note the improvement reflected in the latest graphs. She asked if the data analysis mentioned earlier would show how people were admitted (ie by Ambulance, by GPs, from care homes, etc) and appreciated Mrs Kelly’s confirmation that such data was already being collated routinely. Trends were monitored closely and Mrs Kelly agreed that, as suggested by Ms Dean, it would be useful to factor this into the IPR when the new format was developed (currently under review). Dr Enright also advised that work was ongoing to ensure that all admissions were recorded more accurately, to exclude factors such as internal transfers and day case follow ups. Greater accuracy was also needed in other areas, including VTE assessments, where the Trust over counted by including all patients, which was not mandatory. Mrs Kelly was pleased to highlight recent national media reporting on cancer services, which had shown the Trust rated 9PP

thPP out of 137 trusts across key

indicators, with 100% compliance for 62 days, reflecting the excellent work progressed by the teams involved. More work was continuing with Cancer Alliance partners to take cancer services across the patch forward. The emergency access performance target remained challenging: 91.68% year to date and 87.77% for Q3 (so far). The latter was slightly below the STF trajectory but the Trust remained committed to providing the best and fastest care for patients. ED building works would be completed by the end of November/December, which would help with streaming into primary care services (I-heart Barnsley) too. UUFinanceUUU Mr Wright reiterated the key points reported in the F&P Chair’s Log, as above. The Trust had been on plan at month 6 (year to date) but he was mindful that STF support was largely back loaded for the year and there was a lot of work

Pack pg 42


ahead. The position on agency spend remained good and he predicted an uplift of clinical income, returning to the better performance in months 1-5. Capital was slightly overspent (due to the generator which NHSI had asked the Trust to defer from 2016/17) but was expected to achieve year end broadly on plan. In relation to operating costs Mrs Armitage asked why pay was over but non pay under plan. Mr Wright explained that the position in pay largely related to CBU1 (emergency care) and escalation needs. Non pay had benefitted from efficiencies in BFS and under trading on income (non pay generally tracked activity).

17/175 2017/18 OBJECTIVES (17/11/P-15)Mr Kirton presented and expanded upon progress on the Trust’s Business Plan Objectives as at the end of Q2, the key issues from which had been raised in earlier discussions (above). The report was accepted with a few minor comments and observations:

Dr Enright suggested that the rating for 7-day working could be read as “amber/green” rather than amber as the Trust had made good progress, with support from NHSI

Ms Dean would appreciate larger print for those needing paper copies, to make it easier to read

Ms Moore proposed that the report would be useful earlier on the agenda in future meetings, to set the context for wider debates.

17/176

ACCOUNTABLE CARE SYSTEM (ACS) Dr Jenkins provided a brief verbal update on progress since the last Board meeting:

Latest approved Minutes from the Collaborative Partnership Board (CPB) had been issued; copies would be circulated to the Board for information.

A lot of work had progressed to balance primary care across the area. This was not core business for BHNFT but would have implications for its plans.

There was a drive for ACSs to take a lead on performance management for the cancer 62 days targets. It had been recognised that this was an indicator of other changes ahead.

Stroke had been the only ‘red’ indicator on the Objectives report. Review across the area had identified seven out of nine vacancies in stroke (excluding the Teaching Hospital). On behalf of the ACS, Dr Jenkins was now leading work to try to introduce a more collective approach within the ACS and recruit consultants on that basis. The final decision on the Hyper Acute Stroke Unit reconfiguration was still awaited.

Five areas had been identified for focus within the Hospital Services Review: ED, gastro and endoscopy, maternity, paediatrics and non-hyper acute stroke. Dr Jenkins was confident that the Trust was strong in four of the five areas. The ET had met with staff in the areas under review and would work closely with the teams in the HSR.

The Chairman advised that Mr Kirton would be meeting with the Governors shortly to provide more information on the development of the ACS. In reply to a question from Mr Higgins, Mr Kirton confirmed the date of the next Barnsley ACO delivery board. The meeting would be held in public.

RJ

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17/177 CHAIRMAN’S REPORT (17/11/P-17)The report was received and noted, providing an overview on a number of activities undertaken by the Chairman since the last Board meeting, items of interest, including feedback from national and local events, and the continuing work of the Council of Governors. The Chairman highlighted one issue from the report and two further items:

At the latest meeting of the Trust’s Remuneration & Terms of Service Committee, Members had considered and supported proposed changes to the ET structure. This would require some adjustments to salaries accordingly to reflect the changing responsibilities. More information would be provided at the next Board meeting (per Minute 17/172).

The Constitution review working group would meet in mid-November. Membership open to all Governors and Directors

Christmas party tickets were now on sale

Work had been continued by the Organ Donation Committee, which he Chaired, to provide a suitable memorial for donors over the past 10 years. The Trust would be working with Barnsley College to invite students to submit designs, with a brief written by the Curator from the Yorkshire Sculpture Park. The memorial was intended to be one that could be added to annually.

Reports from the Non Executive Directors (NED) included:

Confirmation from Mr Mapstone that he had taken on the role of NED-lead for Freedom to Speak Up (FTSU) and had recently met with Ms Pollington, the FTSU Guardian. Dr Jenkins flagged that Ms Pollington had taken on the role with the same time allocation as the previous postholder; he had, however, recently agreed to increase this, reflecting the growing import of the role. For the benefit of the meeting, Dr Jenkins also briefly outlined how staff could gain access to the FTSU Guardian and highlighted the Guardian’s direct access to both him, as CEO, and national leads.

Mr Mapstone also advised that the 2015/16 Employer Based Clinical Excellence Awards for Consultants were being rerun as the first round had been flawed. The outcomes would be reported as soon as possible in the new year. Dr Enright reported that the consultant body had supported this as the fairest approach. Ms Moore was involved with the national nursing awards, which had caused her to reflect on how other staff might also be better recognised and rewarded. Dr Jenkins agreed that the Trust could be more proactive and advised that this would be addressed in some of the work being led by Mrs Grosvenor. Ms Parkes also affirmed that the Trust had established a better system to link into national awards where appropriate, with potential nominations being reviewed by ET regularly.

17/178 CHIEF EXECUTIVE’S REPORT (17/11/P-18)Dr Jenkins’ report on regional and national news and updates on a range of activities undertaken as CEO since the last Board meeting held in public was received and noted. He drew attention to two issues: firstly the Stoma Care day, which he had recently attended and which had provided a real example of holistic care for patients following major bowel surgery. Secondly, the useful discussions with Professor Keith Willett, the national lead on End of Life Care, ahead of his presentation at the Core.

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17/179 COUNCIL OF GOVERNORS (17/11/P-19)The agenda (October) and approved Minutes (August) from the Council of Governors’ latest General Meeting were received and noted.

17/180 HORIZON SCANNER (17/11/P-20)The monthly Horizon Scanner was received and reviewed. Ms Parkes drew attention to the latest postings on NHS Choices (six in total, all five star rated), and reported developments across ACSs nationally. She also highlighted the national focus on readmissions and consultations regarding the role of Nursing Associates. The Board continued to find the Scanner a very useful regular report.

17/181 ANY OTHER BUSINESS & DATE OF NEXT MEETING. There being no further comments from the public and or any other business, and in accordance with the Trust’s Constitution and Standing Orders, it was resolved that members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted. The Chairman reminded members that this excluded the Governors, who had been invited to join the Board for both parts of the meeting. Members were reminded that the next meeting of the Board of Directors to be held in public was scheduled for 7PP

thPP December 2017.

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Created by: Healthcare Information and Insight Service

Title of report: Integrated Performance Report

Executive Lead: Karen Kelly

`

October 2017

Integrated Performance Report

Pack pg 46

;

Executive Summary by Exception

Key Messages

1 Patients will experience safe care Committee: Q&G Page: 11-30

Quality & Patient Experience:-

Complaints

FallsDuring the period 1st-31st October 2017, there were 90 inpatient falls reported and this includes 24 repeat falls. The majority of falls resulted in no harm or low harm. There have

been 3 falls incidents resulting in moderate and above harm and 2 of these incidents are currently being investigated under our serious incident (SI) investigation process. FYTD

the total number of inpatient falls is 441 and the total number of falls incidents resulting in moderate harm or above is 14.

There continues to be a variation through the months with the number of inpatient falls that occur at the Trust and this is to be expected. The data collected on the actual number

of falls per 1,000 bed days and number of harmful falls per 1,000 bed day’s shows that we remain below our set upper warning limits in October 2017.

A Falls Forum has been developed to review and scrutinised all fall incidents that result in moderate harm or above, this is to determine if the fall was avoidable or unavoidable.

Ensuring that any learning from these incidents is shared to prevent further harms from falls.

The Falls and Syncope Nurse Specialist is working with the Yorkshire and Humber Improvement Academy in her role as Safety Huddles coach to encourage and support Trust staff

to promote all aspects of patient safety including reducing falls.

The falls team continues to provide advice, support and training for staff around best falls prevention practices and falls documentation. Inpatient falls and staff training

compliance is monitored and monthly reports are disseminated through the Falls Prevention Group.

During October the Trust received 27 new complaints bringing the YTD total to 161. Of this number 14 were for CBU 1, 9 for CBU 2, 2 for CBU 3 and 2 for Corporate Services.

The primary themes of new complaints were Clinical Care/Treatment (11), Access issues (6) and Communication concerns (7). On initial assessment 6 complaints were assessed

as high risk. The number of cases closed with agreed timeframe/or extension was 89% and the year to date position is 92%. The average number of working days taken to

investigate complaints was 53 days. 3 complaints were re-opened due to additional issues being raised/meeting request. The Patient Advice team handled 291

concerns/enquiries during the month which is a significant increase on previous month’s figures.

Patients Partnerships People Performance

2 Pack pg 47


Key Messages

1 Patients will experience safe care cont. Committee: Q&G Page: 11-30Pressure UlcersThere have been no hospital acquired pressure ulcers in October. The Trust objective of zero hospital acquired avoidable grade 3 or 4 pressure ulcers has therefore been achieved

again this month.

On-going work continues by the Tissue Viability team to support Trust staff around pressure ulcer prevention, including the delivery of training at Band 2 upskilling sessions and

Winter Pressures sessions.

The very high risk mattresses which were recently purchased are in now in use Trust wide for patients who require additional support around pressure area care.

An audit tool has been designed and piloted on 2 wards as part of a Quality Improvement Project to look into the use of the Pressure Ulcer Traffic Light Documents. The audit will

take place during the remainder of Quarter Three, with an action plan formulated following this.

The Senior TVN continues to work alongside the Improvement Academy in her role as Safety Huddle Coach to encourage and support Trust staff to promote all aspects of patient

safety, including the reduction of hospital acquired pressure ulcers.


3 Pack pg 48


Key Messages

1 Patients will experience safe care cont. Committee: Q&G Page: 11-30

Safety

Medication Incident Resulting in Harm

Incident Resulting in Severe Harm

A&E 4 Hour Wait

The 5 SIs reported in October are as follows

• 2017/26170 – undiagnosed AAA in CBU 2 (DTX 40485). Incident occurred in June 17.

• 2017/25605– slip, trip, fall resulting in a head injury in CBU 1(DTX 40121). Incident occurred in October 2017

• 2017/25041 – slip, trip, fall resulting in a fractured neck of femur in CBU 1 (DTX 39996). Incident occurred in October 2017

• 2017/24951 – Potential delay in treatment/procedure due to referrals codes on Lorenzo being automatically converted in CBU 2 (DTX 40509). Incident occurred in September 2017.

• 2017/24340 – confidentiality breach occurring in risk management, corporate (DTX 39873). Incident occurred in October 2017

• Inpatient fall on AMU; patient sustained a fractured neck of femur. Declared as a SI 2017/25041 (DTX 39996)

• Inpatient fall on AMU; patient sustained a head injury. Patient transferred to Sheffield and underwent neurosurgery. Declared as a SI 2017/25605 (DTX 40121)

• Inpatient fall on ward 18; patient sustained a fractured neck of femur. RCA being completed and to be presented at November’s falls forum (DTX 40634)


Serious Incidents

• Incident resulting in potential moderate harm. Patient was given the incorrect dose of Gentamicin on ward 15; the drug prescribed correctly but error made during administration of drug.

Patient given approximately 3 times too much of drug. (DTX 40367)

ED performance achieved at 87.6% against agreed trajectory of 95%, Year To date position 91.7%


4 Pack pg 49


Key Messages3 People will be proud to work for us Committee: F&P Page: 31-34

Staff Turnover

Appraisals

Mandatory Training

Sickness Absence

Has worsened this month. All areas are in red except Corporate. The CBU breakdown is as follows: CBU 1 4.45% CBU 2 4.48% CBU 3 4.56% Corp 3.35% BFS

4.97%. Overall cumulative figure to date is 4.0% (amber)

Overall compliance for October is 87.1%, CBU 3 has achieved compliance at 90.6%, the remainder are as follows;

Corporate services 85.8%, CBU1 83.7%, CBU2 87.5%

This month is within the expected range. The rolling 12 months figure is high due to the TUPE transfer of staff to BFS in September. At the request of Board, work is

underway to recalculate with this removed.

Appraisals Medical - Percentage of doctors (eligible for appraisal) in date at 31/10/2017 was 97.7%.

CBU 1 Medicine = 96.9% CBU 2 Surgery = 97.3% CBU 3 W&C & Clinical Services = 100%

Appraisals Non Medical - Overall compliance is 93.4%


5 Pack pg 50

Executive Summary by Exception cont.

Key Messages4 Performance Matters Committee: F&P Page: 35-51

a) Key Performance Indicators62 Day - Urgent GP Referral to Treatment

Consultant Upgrade

Breast symptomatic 2WW

The uploaded and published September performance shows the Trust has achieved 100% compliance with this target. There were no shared pathway breaches of this target in

September. 1 x compliant pathway was referred after IPT Day 38, so a minor local adjustment to position is noted. However the target shows high levels of achievement. The Trust

continues to perform well when bench marked across the Cancer Alliance and against the national picture. However improvement work at site specific pathway level is on-going

to ensure performance is sustained.

The locally agreed 62 Day ‘Consultant Upgrade’ target was compliant in September and is forecast to remain this way in October (subject to validation). This includes any changes

applied following application of the IPT Policy.

The validated September performance shows compliance with the Breast Symptomatic target and this was maintained at Q2 end. Additionally the October performance (subject

to validation) suggests 100% compliance will be reported at month end with Q3 to date, also compliant.


6 Pack pg 51

Executive Summary by Exception cont.

Key Messages4 Performance Matters cont. Committee: F&P Page: 52-55b) Financial overview

The Trust has a consolidated year to date deficit position of £7.5m that is slightly favourable to plan. CIP delivery for month 7 is ahead of plan year to date. Clinical income is £1.3m

ahead of plan, although the activity mix is varied. Other income is adverse to plan at month 7. Planned Sustainability and Transformation funding has not been realised in month

due to the A&E target being off trajectory in month. Capital expenditure is £0.28 above plan. Loan funding of £6.43m has been drawn year to date.


7 Pack pg 52

1 2 3 4 6 7 9 10 11 12 13 14 15 16

Domain KPI Target Set By Current Qtr. Year to Date Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

Q - FFT Positivity Rates - EDG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT 86.5% 85.2% 97.1% 82.6% 80.3% 91.0% 87.1% 88.8% 79.8% 84.3% 83.9% 82.3% 86.6% 90.0% 86.5%

Q - FFT Positivity Rates - IPG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT 96.9% 97.1% 96.9% 96.9% 97.3% 97.1% 97.9% 98.4% 97.2% 97.6% 96.8% 96.1% 99.1% 96.2% 96.9%

Q - FFT Positivity Rates - OPG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT 94.5% 95.2% 93.3% 93.8% 95.4% 95.3% 95.7% 95.5% 92.9% 95.3% 95.2% 95.5% 95.5% 96.4% 94.5%

Q - FFT Positivity Rates - MATG >87.5%, A >=82.5%-87.5%, R

<82.5% (> )BHNFT 97.5% 98.0% 98.4% 96.7% 99.1% 97.9% 98.4% 98.5% 97.9% 99.5% 97.3% 99.6% 95.3% 98.0% 97.5%

Q - Complaints closed within target % G >90%, A >=70%-90%, R <70% (>) BHNFT 88.9% 92.2% 85.7% 87.1% 73.3% 73.7% 78.3% 90.9% 83.3% 93.3% 92.3% 94.7% 95.8% 94.7% 88.9%

Dementia - Find/Assess 90% (>) National 96.5% 91.5% 93.8% 92.0% 91.8% 93.9% 98.2% 90.4% 92.2% 93.6% 92.4% 88.3% 87.2% 89.5% 96.5%

Dementia - Investigate 90% (>) National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Dementia - Refer 90% (>) National 100.0% 100.0% - 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% - 100.0%

Falls 785 (<) BHNFT 90 439 71 73 87 70 55 76 58 61 59 52 54 65 90

Multiple Falls n/a BHNFT 24 88 19 21 21 15 12 18 8 8 13 8 13 14 24

Falls resulting in moderate harm or above 20 (<) BHNFT 3 14 0 0 1 1 0 0 2 3 4 1 0 1 3

Hand washing 95% (>) National 99.8% 99.2% 99.7% 99.7% 99.9% 99.6% 99.5% 99.9% 99.7% 99.4% 99.9% 98.7% 97.1% 99.8% 99.8%

Pressure Ulcers Grade 3 & 4 (Avoidable) 0 BHNFT 0 5 1 3 1 3 2 0 0 0 2 1 2 0 0

Pressure Ulcers Grade 2 (Avoidable) 0 BHNFT 0 11 1 7 1 1 2 3 2 2 4 1 2 0 0

Single Sex Breaches 0 National 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Hospital Acquired Clostridium Difficile 13 (<) NHSE 0 4 3 0 2 0 3 0 1 0 1 0 1 1 0

MRSA Bacteraemia 0 NHSE 0 2 0 0 0 0 0 0 0 1 0 0 0 1 0

VTE Screening Compliance 95% (>) NHSE 97.3% 88.8% 89.2% 86.1% 82.8% 78.2% 79.2% 79.0% 78.7% 86.6% 86.0% 86.9% 91.6% 93.2% 97.3%

Recorded Medication Incidents 400 (<) National 28 207 27 34 41 40 45 37 32 34 21 33 21 38 28

Recorded Medication Errors - Causing harm 10 (<) National 1 12 0 3 1 0 4 1 3 0 1 1 1 4 1

Q - Never Events - Reported in Month 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Q - Serious Incidents - NHSE 5 39 1 2 7 5 10 6 8 5 6 7 3 5 5

Q - Total Number of Incidents Resulting in Death 0 National 0 3 0 0 1 0 0 0 0 0 2 0 0 1 0

Q - Total Number of Incidents Resulting in Severe Harm 0 National 0 10 1 0 2 1 1 1 3 3 2 2 0 0 0

Q - Percentage of Incidents Causing Harm 28% (<) BHNFT 10.4% 6.9% 5.7% 9.3% 6.7% 5.1% 8.0% 8.0% 9.3% 4.8% 7.3% 5.2% 6.0% 5.4% 10.4%

Q - Total (All) 7400 (>) National 693 4293 619 674 689 651 625 589 570 666 613 573 604 574 693

Q - HSMR (Rolling 12 months) Latest Data is July 2017 100 (<) National 97 96 95 95 95 94 95 95 95 95 93 94 93

Crude Mortality - 74 89 103 116 96 87 69 81 69 74 72 71 82

SHMI (Rolling 12 months) Latest Data is March 2017 105 (<) National 102.0 100.4 99 102

Q - HSMR (Financial Year to date) - April 17 - July 2017 100 (<) 79 86 86 87 90 92 94 95 93 84 83 81 83 80

Duty of Candour Q - Duty of Candour Breaches 0 National 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance does not apply to Cancer & A&E targets

which will be RED if the target is not achieved)

GREEN Achieved Target

< Less Is Good

> More is good

Q KPI is in the Quality Schedule

Summary

Quality & Patient

Experience

Mortality

Patient Safety

0 NHSE

Patients will experience safe care


8 Pack pg 53

Domain KPI Target Set By Current Qtr. Year to Date Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

Staff Turnover (Rolling 12 months) G <=10%, A >10%-11%, R >11% (<) BHNFT 13.9% 11.3% 9.0% 8.8% 8.5% 8.6% 8.8% 8.9% 9.4% 9.4% 9.4% 9.5% 13.5% 14.0% 13.9%

Appraisals G >90%, A >=70%-90%, R <70% (>) BHNFT 93.7% 70.6% 94.2% 94.1% 93.6% 93.2% 93.0% 92.9% 11.7% 31.3% 87.1% 94.4% 94.7% 81.8% 93.7%

Mandatory Training G >90%, A >=85%-90%, R <85% (>) BHNFT 87.1% 87.6% 86.9% 87.8% 88.6% 87.6% 86.7% 87.7% 88.0% 88.2% 88.5% 87.7% 87.0% 87.0% 87.1%

Sickness AbsenceG <=3.75%, A >3.75%-4.25%, R >4.25%

(<)BHNFT 4.0% 3.8% 4.1% 4.6% 4.2% 4.5% 4.4% 4.1% 3.8% 3.5% 3.7% 4.0% 3.6% 3.9% 4.0%

RTT Incomplete Pathways (October 2017) 92% (>) National 92.1% 91.7% 94.1% 93.3% 94.0% 92.7% 93.1% 92.8% 90.0% 91.4% 92.3% 92.2% 92.1% 92.1% 92.1%

Q - Cancer 2 Week Waits 93% (>) National 95.5% 95.5% 95.1% 95.5% 96.1% 94.2% 95.4% 95.9% 95.0% 95.8% 94.2% 96.3% 95.8% 95.9% 95.5%

Q - Symptomatic Breast 2 Week Waits 93% (>) National 100.0% 94.5% 95.2% 98.2% 95.1% 96.5% 95.3% 95.4% 94.6% 97.2% 90.3% 89.0% 94.7% 97.6% 100.0%

Q - 31 Day - 1st Definitive Treatment 96% (>) National 100.0% 99.6% 100.0% 98.7% 97.1% 100.0% 95.2% 98.4% 100.0% 98.4% 100.0% 100.0% 98.5% 100.0% 100.0%

Q - 31 Day - Subsequent Treatment (Surgery) 94% (>) National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 88.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Q - 31 Day - Subsequent Treatment (Chemotherapy) 98% (>) National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Q - 38 Day - Inter-Provider Transfer 85% (>) BHNFT 81.0% 86.2% 82.5% 81.5% 73.3% 65.6% 91.3% 76.3% 81.1% 87.8% 88.9% 94.9% 86.7% 80.0% 81.8%

Q - 62 Day - GP Referral to Treatment 85% (>) National 93.2% 92.8% 91.8% 95.0% 85.7% 91.6% 86.7% 87.2% 93.5% 88.4% 92.9% 93.1% 92.6% 100.0% 93.2%

Q - 62 Day - Screening Referral to Treatment 90% (>) National 92.3% 93.6% 100.0% 100.0% 100.0% 90.9% 93.3% 100.0% 100.0% 88.2% 88.9% 100.0% 85.7% 100.0% 92.3%

Q - 62 Day - Consultant Upgrade to Treatment 85% (>) BHNFT 85.7% 85.6% 81.3% 85.7% 100.0% 100.0% 85.7% 69.2% 90.0% 87.5% 66.7% 81.8% 90.9% 86.7% 85.7%

Emergency % Patients Waiting <4 Hours 95% (>) National 87.6% 91.7% 93.2% 87.7% 83.5% 87.1% 85.0% 92.5% 89.0% 91.1% 91.8% 95.2% 92.5% 94.6% 87.6%

Average Length of Stay - Elective G <=2.42, A >2.42-2.67, R >2.67 (<) BHNFT 2.16 2.45 2.87 2.86 2.30 2.12 2.48 2.44 2.52 2.48 2.15 2.66 2.89 2.29 2.16

Average Length of Stay - Non-Elective G <=3.44, A >3.44-3.69, R >3.69 (<) BHNFT 2.39 2.47 2.30 2.55 2.43 2.45 2.54 2.56 2.33 2.38 2.25 3.29 2.29 2.34 2.39

Re-admissions % 8.63% BHNFT 9.2% 9.4% 9.8% 10.0% 9.6% 9.1% 9.8% 8.7% 9.9% 9.6% 10.1% 9.9% 8.6% 8.6% 9.2%

Cancelled Operations - Breaches of the 28 day rule 0 National 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

DNA Outpatient DNA Rates G <=10%, A >10%-11%, R >11% (<) BHNFT 7.8% 8.4% 8.7% 8.6% 8.7% 8.2% 7.7% 7.9% 7.7% 8.1% 8.9% 9.3% 8.2% 9.0% 7.8%

RAG Description

RED Failed Target

AMBER Failed by <5% (This tolerance does not apply to Cancer & A&E targets

which will be RED if the target is not achieved)

GREEN Achieved Target

< Less Is Good

> More is good

Q KPI is in the Quality Schedule

NOTE: National Indicators such as Cancer, RTT, Cancelled Ops, etc. are considered as being either Achieved or Failed. These are therefore RAG rated as Green or Red.

All other indicators are classed as Achieved or Failed with the exception of all Workforce KPIs, Average Length of Stay & DNA rates which detail the tolerances applied in the Target column.

Elective Access

Cancer

Operational

Efficiency

Performance matters - Key Performance Indicators

People will be proud to work for us

Workforce

Summary


9 Pack pg 54

Patients will experience safe care (Safety)

Incidents (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Med

icat

ion

Inci

de

nts

- C

ausi

ng

har

m

Nev

er E

ven

ts &

Ser

iou

s In

cid

en

ts

Inci

de

nt

Gra

din

g

Pat

ien

t Sa

fety

Inci

den

ts (

All)


0

5

10

15

20

25

30

35

40

0

2

4

6

8

10

12

Total Medication Incidents Causing Harm Target Causing Harm Actual

0

1

2

3

4

5

6

7

8

9

Serious Incidents Never Events

0

100

200

300

400

500

600

700

800

Actual Target

0%

2%

4%

6%

8%

10%

12%

0

10

20

30

40

50

60

70

80

Pe

rce

nta

ge C

ausi

ng

Har

m

Gra

din

g

Low Moderate Severe Death % Causing Harm

Never Events target is '0'

10 Pack pg 55

Patients will experience safe care (Quality & Experience)

7

9

Frie

nd

s &

Fam

ily T

est

Frie

nd

s &

Fam

ily T

est


0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ED Actual IP Actual OP Actual MAT Actual Target

95.5% 97% 97% 100% 95% 99% 97% 99% 96% 98% 98%

77%

96% 98% 97%

0%

20%

40%

60%

80%

100%

Friends & Family Test - Inpatient Benchmarking (Latest NHS England Published Data - June 2017)

Peer Group Local Target

95.9%

86%

96% 99%

98% 99% 96% 96%

94% 96%

99% 97% 98% 98%

75%

80%

85%

90%

95%

100%

Friends & Family Test - Maternity Benchmarking (Latest NHS England Published Data - June 2017)


86% 94%

84% 77%

85% 90% 91%

74%

87% 96%

77%

95% 88%

95%

84%

0%10%20%30%40%50%60%70%80%90%

100%

Friends & Family Test - A&E Benchmarking (Latest NHS England Published Data - June 2017)


11 Pack pg 56



Complaints (Quality Strategy - Goal 1: Delivering Patient Centred Care)

Comments:

Co

mp

lain

tsC

om

pla

ints

Co

mp

lain

ts

During October the Trust received 27 new complaints bringing the YTD total to 161. Of this number 14 were for

CBU 1, 9 for CBU 2, 2 for CBU 3 and 2 for Corporate Services. The primary themes of new complaints were Clinical

Care/Treatment (11), Access issues (6) and Communication concerns (7). On initial assessment 6 complaints were

assessed as high risk. The number of cases closed with agreed timeframe/or extension was 89% and the year to

date position is 92%. The average number of working days taken to investigate complaints was 53 days. 3

complaints were re-opened due to additional issues being raised/meeting request. The Patient Advice team

handled 291 concerns/enquiries during the month which is a significant increase on previous month’s figures.

0

5

10

15

20

25

30

35

Nu

mb

er

of

Co

mp

lain

ts b

y C

ate

gory

Complaints by Category

Patient Care Access, Appts, etc Communication Medical Records Medication

Falls Infection Control Infrastructure Other

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge w

ith

in t

arge

t

Complaints Closed within Target

% closed Target

0

50

100

150

200

250

300

350

0

5

10

15

20

25

30

35

Nu

mb

er

of

Co

mp

lain

ts &

Co

nce

rns

Complaints & Concerns

Complaints

Re-opened

Number of Enquiries received through Patient Advice and Liaison Service

12 Pack pg 57



Dementia (Quality Strategy - Goal 1: Delivering Patient Centred Care)

De

me

nti

a -

Be

nch

mar

kin

g

De

me

nti

aD

em

en

tia

- B

en

chm

arki

ng

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Find/Assess Actual Investigate Actual Refer Actual Target

84% 94% 90%

98% 90% 96%

83% 79% 90%

99% 99%

0%10%20%30%40%50%60%70%80%90%

100%

Percentage of Cases Identified (Latest NHS England published data May 2017)

Peer Group Target

100% 100% 100%

95%

100% 99% 97%

100%

95%

100% 100%

84%86%88%90%92%94%96%98%

100%

Percentage of Cases with Diagnostic Assessment (Latest NHS England

Published data May 2017)

Peer Group Target

13 Pack pg 58



Falls (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Comments:

The number of falls reported in February remains around the same number as prior

months.

Mu

ltip

le F

alls

During the period 1st-31st October 2017, there were 90 inpatient falls reported and this includes 24 repeat falls. The majority of falls resulted

in no harm or low harm. There have been 3 falls incidents resulting in moderate and above harm and 2 of these incidents are currently being

investigated under our serious incident (SI) investigation process. FYTD the total number of inpatient falls is 441 and the total number of falls

incidents resulting in moderate harm or above is 14.

There continues to be a variation through the months with the number of inpatient falls that occur at the Trust and this is to be expected. The

data collected on the actual number of falls per 1,000 bed days and number of harmful falls per 1,000 bed day’s shows that we remain below

our set upper warning limits in October 2017.

A Falls Forum has been developed to review and scrutinised all fall incidents that result in moderate harm or above, this is to determine if the

fall was avoidable or unavoidable. Ensuring that any learning from these incidents is shared to prevent further harms from falls.

The Falls and Syncope Nurse Specialist is working with the Yorkshire and Humber Improvement Academy in her role as Safety Huddles coach to

encourage and support Trust staff to promote all aspects of patient safety including reducing falls.

The falls team continues to provide advice, support and training for staff around best falls prevention practices and falls documentation.

Inpatient falls and staff training compliance is monitored and monthly reports are disseminated through the Falls Prevention Group.

Falls

Falls

re

sult

ing

in m

od

era

te h

arm

or

abo

ve

0

10

20

30

40

50

60

70

80

90

100

No

. of

Falls

No. of Falls

Actual

Falls target is '0'

0

5

10

15

20

25

30

No

. of

Mu

ltip

le F

alls

Multiple Falls

Actual

0

1

2

3

4

No

. of

Falls

Falls resulting in moderate harm or above

Actual Target

Multiple falls target is '0'

14 Pack pg 59



Pressure Ulcers (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Comments:

As stated

last

Comments:

There have been no hospital acquired pressure ulcers in October, therefore no avoidable pressure ulcers to report.

There have been no hospital acquired pressure ulcers in October, therefore no avoidable pressure ulcers to report.

Pre

ssu

re U

lce

rs -

Gra

de

3 &

4P

ress

ure

Ulc

ers

- G

rad

e 2

0

1

2

3

4

5

6

7

8

9

10

Tota

l nu

mb

er

of

Gra

de

2 P

ress

ure

Ulc

ers

Grade 2 Unavoidable Grade 2 Avoidable

Grade 2 Pressure Ulcers target is '0'

0

1

2

3

4

5

6

7

8

9

10

Tota

l nu

mb

er

of

Gra

de

3 &

4 P

ress

ure

Ulc

ers

Grade 3&4 Unavoidable Grade 3&4 Avoidable

Grade 3&4 Pressure Ulcers target is '0'

15 Pack pg 60



Infections (Quality Strategy - Goal 2: Delivering Consistently Safe Care)

Comments:

MSS

A

(Met

hic

illin

-Sen

siti

ve S

tap

hyl

oco

ccu

s

Au

reu

s)

E.co

li B

acte

rae

mia

There are 2 x cases of hospital acquired E’Coli Bacteraemia identified, 1 on Ward 17 and the other on the Elderly

Care Ward, both CBU1.

There are 2 x cases of Hospital Acquired MSSA identified one on Ward 17 and the other on Ward 18, both CBU1.

Ho

spit

al A

cqu

ire

d C

.Dif

f T

oxi

n

0

1

2

3

4

5

6

7

8

Nu

mb

er

of

E.co

li C

ase

s

E.coli Bacteraemia (Escherichia coli)

0123456789

10111213

Hospital Acquired C.diff Toxin (cumulative position)

Tolerance Actual

0

1

2

3

4

5

6

7

8

Nu

mb

er

of

MSS

A C

ase

s

MSSA (Methicillin-Sensitive Staphylococcus Aureus)

16 Pack pg 61



Nursing Staffing Fill Rate (Quality Strategy - Goal 4: Building on Capacity and Capability)

14 85.5% 97.6% 90.3% 90.3% 3.1 2.1 5.2 Registered Nurses

17 86.3% 96.7% 95.8% 100.0% 2.9 2.1 5.1 Registered Midwives

18 74.5% 94.3% 122.6% 101.6% 3.5 3.0 6.4 Unregistered health care/midwifery care assistants

19/20 77.1% 79.9% 99.8% 100.9% 2.3 4.2 6.5 Unregistered nursing/midwifery auxiliaries.

AMU 75.3% 85.1% 111.3% 100.0% 4.9 2.9 7.7

Acute Stroke 101.0% 98.8% 100.4% 121.5% 3.0 3.1 6.1

24 102.9% 93.5% 96.9% 109.5% 4.7 3.6 8.3

21 81.6% 81.2% 103.3% 119.6% 2.4 2.6 5.0

ISU 74.0% 93.5% 106.5% 97.7% 2.2 2.8 5.0

33/34 81.7% 90.5% 96.8% 102.1% 3.4 3.0 6.3

ITU 97.2% 83.8% 95.6% - 31.6 2.5 34.1

SHDU 94.5% 80.8% 100.1% - 14.8 3.2 18.0

CCU 84.2% 75.2% 100.4% - 11.1 1.3 12.4

AN/PN 96.5% 90.8% 98.2% 94.6% 3.0 1.2 4.2

Birthing Centre 96.4% 94.2% 97.5% 96.8% 29.5 5.0 34.5

37 93.0% 89.7% 99.0% - 8.8 1.4 10.2

15 96.9% 103.3% 98.4% 96.3% 10.6 2.5 13.1

Diabetes/Endo 61.4% 100.6% 91.3% 171.2% 2.4 3.9 6.4

This allows for contingency plans to be made where the roster identifies that the

planned staffing falls short of the minimum requirement, for example where there

are vacant nursing posts or staff appointed have not started in post. These

contingency plans can include: moving staff from a shift which is above the

minimum required level, moving staff from another ward/area which is above the

minimum required level, or the use of flexible/temporary staffing from the Trust’s

internal bank or via an external nursing agency.

In October there were five in patient wards with a fill rate for registered staff of

below 80%, wards 18, 19/20 and 22, the Integrated Surgical Unit, and the Acute

medical Unit, this is due to a number of reasons including vacancies, sickness and

supporting the escalation ward. Overall the fill rate for registered nurses continues

to stay stable on both day and night shifts. In order to ensure safe deployment of

staff whilst escalation areas continue to be used the Matrons are overseeing the

staffing plans with support from the Heads of Nursing. Care Hours per Patient Day

continue to be monitored as does the use of agency. The highest user of agency

nurses continues to be in the Emergency Department..

320 - CARDIOLOGY

The Trust uses an e-rostering system with duty rosters created eight weeks in

advance to ensure the levels and skill mix of the nursing staff on duty are appropriate

for providing safe and effective care.

Ave fill rate

Care staff (%)

340 - RESPIRATORY MEDICINE

430 - GERIATRIC MEDICINE

502 - GYNAECOLOGY

BHNFT is committed to ensuring that levels of nursing staff, match the acuity and

dependency needs of patients in order to provide safe and effective care. Nurse

staffing includes:

300 - GENERAL MEDICINE

Care Staff

370 - MEDICAL ONCOLOGY

301 - GASTROENTEROLOGY

100 - GENERAL SURGERY

192 - CRITICAL CARE MEDICINE

Ave fill rate

Care staff

(%)

Registered

Nurses/Midwi

ves

Overall

A monthly nurse staffing paper is presented to the Quality and Governance

Committee. This paper presents in depth information on all aspects of nurse staffing

including; vacancies, bank and agency usage, risk areas and mitigation of risk. The

paper also triangulates nursing staffing against a heat map of harm. There is a full

discussion at each meeting regarding this paper.

SpecialtyAve fill rate

Registered

Nu

rsin

g St

affi

ng

Fill

Rat

e

307 - DIABETIC MEDICINE

300 - GENERAL MEDICINE

320 - CARDIOLOGY

422- NEONATOLOGY

Ward

name

Ave fill rate

Registered

Night Care Hours Per PatientDay

420 - PAEDIATRICS

110 - TRAUMA & ORTHOPAEDICS

192 - CRITICAL CARE MEDICINE

501 - OBSTETRICS

501 - OBSTETRICS

17 Pack pg 62

Patients will experience safe careHeatmap Oct-17

MR

SA

Bac

tera

emia

C D

iff

Falls

- N

o

Ad

vers

e

Ou

tco

me

Falls

- Ad

vers

e O

utco

me

Mu

ltip

le f

alls

- N

o A

dve

rse

Ou

tco

me

Mu

ltip

le f

alls

- A

dve

rse

Ou

tco

me

Med

icat

ion

Erro

rs -

No

Ad

vers

e

Ou

tco

me

Med

icat

ion

Erro

rs -

Nea

r

mis

s

Med

icat

ion

Erro

rs -

Cau

sin

g H

arm

Nu

mb

er o

f

Seri

ou

s

Inci

den

ts

Nu

mb

er o

f

Nev

er E

ven

ts

Pre

ssu

re

Ulc

ers

Gra

de

2 (A

void

able

)

Pre

ssu

re

Ulc

ers

Gra

de

3 (A

void

able

)

Pre

ssu

re

Ulc

ers

Gra

de

4 (A

void

able

)

Inci

den

ts -

Dea

th

Inci

den

ts -

Seve

re

Inci

den

ts -

Mo

der

ate

Inci

den

ts -

Low

Inci

den

ts -

No

Har

m

Trust 0 0 67 23 21 3 17 10 1 3 0 0 0 0 0 3 2 64 621

Acute Stroke Unit 3 1 1 6 27

AMU 12 3 2 1 1 2 2 2 75

Cardiology Department 1

CCU 12

CDU 1 1 21

Chemotherapy Unit 3

Dermatology 1

Discharge Unit 6

ED 1 1 5 72

Elderly Care - Ward 19/20 10 2 3 5 22

Planned Investigation Unit 1 1 2

Endoscopy 6

Rheumatology 1

Ward 17 3 5

Ward 18 2 2 2 1 1 17

Ward 21 6 3 1 1 2 1 3 19

Ward 22 15 1 9 2 35

Ward 23 7 2 4 1 2 3 24Ward 24 2 1 1 10

Breast Outpatients 4

Day Surgery 1 9

Fracture Clinic 4

Hospital at Night 1

ICU 4

Inpatient Surgical Unit 0 2 1 3 12

Opthalmology OPD 1

Orthopaedic OPD 1

Pre-assessment 2

SHDU 1 2 2

Surgical Admissions 6

Theatre Arrivals 5

Theatres 2 7

Theatres recovery 1

Ward 29 0 1 1 1

Ward 32 0 1 1 4 4Ward 33/34 7 2 2 2 3 1 8 45

Antenatal Clinic 3

Childrens Assessment Unit 2

Community Midwifery 1 6

Early Pregnancy Assessment Unit 1

Labour Suite 5 79

Medical Imaging 1 8

Paediatric OPD 2

Pathology 6

Pharmacy 1

Physiotherapy 1

Postnatal/Antenatal Ward 1 12

Ultrasound 2

Ward 14 2 2 3 12

Ward 15 1 1 3

Ward 37 1 1 1 9Ward 38 1

Basement 1

Chest Clinic 1

Clinical Systems 1

Portering 3

Risk Management 1 1

Surgical Outpatients 1

CB

U 1

CB

U 2

CB

U 3

Co

rpo

rate


18 Pack pg 63

Patients will experience safe careHeatmap

Reporting Month: Oct-17

Executive lead : Heather McNair

Comments

Serious Incidents


• 2017/25605– slip, trip, fall resulting in a head injury in CBU 1(DTX 40121). Incident occurred in October 2017 (as above)

• 2017/25041 – slip, trip, fall resulting in a fractured neck of femur in CBU 1 (DTX 39996). Incident occurred in October 2017 (as above)

• 2017/24951 – delay in treatment/procedure due to referrals codes on Lorenzo being automatically converted in CBU 2 (DTX 40509). Incident occurred in September 2017.

• 2017/24340 – confidentiality breach occurring in risk management, corporate (DTX 39873). Incident occurred in October 2017

Pressure UlcerThere have been no hospital acquired pressure ulcers in October, therefore no avoidable pressure ulcers to report.

Indicator Name


19 Pack pg 64


Falls SPC Charts


07 Sep 2015 Introduction of: - Multifactorial Falls Assessments (MFA level 1 &2) for inpatients - Lying and Standing BP charts - Bed rail assessment charts - Medical Acute post fall assessment & Secondary fall assessment document - Updated falls careplans on Lorenzo for nursing staff - Patient and Relatives falls prevention advice available at each patients bedside - Promotion of Stickman signage (Red stickman to indicate patient has fall in hospital but now also to include patients admitted with a falls). 28 Sep 2015 - Falls Awareness Week at the Trust

Oct 2015 - Local Falls audit undertaken (including ward spot checks) - Falls Nurse Specialist Secondment commenced

Nov 2015 - Feedback to wards on spot check from local falls audit - Updated falls assessment documentation used on ITU, CCU, & SHDU (live 30.11.15) - Short stay Falls assessment documentation went live 30.11.15 on CDU,PIU,SDA, Wards 31/33/34 (daycases),Day Surgery & Endoscopy Unit

Dec 2015 - Falls Outcomes added to discharge summary letter

Jan 2016 - Inpatient falls assessments provided by Falls Nurse Specialist.

April 2016 - Introduction of bed & chair alarms.

Jun 2016 - Acute Falls Assessment documentation went live June 2016 AMU - Short stay Falls assessment documentation went live June 2016 on AMAC

0

1

2

3

4

5

6

7

8

9

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

All Falls per 1000 Bed Days

Number of Falls Per 1000 Bed Days Average Number of Falls Per 1000 Bed Days Lower Control Limit

Upper Control Limit Lower Warning Limit Upper Warning Limit

* Average number of falls per 1000 bed days based on calculations from Apr-15 to present

26th Sep 2016 - Falls awareness week

4th Oct 2016 - Inpatient Falls Nurse Specialist secondment ended on 4th Oct 2016.

16th Dec 2016 - The Falls Clinical Support Sister's (note change of role name) post is now a permanent position.

Jan 2017 - Daily COE Consultant ward rounds on AMU for frailty/Falls patients

Jul 2017 - Commenced Ward Link Nurse Champions Trail - Promoted ward based training - 'Falls Link Nurse Champions introduced - Ward-based falls prevention training

Aug 2017 - Introduced revised MFA 2 & Lying and standing BP charts/competency

20 Pack pg 65


Falls SPC Charts


0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

Harmful Falls per 1000 Bed Days

Number of Harmful Falls Per 1000 Bed Days Average Number of Falls Per 1000 Bed Days Upper Control Limit Upper Warning Limit

* Average number of falls per 1000 bed days based on calculations from Apr15 - Mar16 and Apr16 - Apr17

07 Sep 2015 Introduction of: - Multifactorial Falls Assessments (MFA level 1 &2) for inpatients - Lying and Standing BP charts - Bed rail assessment charts - Medical Acute post fall assessment & Secondary fall assessment document - Updated falls care plans on Lorenzo for nursing staff - Patient and Relatives falls prevention advice available at each patients bedside - Promotion of Stickman signage (Red stickman to indicate patient has fall in hospital but now also to include patients admitted with a falls). 28 Sep 2015 - Falls Awareness Week at the Trust

Oct 2015 - Local Falls audit undertaken (including ward spot checks) - Falls Nurse Specialist Secondment commenced

Nov 2015 - Feedback to wards on spot check from local falls audit - Updated falls assessment documentation used on ITU, CCU, & SHDU (live 30.11.15) - Short stay Falls assessment documentation went live 30.11.15 on CDU,PIU,SDA, Wards 31/33/34 (daycases),Day Surgery & Endoscopy Unit

Dec 2015 - Falls Outcomes added to discharge summary letter

Jan 2016 - Inpatient falls assessments provided by Falls Nurse Specialist.

April 2016 - Introduction of bed & chair alarms.

Jun 2016 - Acute Falls Assessment documentation went live June 2016 AMU - Short stay Falls assessment documentation went live June 2016 on AMAC

26th Sep 2016 - Falls awareness week

4th Oct 2016 - Inpatient Falls Nurse Specialist secondment ended on 4th Oct 2016.

16th Dec 2016 - The Falls Clinical Support Sister's (note change of role name) post is now a permanent position.

Jan 2017 - Daily COE Consultant ward rounds on AMU for frailty/Falls patients

Jul 2017 - Commenced Ward Link Nurse Champions Trail - Promoted ward based training - 'Falls Link Nurse Champions introduced - Ward-based falls prevention training

Aug 2017 - Introduced revised MFA 2 & Lying and standing BP charts/competency

21 Pack pg 66


Pressure Ulcer SPC Charts


0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

Grade 2 Pressure Ulcers per 1000 Bed Days

Total PU's Grade 2 per 1000 Bed Days Average Upper Control Limit Upper Warning Limit

* The information above represents hospital acquired, avoidable grade 2 pressure ulcers . * The average is calculated from July-15 to present.

Q1 1516 - 164 staff received training on Pressure Ulcer Prevention and Management



Q4 1516 - 169 staff received training on Pressure Ulcer Prevention and

Jun-16 Equipment: Implementation of the hybrid mattress system in ED / CDU (including hybrid

Oct-16 Equipment: Implementation of heel magnets / new intentional rounding charts. Education: React to Red Clinical Support Nurse commences in post . Heel logo magnets implemented Trust wide

Apr-15 Introduction of Pressure Ulcer Prevention patient information leaflet. 1st April Tissue Viability Education Nurse commences in post. w/c 13th April implementation of the hybrid mattress system across the medical block (wards 17, 18, 19, 23, 24, AMU, CCU). Education: Tissue Viability Education Nurse commences in post to specifically deliver Pressure Ulcer Prevention and Management training for one year. Equipment: Implementation of the hybrid mattress system – wards 17, 18, 19, 20, 23, 24, AMU, CCU.

Jul-15 Documentation: New 2 part Pressure Ulcer Pathway and Pressure Ulcer Prevention and Management policy implemented. Education: 4 week intensive Pressure Ulcer Prevention and Management training wards 19 / 20

Aug-15 Equipment: Implementation of the hybrid mattress system – ward 28, 31, 32, 33, 34. Implementation of 4 bariatric hybrid mattresses Trust wide Education: Trust wide Heel Pressure Ulcer Awareness week

Nov-15 Staffing: Vacant part time TVN post (new starter to commence Feb 22nd 2016). Education: TVN / Frailty team ward round ward 19 / 20 three times weekly (from 30th November)

Feb-16 Staffing: Part time TVN commences in post (22nd Feb) . Mar-16

Education: Tissue Viability Education Nurse finishes in post (4th March) .

Nov-16 React to Red training commenced

Dec-16 Repositioning Clocks implemented Trust wide

15th May-17 AMU Tissue Viability Ward Rounds commenced

22 Pack pg 67


Pressure Ulcer SPC Charts


0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

Grade 3 Pressure Ulcers per 1000 Bed Days

Total PU's Grade 3 per 1000 Bed Days Average Lower Control Limit Upper Control Limit Lower Warning Limit Upper Warning Limit

* The information above represents hospital acquired, avoidable grade 3 pressure ulcers . * The average is calculated from July-15 to present.

Jun-16 Equipment: Implementation of the hybrid mattress system in ED / CDU (including hybrid

Oct-16 Equipment: Implementation of heel magnets / new intentional rounding charts. Education: React to Red Clinical Support Nurse commences in post. Heel logo magnets implemented Trust wide

Apr-15 Introduction of Pressure Ulcer Prevention patient information leaflet. 1st April Tissue Viability Education Nurse commences in post. w/c 13th April implementation of the hybrid mattress system across the medical block (wards 17, 18, 19, 23, 24, AMU, CCU). Education: Tissue Viability Education Nurse commences in post to specifically deliver Pressure Ulcer Prevention and Management training for one year. Equipment: Implementation of the hybrid mattress system – wards 17, 18, 19, 20, 23, 24, AMU, CCU.

Jul-15 Documentation: New 2 part Pressure Ulcer Pathway and Pressure Ulcer Prevention and Management policy implemented. Education: 4 week intensive Pressure Ulcer Prevention and Management training wards 19 / 20

Aug-15 Equipment: Implementation of the hybrid mattress system – ward 28, 31, 32, 33, 34. Implementation of 4 bariatric hybrid mattresses Trust wide Education: Trust wide Heel Pressure Ulcer Awareness week

Nov-15 Staffing: Vacant part time TVN post (new starter to commence Feb 22nd 2016). Education: TVN / Frailty team ward round ward 19 / 20 three times weekly (from 30th November)

Feb-16 Staffing: Part time TVN commences in post (22nd Feb) .

Mar-16 Education: Tissue Viability Education Nurse finishes in post (4th March) .

Nov-16 React to Red training commenced

Dec-16 Repositioning Clocks implemented Trust wide




Q4 1516 - 169 staff received training on Pressure Ulcer Prevention and

15th May-17 AMU Tissue Viability Ward Rounds commenced

23 Pack pg 68


Infections SPC Charts


24 Pack pg 69


Infections SPC Charts


25 Pack pg 70


Cardiac Arrest SPC Charts


0

0.5

1

1.5

2

2.5

3

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

Cardiac Arrests per 1000 Admissions

CAs per 1000 Admissions Average CAs per 1000 Admissions Improvement Trajectory Lower Control Limit Upper Control Limit Lower Warning Limit Upper Warning Limit

* Actual Cardiac Arrests - 16/17 target = 69 Current 17/18 total = 36 * 15/16 estimated total CAs = 96 (based on figures Oct15 - Mar16) * Improvement trajectory is based on a 25% reduction of the average calculated between Oct -14 and Mar-16. * Average CAs per 1000 Admissions is calculated from Oct -15 to present.

Oct 2015 - NCAA reporting commenced - Datix reporting commenced

Apr 2016 - DNACPR audit produced and disseminated

Nov 2016 - AMU Relocation - W23 relocated with W20 - New bed configuration

Oct 2016 - Vital PAC Launch Mar 2017

- Vital PAC Launch phase 1 completion due

Jun 2015 - Patient safety huddles

26 Pack pg 71

0 1 2 3 4 5 13 18 19 20 # 22

People - "At a glance"

Target Target Actual Month

17/18 YTD Oct-17 YTD Trend Status

Workforce (Quality Strategy - Goal 4: Building on Capacity and Capability)

Sickness Absence Rate 3.75% 3.75% 4.01% 3.80% ↓ 4.01%

Staff Turnover 10% 10% 13.9% 11.3% ↑ 13.86%

Mandatory Training 90.0% 90.0% 87.1% 87.6% ↔ 87.10%

Appraisal Rates - Medical 90.0% 90.0% 97.7% 98.8% ↑ 98.79%

Appraisal Rates - Non Medical 90.0% 90.0% 93.4% 72.8% ↑ 93.40%

Appraisal Rates - Total 90.0% 90.0% 93.7% 70.6% ↑ 93.65%

Trend arrows relates to improving (Good) or worsening (Bad) performance not the change in the numerical value comparing last month to this month .

People


27 Pack pg 72

People will be proud to work for usQ - Workforce (Quality Strategy - Goal 4: Building on Capacity and Capability)

Comments

Staf

f Tu

rno

ver


5%

6%

7%

8%

9%

10%

Pe

rce

nta

ge T

urn

ove

r Staff Turnover

Actual

Staff Turnover - This month is within the expected range. The rolling 12 months figure is high due to the TUPE transfer of staff to BFS in September. At the request of Board, work is underway to recalculate with this removed.

28 Pack pg 73

People will be proud to work for usWorkforce (Quality Strategy - Goal 4: Building on Capacity and Capability)

Comments

CBU 1 83.7%

CBU 2 87.5%

Corporate Services 85.8%

Comments

CBU 1 96.9%

CBU 2 97.3%

CBU 3 & Clinical Services 100.0%

Appraisals Non Medical - Overall compliance is 93.4%

Man

dat

ory

Tra

inin

gA

pp

rais

als

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

% C

om

ple

ted

Mandatory Training

Actual Target


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% C

om

ple

ted

Appraisals

Total Non-Medical Medical Target

Mandatory Training - Overall compliance for October is 87.1%, CBU 3 has achieved compliance at 90.6%, the remainder are as follows;

Appraisals Medical - Percentage of doctors (eligible for appraisal) in date at 31/10/2017 was 97.7%.

29 Pack pg 74

People will be proud to work for usWorkforce (Quality Strategy - Goal 4: Building on Capacity and Capability)

Comments

Sick

nes

s A

bse

nce

Sick

nes

s A

bse

nce


1%

2%

3%

4%

5%

Pe

rce

nta

ge S

ickn

ess

Ab

sen

ce

Sickness Absence

Actual Target

Sickness - Has worsened this month. All areas are in red except Corporate. The CBU breakdown is as follows: CBU 1 4.45% CBU 2 4.48% CBU 3 4.56% Corp 3.35% BFS 4.97%

30 Pack pg 75

Performance Matters (KPIs)Operational Efficiency

7

9

Ave

rage

Le

ngt

h o

f St

ay

Bre

ast

Sym

pto

mat

ic


0

1

2

3

4

5

ALO

S (E

lect

ive

)

Average Length of Stay (Quality Strategy - Goal 3: Delivering Consistently Effective Care)

Elective Non-Elective Elective Target Non-Elective Target 2016/2017 Elective 2016/2017 Non Elective

31 Pack pg 76

Performance Matters (KPIs)


Comments

Can

celle

d O

pe

rati

on

sR

e-a

dm

issi

on

s

This is the unvalidated readmissions position, without PbR exclusions applied.

For financial penalties associated with the validated position, please see the readmissions dashboard on

IRIS>Finance>Readmissions.

From a Data Quality perspective, there are 143 readmissions within 4 hours of a previous discharge so far this

financial year.

21 of these have been validated as correct, leaving 122 presumed data quality errors in need of correction on

Lorenzo.

Of the presumed DQ errors, 56 are included in financial penalties (the rest are PbR exclusions).

Trust is currently 187 readmissions over threshold (year to date, PbR exclusions applied), leading to an

indicative penalty of £382,976.

The 56 presumed DQ errors year to date contribute £114,688 towards this total penalty.

1.1%

0.4%

0.7%

0.3%

0%

1%

1%

2%

2%

0

1

2

3

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

% o

f C

ance

lled

Op

era

tio

ns

20

16

/17

% o

f C

ance

lled

Op

era

tio

ns

28 Day Breaches % Cancelled Ops 2016/17

Cancelled Operations target is '0'

32 Pack pg 77



The

atre

Uti

lisat

ion

GP

Re

ferr

als

DN

A R

ate

s

0%10%20%30%40%50%60%70%80%90%

100%

% o

f Th

eat

re U

tilis

atio

n

Theatre Utilisation

Day Main Trauma 2016/17

0%2%4%6%8%

10%12%14%

% o

f D

NA

Rat

es

DNA Rates

New Follow Up

Total Target

DNA Rates 2016/17

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

GP Referrals Made & Seen

17/18 Made

17/18 Seen

33 Pack pg 78



Diagnostics

Comments:

Dia

gno

stic

Te

sts

ove

r 6

we

eks

(D

M0

1)

0.4% 0.4% 0.2%

0.3% 0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

0

2

4

6

8

10

12

14

Pe

rce

nta

ge o

ver

6 w

ee

ks

No

. ove

r 6

we

eks

Diagnostic Tests over 6 Weeks

Target Actual 1718 Actual % 1718 Diagnostics 2016/17

Diagnostic tests over 6 weeks target is '0'

34 Pack pg 79



Regulatory Performance - ED

A&E All Types Benchmarking

A&E benchmarking

Quarter 3

Current

Position %YTD %

A&

E 4

Ho

ur

Wai

tA

&E

4 H

ou

r W

ait

- B

en

chm

arki

ng

Sheffield Teaching

Rotherham

Barnsley

84.85% 84.95%

89.60% 91.15%

92.30% 92.43%Doncaster & Bassetlaw

91.85%89.41%

0

500

1000

1500

2000

2500 No. Ambulance Handover Times (pre-validated YAS)

No. under 15 mins No. between 15 & 30 mins

No. between 30 & 60 mins No. between 60 & 120 mins

No. over 120 mins Not recorded

0

1000

2000

3000

4000

5000

6000

7000

8000

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Within 4 Hours Total Attendances

Target % Achievement

35 Pack pg 80



Regulatory Performance - 18 Week Referral to Treatment

As stated

RTT 18 Week Performance - October 2017Validated Position

CommentsSpecialty <18 >18 Total %

General Surgery 1504 159 1663 90.4%Urology 740 54 794 93.2%Trauma & Orthopaedics 1379 73 1452 95.0%ENT 1130 91 1221 92.5%Oral Surgery 1979 171 2150 92.0%Ophthalmology 1017 47 1064 95.6%General Medicine 26 0 26 100.0%Gastroenterology 609 4 613 99.3%Cardiology 654 22 676 96.7%Dermatology 867 296 1163 74.5%Respiratory 312 24 336 92.9%Rheumatology 266 4 270 98.5%Geriatric Medicine 269 13 282 95.4%Gynaecology 747 61 808 92.5%Other 691 32 723 95.6%Total 12190 1051 13241 92.1%

Co

nsu

ltan

t 1

8 W

ee

k R

efe

rral

to

Tre

atm

en

t

Incompletes - Target 92%General Surgery – The specialty has failed to achieve the target (and its trajectory) of 92% at October

month end due to the number of >18 weeks patients who have been transferred from a

neighbouring organisation for treatment. The specialty failed the target by 28 patients, however the

number of >18 weeks patients transferred from the neighbouring Trust was 41, therefore, if the

Trust had not received these patients, the specialty would have achieved the target and its trajectory.

Dermatology – Dermatology RTT performance has failed to achieve as a resulting impact of Medical

Staffing vacancies at Consultant and Senior Medical staffing level in quarter 1 and quarter 2.

Improvements in medical staffing in quarter 3 should enable recovery in quarter 3.

However, the Trust continues to achieve the overall incomplete national target of 92%

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Non-Admitted Pathways

Actual Target

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Incomplete Pathways

Actual Target

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Admitted Pathways

Actual Target

36 Pack pg 81



Regulatory Performance - Cancer

Bre

ast

Sym

pto

mat

ic

All

Can

cer

2 W

eek

Wai

ts

31

Day

- S

ub

seq

ue

nt

Tre

atm

en

t (S

urg

ery

)

31

Day

- T

arge

ts

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Target

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

31 Day Diagnostic to Treatment

Actual Target

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

31 Day Subsequent Treatment (Drugs)

Actual Target

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

31 Day Subsequent Treatment (Surgery)

Actual Target

75%

80%

85%

90%

95%

100%P

erc

en

tage

Po

siti

vity

Actual Target

37 Pack pg 82




62

Day

Can

cer

Targ

ets

62

Day

- S

cree

nin

g P

rogr

amm

e

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Urgent GP Referral to Treatment

Actual Target

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Screening Programme

Actual Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge P

osi

tivi

ty

62 Day - Consultant Upgrades

Actual Target

38 Pack pg 83



Comments

Can

cer

Per

form

ance

by

Tum

ou

r Si

te

The validated September performance against all national and locally defined KPIs for cancer showed compliance across all targets. The nationally uploaded 62 Day 'GP referral to treatment' target demonstrated 100%

compliance. This is not only excellent from a Trust perspective but contributes significantly to the overall position reported by our Cancer Alliance.

Validation of performance across all CWT targets for October is currently underway and will not be uploaded to Open Exeter until the 1st December 2017.

The unvalidated position for October indicates there are no non-compliant targets forecast and Q3 position to date looks favourable. This includes the IPT Day 38 standard which, for Q3 end, is currently above the 85%

threshold.

Most specialties achieved the threshold for the ‘2 week wait’ target in September and this included the Breast Symptomatic target. However, the Lower GI (colorectal) performance was under the 93% target due to patient

choice and capacity reasons (only one offer of appointment within 14 day window). Work has been undertaken by the operational and clinical team to increase clinic capacity which should strengthen the pathway's

performance and allow first 2ww appointment at < Day 7.

All teams achieved 100% compliance across relevant 31 Day pathways in September and this performance (although subject to validation) has been maintained by all site specific teams in October.

All teams achieved 100% compliance with the 62 Day 'GP referral to treatment' target in September including shared pathways. This is an excellent achievement by all.

The 62 Day ‘Screening’ target in September showed improvement from the previous month and was 100% at month end. This was due to 100% compliant screening pathways for both Breast and Lower GI.

The locally agreed 62 Day ‘Consultant Upgrade’ target shows non-compliance as per Open Exeter across the Head and Neck pathway in September, although an overall compliant position for the Trust. This was due to 1 x

shared breached pathway.

2wwBreast

Symptom

First

Treatment

Subsequent

Treatment

Open Exeter Shared Open Exeter Shared Open Exeter Shared

100.0% - 100.0% 100.0% 100.0% - - - 100.0% -

4/4 - 7/7 1/1 1/1 - - - 1/1 -

100.0% - 100.00% - 100.0% 100.0% - - 100.0% 100.0%

26/26 - 4/4 - 4.5/4.5 3.5/3.5 - - 2.5/2.5 1.5/1.5

94.1% - 100.0% 100.0% 100.0% 100.0% - - - -

111/118 - 19/19 7/7 8/8 1/1 - - - -

98.9% 97.6% 100.0% 100.0% 100.0% - 100.0% - 100.0% 100.0%

86/87 82/84 16/16 4/4 8/8 - 5/5 - 2.5/2.5 0.5/0.5

100.0% - 100.0% - 100.0% 100.0% - - 0.0% 0.0%

56/56 - 2/2 - 0.5/0.5 0.5/0.5 - - 0/0.5 0/0.5

92.0% - 100.0% 100.0% 100.0% 100.0% 100.0% - - -

103/112 - 10/10 2/2 2.5/2.5 0.5/0.5 2/2 - - -

93.7% - 100.0% - 100.0% 100.0% - - - -

74/76 - 3/3 - 2.5/2.5 0.5/0.5 - - - -

96.4% - 100.0% 100.0% 100.0% 100.0% - - 100.0% 100.0%

53/55 - 11/11 1/1 5.5/5.5 0.5/0.5 - - 0.5/0.5 0.5/0.5

100.0% - 100.0% - 100.0% - - - - -

46/46 - 4/4 - 3/3 - - - - -

Open Exeter Adjusted Open Exeter Adjusted Open Exeter Adjusted

95.5% 100.0% 100.0% 100.0% 93.2% - 92.3% - 85.7% -

578/605 71/71 71/71 10/10 41/44 - 6/6.5 - 6/7 -

Sep-17 95.9% 97.6% 100.0% 100.0% 100.0% - 100.0% - 92.9% -

Aug-17 95.8% 94.7% 98.5% 100.0% 92.6% - 85.7% - 90.9% -

Jul-17 96.3% 89.0% 100.0% 100.0% 93.1% 92.9% 100.0% - 81.8% -

Jun-17 94.2% 90.3% 100.0% 100.0% 90.5% - 88.9% - 66.7% -

May-17 95.8% 97.2% 98.4% 100.0% 88.4% 90.3% 88.2% - 87.5% 80.0%

Apr-17 95.0% 94.6% 100.0% 100.0% 93.5% 87.2% 100.0% - 90.0% -

Mar-17 95.9% 95.4% 98.5% 94.1% 86.6% - 100.0% - 69.2% -

Feb-17 95.4% 95.3% 95.2% 100.0% 86.7% - 93.3% - 88.2% -

Jan-17 94.2% 96.5% 98.6% 100.0% 93.9% - 90.9% - 100.0% -

Dec-16 96.1% 95.1% 97.1% 100.0% 85.7% - 100.0% - 100.0% -

Nov-16 95.5% 98.2% 98.7% 100.0% 95.0% - 100.0% - 85.7% -

-Target 93% 93% 96%

GP Referral to Treatment Screening

62 Day

Consultant Upgrade

85% 90% 85%

Lung

Skin

Oct-17

Urology

Gynae

Breast

Head & Neck

Lower GI

Upper GI

2 Week 31 Day

Trustwide

Tumour Site

Haematology

CBU 1

CBU 2

CBU 3

Sep-17

39 Pack pg 84




Graph to follow from Cancer services

Comments

Can

cer

Shar

ed P

ath

way

Per

form

ance

IPT performance has been variable over the last couple of months and in October shows a non-compliant position against the 85% target, although there is marginal improvement from the previous

month. However, overall performance is forecast to be compliant at Q3 end. Focus must be maintained in order to see performance exceed 85% and reach the 100% now required of shared pathways.

The impact of later referrals in September and October will potentially be seen in the November or December performance; and already there are a high number of breaches identified in November. All

teams have been reminded of the importance of ensuring timely shared pathway referrals in order to avoid performance allocations back to BHNFT.

Breached pathways – September = 0 therefore there were no allocations to be made.

Compliant pathways – Most shared compliant pathways treated in September were referred by IPT Day 38, with only 1 x Urology pathway referred after Day 38.

Prolonged pathways

There were no prolonged pathways of 104 days or more in September. There is 1 x known pathway > 104 days in October and analysis shows this to be a complex Head and Neck pathway. A full RCA is

underway and results will be reported in next month's IPR.

40 Pack pg 85



Regulatory Performance - Breast Cancer ScreeningSc

ree

nin

g to

issu

e o

f n

orm

al r

esu

lts

<=2

we

eks

Scre

enin

g to

1st

ass

ess

me

nt

Scre

enin

g to

off

er o

f 1

st a

sse

ssm

en

t

<=3

wee

ks

30%

40%

50%

60%

70%

80%

90%

100%P

erc

en

tage

Po

siti

vity

Actual Target

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Target

75%

80%

85%

90%

95%

100%

Pe

rce

nta

ge P

osi

tivi

ty

Actual Target

41 Pack pg 86

Performance Matters Data QualityUncoded Episodes (As at October 2017)

Treatment Specialty Specialty August September October November Total

ACCIDENT AND EMERGENCY AMU 1 7 8

ANTICOAGULANT SERVICE ANTE-NATAL 4 45 81 7 137

BREAST SURGERY ANTICOAGULANT 5 9 74 18 106

CARDIOLOGY CARDIOLOGY 1 26 27

CLINICAL HAEMATOLOGY DERMATOLOGY 2 2 13 6 23

CLINICAL ONCOLOGY DIABETICS CENTRE 1 9 10

COLORECTAL SURGERY DVT 4 8 8 1 21

DERMATOLOGY ED 1 8 9

DIABETIC MEDICINE GASTROENTEROLOGY 3 2 19 11 35

DIAGNOSTIC IMAGING GENMED 5 29 34

ENDOCRINOLOGY MAIN OPD 10 155 95 260

ENT NEW STREET 1 11 23 35

GASTROENTEROLOGY OMFS 9 11 12 32

GENERAL MEDICINE PAEDIATRICS 5 7 19 2 33

GENERAL SURGERY PHYSIOTHERAPY 2 2

GERIATRIC MEDICINE RESPIRATORY MEDICINE 6 6

GYNAECOLOGY UROLOGY 4 3 7

NEONATOLOGY WARD 24 2 3 5

OBSTETRICS PRE-ASSESSMENT 23 127 150

OPHTHALMOLOGY AUDIOLOGY 16 16

ORAL SURGERY (BLANK) 1 23 6 30

PAEDIATRIC CARDIOLOGY GENERAL MEDICINE 1 1

PAEDIATRIC CYSTIC FIBROSIS GENERAL SURGERY 7 7

PAEDIATRIC ENT SDA 1 2 3

PAEDIATRICS

PAEDIATRIC T&O

PAEDIATRIC OPHTHALMOLOGY

RESPIRATORY MEDICINE

RHEUMATOLOGY CommentsStroke Medicine

TRAUMA AND ORTHOPAEDICS

UROLOGY

VASCULAR SURGERY

WELL BABIES

BLANK SPECIALTIES

Total

0

97

12251225

2

29

26

70

5

10

6

1

1

25

21

1

49

331

135

0

18

18

118

27

49

331

Total

0

26

3

31

59

2

1

64

0

1

42

6

0

18

118

27

21

1

42

6

18

2

1

64

1

26

3

31

59

70

5

97

October

Missing Outcomes (As at October 2017)

Uncoded Episodes - There are 1225 for October 2017.

Overall there are 1225 uncoded episodes for 17/18.

135

10

6

1

1

25

2

29

26


42 Pack pg 87

Performance Matters

Ad

mit

ted

Pat

ien

t C

are

CD

S

Barnsley is currently unable to flow the RTT patient pathway data in the APC & OP

datasets, hence the reduced data quality score.

Ad

mit

ted

Pat

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are

CD

SA

dm

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Car

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99.6% 99.2% 98.4% 96.2%

94.8%

84.0%

96.5% 97.6%

75%

80%

85%

90%

95%

100%

Barnsley SheffieldChildren's

SheffieldTeaching

Rotherham Doncaster &Bassetlaw

RDASH NationalAverage

Area Team

Data validity summary average of all fields in SUS Dashboard April-February 2017

99.0%

99.8% 99.9% 99.9% 99.5% 99.5%

99.2% 99.7%

92%

93%

94%

95%

96%

97%

98%

99%

100%


SheffieldTeaching



Area TeamAverage

NHS Number

100.0% 100.0% 100.0% 100.0% 100.0% 99.7% 99.9% 100.0%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Barnsley Sheffield Teaching Doncaster &Bassetlaw

National Average

Registered GP Practice

99.1%

100.0% 100.0% 100.0% 100.0% 99.8% 99.8% 99.9%

92%

93%

94%

95%

96%

97%

98%

99%

100%


SheffieldTeaching



Area TeamAverage

Postcode

43 Pack pg 88

Performance Matters Data Quality - Secondary Uses Service (SUS) Dashboard

Ou

tpa

tien

ts C

DS

Ou

tpa

tien

ts C

DS

Ou

tpa

tien

ts C

DS

Ou

tpa

tien

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DS


99.9% 99.8% 99.9% 100.0% 99.7%

99.4% 99.9%

92%

93%

94%

95%

96%

97%

98%

99%

100%


SheffieldTeaching


NationalAverage

Area TeamAverage

NHS Number 100.0% 100.0% 100.0% 100.0% 100.0% 99.9% 100.0%

92%

93%

94%

95%

96%

97%

98%

99%

100%


SheffieldTeaching


NationalAverage

Area TeamAverage


99.9% 100.0% 100.0% 100.0% 100.0% 99.8% 99.9%

92%

93%

94%

95%

96%

97%

98%

99%

100%


SheffieldTeaching

Rotherham Doncaster&

Bassetlaw

NationalAverage

Area TeamAverage

Postcode

92.4%

100.0% 100.0% 100.0% 98.2% 97.5%

99.2%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


SheffieldTeaching


NationalAverage

Area TeamAverage

Attendance Outcome

44 Pack pg 89

Performance Matters

Q - Data Quality - Secondary Uses Service (SUS) Dashboard

Acc

iden

t &

Em

erge

ncy

CD

SA

ccid

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& E

mer

gen

cy C

DS

Acc

iden

t &

Em

erge

ncy

CD

SA

ccid

ent

& E

mer

gen

cy C

DS


99.3% 99.7%

99.3% 99.2%

97.2% 97.2%

98.6%

92%

93%

94%

95%

96%

97%

98%

99%

100%


SheffieldTeaching


Bassetlaw

NationalAverage

Area TeamAverage

NHS Number 99.9% 100.0% 100.0% 100.0% 99.8%

99.1%

99.9%

92%

93%

94%

95%

96%

97%

98%

99%

100%


SheffieldTeaching


NationalAverage

Area TeamAverage


100.0% 100.0% 100.0% 100.0% 100.0% 99.8% 99.2%

92%

93%

94%

95%

96%

97%

98%

99%

100%


SheffieldTeaching


Bassetlaw

NationalAverage

Area TeamAverage

Postcode 100.0% 100.0% 100.0% 100.0% 100.0%

97.9%

96.2%

92%

93%

94%

95%

96%

97%

98%

99%

100%


SheffieldTeaching


NationalAverage

Area TeamAverage

Attendance Disposal

45 Pack pg 90

Performance MattersActivity

16/17 17/18 17/18

Actual Plan Actual Variance %

Elective Day cases 13,707 15,856 16,205 349 2%

Elective Inpatients 2,450 2,573 2,433 -140 -5%

Elective Total 16,157 18,429 18,638 209 1%

Non Elective 20,814 20,459 21,273 814 4%

Maternity Pathway 3,529 3,883 3,823 -60 -2%

A&E Attendances 47,152 50,373 49,287 -1086 -2%

Outpatients 139,421 205,239 193,481 -11758 -6%

* Please note excess bed days are not included in these figures. 2017/18 Activity Plan

2017/18 Activity Actual

2016/17 Outturn

2017/18 Activity Plan 2017/18 Activity Plan

2017/18 Activity Actual 2017/18 Activity Actual

2016/17 Outturn 2016/17 Outturn

Act

ivit

y

Day

Cas

es

Obstetric outpatient attendances are excluded as they are covered by the Maternity Pathways

Ele

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e In

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ive

Inp

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0

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1000

1500

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Apr May June July Aug Sept Oct Nov Dec Jan Feb March

Act

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Act

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Elective Inpatients

2500

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3300


Act

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Month

Non-Elective Inpatients

46 Pack pg 91

Performance MattersActivity

2017/18 Activity Plan 2017/18 Activity Plan

2017/18 Activity Actual 2017/18 Activity Actual

2016/17 Outturn 2016/17 Outturn

Comments:

2017/18 Activity Plan

2017/18 Activity Actual2016/17 Outturn

Ou

tpat

ien

tsM

ate

rnit

y P

ath

way

A&

E A

tte

nd

ance

s

Main areas of underperformance are Outpatients and A&E. Main area of overperformance is Non-Elective Inpatients.

Outpatients:- areas of underperformance with the highest variances (against aggregated attendances and procedure plans) in

Ophthalmology -1395, Dermatology -1512, Anticoagulant Service - 3584, General Surgery -636, Gynaecology -741,

Rheumatology -701 and Endocrinology -693. Overperforming are T&O Pre-Assessment 393, Physiotherapy 892, ENT 585 and

Gastro Pre-assessments 650.

Non-Elective Inpatients:- Overperformance is mainly due to Gynaecology, General Medicine & Paediatrics.


0

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Act

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Maternity Pathway

6000

6200

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7600


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A&E Attendances

0

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10000

15000

20000

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Act

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Outpatients

47 Pack pg 92

Performance - "At a glance"

Month

Plan

Month

Actual

Variance

%Variance Plan YTD Actual YTD

Variance

%Variance

Month

Plan

Month

ActualVariance % Variance

Plan

YTD

Actual

YTD

Variance

%Variance

ACTIVITY LEVELS (PROVISIONAL) £'000 £'000 £'000 £'000 £'000 £'000

Elective inpatients 378 392 3.70% 14 2,573 2,433 -5.44% -140 EBITDA 203 224 -10.34% 21 -3,595 -3,704 -3.03% -109

Day Cases 2,332 2,394 2.66% 62 15,856 16,205 2.20% 349 Depreciation -422 -417 1.18% 5 -2915 -2891 0.82% 24

Non-elective inpatients 2,878 3,048 5.91% 170 20,518 21,301 3.82% 783 Restructuring & Other -17 -57 -235.29% -40 -119 -26 78.15% 93

Outpatients 29,972 29,120 -2.84% -852 203,828 191,906 -5.85% -11,922 Financing Costs -125 -127 -1.60% -2 -875 -878 -0.34% -3

A&E 7,134 7,412 3.90% 278 50,373 49,287 -2.16% -1,086 SURPLUS/(DEFICIT) -361 -377 -4.43% -16 -7,504 -7,499 0.07% 5

'Clinical' Activity

Other (excludes direct access tests) 9,334 6,341 -32.07% -2,993 57,998 54,236 -6.49% -3,762 SOFP £'000 £'000 £'000 £'000 £'000 £'000

Total activity 52,028 48,707 -6.38% -3,321 351,146 335,368 -4.49% -15,778 Capital Spend -490 -198 -59.59% 292 -2,277 -2,552 12.08% -275

Inventory 2,344 2,049 12.59% 295

CIP £'000 £'000 £'000 £'000 £'000 £'000 Receivables & Prepayments 9,489 10,754 -13.33% -1,265

Income 136 24 -82.35% -112 522 553 5.94% 31 Payables -14,040 -22,159 57.83% 8,119

Pay 426 335 -21.36% -91 2,412 1,857 -23.01% -555 Accruals -6,256 -5,691 -9.03% -565

Non-Pay 225 745 231.11% 520 775 1,443 86.19% 668 Deferred Income -511 -1,084 112.13% 573

Total CIP 787 1,104 40.28% 317 3,709 3,853 3.88% 144

Cash & Loan Funding £'000 £'000 £'000 £'000 £'000 £'000

INCOME £'000 £'000 £'000 £'000 £'000 £'000 Cash 1,060 1,576 48.68% 516

Clinical (Activity) 10,708 11,084 3.51% 376 73,800 74,677 1.19% 877 Loan Funding -52,705 -54,149 -2.74% -1,444

Other Clinical 3,556 4,245 19.38% 689 24,732 25,174 1.79% 442

CQUINS 316 330 4.43% 14 2,165 2,179 0.65% 14 KPIs

Risks & Penalties 0 -92 -92 0 -597 -597 EBITDA % 1.23% 1.28% 4.31% 0.05% -3.19% -3.27% -2.46% -0.08%

Non Recurrent Income 0 49 #DIV/0! 49 0 553 #DIV/0! 553 Deficit % -2.19% -2.16% 1.28% 0.03% -6.66% -6.62% 0.62% 0.04%

ST & T Funding 588 412 -29.93% -176 2,646 2,470 -6.65% -176 Receivable Days 17.6 19.9 -13.33% -2.3

Other 1,329 1,423 7.07% 94 9,303 8,819 -5.20% -484 Payable (excluding accruals) Days 69.0 108.8 57.83% 39.9

Total income 16,497 17,451 5.78% 954 112,646 113,275 0.56% 629 Payable (including accruals) Days 99.7 136.8 37.22% 37

Use of Resource metric 3 3 0.00% 0

OPERATING COSTS £'000 £'000 £'000 £'000 £'000 £'000

Pay -10,689 -11,370 -6.37% -681 -76,208 -77,808 -2.10% -1,600

Drugs -1,262 -1,320 -4.60% -58 -8,834 -8,832 0.02% 2

Non-Pay -4,343 -4,537 -4.47% -194 -31,199 -30,339 2.76% 860 Consolidated

Total Costs -16,294 -17,227 -5.73% -933 -116,241 -116,979 -0.63% -738 excl charity

Payable days are total op exps, less total pay, add back lead units and agency control total

Payables are Trade & Other only

Performance - Financial Overview Performance - Financial Overview


Page 48 of 51 Pack pg 93

Performance Matters - Finance

October 2017 Summary

Summary Performance:


Commentary Key to RAG Rating The RAG rating applied to Variance % is based on the following criteria: • Green equating to 0% or greater • Amber behind plan by up to 5% • Red greater than 5% behind plan

The key points derived from this table are as follows: • Total activity is adverse to plan year to date excluding Direct Access. The main driver is underperformance on Outpatient & A&E activity. Direct Access tests were excluded from the Other

activity because large variances in these figures skew the overall activity variance.

• CIP achievement is favourable to plan by £0.1m.

• Clinical activity based income is £0.88m favourable to plan before risks and penalties. The main variances are outpatients income £1.44m adverse to plan, elective and daycase income £1.77m favourable.

• ST & T funding has been accrued less the A&E target /GP streaming element in month. Other income is adverse to plan by £.48m.

• Operating costs are adverse to plan in total. Pay is £1.65m adverse.

• Non-pay costs total are £0.9m favourable to plan, which links to activity.

• EBITDA is £0.06m below plan.

• Depreciation, restructuring and finance costs are £0.11m favourable to plan in total.

• The overall deficit is broadly to plan.

• Capital expenditure is £0.28m adverse to plan.

• Inventory is £0.3m below plan.

• Total receivables incl. prepayments are £10.8 above plan due to VAT recharges between BFS and the Trust.

• Total payables incl. accruals are £7.5m adverse to plan due to the VAT charges referred to above .

• Deferred income is £0.57m above plan.

• Cash is £0.52m favourable to plan.

• Debtor days are 19.9 year to date, which is 2.3 days adverse to plan.

• Payable days are 108.8 year to date which is 39.9 days more than plan. Payable days have been calculated excluding accruals, because whilst accruals include certainties in respect of future payments, the timing of these payments is uncertain.


Performance Matters (Financial Overview)

Comments:

Clinical income per day - this is above plan for October 2017

Act

ual

Inco

me

An

alys

is

Clin

ical

Inco

me

Pe

r D

ay

Pay

as

a %

of

Inco

me

Income analysis - this graph analyses the split of income on a monthly basis and

demonstrates the variability of clinical income.

Pay as a % of clinical income is above plan for October 2017



Performance Matters (Financial Overview)


Comments:

CIP is £0.14m ahead of plan at month 6.

Age

ncy

Mo

nth

ly S

pe

nd

CIP

Ach

ieve

me

nt

- C

um

ula

tive

De

fici

t Tr

en

d A

nal

ysis

Agency monthly spend - Total agency spend ytd is £2.69m. Agency expenditure is

reviewed in depth.

Deficit trend analysis - this graph highlights the gap between plan and actual at month 7.

Currently the Trust deficit is broadly to plan.


EXECUTIVE SUMMARY

RECOMMENDATIONS

STRATEGIC CONTEXT

REPORT TO THE BOARD OF DIRECTORS REF: BoD 17/12/P-16 SUBJECT: HORIZON SCANNER DATE: DECEMBER 2017

PURPOSE:

Tick as applicable Tick as

applicable For decision/approval Assurance For review Governance For information Strategy

PREPARED BY: EMMA PARKES, DIRECTOR OF MARKETING & COMMUNCATIONS

SPONSORED BY: DR RICHARD JENKINS, CHIEF EXECUTIVE

PRESENTED BY: EMMA PARKES, DIRECTOR OF MARKETING & COMMUNICATIONS

To provide a brief overview of key developments and initiatives across the national and regional healthcare landscape which may impact or influence the Trust’s strategic direction.

Summary of content:

• MY NHS/NHS Choices • National funding for NHS Estates • New hospital in exchange for houses in Kent • Technology enabled Care Framework (TECS) • Review into NHS Never Events • Paramedics able to treat more patients • NHS national communications – Winter • Around 675 patients falling on NHS wards every day • Framework for local health and care systems

The Board of Directors is asked to receive the contents of this report for information.

BoD Dec 17 - Horizon Scanner

Pack pg 97

Subject: INTELLIGENCE MONITORING/HORIZON SCANNING NOVEMBER 2017 Ref: BoD 17/12/P-16

*please note that this is not an exhaustive report, submissions welcome to [email protected] Publication Detail Impact/ Action/

Owner / Will Board be involved?

My NHS/NHS Choices

NHS Choices User Rating – 4.5* (5* is Excellent) 7 reviews in November, all of which were 5 star ratings. No negative reviews. Feedback Excellent staff and department - My Gran was admitted to ITU from ward 33. The care received by the staff on ITU was outstanding, all family (lots of us) were allowed to sit round her bed whilst they delivered end of life care. We were looked after just as much as gran was, very regular updates, regular cuppa' s and above all a listening ear. Staff made her last hours dignified and comfortable. An excellent team who made our grief more bearable. We can't thank you enough. Arthroscopy at BDGH - Many thanks to all the staff who were involved in my arthroscopy on 17th November, 2017. From arriving until leaving, a professional & caring service throughout. Colposcopy ward - I just wanted to say a massive thank you to ask the nurses on the colposcopy ward today 21/11/17. I was quite nervous about visiting but straight away they made me feel completely at ease and safe. Hysterectomy - I had an hysterectomy on Monday 20/11/2017 and I must say that from first being seen to being discharged i was given exceptional care, the surgeon and their team were wonderful and they are an amazing surgeon who was caring and understanding and informed me every step of the way but so have all the people I’ve seen from pre assessment ,theatre to nursing staff I want to say a big thankyou you get a lot of grief but not enough praise thankyou. Mum's recent cancer treatment was exemplary - My mum was recently diagnosed with bladder cancer. From the beginning of her investigations through to her treatment and after care, everything has been exemplary. The specialist nurse, outpatients and day surgery team dealt with her care, kept her informed and treated her as an individual. They made her, and me as her next of kin, feel like their priority. They provided tailored plans, and gave reassurance at every stage. As a nurse myself, I cannot fault their professionalism, patient focus and care. I am truly impressed with the level of service provided. Thank you.

Potential impact on reputation / All postings responded to / Board to note for information


Pack pg 98

Publication Detail Impact/ Action/ Owner / Will Board be involved?

National The Treasury has committed an extra £3.5bn to NHS capital spending over the next five years. Chancellor Philip Hammond announced £2.6bn of the £3.5bn would be allocated through sustainability and transformation partnerships. These are subject to business case approval by NHS England, NHS Improvement and finally the Department of Health. Sir Robert Naylor’s review into NHS estates recommended £10bn in extra funding be found for capital projects: £5bn for schemes within STP plans and another £5bn to address backlog maintenance. Twelve STP projects receiving first wave of extra capital funding: 1. Barnsley Hospital Children’s Emergency Department and

Assessment Unit scheme (South Yorkshire and Bassetlaw STP) to support the rapid assessment and treatment of children.

2. Doncaster Urgent and Emergency Care scheme (South Yorkshire and Bassetlaw STP) to expand, redesign and improve emergency care.

3. Leeds Community Child and Adolescent Mental Health Inpatient Unit scheme (West Yorkshire STP) to provide a new specialist inpatient unit for young people and children with mental health conditions.

4. Chesterfield Urgent Care scheme (Derbyshire STP) to provide a modern urgent care facility at Chesterfield Royal NHS Foundation Trust.

5. Russell’s Hall Hospital Dudley Urgent Care Centre scheme (Black Country STP) to better integrate their urgent and emergency care Department.

6. Birmingham Children’s Hospital Emergency Department scheme (Birmingham and Solihull STP) to increase emergency care capacity and improve patient experience.

7. South Warwickshire NHS Foundation Trust Out of Hospital Care scheme (Coventry and Warwickshire STP) to provide an integrated information system between local trusts.

8. Mid and South Essex Acute Hospitals reconfiguration scheme (Mid-and-South Essex STP) to upgrade facilities to help meet increasing demand.

9. South West London and St George’s NHS Mental Health Trust Estates Modernisation scheme (South West London STP) to improve inpatient care and free up land for housing.

10. Frimley Out of Hospital Integrated Care Hubs scheme (Frimley Health STP) to enable patients to be treated out of hospital.

11. Bracknell Forest Heathlands scheme (Frimley Health STP) to build a new care home for elderly mentally infirm patients.

12. Chiltern and Aylesbury Vale Primary Care Hub scheme (Buckinghamshire, Oxfordshire and Berkshire West STP) to allow the expansion of community teams and care provision outside of traditional hospital settings.

Board to note. Executive Team and BFS to progress.


Pack pg 99


NHS in general

Private firm offers Canterbury new hospital in exchange for housing permissions A housing development firm in Canterbury has offered to construct and pay for a new hospital in exchange for permission to build 2,000 homes. Currently, plans are underway to open an A&E hub in the city as changes to the current services mean some patients have to travel further to receive important emergency treatment. Kent and Canterbury (K&C) Hospital was forced to limit some of its services as part of long-term reorganisation and sustainability plans, which has in turn increased stress on Margate and Ashford. East Kent Hospital University NHS FT said the community had two options for reorganisation plans. Either the three hospitals will see reorganisation, leaving two hospitals (Queen Elizabeth The Queen Mother and William Harvey hospitals) with A&E services and the third with a GP-led urgent care centre, or there will be a new development at K&C which would open a single major emergency treatment centre for the whole region. This would mean the hospital would become a central hub for most emergency services and the other two facilities would be reduced to GP-led emergency services.

Board to note for information

National New framework to offer NHS access to ‘cutting-edge technology’ A new framework to enable health and social care providers to support direct patient care has been launched by NHS Shared Business Services (SBS). The Technology Enabled Care Services (TECS) framework helps NHS providers deliver round-the-clock personalised care to patients with long term conditions and complex care needs. NHS SBS has developed the framework as a response to the increasing opportunities to use modern technology for those with ongoing care and support needs and aims to meet local and national objectives, such as the NHS Outcomes Framework. Following a procurement process, 20 suppliers were awarded a place on the TECS framework across four different lots, covering a range of products and services that it says are convenient, accessible and cost-effective. The contracts will run until 2021 and are free to access for all public sector organisations, including the NHS. They are Official Journal of the European Union (OJEU) compliant, meaning that users can choose to make direct purchases to reduce time and administration costs, or run mini-tenders to drive additional value and ensure any more complex requirements are met. The framework also includes continuous monitoring products and services which enable the exchange of data between a patient and their clinician, assisting in the diagnosis and monitoring of those with long term conditions.

Director of ICT to monitor


Pack pg 100

http://www.nationalhealthexecutive.com/Search/canterbury

http://www.nationalhealthexecutive.com/Search/kent%20and%20canterbury

http://www.nationalhealthexecutive.com/Search/east%20kent


National Jeremy Hunt has ordered a review into preventable “never events” in NHS hospitals amid concern that the numbers of serious mistakes are not reducing. The health secretary has used powers under the Health and Social Care Act 2012 to direct the Care Quality Commission to carry out the investigation to identify what is preventing trusts from learning from mistakes that means incidents are repeated. The review of never event incidents – defined as mistakes in patient care that are entirely preventable – is part of wider effort by the Department of Health to standardise safety processes to reduce variation in care. Mr hunt, together with NHS Improvement, the CQC and NHS England plan to establish a clinician led central committee that could mandate processes, equipment and technology proven to save lives and reduce harm that all providers would be expected to adopt. Its recommendations would be limited to a small number each year and focused on the most critical issues. The CQC would then regulate providers against these recommendations to ensure they are adopted.

Board to note potential future impact.

National Paramedics given new remit to give certain treatments Paramedics are to be given new remit to prescribe medication in an effort to speed up access to treatment and prevent thousands of needless hospital visits. Ambulance workers with special training will be able to take on duties traditionally performed by GPs and hospital doctors, meaning many more patients can be treated upon arrival. Paramedics are currently allowed to prescribe a limited number of drugs, on the authority of a doctor. The reforms would expand their powers further, so that those with advanced training and several years’ experience are able to prescribe independently. Paramedics have backed the plans, but patients groups have raised some concerns about whether the ambulance workers are skilled enough to make an accurate diagnosis.


National New £20m NHS cyber security unit to make use of ethical hackers The NHS is to spend £20 million on a central cybersecurity unit that will use “ethical hackers” to probe for weakness in health service defences. The unit will be part of efforts to avoid a repeat of the Wannacry attack. NHS Digital is tendering a £20 million contract for IT consultants to create a “security operations centre” to help it to protect sensitive patient information at risk from hackers by creating a “national, near real-time monitoring and alerting service that covers the whole health and care system”, rather than leaving hospitals to rely on their own efforts. A National Audit Office report concluded that the Wannacry attack could have been prevented by “basic IT security best practice” and criticised poor communication between the government and local hospitals in the response to the hack.

Director of ICT to monitor


Pack pg 101


National and regional

National communications approach to Winter Nationally, NHS England and NHS Improvement have agreed to jointly staff and operate a national winter comms team. This will include: • Oversight from NHS England’s director of communications,

Simon Enright, head of media and public affairs, James Lyons, and NHS Improvements director of communications, Tim Jones and deputy director, of strategy, operations and incident response, Phil Groves.

• An escalation model, whereby the team will function in a virtual form from 1 Dec but prepared to physically sit together, next to the national winter operations team at Skipton House, London as necessary.

• A national media protocol – whereby any national winter enquiries to either NHS England or NHS Improvement’s national press offices will go to the national winter comms team for handling (including briefing, drafting reactive lines, and preparing proactive comms as necessary).

• Weekly, and, if necessary, daily teleconferences between the national team and the regions of both NHS England and NHS Improvement.

This national team will also oversee media bids for national spokespeople and operate a rota of spokespeople, including NHS England’s, director for acute care, Keith Willet and NHS Improvement’s, executive medical director and interim chief operating officer, Kathy Maclean. In addition there will be a new, format for regular national operational communications to trust executives this winter. Pauline Philip, national director for urgency and emergency care, will write to all trust CEOs and CCG accountable officers every two to three weeks. The briefing will round up key national updates and requests and will be co-signed by regional directors. Regionally, NHS England and NHS Improvement have established a joint winter room in the North to provide oversight on local performance, look for escalating pressure points and ensure support is made available in those pressured areas, as and when it is appropriate.

Director of Marketing & Communications to monitor.

National Study

Around 675 patients falling on NHS wards every day An audit by the Royal College of Physicians has established that there were 246,425 falls on NHS wards in 2015/16, around 675 a day, and many trusts were failing to take basic measures to prevent them. The audit is based on figures from 138 hospital trusts, mental health organisations and community centres. It argues many of the falls are preventable and caused by patients not having walking frames or being unsteady from medication.



Pack pg 102


More than half of respondents (52%) admitted they did not carry out medication reviews to ensure drugs were not making patients unsteady on their feet. Nice has previously estimated that falls are costing the NHS at least £2.3billion a year – and 30% are preventable.

National NHS England is developing a new framework for local health systems to buy products and services ranging from workforce advice to IT systems. The national commissioning body is asking for feedback on a single framework for sustainability and transformation partnerships and accountable care systems which is hope to be in place by 2018/19. The framework will cover a wide range of items intended to support greater health and social care integration, focusing heavily on digital technology, as specified in the Five Year Forward View. Services and products likely to be covered by the framework include: Population health analytics; data management; connecting and integrating clinical IT systems across health economies; system and care pathway redesign support, including in primary care; GP IT systems; supply chain support; medicine optimisation; personal health budgets ; IT Infrastructure support; and workforce development. The framework will also cover some of NHS England’s central digital technology programmes, including IT for GPs, global digital exemplars and scaling up the seven innovation “test beds”.

Director of ICT to monitor and feedback as appropriate


Pack pg 103