agenda - hgs.uhb.nhs.uk · awards in women & children’s, and (3) the hiv saving lives open...

AGENDA for a meeting of the Board of Directors of Heart of England NHS Foundation Trust

to be held in the Harry Hollier Lecture Theatre, Good Hope Hospital on 2 March 2016 at 12.00 noon

12.00 NOON – 1.30PM: Indicative Timings

(Minutes)

1. APOLOGIES

1 (Oral)

2. APPOINTMENT OF FINANCE DIRECTOR – RATIFICATION (JS)

1 (Enclosure)

3. DECLARATIONS OF INTEREST

1 (Enclosure)

4. MINUTES – 6 JANUARY 2016

2 (Enclosure)

5. MATTERS ARISING (KS)

2 (Enclosure)

6. CHAIR’S UPDATE (JS)

5 (Enclosure)

7. CHIEF EXECUTIVE’S UPDATE (DJM)

5 (Oral)

8. PERFORMANCE REPORT (KB)

15 (Enclosure)

9. CLINICAL QUALITY REPORT (DR)

10 (Enclosure)

10. CARE QUALITY REPORT, INCL. INFECTION CONTROL (SF)

10 (Enclosure)

11. FINANCE REPORT (JM)

10 (Enclosure)

12. OPERATIONAL STRUCTURES (KB)

5 (Oral)

13. BOARD ASSURANCE FRAMEWORK AND RISK REGISTER (SF)

5 (Enclosure)

14. BOARD COMMITTEE MINUTES & REPORTS 14.1 Audit Committee (20.01.16) (KS) 14.2 Donated Funds Committee (29.01.16) (JS) 14.3 Monitor Standing Committee (29.01.16) (JS)

5 (Oral) (Enclosure) (Enclosure)

15. POLICIES FOR APPROVAL 15.1 Celebrity and VIP Visitor Policy (SF) 15.2 Consent Policy (DR)

2

(Enclosure)

16. ANY OTHER BUSINESS PREVIOUSLY ADVISED TO THE CHAIR

Date of next meeting – 11 May 2016 Harry Hollier Lecture Theatre, Good Hope Hospital.

PRESS AND PUBLIC ARE WELCOME TO ATTEND THIS MEETING AS OBSERVERS ONLY

EXCLUSION OF THE PRESS AND PUBLIC

The Board will be asked to resolve “That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”. PART TWO (PRIVATE)

Title: Appointment of Finance Director - Ratification Attachments: 0

From: Jacqui Smith, Chair To: Board

The Report is being provided for:

Decision Y Discussion Y Assurance N Endorsement N

The Board is being asked to:

Ratify the appointment of Julian Miller as interim Finance Director (a voting director

position) with effect from 3 February 2016, in accordance with a recommendation from the

Nominations Committee.

Key points/Summary:

The Nominations Committee met on 3 February and approved the appointment of Julian Miller as interim Finance Director with immediate effect at the recommendation of the Chief Executive and resolved to recommend the ratification of that appointment to the Board.

Recommendation(s):

Ratify Julian Miller’s appointment as interim Finance Director (a voting director position) with effect from 3 February 2016.

Assurance Implications:

Strategic Risk Register

N Performance KPIs year to date N

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

N Information Exempt from Disclosure

N

Identify any Equality & Diversity issues

N/A

Outline how any Equality & Diversity risks are to be managed

N/A

Which Committees has this paper been to? (e.g. F&PC, QC, etc.)

Nominations Committee

Jacqui Smith Chair 22 February 2016

REGISTER OF DIRECTORS and REGISTER OF DIRECTORS’ INTERESTS

VOTING DIRECTORS

NAME DATE OF

APPOINTMENT INTEREST (if any)

DATE OF NOTIFICATION

DATE OF TERMINATION OF INTEREST

Mr Jonathan Brotherton

04.03.15 Nothing to declare 04.03.15

Dr Andrew Catto 01.03.14 (Interim CEO -

14.11.14 to 16.02.15)

Nothing to declare. 01.03.14

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

01.10.14

Mrs Sam Foster 01.09.13 Nothing to declare. 01.09.13

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

2. Senior Fellow, NIHR School for Social Care Research

3. Member of Birmingham Health Partners Executive Group

01.10.15

01.10.15

01.10.15

Ms Hazel Gunter 04.03.15

Nothing to declare. 04.03.15

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

2. Part time judge Social Entitlement Chamber Fitness to Practise

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

equalities think tank.

01.10.14

01.10.14

01.10.14 01.10.14

Mr Julian Miller 03.02.16 1. Director of Finance (non-voting) – University Hospitals Birmingham NHS Foundation Trust

03.02.16

Dame Julie Moore 26.10.2015 2. Birmingham Systems Ltd 3. Director of Innovating Global Health

China Ltd (registered in Hong Kong) 4. Member of Birmingham Business

School Advisory Board 5. Court of the University of Birmingham 6. Governor – Birmingham City University 7. Non-Executive Director – Precision

Medicine Catapult (PMC) 8. CEO – University Hospitals

Birmingham NHS Foundation Trust

26.10.15 26.10.15 26.10.15

26.10.15 26.10.15 26.10.15

26.10.15

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

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

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

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

01.07.13

01.07.13

01.07.13

01.07.13

Jul 2013

NAME DATE OF

APPOINTMENT INTEREST (if any)

DATE OF NOTIFICATION

DATE OF TERMINATION OF INTEREST

Rt Hon Jacqui Smith 01.12.15 1. Chair – The Precious Trust

2. Chair – Public Affairs Practice for Westbourne Communications

3. Associate – Cumberledge Eden & Partners

4. Associate, Global Partners Governance.

5. Chair – University Hospitals Birmingham NHS Foundation Trust

01.12.15 01.12.15

01.12.15

01.12.15

01.12.15

Minutes of a meeting of the Board of Directors

of Heart of England NHS Foundation Trust

held in the Education Centre, Birmingham Heartlands Hospital

on 6 January 2016 at 12.30pm

PRESENT: J Smith, interim Chair

A Catto, Medical Director

J Brotherton, Director of Operations

A Edwards, Non-executive Director

S Foster, Chief Nurse

J Glasby, Non-executive Director

H Gunter, Director of Workforce & OD

K Kneller, Non-executive Director

D Lock, Non-executive Director

J Moore, interim Chief Executive Officer

IN ATTENDANCE: M Cooke, Director of Strategy/ Deputy Medical Director

K Bolger, interim Deputy Chief Executive Improvement

A Hudson, Minutes

J Miller, interim Finance Director

D Rosser, interim Deputy Chief Executive Clinical Quality

K Smith, Company Secretary

Governors

K Bell

E Coulthard

R Hughes

M Hutchby

S Hutchings

J Thomas

D Treadwell

and members of the public

16.001 APOLOGIES & WELCOME

The Chair welcomed everyone present to the meeting.

Apologies had been received from A Lord and J Rao.

16.002 DECLARATIONS OF INTEREST

The Directors’ Register of Interests was received.

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J Glasby declared that he undertook work on behalf of the University of Birmingham with

Birmingham Safeguarding Children’s Board from time to time.

16.003 MINUTES

The minutes of the meeting of 7 October 2015 were approved as a true record.

In relation to the minutes of the meeting of 4 November 2015 the following were noted:

15.161, first paragraph, A Lord had asked that the words ‘adding value.’ be replaced by ‘adjusting

the work plan of the Committee and Internal Audit, to reflect the changed risk arising from the

Trust’s deteriorating financial position.’

15.164, eleventh paragraph, J Brotherton noted that the words ‘£24m of’ should be deleted, so that

the sentence would read ‘J Brotherton confirmed that demand/ capacity planning had been robust

and included investment in five new wards’

15.165, third paragraph, K Kneller and A Edwards had volunteered to take the two new cases.

Subject to the foregoing the minutes were approved.

16.004 MATTERS ARISING & RECOMMENDATION TRACKING REPORT

There were no matters arising.

16.005 CHAIRS UPDATE REPORT

J Smith reported that during her first month in post she had undertaken some work on Board

structures and familiarisation with the work being done within the organisation. She had attended

several events including (1) the staff briefings that were now being held monthly at each of the

main sites, these presented an opportunity to meet and hear from staff, (2) the Compassion

Awards in Women & Children’s, and (3) the HIV Saving Lives open day.

The Chair had also met with a number of external stakeholders including CCGs, chairs of other

provider trusts and MP’s. Together with J Moore, she had attended the Solihull Overview and

Scrutiny Committee and met with Solihull Councillors. She had agreed to take over from L

Lawrence as deputy Chair of ICASS and she had met with the new leader of Birmingham City

Council regarding health and social care issues. Forthcoming meetings included Andrew Mitchell

MP and representatives of the ‘Save Good Hope Hospital Campaign’.

16.006 CHIEF EXECUTIVE’S REPORT

J Moore explained that the Chair had covered the matters she would otherwise have raised in her

report.

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16.007 PERFORMANCE REPORT

K Bolger presented a new style report that summarised the Trust’s performance against national indicators and targets and the Trust’s local priorities; material risks to the Trust’s Provider Licence or Governance Ratings, finances, reputation or clinical quality that resulted from performance against indicators, in order to give an overall review of the position of the Trust and set out the actions for those indicators that were failing to achieve compliance with targets. It was intended that future reports would move to a more ‘RAG-rated’ update that included comments on improvements. As this was the first of the new style reports the commentary was more comprehensive than might be the case for future reports. Monitor Risk Assessment Framework Of the 13 indicators set out in the framework nine were on target; two cancer targets, the 4-hour A&E wait and the 18 week RTT incomplete pathway targets had not been met.

The 4-hour A&E target had continued to be challenging with performance over the last three weeks even lower but in line with national trends. The mitigations set out in the report had been implemented before Christmas but significant pressure still remained. There had been an 8% increase in attendance during November compared to the same month in 2014. Admissions from the Emergency Department had increased by 12% and there had been a significant increase in the number of delayed transfers of care (DTOCs) related to failed discharges due to patient transport delays. The financial penalties were noted.

The Trust had missed two national cancer targets in October – 2 week wait from referral to appointment and the 62 day urgent GP referral to first treatment. There had been some positive work done over the last six months to improve the 62 day standard and the unvalidated position for November showed performance at 86.89% which was above the 85% target - operational teams were commended. 2 week waits had also shown improved performance with the unvalidated November performance at 93.06%; the first time since December 2013.

Referral to Treatment time (RTT) had improved to 91.34% and it was expected that the Trust would be on trajectory to achieve the 92% target at December 2015. The Good Hope Hospital Vanguard theatre had ceased and activity had been managed within house. It was noted that trusts did not get prior notice when public health warnings were issued or financial assistance with the consequential impact these had on demand. National targets monitored locally through CCG Contract Of the 15 national targets not included in Monitor’s Risk Assessment Framework but included in the CCG contract the Trust had delivered nine with six targets were behind plan.

6 week diagnostics continued to improve; the biggest problem being Endoscopy. There was a Vanguard endoscopy unit on the Heartlands site but the increase in demand remained a challenge. In response to a question from J Glasby, D Rosser advised that the NICE guidance had resulted in an increase in referrals for over 50’s without finance being assigned.

Work was underway to improve ambulance handovers; revalidation of breach data was also in hand. The financial penalty associated with handover breaches was noted.

Safer staffing would be covered in the Chief Nurse’s report later in the agenda but it was noted that Midwifery and A&E were an areas of concern.

Consultant upgrade performance had deteriorated from 75.4% in September to 64.295 in October with a total of eight breaches.

There had been one sleeping accommodation breach in November affecting 5 patients, 1 female

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and 4 male – work was underway to reduce the number of incidences.

There had been two breaches for urgent operations cancelled for the second time; both patients concerned were then operated on within 24 hours. The financial penalty was £5,000 per patient.

There had been no genuine 52 week breach patients; however there was one incomplete pathway 52 week breach Urology patient who was a legacy from the previous open clock cohort. The financial penalty for the breach was £5,000.

The reporting requirement on Duty of Candour had changed and would shortly begin reporting two months in arrears.

There had been one never event in November, there had been no harm but the case was under review. There was a potential financial penalty but it had not yet been calculated for this event.

Local indicators – Contract/ local There were 53 indicators that reflect the Trust’s priorities and contractual obligations; 22 were reported monthly, of these 16 were on target and six below target.

Babies at risk of TB - performance had dropped to 35.06% against a target of 98% due to a national shortage of the vaccine. Supplies had now been received and a number of catch up clinics were being held. Performance was back on track.

Breast feeding rates were below the 72% target and more work was required to understand cultural and other factors.

Appraisal rates were below the 85% target resulting in missed opportunities to discuss performance with staff.

The Trust was delivering its overall mandatory training performance; Information Governance training would be included going forward.

Local indicators – internal The Trust had a number of internal KPIs that were reviewed on a monthly basis under the heading of workforce and quality and safety. Those not being achieved included:

Staff in post vs budget establishment (excluding nurses) – stood at 91.5% against a target of 95–100%. New recruitment controls were reducing appointments and therefore impacting performance for this target. D Lock questioned whether staff numbers were a true reflection of establishment required to operate the Trust efficiently. K Bolger explained that he was unable to give that assurance as more work was required to understand the numbers required and the impact of flex. Work had been undertaken looking at locum utilisation and the results had shown that A&E, AMU and Elderly care where the areas of greatest pressure and demand. It was noted that recruitment had increased over the last 6 months and that it needed to continue both in the UK and overseas, as this continued to be a key strategic risk. J Moore confirmed that absolute assurance on staffing levels couldn’t be given at present but that the Trust was probably in a better place than many other trusts and a than it had been prior to the recent recruitment drive.

Delayed Transfers of Care (DTOCs) continued to be high; there was a focus on how the process was being managed including better interaction with Councils and Commissioners.

MRSA screening rates remained below the 90% target at 82.45%.

There had been five patients without confirmed treatment dates that had waited longer than 100 days from referral; all patients had now received dates.

There had been 88 operations cancelled on the day in November for non-clinical reasons; there had been no breaches to the contractual target requiring patients to have surgery within 28 days of

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the cancellation of surgery.

Admissions, Discharges and Transfers (ADTs) 2 hour recording performance was 76.48% against a target of 90%; a review was underway to understand why compliance was so low.

The dementia CQUIN was a key focus for the Trust given its level of elderly care. Solihull Community contract The Community contract had a value of approximately £20m and was commissioned by Solihull CCG, Solihull Metropolitan Borough Council (SMBC) and NHS England for a total of 40 services. In response to a question from D Lock, J Brotherton confirmed that the Community contract was subject to the same level of scrutiny on financial performance as other services. K Bolger had met with SMBC the previous day to get a better understanding of services including those to be de-commissioned; communication with staff and the public would be difficult. NHS preparedness for a major incident K Bolger gave an overview of the report that described the Trust’s state of readiness for a major incident. This had come following the tragic events in Paris in November 2015. Having reviewed and taken into account the content the report, the Board was assured that it was ready, to the best of its ability, to respond in the event of a major incident. The Chair noted that delivery of the Performance Report had taken longer than allocated but it had been important that the Board had time to carefully consider the content, particularly on this first run through of this new report. .

16.008 CLINICAL QUALITY REPORT

A Catto gave an update on clinical quality matters and it was noted that future clinical quality reports would be written. This month’s report was exceptional in that it included updates on three recall incidents. The report covered eight areas of quality. Investigations into doctors’ performance

There were currently seven medical practitioners within the formal review process; five were predominantly conduct matters and two were capability matters. A robust process was being followed. Mortality indicators

The Trust’s HSMR at 89.7 was below the average for Midland’s trusts of 92.7 and had shown a favourable downward trend; of 137 trusts the Trust was positioned at 45, the lowest position being best.

The Trust’s SHMI was 97.5, which was good news. However, as previously reported, there had been some data inaccuracies between July 2014 and March 2015, which would continue to impact the SHMI measure until the historical data had worked its way through the rolling year calculation.

There had been six new condition alerts, which were based on the number re-occurring medical conditions seen at death; a review was underway and a report would be presented to a future meeting.

A Edwards referred to the mortality review undertaken by Prof Stan Silverman, questioning whether he was still involved with the Trust and the reliability of the Trust’s PMS2 data; A Catto confirmed that the Board could invite Prof Silverman to re-visit the Trust at any time if it wished to do so to undertake a follow up on his previous review and gave assurance that the Trust’s data was now more robust.

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Breast recall – status update

A Catto reported that data validation had been completed. Protocols had been developed through a national MDT. The second phase of the breast recall programme had commenced with 215 patients reviewed by a virtual MDT, comprising experts from the national MDT. An external clinical provider from the private sector had been identified.

The previously proposed Royal College of Surgeons invited review had been paused pending further consideration of pan-Birmingham services.

Urology recall – status update

A Catto had instigated a review of Mr Manu Nair’s (MN) practice by the RCS in 2014, following which a recall exercise of all MN’s patients who had undergone a radical prostatectomy had been carried out. All recalled patients were seen by an external consultant and specialist nurse. A further review of MN’s remaining patients was underway.

A provision of £647k had been made with expenditure to date of around £400k.

Hip prosthesis

In June 2015 it had become apparent that a non-approved combination of stem and head for total hip replacement had been used on some patients; it was subsequently confirmed that this applied to 57 patients. A root cause analysis was instigated and was ongoing. After initial reluctance the stem manufacturer had undertaken tests of the combination and concluded there was no evidence of likely harm for patients; the conclusions of additional expert opinions were imminent.

Incident form backlog

A Catto advised that at June 2015 there had been around 5,000 incidents on the Datix system reported as not being closed. The timeline for review of incidents was 7 days from reporting for initial review and 28 days from reporting to close; breach of either limit defines a backlog. .A review by the central governance team had shown that clinical teams had not been completing investigations to close the incidents in a timely manner. The vast majority of the backlog related to no or low harm matters. The Trust typically sees around 370 new incidents reported a week. Progress in closing cases had been made with 1,258 incidents open at the beginning of January.

Lessons learned included the need for better training in the use of Datix, more effective monitoring of backlogs, medical and nursing leadership to strengthen accountability and better local governance support.

J Moore explained that the new leadership team had identified governance as a priority area and that a significant backlog of incidents was unacceptable.

Incident reporting rates

The Trust reported 5,041 incidents in Q2 2015 of which around 76% resulted in no harm. The Board noted that increased reporting was to be encouraged, together with the learning that this could bring.

Endoscopy strategy

The Board noted the need to improve the Trust’s Endoscopy service, particularly at the Heartlands site. A business case was being prepared.

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16.009 CARE QUALITY REPORT

S Foster referred to the pre-circulated report that summarised the Trust’s performance against national quality indicators and targets, including those set out in Monitor’s Risk Assessment Framework, and local priorities. Infection control was on track and remained within trajectory for C.diff; there had been two cases of Trust-attributable MRSA bacteraemia year to date. Whilst performance was strong the Trust needed to ensure that it remained focussed on ensuring compliance; A Hussain, the Director of Infection Performance and Control, was looking ways to improve performance that included a no complacency attitude. Work around Patient Experience and the Friends and Family Test (FFT) continued. A&E and Maternity were the current areas of focus for improvement. Following the external review of the complaints process, work was being done to improve recording, grading and responses to complaints; it was anticipated that an improvement in the closure of complaints cases within 25 working days would be seen over the coming months. Harm was measured through the National Safety Thermometer. The Trust’s positive performance in reducing falls had continued within the agreed trajectory. The performance for reduction of Grade 2 pressure ulcers continued to improve within the agreed trajectory; reduction of Grade 3 pressure ulcers was more challenging with 39 year to date against the agreed target of 29. Various initiatives had been implemented in quarter 3 with the aim of focused improvement. There was a further discussion around DTOCs; it was noted that the Trust had been found to be responsible for around 15% but that this equated to less than 2% of Occupied Bed Days. It was noted that collaborative working with colleagues from across the healthcare system on Jonah rounds had resulted in significant improvements. Nurse staffing levels were monitored daily by site with the Chief Nurse overseeing activity weekly and monthly; key hot spots were theatre and the Emergency Department. Weekly UNIFY submissions were published on the Trust’s website. The most significant challenge for safer nurse staffing was reducing the number of vacancies for registered nurses and midwives across the Trust; there were currently 156 vacancies but there were 41 planned starters over December-January. Focused overseas recruitment was being scoped, in particular Romania, but 300 Pilipino nurses had been blocked from working at the Royal Wolverhampton NHS Trust because of the need to pass English tests, which was an example of the challenges encountered. CQUINS targets for Q2 were delivered; Q3 & 4 performance was at risk and would be discussed at the upcoming Chief Executive’s Group meeting; priorities included dementia & delirium, sepsis and acute kidney injury with the need for ownership at divisional level. J Brotherton noted that the CQUIN with the highest value at risk was Ambulatory Emergency Care. Q3 Compliance and Assurance Report

S Foster referred to the pre-circulated report that was designed to give assurance to the Board regarding internal and external compliance. Reviews had continued by Safety & Governance using the Trust’s quality review tool that was based on the CQC Regulations and Key Lines of Enquiry. A new programme of Board Unannounced Governance Visits had commenced in December 2015, these had replaced the former ‘Patient Safety Visits’; the aim of the new programme was to give the Board further assurance.

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The Trust had achieved 97% compliance against the NICE Technology Appraisal (TA), which was well understood by clinicians; the two exceptions were noted and would be monitored by the Clinical Effectiveness Group. The Trust had a process in place to implement, review and record decisions where recommendations had not being met. Actions from CQC Inspection

S Foster reported on progress against the action plan that had been put in place following the CQC inspection in December 2014 and noted that monthly update reports were required against incomplete actions; where no movement occurs the matter is escalated to the lead Executive Director.

16.010 FINANCE REPORT

J Miller, Interim Finance Director, presented the report for the period ending November 2015 (M8). The Trust had reported an I&E deficit of £5.4m in M8 leading to a cumulative deficit of £45.9m for the year to date (YTD); this represented an adverse variance of £38.5m against the planned deficit of £7.4m YTD with the main variances being Medical staffing (£10.0m), Nursing staffing (£7.7m) and unachieved CIP – 2015/16 (£7.8m) and prior years (£11.3m) – totalling (£19.1m).

The Trust was pursuing a financial recovery process supported by Ernst & Young (EY). Short term measures (enhanced controls) had reduced the monthly run-rate from an average of £7.1m per month in Q2 to an average of around £5.0m per month in Q3. However the easy wins had largely been delivered and a longer term plan would be required to tackle the residual deficit. The latest year end forecast was projecting a deficit of between £53.0m (best case) and £64.0m (worst case), dependent upon the extent to which recovery schemes delivered. There was further risk associated with winter pressures; a balance would need to be struck between performance and finance over the next few months. Activity had been above plan in November including increases in A&E attendances by 4%, emergency admissions by 3.9%, electives by 11.6% and outpatient attendances had increase by 7.3%. All points of delivery were on or above plan YTD. NHS clinical income was £10.3m above plan, although payment challenges had been issued by the CCG totalling a similar value; J Moore suggested that around one third of this might be a reasonable challenge. CIP delivery for the current year stood at 69% to M8 with slippage of around £5.0m (20%) projected by year end. Around one third of identified savings had been delivered non-recurrently for which replacement schemes would need to be identified in 2016/17. Most significantly the cash position had improved further to £50.3m, but remained £21.6m below plan. This reflected improved working capital management including enhanced debtor collection and creditor stretch. The scope for further working capital improvement was now limited, going forward cash was likely to mirror the income and expenditure (I&E) trend. The latest forecast indicated a balance of between £15.1m and £23.0m at year end, dependent upon the I&E deficit. The Trust’s Financial Sustainability Risk Rating had now fallen to 1 (the lowest possible rating). In response to a question from the Chair, J Miller explained that the CIP slippage was a NHS-wide problem for providers; the Trust wasn’t an outlier but the 2015/16 plan had been unrealistic. It was further noted that financial planning for the year had been unrealistic and this had been exacerbated by previous years’ under-delivery of CIP and issues around controls. J Miller confirmed that Monitor was being kept up to date on regular conference calls. In response to a question from A Edwards, J Moore suggested that it might take two years to get back to surplus but this was dependent upon identifying and delivering measures to achieve this.

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16.011 OPERATIONAL STRUCTURES

K Bolger reported that a review had been undertaken that included operational structures. Staff had been unclear for some time on their reporting lines; clarity was required. It was proposed to revise structures by the end of January 2016. The revisions revolved around aligning structures rather than wholesale change; the ultimate target was stabilisation of the organisation. There was a discussion around the communications process. It was explained that the senior teams would be briefed first and the messages would then be cascaded quickly through the divisions.

16.012 BOARD STRUCTURES

The Chair referred to the pre-circulated paper. Following a Board development session lead by the Good Governance Institute (GGI) in December 2015 it was proposed to simplify Board structures to improve clear lines of sight and shift the focus of Non-executive Directors to a more strategic level. The role of the Quality Committee was to be re-focussed to one of supporting and providing continuity for the Board in relation to its responsibility for ensuring that the care provided by the Trust was of an appropriate quality; it was intended that this Committee would meet on a bi-monthly basis and the membership would consist of all the Non-Executive Directors, including the Chair, the Chief Executive, the Medical Director, the Chief Nurse and the Director of Operations. Other officers of the Trust, including members of the Executive Team, would be invited to attend the Quality Committee as and when required. It was further recommended that the Appointments Committee was amalgamated into the Nominations Committee, the membership of which would be all of the Non-Executive Directors, including the Chair, and the Chief Executive; the revised terms of reference were included in the pack. There were no immediate plans to disestablish the following Board Committees:

Audit Committee

Donated Funds Committee

Monitor Standing Committee

Remuneration Committee The membership of the above committees would be revised as set out with immediate effect. The Chair would ensure all statutory items were bought to Board and would be timetabled into the annual cycle. A review of the new arrangements would be undertaken after six months. In response to a question from S Foster as to whether the Council of Governor Committee’s committees would be reviewed, the Chair advised that Governor committees were slightly different and although she would be looking at these committees, some were of considerable value to the Trust. After due consideration all of the recommendations, as set out in the pre-circulated paper, were approved.

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16.013 BOARD ASSURANCE FRAMEWORK & RISK REGISTER

The report was taken as read. S Foster explained that the Board Assurance Framework had been evolving over time and was now more reflective of the views of the Directors. It continued to be a working document and work on the corporate risk register would enable its integration to ensure that operational risks were appropriately recorded and reflected.

16.014 ANNUAL SAFEGUARDING REPORT

S Foster presented the pre-circulated report and commented on the Birmingham and Solihull Safeguarding Children Boards’ reports providing context to the safeguarding activities of the Trust. The Trust saw and treated over 132,000 children under the age of 16. There was an established Specialist Safeguarding Team that reported to the Executive Lead for Safeguard (the Chief Nurse) and internal governance procedures oversaw the effectiveness of safeguarding arrangements within the Trust. The Trust reviewed compliance with the CQC safeguarding regulations and Section 11 quarterly. External scrutiny of safeguarding standards was through the CCG’s, LSCB’S, the CQC and Monitor. In light of growing demand and new ways of working the Trust had undertaken a capacity review of specialist safeguarding resource including Multi-agency Safeguarding Hubs (MASH). There was a discussion regarding the Trust’s role and whether it should be taking a more externally focussed leadership role in relation to children safeguarding. It was acknowledged that the Trust could contemplate a more involved role over time.

16.015 BOARD COMMITTEE MINUTES AND REPORTS

Audit Committee

K Smith presented the pre-circulated minutes on behalf of A Lord and confirmed a significant part of the Committee’s activity in recent months had been adjusting the work plan of the Committee and Internal Audit, to reflect the changed risk arising from the Trust’s deteriorating financial position. The Committee also continued to monitor remediation activities from previous Internal Audit reviews and receive reports on recently completed Internal Audit reviews, such as cash management, income and debtors, and payments and creditors. Donated Funds Committee

The Committee had met on the 20 November 2015; the minutes were received. Monitor Standing Committee

The Committee had met on 29 October 2015 to approve the Monitor quarter 2 return; the minutes were received.

16.016 POLICIES FOR APPROVAL

A Catto presented the Consultant and SAS job planning policy and procedure. D Rosser explained that he had some reservations and it was agreed to defer consideration of the policy and procedure to the next meeting.

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16.017 DATE OF NEXT MEETING

2 March 2016 in the Harry Hollier Lecture Theatre, Partnership Learning Centre, Good Hope Hospital. The Board resolved “That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.”

PART TWO

16.021 ANY OTHER BUSINESS

There being no further business the meeting closed.

....................................... Chair

BOARD OF DIRECTORS

Matters Arising & Decisions/Recommendations Tracker

Date raised

Minute No

Detail Action Due Status Completed

7 Oct 2015

15.141 Report back on financial modelling for and progress with Priority Programme for Frailty.

IP/ RC Apr 16

6 Jan 2016

16.016 Bring Consultant and SAS job planning policy and procedure back to CEG/ Board for approval after further review with D Rosser.

AC/DR Apr 16

HEART OF ENGLAND NHS FOUNDATION TRUST

BOARD OF DIRECTORS

WEDNESDAY 2 MARCH 2016

CHAIR’S REPORT

As promised, I am producing this summary of some of the key events and meetings that I

have attended in the last month.

I was able to attend my first Donated Funds Committee chaired by Paul Hensel. It was good

to meet him and to get a better understanding of the work of our fundraising. There is much

good work undertaken by individuals raising funds for the Trust’s charitable activities. The

meeting also discussed whether the current structure of the fundraising function is as

effective as it could be and how we can maximise the fundraising and the impact of the

money kindly donated.

I met with the Good Governance Institute to hear some interim feedback from their

Governance Review. I am keen to organise a development session for the Council of

Governors to review the extent to which we are fulfilling our statutory functions and to

consider how we could improve the current committee structure. Linked to this, I had a good

discussion with Mark Pearson, Chair of the CoG Quality and Risk Committee about how to

improve the way that governors are informed about quality and risk issues and how they can

be involved fully.

I attended the Birmingham and Solihull Council Overview and Scrutiny committee with Kevin

Bolger and Rachel Cashman. I briefed the councillors on the key HEFT performance and

finance issues and answered a range of questions. The councillors were grateful for the full

and comprehensive briefing provided.

I spoke at the launch of the West Midlands Violence Prevention Network. I have been asked

to join the Advisory Board and am keen to ensure that health bodies play a full role. Working

more closely with the police, local authorities and offender management services can help to

reduce levels of violence. We see the victims in our Emergency Department; violence

impacts on health throughout your life and too many of our staff are victims too.

I am a member of the Chair’s Advisory Group for the newly formed NHS Improvement. This

body brings together Monitor - our regulator as a foundation trust - and the Trust

Development Agency. The launch conference in London was addressed by Health

Secretary Jeremy Hunt and Simon Stevens of NHS England as well as Jim Mackey, the new

CEO of NHSI. There is a clear intention to ensure that NHSI works better in the regions, has

a closer and more constructive relationship with providers and brings some consistency

across national bodies. We can watch with interest.

I met with Helen Kelly, Director of Integrated Care and Support in Solihull to talk about the

well-developed partnership work in the borough. I will be attending the Leaders Board in

Solihull in the future. Our community services are an important, but sometimes

unrecognised part of the Trust. Last week’s Governors’ Breakfast agreed to invite senior

staff from Community Services to give a presentation at the next Breakfast meeting.

Jacqui Smith Chair

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BOARD OF DIRECTORS


Title: Performance Indicators Report

Attachments: 1

From: Kevin Bolger, Interim Deputy CEO - Improvement

To: Board of Directors


Decision N Discussion Y Assurance Y Endorsement Y

The Committee is being asked to:

Note the content of the report and note the action being taken to achieve compliance with

the Trust’s performance indicators.

Key points/Summary:

Exception summaries have been provided where there are current or future risks to performance for targets and indicators included in Monitor’s Risk Assessment Framework, national and contractual targets and internal indicators.

Recommendation(s):

The Board of Directors is requested to:

Accept the report on progress made towards achieving performance targets and associated actions and risks.



N Performance KPIs year to date Y


Y Information Exempt from Disclosure

N


None


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

None

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BOARD OF DIRECTORS


PERFORMANCE INDICATORS REPORT

PRESENTED BY INTERIM DEPUTY CEO - IMPROVEMENT 1. Purpose

This paper summarises the Trust’s performance against national indicators and targets, including those in Monitor’s Risk Assessment Framework, as well as local priorities. Material risks to the Trust’s Monitor Provider Licence or Governance Rating, finances, reputation or clinical quality resulting from performance against indicators are detailed below.

2. HEFT Key Performance Indicators

The Trust has a suite of Key Performance Indicators that includes national targets set by the Department of Health (DH) and local indicators selected by the Trust as priority areas, some of which are jointly agreed with the Trust’s commissioners. This report is intended to give a view of overall performance of the organisation in a concise format and highlight key risks particularly around national and contractual targets as well as an overall indication of achievement of key objectives. The Trust currently rates indicators as either green – meeting the target or red - failing the target. For this report all indicators that are failing to achieve compliance with targets have been reported on. The report also contains a short overview of performance against the Solihull Community Contract.

3. Material Risks The DH sets out a number of national targets for the NHS each year which are priorities to improve quality and access to healthcare. Monitor tracks the Trust’s performance against a subset of these targets under its Risk Assessment Framework. The remaining national targets that are part of the Everyone Counts document from the DH but not in Monitor’s Risk Assessment Framework are included separately. 3.1 Monitor

Of the 14 indicators currently included in Monitor’s Risk Assessment Framework (RAF), 10 were on target in the most recent month. 1 cancer target (reported a month in arrears), the A&E 4 hour wait target, the 18 week RTT incomplete pathways target and the in-month C.difficile target were not met.

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The Trust is currently working with key stakeholders to review and revise trajectories for 4 key national targets A&E, 18 week RTT, diagnostics and cancer 62 day waits.

3.1.1 A&E 4 Hour Waits

The Trust continues to fail to meet the % patients waiting >4 hours in A&E target. January’s performance is 84.3%, against 83% in January 2015

The number of attendances in January 2016 was 22,011 against 19,257 in January 2015. The Trust is seeing on average 89 attendances more per day.

There were no 12 hour trolley breaches.

3.1.2 Cancer Targets (month in arrears) 62 day cancer target

The 85% 62-day urgent GP referral standard was achieved in December 2015 85.36% against a target of 85%;

The Trust trajectory for sustained delivery of this target is from the end of January 2016. Delivery of this seems unlikely with January’s unvalidated performance showing a deterioration to 76.5%, as Urology clears its backlog of long waiters

As Urology represents the highest volume of activity in the 62 day pathway and so has the most significant impact on performance

against this target there is a risk to delivery in Jan-March. Work is also being done to improve performance for Lung cancer patients on 62 day pathways.

2 week cancer wait

2016 366

2015 299

Var 67

2016 236

2015 217

Var 19

2016 109

2015 106

Var 3

2016 711

2015 622

Var 89

BHH - Avg per day

GHH - Avg per day

SOL - Avg per day

Trust - Avg per day

Table 1 - A&E Attendances Jan15 v Jan 16

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The performance for December 2015 against this indicator was 94.79% against a target of 93%. The Trust has met it’s trajectory to recover performance by December 2015, having met the target for the last 2 months. 2 week wait breast Performance for December 2015 against this target was 88.24%. The mammogram machine has been fully operational since early December. The resulting backlog has been cleared. There is a revised escalation process in place with respect to booking and there is confidence that the indicator will be delivered in February.

3.1.3 Referral to Treatment Time

Performance against the 92% incomplete 18 week referral to treatment target in January was 91.24%, ahead of trajectory (89.92%), but still below the national threshold of 92%.

The Trust trajectory for delivery of this target is to deliver 92% by the end of March 2016.

The number of patients waiting over 18 weeks for inpatient treatment at the end of December was 1328, the January unadjusted unvalidated position is 1405. Meetings have been held with the divisions where growth in the backlog has been unexpected to gain an understanding of the issues and plans will be developed to address these.

3.1.4 C.difficile

In January the Trust had 7 cases of c.difficile (4 at BHH, 2 at GHH and 1 at SH), against an in-month target of 6. This is the second month the Trust has exceeded its in-month target. The Trust has had 48 cases against the in-year target of 60. All January cases have been reviewed with the CCG and 3 have been determined as avoidable, bringing the year to date total to 12 avoidable cases.

3.2 National Targets Monitored Locally Through CCG Contract

Of the 17 national targets that are not included in Monitor’s Risk Assessment Framework but are included in the CCG contract the Trust is on target for 9 and not delivering against 6.

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3.2.1 6 Week Diagnostics

January performance deteriorated slightly against the December position achieving 96.88% against a target of 99%. The majority of patients waiting over 6 weeks are on the endoscopy waiting list; however there has been an increase in imaging waits in December and January, particularly in non-obstetric ultrasounds and MRI scanning. The Trust trajectory for delivery of this metric expected us to return to compliance with the 99% target in December 2015. As a result of our failure to return to compliance the Trust has received a Contract Performance Notice from the CCG in relation to the diagnostic performance, both in relation to our failure to deliver the 99% performance against an agreed trajectory and our failure to alert the commissioners that we were likely to fail the target. A meeting is currently being arranged to discuss the performance notice with the CCG and a full remedial action plan and revised trajectory is being prepared for that meeting.

3.2.2 Ambulance Handover

The final January position was similar to that of December with 287 patients waiting over 30 minutes and 5 patients waiting over 60 minutes for handover from the ambulance to A&E Table 3 below shows a 10% increase in the number of ambulance attendances at the Trust compared to January 2015

Table 3 - Ambulance Attendances

Site Jan-15 Jan-16

Variance (no.)

Variance (%)

BHH 3412 3882 470 14%

GHH 2487 2635 148 6%

SH 678 741 63 9%

Trust 6577 7258 681 10%

3.2.3 MRSA

There were 2 confirmed cases of MRSA bacteraemia in January; one on ward 24 at BHH, the other was identified in A&E (BHH), however the patient had only been discharged from Ward 4 BHH a few days previously, so this case despite being a pre-48hr bacteraemia has been attributed to the Trust. Ward 4 also had a post 48 hour MRSA bacteraemia in December.

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This brings the Trust total ytd to 5 MRSA bacteraemia. The Trust only had one case last year (14/15).

3.2.4 Sleeping Accommodation Breach

There were 2 occasions of mixed sex accommodation breaches affecting 5 patients in total, both events happened in HDU at BHH. RCA’s have been requested.

3.2.5 Urgent Operations cancelled for the second time

There was one urgent operation cancelled for the second time in January. This was due to the lack of a critical care bed on both occasions; the patient has since been treated.

4. Local Indicators – contract

There are a number of local contractual indicators that the Trust’s performance is measured against details of those indicators failing to meet their targets are provided below:

4.1 Breast feeding rates

Breast feeding performance dipped in January to 68.87% against a target of 72%. Both BHH and GHH failed to meet the target achieving 68.1% and 69.5% respectively. There is an action place to support delivery of this target and this will be discussed with the division at the Executive Performance Review Meeting on 29 February.

4.2 Compliance with nursing care indicators (tissue viability/SSKIN bundle) –

total score and repositioning frequency adhered to for 3 days.

The Trust failed to meet the nursing care indicator relating to tissue viability compliance, this is a composite indicator made up of 3 sub-measures.

The overall compliance score was 93% against a target of 95%, the sub-measure that impacted most on the overall score was the metric to ensure that repositioning frequency is adhered to for 3 days which only achieved 80% against a 90% target. See Care Quality Report for more detail.

4.3 Falls Rate

The Trust overall falls rate has seen an increase in January, for the first time this year. The Care Quality Report provides more detail on this.

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4.4 Appraisal rates

The appraisal rate remains below the target of 85%, but has increased on last month (68.64%) to 72.05% in January. A revised trajectory for delivery based on January’s performance has been agreed, see table 4 below:

5. Local Indicators - Internal

The Trust has a number of internal KPIs that it reviews on a monthly basis, these are classed under the headings of workforce and quality and safety

Details of those not being achieved are provided below:

5.1 Workforce KPIs The January position against the workforce KPIs shows no significant shift from the December reported position with the following indicators continuing to underperform:

Staff in post v budget established (excluding nursing)

Nursing staff in post v budget established

Average time to recruit – hiring manager and total time to recruit

Voluntary turnover

The Workforce Team have a number of plans in place to address these issues and it is proposed that to enable these to take effect that the next performance report to the Board on this indicator is at the end of March.

5.2 Trust wide Agency Spend

In January the Trust has set a target for this indicator to 3% for agency as total of pay spend. This is on the basis that 3% is the Trust’s agency cap as per Monitor for Nursing. The Trust continues to overspend against its Trust wide Agency Spend indicator. The January position is 8.18%. Work to address this is being undertaken through the finance recovery programme.

Jan Feb Mar Apr May Jun

Performance 72%

Revised trajectory 70% 73% 76% 79% 82% 85%

Table 4 - Appraisals Trajectory

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5.3 Delayed Transfers of Care (DTOC)

Performance in January improved to 4.62%, this is a reduction of 0.51% on the previous month and a total reduction of 1.41% since the implementation of the DTOC Improvement plan. Current performance is slightly above the expected trajectory of 4.49% to deliver 2.5% by May 2016. See Care Quality Report for more detail.

5.4 MRSA Emergency Screening Rates (% patients screened)

MRSA emergency screening performance remains below the 90% target at 82.54% in November. The sites achieved 79.63% at Heartlands, 90.54% at Good Hope and 87.89% at Solihull. There are a number of actions in place to address this and it is proposed that to enable these to take effect that the next performance report to the Board on this indicator is at the end of March.

5.5 Patients receiving their first definitive treatment for cancer within 100 days of

GP or dentist urgent referral for suspected cancer

In December there were 4 patients treated that waited over 100 days.

As reported to Clinical Quality Committee a new methodology for reporting 100 day cancer waits is being developed by the cancer team and reporting using this new approach will commence from 1st April The cancer team have been developed an 80 day forward look process to manage patients before they reach 100 days, this will be used at the weekly cancer performance meetings.

5.6 Operations cancelled on the day

The Trust cancelled 0.88% of operations at short notice in January (against a target of 0.8%) this is an improvement on December’s performance of 1.03%. The actual number of cancellations reduced from 83 in December to 71 in January.

There have been no breaches of the contractual target requiring patients to have surgery within 28 days of cancellation of surgery since August.

5.7 Nursing Metrics – quality of care

Performance dipped in January to 94% from 95% in December. Individual Site performance was 93% at Heartlands, 96% at Good Hope and 96% at Solihull.

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Weekly metric monitoring has been put in place for those wards achieving less that 90% for two key metrics blood glucose monitoring and fluid balance compliance. See Care Quality Report for more detail.

5.8 Admissions, Discharges and Transfers (ADT) recorded within 2 hours

The Trust has a requirement for 90% of ADTs to be recorded within 2 hours performance in January was 77.01%. There are a number of actions in place to address this and it is proposed that to enable these to take effect that the next performance report to the Board on this indicator is at the end of March. See Care Quality Report for more detail.

5.9 % patients seen in 18 weeks for Direct Access Audiology (month in arrears)

Performance in December improved to that of November (78.02%), achieving 81.59% against a 90% target. This is an aggregated indicator made up of acute and community performance against this target. Work has been undertaken to address the backlog in the community and it is likely that this indicator will be met in January.

5.10 Dementia CQUIN

In January the Trust performance against the dementia CQUIN indicator of the percentage of eligible patients aged over 75 asked the dementia question was 87.52%. The Trust has only achieved this target in two months year to date.

6. CQUINs The Trust made its Q3 submission to the Commissioners on 12 February and is currently waiting for feedback and details of fines associated with non-delivery.

There are a number of risks to delivery in Q4 see Care Quality Report for information.

7. Solihull Community Contract

The majority of Community Services CCG indicators were achieved during December and Quarter 3.

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The Community Services 18 weeks RTT performance was 100% in December, this is an improvement when compared with November (77.8%). The under performance in November was due to a training issue. This has since been addressed and a more robust process is in place for checking impending breaches.

There were three exceptions reported on the CCG / SMBC KPI reports, this includes a level four pressure ulcer in September that was reported in December, breastfeeding initiation achieved 65.78% below the 70% target. The remaining indicator that failed to achieve the contractual target was the number of appraisals completed (Trust wide measure).

8. Solihull Metropolitan Borough Council (SMBC) Contract

The Trust has a contract with SMBC, which focuses on the performance of the Health Visiting Service managed by the Solihull Community Team. All indicators are monitored quarterly; the performance for Q3 shows that the Trust is only achieving 3 of the 9 indicators. Changes to the Health Visiting contract in October resulted in the transfer of a high number of patients from Birmingham GPs (that live in Solihull) and vice versa which means that it’s not always clear that the patient have been treated in the correct pathway.

9. Recommendations The Board of Directors is requested to: 7.1 Accept the report on progress made towards achieving performance targets

and associated actions and risks.

Kevin Bolger Interim Deputy CEO – Improvement

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BOARD OF DIRECTORS

WEDNESDAY 2nd MARCH 2016

Title: Clinical Quality Report Appendices 0

Presented by: Executive Medical Director Prepared by: Dr Clive Ryder & Dr Ann Keogh



Decision N Discussion Y Assurance Y Endorsement Y


Receive and note the contents of this report.

Key points/Summary:

The Board of Directors will consider:

Current investigations into doctors’ performance currently underway

Mortality indicators CUSUM, HSMR, CRAB and SHMI

Themes from the action plan following the Board of Directors December 2015 unannounced governance visit to Solihull Hospital, ward 15.

Recommendation(s):

Receive, reflect and note the contents of the report. To receive Board feedback on unannounced visits



Y Performance KPIs year to date Y



Y


None identified.


None identified.

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

Chief Executives Group 16th February 2016

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HEART OF ENGLAND NHS FOUNDATION TRUST BOARD OF DIRECTORS

WEDNESDAY 2nd MARCH 2016 CLINICAL QUALITY REPORT

PRESENTED BY EXECUTIVE MEDICAL DIRECTOR 1. Introduction

The purpose of this paper is to provide assurance of the clinical quality to the Board of Directors The Board of Directors is requested to discuss the contents of this report and approve the actions identified.

2. Investigations into Doctors’ Performance

At the time of reporting there are 13 medical practitioners within a formal process at the Trust, of which one is a Junior Doctor, five are SAS doctors and seven are Consultants. There are two cases that deal predominantly with capability matters while the remaining eleven cases are predominantly conduct matters. In five of the cases the practitioner is either excluded or has restrictions on their practice. Of these cases, there are two Hearings that have been arranged: a conduct Disciplinary Hearing arranged in February resulted in a dismissal and a Capability Hearing has been arranged for March. There are two investigations that have exceeded the expected timescale laid down within MHPS. However, these are being managed effectively by the Case Manager and plans are in place to receive completed reports. There is also one outstanding Employment Tribunal associated with a doctor who has now left the Trust. The claim is for unlawful deduction of wages. In addition to the above, Case Management Training has taken place and Case Investigation Training will be arranged within the next 3 months to ensure there are sufficient trained investigators going forward.

3. Mortality monitoring data

3.1 Trust Summary Mortality Overview The Trust April – October 2015 HSMR of 91.8 is below the national average HSMR index.

3.2 CUSUM / HSMR Alerts

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Exception update on previous CUSUM alerts Review of urethral catheterisation of bladder In the period April–August 2015, the Trust received an alert in the urethral catheterisation of bladder category. This is currently being investigated further but it must be noted that the alert does not indicate the number of patients that have died because of a urinary catheterisation. It indicates that a number of patients had urinary catheterisation performed for retention and subsequently the patient died during that admission, regardless of cause of death. This is because Acute Trust coding is for the purposes of morbidity rather than mortality and therefore the Trust is mandated to code what is treated and not the cause of death. We are identified as a high recorder of urethral catheterisation secondary to retention of urine (as the code requires). We have undertaken an analytical data review, review of coding and following a discussion with other trust and the HSCIC and Dr Foster a change in recording of coding priorities for this procedure will be trialled. We are also auditing practice in a number of specialities. A full report will be brought to a future meeting. 3.3 Hospital Standardised Mortality Ratio

HSMR Trend: April 2008 - October 2015 continues to show a favourable picture with October 2015 HSMR 88. (The Dr Foster benchmark used is up to July 2015).

Table 1: Yearly Dr Foster HSMR by Hospital, 2007/8 to April 2014 – October 2015

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3.4 Summary Hospital-level Mortality Indicator (SHMI) The latest SHMI is 95 for July 2014 – June 2015 representing an HSCIC ‘as expected’ banding. This is the lowest it has ever been. However, the trend is consistently downwards and the influence of data quality concerns lessens with each iteration of the SHMI.

3.5 CRAB (Copeland Risk Adjusted Barometer) surgical 30 day risk adjusted mortality ratio to November 2015. The CRAB system uses an organisation’s own data for all patients coded at the time of discharge to risk-adjust all surgical morbidity and mortality and also to identify the incidence of triggers of possible avoidable harm in ward care and medical care based on the UK Global Trigger Tool. The system comprises 2 principal modules: surgical and medical. The surgical module for 30 day mortality Produces risk predictions for each patient treated by calculating POSSUM scores from clinical coding and generates an observed /expected ratio for both mortality and morbidity: average = 1 Uses POSSUM score Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity. • risk-adjusted 18 variables – 12 physiological, 6 operative, each weighted and

scored in combination • risk-adjusted for complications • International benchmarking.

The CRAB 30 day surgical mortality O/E ratio continues to show a low level below the average of 1. There are currently no individual surgeon mortality outliers at HEFT using the CRAB tool. This position was confirmed at the CRAB benchmarking group, chaired by Dr Clive Ryder, with a representative from the company C-CI Ltd.

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4.0 Board of Directors Unannounced Visits A programme of monthly Board of Directors’ Unannounced Governance Visits involving Non-Executive Directors and Executives commenced in December 2015. The first visit took place on 18 December 2015 and was to ward 15 at Solihull Hospital. The themes from this are below.

Board of Directors’ Unannounced Governance Visit Feedback The first Board of Directors’ Unannounced Governance Visit took place in December to Ward 15, Solihull Hospital. This is an elective orthopaedic ward.

Patients

Patients were generally very happy with the care provided by staff on the ward. One patient commented that there was a lack of continuity of medical staff and he had to repeat himself. Some patients reported that they were not aware of when they were likely to be discharged.

Concerns were raised around the availability of HDU

Staff

A good, supportive relationship was observed between the different staff groups working on the ward and a number were positive about working on the ward. Two doctors commented on the benefits that the additional consultant input on the ward had made.

It was felt that the open visiting times could be confusing for patients and visitors as staff did not appear to be clear on the rules. Some staff also felt that open visiting could delay discharge

Environment and Equipment

The ward was very clean and tidy. However there were some issues identified with signage, patient property storage facilities and broken IT equipment along with some estates issues which were requiring addressing at the time of the visit. It was also observed that some computer screens were visible to the patients

Overall: A very positive visit with excellent feedback from patients and staff; ward very clean and tidy although signage and broken IT kit needs addressing.

5.0 Recommendations

The Board of Directors is asked to: Discuss the contents of this report and approve the actions identified.

Dr Andrew Catto Executive Medical Director

HEART OF ENGLAND NHS FOUNDATION TRUST BOARD OF DIRECTORS

WEDNESDAY 2ND MARCH 2016

Title: Care Quality Board Report Attachments:

From: Sam Foster To: Board of Directors


Decision N Discussion Y Assurance Y Endorsement N


Note the content of the report and the required onward actions.

Key points/Summary:

Infection control - There are now 5 trust apportioned MRSA Bacteraemias and one outbreak of CPE.

Performance against the total numbers of avoidable hospital acquired pressure ulcers, for both grades 2 and 3, has improved this year when compared to the same period in 2014-15.

The falls rate has increased in month to 6.99 falls per 1,000 occupied bed days. This is the highest rate recorded so far during 2015-16 and means that the Trust is now above the year end trajectory of 6.36. Comparatively the January 2015 rate was 7.26 compared with January 2016 rate of 6.99.

Recording of Admission Discharge and Transfer on the Trust IT system overall performance for January 2016 has demonstrated a negligible improvement to 79.5% from 79.09% for December 2015. Whilst performance remains off the agreed target of 90%, there have been some noticeable pockets of improvement.

Delayed Transfers of Care (DToC) Trust performance in January 2016 was 4.62%. This is a reduction of 0.51% on the previous month and a total reduction of 1.41% since the implementation of the DTOC Improvement Plan. Current performance is slightly under the expected trajectory of 4.49% to deliver 2.5% by May 2016.

Nurse recruitment plans on track.

Revised complaints policy implementation in progress, re-opened complaints reducing in line with improved quality of complaint responses.

Focused work in progress in progress to ensure that paediatric patient feedback captured.

Community nursing delivering the majority of requirements.

Trust review of open visiting summary shares positive feedback and revised visitors code and associated harm reduction.

Senior nurse workshops commenced with Royal College of Nursing to encourage best practice in raising concerns.

CQUIN delivery exceptions - The Trust made its quarter 3 submissions to the Commissioners on 12th February and is currently waiting for feedback and details of fines associated with non-delivery. The Trust believes this risk to be approximately £293k.

Recommendation(s):

For the Board of Directors to receive and endorse the proposed actions to improve quality performance

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Strategic Risk Register Y/N Performance KPIs year to date Y/N


Y/N Information Exempt from Disclosure Y/N



Which other Committees has this paper been to?

None

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BOARD OF DIRECTORS

WEDNESDAY 2ND MARCH 2016

CARE QUALITY BOARD REPORT

PRESENTED BY THE CHIEF NURSE 1. Purpose

This paper summarises the Trust’s performance against national quality indicators and targets including those in Monitor’s Risk Assessment Framework as well as local priorities. It outlines the current position with performance and actions required in key areas to build on the care provided to patients in our hospitals.

2. Infection Control 2.1 Meticillin Resistant Staphylococcus aureus (MRSA)

There was one post 48 hour MRSA bacteraemia reported in January 2016. A second case in January (although a pre 48 hour case) was Trust apportioned after definitive demonstration of transmission on Heartlands Ward 4. A post infection review has been carried out for each of the cases.

Cumulative Trust attributable MRSA cases (Heartlands Hospital)

In total there have been five Trust apportioned bacteraemia for this financial year. Detailed reviews have been undertaken to ascertain the root cause of these bacteraemia and the key actions for improvement are:

Pocket Infection Prevention and Control (IPC) practice reminder cards have been produced and these are available to temporary staff at the start of shifts and are also issued to staff at clinical induction and mandatory training. MRSA screening, PVC management, and hand hygiene are included on the card.

Practical hand hygiene training is delivered as part of Junior Doctors induction training.

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A new programme of induction for senior medical staff commenced in January 2016 which includes PVC management, hand hygiene, and the importance of role models for IPC practice.

Targeted hand hygiene education for medical staff will be taking place throughout the Trust during February 2016. This will take the form of a roving glo box.

Monthly hand hygiene audits are to be undertaken in clinical areas during March 2016, to be carried out with medical staff only.

Peer audit of PVC practice will be carried out in all clinical areas by infection prevention and control nurses during Quarter 4. This will identify common themes and enable education, specific action plans, and a review of practices to be appropriately implemented.

MRSA screening video was has been developed. This will form part of clinical mandatory training and will be available on the IPC intranet page.

Re-launch and re-distribution of MRSA screening poster and ward / department MRSA education to be carried out by the IPC team during February and March 2016.

Re-launch of Octenisan anti-microbial wash for routine use with adult inpatients not colonized with MRSA to commence in Quarter 4 and continue into 2016-17.

2.2 Clostridium Difficile Infection (CDI)

No CDI exceptions are indicated (the Trust is below its annual trajectory). Actions to improve CDI performance continue with a specific focus on antimicrobial prescribing, as well as maintaining the rolling cleaning programme across all three sites.

Cumulative C.Diff toxin positive post 48 hour cases

Heart of England NHS Foundation Trust has pioneered the treatment of CDI with faecal microbiota transplant (FMT). The service is led by Professor Peter Hawkey and delivered by Public Health England Public Health Laboratory, Birmingham in conjunction with the Infectious Diseases Department. Since the first treatment delivery in March 2013, 49 HEFT patients have been treated. The success rates have been impressive, with only one patient requiring a second infusion of FMT. The service will increase further as the storage of delivery of FMT has become more robust.

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2.3 Carbapenamase Producing Entrobacteriaceae (CPE) Outbreak

An outbreak of CPE on Ward 9 at Heartlands was reported in January 2016. This brings the total number of CPE outbreaks for HEFT to three YTD. Three patients were affected, one of whom met the criteria for screening having had surgery in Dubai, another of whom had CPE cultured from a clinical specimen (urine), and a third patient was identified following cloud screening on the ward. A Root Cause Analysis (RCA) was carried out and the following issues and actions were identified:

Assessment of potentially infectious and infected patients for isolation in side rooms as the index patient was admitted to an open bay despite having an infected wound and a history of hospitalisation abroad.

There is a lack of awareness of CPE and the Trust cleaning matrix. Plan to re-launch CPE message of the month, liaise with the Heartlands site team regarding the use of the cleaning matrix, and discuss the outbreak at Trauma & Orthopaedic directorate meeting. CPE alert to be re-instated on electronic systems, e.g., iCare.

Poor compliance with hand hygiene. Plan to increase awareness with a roving glo box and increase ward based education.

3. Pressure Ulcers

3.1 Avoidable Hospital Acquired Pressure Ulcers

The priority for HEFT is to reduce the overall number of patients who acquire avoidable pressure ulcers whilst in hospital. During the 2015-16 financial year, the agreed reduction trajectory for HEFT set with the commissioners was to achieve a 10% reduction for avoidable hospital acquired grade 2 pressure ulcers, and a 50% reduction for avoidable hospital acquired grade 3 and necrotic pressure ulcers, based on the Trusts overall performance in these areas for 2014-15. In addition to this, the following three Key Performance Indicators (KPIs) are outlined within the contract: Documented repositioning; Actual repositioning; and Daily skin inspection, all of which are to achieve compliance of 90% by the end of Quarter 2, and 95% overall by the end of Quarter 4. Whilst it is important to achieve the target, the priority is to ensure that incidents of patient harm caused by pressure ulcers is minimised through robust root cause analysis and shared learning.

3.2 Current Position

Performance against the total numbers of avoidable hospital acquired pressure ulcers, for both grades 2 and 3, has improved this year when compared to the same period in 2014-15.

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3.3 Grade 2 Avoidable Pressure Ulcers

Current performance as at the end of January 2016 for avoidable hospital acquired grade 2 pressure ulcers equate to 155 against a target of no more than 187 for the year. Performance has improved this year compared to the same period last year when 188 avoidable grade 2 pressure ulcers had been reported up to the end of Jan-15, an improvement of 17.6%.

Number of avoidable grade 2 pressure ulcers 3.4 Grade 3 Avoidable Pressure Ulcers

Performance for avoidable grade 3 and necrotic pressure ulcers is 45 reported against a strategic target of no more than 29 for the year, breaching the Trust trajectory for 2015-16. However, performance has improved this year compared to the same period last year when 48 grade 3 and necrotic pressure ulcers had been reported up to the end of Jan-15, an improvement of 6.25%.

Number of avoidable grade 3 pressure ulcers 3.5 Grade 4 Avoidable Pressure Ulcers

There was a grade 4 avoidable pressure ulcer reported for Community Services in December 2015. The patient was originally reported to have a grade 3 pressure ulcer to the sacrum in September 2015, however following review of the documentation of this incident it is clear that the wound was

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100% covered with slough. Following this, the wound was debrided successfully and it became able to accurately assess the pressure ulcer as a grade 4 The initial reporting of the incident was reported as a grade 3 as the district nurse would know that there was definitely substantial tissue loss however depth could not have been truly known until debridement. Therefore this pressure ulcer was originally a grade 4 and is not a deteriorating grade 3.

3.6 Performance Against Tissue Viability Key Performance Indicators (KPIs)

The following chart outlines the divisional positions against the KPIs along with the total number of hospital acquired pressure ulcers compared to the previous month.

Site Month No of PU2 in month

No of PU3 in month

Repositioning adhered to

Overall KPI score

BHH Dec 8 3 83% 93%

Jan 1 1 72% 91%

SH Dec 1 1 91% 97%

Jan 4 0 82% 94%

GHH Dec 6 0 98% 98%

Jan 5 0 92% 97%

Performance against the repositioning of patients adhered to has deteriorated in January 2016 within all divisions, with the poorest performing being at 72% for the Heartlands Division. To address this serious concern there has been a revised structure and process put into place at Heartlands Division from January 2016 to ensure that compliance is achieved and sustained, in turn reducing the risk of harm to patients. Performance against this KPI will continue to be monitored through the Trust Wide Tissue Viability Steering Group, with revised remedial action plans in place for each of the divisions. Performance against the two remaining KPIs in month is within trajectory. Documented repositioning is at 97% and daily skin inspection is it at 90%.

3.7 Additional Actions

One of the main aims across all divisions to minimise patient harm is to reduce the deterioration of existing pressure ulcers, the incidence of device related pressure ulcers and reduction in the incidence of avoidable pressure ulcers. Work has commenced with regards to reducing the deterioration of existing pressure ulcer with the pilot of an ‘Avoidability Checklist’ for grade 2 and purple pressure ulcers. This tool acts as an aid memoire and allows analysis of the patients care if a pressure ulcer develops to minimise the risk of further development or deterioration.

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4. Falls Rate per 1,000 Occupied Bed Days The falls rate has increased in month to 6.99 falls per 1,000 occupied bed days. This is the highest rate recorded so far during 2015-16 and means that the Trust is now above the year end trajectory of 6.36. Comparatively the January 2015 rate was 7.26 compared with January 2016 rate of 6.99.

Falls rate per 1,000 occupied bed days The main area of concern is Rowan Ward on the Heartlands division which opened on 29th December 2015 as a medical step-down ward and recorded 14 falls during January. Two patients fell three times, and two patients fell twice during January on Rowan Ward. Other areas reporting a high number of falls in month were 30 BHH (16), 21 GHH (14), 11 GHH (12), 9 GHH (11), 20 AMU 1 BHH (11), 8 BHH (11). 4.1 Actions Taken

Rowan Ward is a new ward for patients whom are medically fit for discharge, primarily for patients from the Care of the Elderly wards. A Senior Sister is in post with further recruitment on-going, experienced nursing support is being provided from other wards. The ward had a number of falls from beds and Hi-Lo beds have been leased with further nine Profiling Beds sourced from within the hospital.

The Falls Clinical Nurse Specialist has undertaken an initial review of Rowan ward and recommended further education / training with enhanced observation and is scheduled to undertake an in-depth review week commencing 22nd February 2016.

Ward 11 GHH Senior Charge Nurse has returned from sick leave, ward meeting held on 16th February with site falls co-ordinator to review incidents with staff.

The Trust Falls Steering Group is due to take place on the 23rd February 2016 where each site will present their actions plans. All areas with non-compliance with metrics will submit an improvement plan to their Matron and will undertake weekly metrics until required standards achieved.

To continue to review all patients that fall multiple times and that all appropriate safety measures have been implemented to prevent repeat falls occurring including transferring between wards

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To introduce ‘exception reporting’ for the top 5 wards across all sites. 5. Admissions, Discharges & Transfers (ADTs) Recorded Within Two Hours

The Trust overall performance for January 2016 has demonstrated a negligible improvement to 79.5% from 79.09% for December 2015. Whilst performance remains off the agreed target of 90%, there have been some noticeable pockets of improvement.

Site Admissions %

Discharges% Transfer %

Overall Performance%

Dec Jan Dec Jan Dec Jan Dec Jan

BHH 77.1 77.1 71.2 71.2 87.0 86.1 78.0 78.1

GHH 77.0 80.2 70.0 71.8 85.0 86.7 76.0 79.5

SOL 85.0 76.5 80.0 71.3 81.0 95.0 82.0 80.9

Trust wide

79.3 77.9 74.0 71.4 84.0 89.2 79.0 79.5

Activity within agreed two hours Since the introduction of Patient Management System 2 (PMS2) in 2014 there has been a significant investment in training for frontline staff which has included revised training programmes and delivery methods with training taking place in the clinical area to ensure staff can receive training when they cannot be released due to clinical pressures. To support ward activity particularly out of hours, nights, weekends, all clinical areas had to identify their minimum number of staff who could undertake ADTs. Good Hope site with the new AMU area have invested in 24/7 ward clerks which may be the reason for the site improvement.

Site Admissions %

Discharge %

Transfer %

Overall Performance%

Dec Jan Dec Jan Dec Jan Dec Jan

BHH 72.0 69.9 71.0 70.2 54.0 53.7 68.0 64.6

GHH 80.0 77.8 80.0 77.3 65.0 62.7 77.0 72.6

SOL 85.0 83.9 80.0 78.5 81.0 54.8 82.0 72.4

Trust wide

78.0 77.2 76.0 75.3 78.0 57.0 77.0 69.8

Activity within core business hours (7.00am to 18:00hrs) Core hours have been defined as from 07:00 to 18:00hrs as many clinical areas have admin support across this time span. The agreed standard is for at least two members of staff to be ADT competent, during core hour this may include the ward clerk/ administrator. All three sites have indicated an increase in activity outside of core hours, particularly surrounding transferring patients, with both Heartlands and Solihull having almost 50% of their transfer activity occurring outside core hours.

All sites need to provide assurance through the Nursing Performance Committee of the plans to improve compliance and to review the activity outside of core hours as to whether this is genuine or merely another indicator of late reporting.

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6. Delayed Transfers of Care (DToC) Trust performance in January 2016 was 4.62%. This is a reduction of 0.51% on the previous month and a total reduction of 1.41% since the implementation of the DTOC Improvement Plan. Current performance is slightly under the expected trajectory of 4.49% to deliver 2.5% by May 2016. Although largely on target, it should be noted that the overall bed days associated with DTOC have increased on the Heartlands site. Good Hope have made the most significant improvement in both patients delayed and associated bed days. The DTOC improvement plan and associated trajectory is expected to deliver performance of 2.5% from 1st June 2016. Current performance is largely aligned with the agreed trajectory and shows continued improvement during difficult and surge periods. Risks associated with the plan continue to be as previously stated, with the exception of the separate local health and social care meetings for Solihull and Good Hope. These have now taken place but robust plans have yet to be activated. 6.1 Actions Taken and Planned

The original 18 point action plan has been revised to take account of new actions identified post December 2015. The plan has allocated leads across the health and social care economy and is relevant to all three Hospital sites. The trajectory developed for the plan takes account of the impact of winter and surge activity, combined with the extended bank holiday period. The plan is monitored via SRG with HEFT leads acting as custodians of the plan. Current performance needs to be seen in conjunction with the additional front door activity for the Trust. The plans cover strategic response and operational application. DTOC is reviewed weekly across each site and there are comprehensive reports that reflect responsible organisations now in place. Separate meetings have now taken place with Solihull Metropolitan Borough Council and Solihull Clinical Commissioning Group and also with the South Staffordshire economy.

7. Nurse Staffing Update 7.1 UNIFY Staffing Return

SITE / DIVISION

QUALIFIED COMPLIANCE

HCA COMPLIANCE

BHH 99% 108%

GHH 96% 105%

SOL 99% 119%

O&G 98% 83%

TRUST 98% 103%

Division level UNIFY nurse staffing compliance for January 2016

7.1.1 Areas of Concern

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Rowan Ward BHH - red for HCA compliance. Ward monitored daily by the Matron and Associate Head Nurse. Flex bundle implemented including daily risk assessments which are escalated to site team currently establishing the ward and therefore there are significant vacancies for both qualified nurses and HCA’s with a 94% temporary staffing usage rate.

Maternity Support Workers (MSW) across Maternity Services - 83% compliance with MSW staffing. Seven MSWs commenced in post in January 2016 with a further seven due to start in March 2016.

7.2 Qualified Nursing Vacancy Position

Qualified Nursing Vacancy Position for January 2016 Current qualified vacancies across the AMUs and base wards are 161 WTE with 79 new starters planned up until April 2016. The number of vacancies has increased from December 2015 due to the addition of the qualified establishment for Rowan Ward (17 WTE). An elderly care recruitment open day is being held in March 2016 to start to recruit to Rowan Ward. An EU recruitment tendering process is underway with the HealthTrust Europe Framework Suppliers. The bids are currently being reviewed with the aim of identifying agencies that can provide a sustainable source of EU nurses that are compliant with the IELTS level 7 qualification for registration with the NMC. The Trust will be represented at the BCU jobs fare in February 2016 to attract applications from student nurses qualifying in September 2016. A generic interview day is being held for these applicants on Saturday 2nd April 2016. The BHH ED open day was successful with 14 offers made on the day. GHH ED will be represented at the generic interview day on the 2nd April 2016.

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Work is underway to ensure that the funded establishments are correct across BHH wards. This work is being supported by EY and the Trust finance team. When completed a final check will be made of the vacancy gap to ensure the reported vacancy position is aligned with funded posts. 8. CQUINs

The Trust currently has 12 CQUINs (7 relating to the Acute Contract, 3 to the Specialised Services Contract, 1 to the Solihull Community Contract and 1 to the Public Health Contract). The Trust made its quarter 3 submission to the Commissioners on 12th February and is currently waiting for feedback and details of fines associated with non-delivery. The Trust believes this risk to be approximately £293k. There are a number of risks to delivery in quarter 4 - See table in Appendix One.

9. Complaints 9.1 Closure Rate of Complaints Within 25 Working Days

Closure rate of complaints within 25 working days

The closure rate for complaints decreased in January 2016. Whilst there has been concentrated focus on improving the quality of compliant responses, timeliness remains an issue. Overdue complaints are escalated to Divisional leads each week. Each document by Division explains where each complaint is in the process

Following ratification of the updated complaints policy, compliance will be monitored to a 30 working day timeframe. There is an expectation that once outstanding complaints have been closed, the transition to business as usual will see complaints increasingly completed within this timescale. Training in policy requirements and expectations for all involved in the complaints process has begun and will continue across the Trust in the weeks ahead.

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9.2 Reopened Complaints

Number of reopened complaints by division

There were four reopened complaints in January. This is an early indication that the focus on quality and a less defensive approach to complaint responses may have had an impact. Monitoring of this standard will continue in the months ahead. The 18 complaints reopened in November were analysed to establish the reasons for reopening. As a result of this analysis, themes are used as a guide to quality assurance and are explained through the training.

9.3 Number of Live Complaints

Number of complaints

The quality assurance process is now embedded. The time required to ensure rigorous quality assurance has impacted on the numbers of live complaints. The increase in complaints in November and January, both new and re-opened has also contributed. The 5 stage quality assurance process is outlined below: 1. Clinical Accuracy; 2. Division / Triumvirate Head;

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3. Senior Complaints review; 4. Chief Nurse; 5. Chief Executive.

It is currently rare for a complaint to pass straight through this process without intervention at one or more stages.

9.4 Actions to Improve

In addition to the continued focus on quality assurance and improved quality complaint responses:

Policy training commenced and to continue across divisional teams;

Early clinical risk assessment of complaints and appropriate escalation;

Simplification of the weekly divisional / Chief Nurse / CEO escalation document;

Early round table discussions to devise management plans for complex complaints;

Confirm and challenge /scrutinisation over strength of action taken in response to complaints;

Process agreed with Associate Medical Director (Revalidation) for monitoring doctors involvement in complaints.

10. Friends & Family Test (FFT)

10.1 Adult Inpatients FFT

Adult Inpatients Friends & Family Test

The FFT positive responder score remained at 92% in January 2016. The December / January score was lower than the post-August scores of 94% - 95% positive. The January score for 2015 however was 90%, therefore a 3% year on year improvement.

The January response rate dipped by 10%. This was 4% higher than the national rate of 24% (one month in arrears).

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10.2 Emergency Department FFT

Emergency Department Friends & Family Test

The percentage of positive responder score increased to 81% in January, the corresponding score in 2015 was 77%, and the average score for all 2015 was 79%. The national positive recommender score for Emergency Departments (ED) was 87% (a month in arrears). Whilst remaining 6% behind the national score, HEFT continues to have a higher participation rate when compared nationally and regionally.

10.3 FFT Themes

FFT qualitative feedback (patient comments) were analysed as shown in the graph below:

Number of positive comments and number of comments with suggestions for improvement

83 % of comments were positive. There remaining 17% suggested areas for improvement as shown in the table below:

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HEFT Service Top 3 Improvement Themes Q3 %

Outpatient Staff attitude 285 4%

Environment 211 3%

Waiting time 197 2%

Emergency Staff attitude 323 5%

Environment 268 3%

Waiting time 265 3%

Inpatient Staff attitude 101 1%

Implementation of care 67 1%

Environment 64 1%

Maternity Staff attitude 17 3%

Environment 11 2%

Implementation of care 10 2%

FFT top three improvement themes by HEFT Service for Quarter 3 2015-16

The chart below shows the rate of positive recommenders in the ED departments by site on each day of the week. Wednesday and Thursday at Solihull continues to receive the highest rating. Saturday at Heartlands continues to return the lowest satisfaction score.

Proportion of FFT responders for ED by site split by day of week 10.4 Actions Taken

Patient Comments (qualitative data) are used by supervisory ward sisters via the nursing quality dashboard for base wards;

Analysis of FFT inpatient qualitative data;

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FFT performance is discussed at Divisional confirm and challenge / performance meetings;

GHH - Quality reviews are in place for all wards. Reviewing of discharge plans and non-compliance reported to the Head Nurse;

BHH - review of morning waking times showed inconsistency in compliance. All ward supervisory ward sisters have had 1 to 1 meeting with the Head Nurse to establish expectations. To be monitored by Associate Head Nurses and Matrons;

SH - Noise at night task and finish group with review meeting in March 2016. Re-issuing of discharge home leaflets;

Trust wide monitoring of patient views of night and weekend experience;

ED - Increased FFT score against 2015 average;

Work with ED and Patient Community Panels to improve experiences and FFT positive responder score;

The Volunteer Service has started a recruitment campaign to provide volunteers into the department to help and support vulnerable people.

10.5 Actions Planned

ED / OPD / Day Case / Maternity FFT to be developed to be displayed

via nursing quality dashboard;

Increase in maternity and community FFT feedback;

FFT SMS texting Services introduced for Maternity patients to improve response rate;

Local staff training to be provided by FFT contracted provider in use of data and themes from the online FFT platform;

Renewed focus in inpatient response rate through existing nursing forums;

Wards and departments with low quality scores to submit rectification plans with agreed improvement trajectory via the nursing performance meetings that occurs monthly.

On-going meetings with Patient Services and Matrons for ED to discuss improvement plans.

11. Paediatric Patient Feedback and Quality Issues

This update provides an overview of the position within the Directorate of Paediatrics and Neonates for January 2016 in relation to patient experience. The Trust currently collects feedback from parents / guardians using the Friends and Family Test across all areas. Paediatrics has recently commenced a two-tier system whereby data is collected via SMS messaging as well as postcards. The aim is to roll this out to neonates in the near future. The Trust also collects feedback directly from paediatric patients using a Fabio system. This is a computerised child friendly questionnaire that can be adapted to the child’s age and understanding. Questions are revised according to the service provision and can focus on specific themes that may have been raised from incidents.

11.1 Friends and Family Test

Due to poor response rates (November showed 4% for paediatrics and 8% for neonates), the division implemented a SMS messaging service in paediatrics

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from the 1st December 2015 which currently runs parallel to the service of postcard returns. One of the advantages of SMS messaging is that is an automated service, however it does not collect specific comments. The table below outlines the results of the SMS texting for January 2016. During this period there were a total of 1044 discharges and of these 635 SMS surveys were sent to participants. Those that were not sent were due to incorrect contact details being available or missing details from the data system.

Survey Status No. of Discharges % of Total

Survey Sent 635 60.82%

Message not scheduled due to error 398 38.12%

Excluded due to opt-out 11 1.05%

Question 1 Ratings Received Response

Rate

SMS 81 7.75%

Totals: 1044 100%

Number of SMS text messages sent during January 2016

The SMS messaging service relies on correct contact details of parents / guardians which is taken from PMS2. Further work is required to ensure that the demographic details of all patients are up to date and valid during admission. The following table outlines the results of patients; views in terms of recommending the division as a place to receive care through SMS and postcard responses.

Hospital Site name

Ward

1 - E

xtre

me

ly

Lik

ely

2 - L

ikely

3 - N

eith

er

likely

or

un

likely

4 - U

nlik

ely

5- E

xtre

mely

u

nlik

ely

6 - D

on

't Kn

ow

Total

Good Hope NCAU 17 7 3 2 0 0 29

Heartlands 14 0 0 0 0 0 0 0

Heartlands 15 0 0 0 0 0 0 0

Heartlands 16 4 3 0 1 0 0 8

Heartlands 16HD 2 0 0 0 0 0 2

Heartlands PAU 26 9 1 0 5 1 42

Total 49 19 4 3 5 1 81

SMS January 2016 (Completed Surveys and Quality Scores)

The table above shows that 83% of those that responded would be ‘extremely likely’ or ‘likely’ recommend the service as a place to receive care. 9% would not recommend the service and the remaining 8% either are unsure or neither likely nor unlikely.

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PEADIATRICS Ward

1 - E

xtre

mely

Lik

ely

2 - L

ike

ly

3 - N

eith

er lik

ely

no

r unlik

ely

4 - U

nlik

ely

5 - E

xtre

mely

un

like

ly

6 - D

on

't Kno

w

Eligible Completed % PR NR №

Positive

Heartlands Ward 14 2 0 0 0 0 0 53 2 4% 100% 0% 2

Heartlands Ward 15 0 0 0 0 0 0 7 0 0% - - 0

Heartlands Ward 16 8 5 1 1 1 1 134 17 13% 76% 12% 13

Heartlands Ward 16HD 2 0 0 0 0 0 15 2 13% 100% 0% 2

Heartlands PAU 56 16 1 0 5 1 390 79 20% 91% 6% 72

Good Hope NCAU 18 7 3 2 0 0 445 30 7% 83% 7% 25

Paediatrics All 86 28 5 3 6 2 1044 130 12% 88% 7% 114

Postcard responses for January 2016

The table above shows that 130 responses (12%) were taken from the postcards. Out of these, 87% would be ‘extremely likely’ or ‘likely’ to recommend the service as a place to receive care. The data indicates that the response rate is higher in PAU (Paediatric Assessment Unit at BHH). Often paediatric patients pass through a number of areas, for example PAU, ward 16 and HDU, therefore it is difficult to assess which area they may comment on.

11.2 Fabio

Fabio was initially launched in 2010 and, at the time, this was the only method of collecting patient feedback. When the launch of the national friends and family test (FFT) occurred, a decision was made to run this simultaneously as Fabio seeks feedback directly from the patient while the FFT collects feedback from the parents. Fabio is a national tool and the survey is locally designed specifically for the children’s service. It is reviewed frequently and the questions are adapted according to the information is required at the time. Topics include play, pain and communication. Fabio was put on hold for a considerable amount of time when the Trust changed to Windows 7 as the tough books that were used to collect the data were no longer compatible. The Trust has recently inherited ipads which are compatible to the hardware and Fabio was re-launched in November 2015. The results for January show a very poor response rate at only 8 returns. All paediatric patients 4 years and above should be asked to participate. As a result of this we have requested that all staff encourage responses in their daily routine and next steps include roll out training to other staff groups.

11.3 Next Steps

The plan moving forward is to review Fabio questions for inpatients; and design questionnaires suitable for all other areas and roll out across rest of the children’s wards. Further work is required to train a wider workforce to carry out the questionnaires.

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With regards to FFT, a meeting is being scheduled with Patient Services to review the current data and look at improved ways to enhance the response rate. If the SMS service proves to be successful, this will be rolled out to the rest of Children’s Services, including neonates. Once the above is in place, weekly ward rounds will take place led by the Head Nurse and Matrons. The aim of the ward rounds will be to address frontline issues in a more timely manner and to encourage positive feedback and suggestions to improve the service.

12. Maternity Safety Thermometer

The total number of postnatal women that have been included in the audit since March 2015 is 1,602 which equates to 10.8% of the national audit. HEFT Physical Harm Free Care was above the national average of 78.0% for January 2016 with a score of 78.8%. The measure of physical harm is defined as any of the following:

Term babies with an Apgar less than 7 at 5 minutes;

Women that had a post-partum haemorrhage (PPH) of more than 1000mls;

Women that had a 3rd/4th degree perineal trauma. However, the Women’s Perception of Safety measure is below the national average of 92% and is currently 85.2% for January 2016. This measure of harm is defined as the proportion of women who were left alone at a time that worried them; and the proportion of women who had concerns about safety during labour and birth that they felt were not taken seriously. Concerns not taken seriously showed a decrease from 18.0% in November 2015 to 8.95% in December 2015 and in January 2016 it sits at 13.2% against a national average of 5.7%. Women being left alone at a time that worried them has shown a decrease since December (5.6%) to 1.6% in January 2016 against a national average of 2.3%. 12.1 Actions Taken to Improve Women’s Perception of Safety

Ongoing actions are in place to continue to gain an understanding of the reasons for women’s perception of safety by seeking further clarification at the time of the audit. Auditors are annotating the reasons given by the patients, and if action had been taken for any of the women with concerns about safety during labour and birth who felt their concerns were not taken seriously. For January’s audit there has been several annotations indicating that the patient did have a debrief by their named midwife or has met with the doctor prior to discharge. A reminder briefing has been sent out to all auditors to ensure that this is a mandatory completion for the next audit on 24th February 2016. The number of women that reported they were separated from baby has also improved and this is partly due to one of the reasons this was being recorded was because some mother’s had to return to theatre following postpartum haemorrhage or for a procedure, i.e., perineal suturing.

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13. Review of Open Visiting

13.1 Introduction Following a successful three month pilot at Solihull Hospital in 2014, a decision was made to implement open visiting on April 1st 2015 across all three hospitals. Open visiting can be defined as allowing visitors (carers / families) to access patients in hospital outside of the traditional set hospital hours. These hours are often set as two time periods during set times with a restrictive visiting policy permit at the majority of NHS Hospitals. These are a two-hourly periods in the afternoon and in the evening. Some NHS organisations have implemented an extended visiting policy when visitors are most frequently permitted between the hours of 2:00pm to 8:00pm daily. When open visiting was launched it was agreed that a Trust wide review would take place six months into the change. The review took place during September / October 2015 with the aim of exploring both patient and staff views of open visiting across the Trust.

13.2 Methodology

The methodology undertaken consisted of three staff focus groups at one hospital, and included 25 members of staff. The groups were audio recorded and the data was analysed using the six-step Brown and Clark framework (2006). During the groups, individuals reported that the views expressed were collective comments from a substantial number of colleagues as well as attendees at the groups. In addition to this a total of 233 patient questionnaires were completed across the three hospital sites during the month of August 2015.

13.3 Findings 13.3.1 Staff Members

There was a view from the staff at the Focus Groups that open visiting has created disruption in ward areas. There were a number of recommendations posed which included a review of structure, safety, relationships and the need for a policy. Sub themes of safety related to security and confidentiality. Structure included consequences, and privacy and dignity. Policy related to communication and suggestions for change and, of relationships, included patient to patient, patient to visitor, patient to staff, and staff to visitor. Positive findings included an observed reduction in the number of patient falls month on month ( total of 259 from April 2015 to February 2016), better access for visitors to help with patient feeding and increased flexibility for visitors. The majority of staff expressed a preference not to return to restricted visiting hours, however all expressed a preference for some restrictions to take place to allow time to care, treatments and cleaning to take place on wards.

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13.3.2 Patients and Carers

There was a strong theme that responders (patients / carers) believed that open visiting had been a positive step forward in improving their experience in hospital. There was a view from respondents across each of the divisions that at times open visitors has somewhat contributed to disturbance in bays with sleep rest and privacy. Upon further investigations this related to the total number of visitors in a bay at any one time. Table 1 below outlines the total percentage of positive responses at each division, and of these responses the total number of patients who expressed a view that they had experienced disturbance in bays.

BHH SOL GHH

Total positive experiences 88% 68% 90.5%

Total responses of patients disturbed in bays

22% 32% 9.5%

Table 1: Percentage of positive responses Table 2 below outlines examples of positive comments from patients and carers.

BHH SOL GHH

It helped dad, aged 94 to keep normal days.

It allowed me to support mum with personal care in the morning

You can work around your job, school and children

It was good to have a family member there, it stops you being lonely

It allows freedom for friends to visit as well as family

Easier access to visit a loved one

It works around people’s working hours

Family were able to help with meals

Helps patients to be more relaxed

Mum feels reassured at hospital

Able to use bus pass and stay longer

Daughter having an operation and I was able to stay with her

Spending more time with mother has helped with her anxiety

Parking is easier Parking is easier

Table 2: Examples of positive comments from patients and carers

13.4 Overall Recommendations The following recommendations have been agreed across all three hospitals:

Open visiting will continue across all hospitals;

The Visitors Code has been revised and disseminated and has narrative to explain that there are a restricted number of visitors per bed, to request that visitors nominate one family member to liaise with staff and cascade all information about care. (In exceptional circumstances

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family members will be able to request additional visitors at any one time);

Matrons will be responsible for educating all staff in their area of responsibility with regards to the use of the Visitors Code;

Request that visitors do not keep ward entrance doors open in the interest of the safety of all patients.

In addition to the above recommendations, a Standard Operating Procedure has been created and circulated to all ward areas. Finally, there will be an annual review of open visiting led by the Patient Experience Team. The next review will take place in October 2016 and findings will be fed back to the Trust Executive Board.

14. Whistleblowing and Raising Concerns

A series of workshops across the nursing workforce commenced in February 2016 at Good Hope Hospital Division. The objective of the pilot workshops is to encourage best practice in raising concerns (or whistleblowing) and in responding appropriately when such matters are raised. The workshops are being delivered by the Regional Director RCN West Midlands, and an independent investigator, and will build upon the work already delivered in the Trust’s “Speak out safely” programme of work. The desired outcomes of 12 pilot workshops are as follows:

Increased awareness amongst staff of the difference between raising concerns, being a whistle-blower, raising a personal grievance and use of the appropriate policy in each circumstance;

Increased awareness amongst nurse managers of the appropriate first steps to take in each circumstance;

To provide data to inform HEFT of the steps required to developing a Trust model of best practice in dealing with concerns and whistleblowing;

A pocket guide for each delegate. It is important to note that there may be an increase in concerns raised at Good Hope Hospital Division in the first instance in response to the sessions. The Triumvirate have been briefed about this possibility.

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APPENDIX ONE

CQUIN Update: Quarter 4 Delivery

Acute Contract:

CQUIN Name Quarter 4 Risks

1 Acute Kidney Injury (AKI)

Issues with the IT system that has been developed in order to populate the discharge summaries with required key information in relation to AKI. This issue has been escalated to IT Services for investigation and rectification.

2a Sepsis: Screening Trust is not on track to achieve the Q4 target of 90%. Good Hope is currently lowest performing site (53% for Q3). Current performance indicates that the Trust is only likely to achieve 5% of the total CQUIN value for Q4.

2b Sepsis: Antibiotic Administration

Trust is not on track to achieve the Q4 target of 90%. Solihull is currently lowest performing site (41% for Q3). Current performance indicates that the Trust is only likely to achieve 5% of the total CQUIN value for Q4.

3a Dementia: Find, Assess & Refer

Based on current performance, the Trust is only likely to achieve 70% of the Q4 CQUIN value. Concerns have been escalated continually and list of PIDs for patients requiring screening is emailed daily to all relevant consultants.

3b Dementia: Staff Training

There are concerns that training may cease due to winter pressures and cost issues, and that staff may not be released to attend training. There is no sliding scale for payment so the Trust must achieve the target of 90% of staff to be trained by the end of Q4 in order to secure payment for Q4.

4a COPD: Discharge Bundle

Heartlands and Good Hope sites not on track to achieve the Q4 target of 80%. Current performance indicates a partial achievement of 90% of the Q4 value for BHH site and 0% for GHH. Solihull site is on track to achieve their Q4 target.

4b COPD: Specialist Respiratory Review

Heartlands and Good Hope sites not on track to achieve the Q4 target of 90%. Current performance indicates a partial achievement of 70% of the Q4 value for both BHH and GHH sites. Solihull site is on track to achieve their Q4 target.

4c COPD: Staff Education and Training

There is a chance that the Trust may not achieve the 95% target of staff to receive training by the end of Mar-16 due to Winter pressures, although the number of staff still to be trained as at the end of Quarter 3 is small (BHH 4, GHH 3, SH 2).

7a Reducing the proportion of Avoidable Emergency Admissions to Hospital (AEC)

Achievement of this CQUIN is partially at risk for Q4 with current performance for the Trust at 18.5% against a year end target of 19%. The conversion rate is currently at 38.8% and must not exceed 39.9%.

of 25

Community Contract:


3a Dementia: Find, Assess & Refer

Current performance for Quarter 3 indicates the Trust has achieved 47.5% for Find, and 64.5% for Refer meaning that it is unlikely that the Trust will achieve the 90% target for Quarter 4.

3b Dementia: Staff Training

The Dementia Training Programme is a combined acute and community programme, therefore the concerns are the same as for the acute CQUIN: that training may cease due to winter pressures and cost issues, and that staff may not be released to attend training.

3c Dementia: Supporting Carers

Figures have yet to be received from Community Services to demonstrate the number of completed ‘About Me’ booklets, therefore this CQUIN remains at risk as there is a 90% target associated with Quarter 4 performance.

Specialised Services Contract:


B2 HIV: Reducing unnecessary CD4 monitoring

The Trust is unlikely to achieve the target of 90% by year end. The Trust wrote to commissioners on 28th January 2016 proposing an interim target of 65% of clinically appropriate caseload having annual CD4 counts by the end March 2016.

CUR1 Clinical Utilisation Review: Installing and implementation

The Trust signed a 24 month contract with MCAP software (70% milestone achieved = £350,023). Implementation has now stalled due to ICT issues with the CUR Tool.

1


BOARD OF DIRECTORS


Title: Finance Report to 31 January 2016 Attachments: 0

From: Interim Director of Finance To: Board of Directors (2 Mar 2016)


Decision N Discussion Y Assurance Y Endorsement N


Receive the Finance Report for the period ending 31 January 2016.

Key points/Summary:

The Trust has reported an I&E deficit of (£4.6m) in Month 10 (January 2016) of the 2016/17 Financial Year, leading to a year to date deficit of (£56.0m) which is (£47.8m) above plan.

The current forecast year end deficit is in the range of (£41.7m) and (£44.7m) deficit including a benefit of £18.6m from the Trust’s share of a national capital to revenue transfer. This is a non-recurrent technical adjustment and therefore the normalised forecast deficit for the year remains within the range of (£60.3m) to (£63.3m).

The cash balance is £41.6m at 31 January 2016.

The Financial Sustainability Risk Rating remains at 1.

Recommendation(s):


Receive the contents of this report.

Note the range anticipated for the reforecast year end trajectories for 2015/16.



Y Performance KPIs year to date Y



N


N/A


N/A

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

None

2


BOARD OF DIRECTORS


FINANCE REPORT FOR THE PERIOD ENDING 31 JANUARY 2016

PRESENTED BY THE INTERIM DIRECTOR OF FINANCE

1. Introduction

This report covers the first ten months of the 2015/16 financial year (1 April 2015 to 31 January 2016). The report summarises the Trust’s year to date financial performance and includes information on healthcare activity, expenditure variances and Cost Improvement Programme (CIP) delivery.

The Trust has reported a deficit of (£4.6m) during January 2016, leading to a deficit of (£56.0m) for the year to date. This represents an adverse variance of (£47.8m) against the plan at month 10. The adverse variance is partially driven by Medical staffing (£11.2m) and Nursing staffing (£9.2m) reflecting expenditure linked to additional capacity to meet the growth in activity and premium rate cover for vacancies. Other key drivers of the adverse variance are the use of Private Sector capacity (£3.6m) and slippage against CIP delivery (£23.2m) which includes under delivery in both the current year and prior years.

Whilst the process of recovery has started to deliver improvements in the monthly financial position, this has been impacted by seasonal factors including the need to open additional unfunded capacity due to growth in emergency demand in recent months.

Currently the normalised year end forecast is expected to be within the range of (£60.3m) deficit and (£63.3m) deficit. Recently Monitor has agreed a capital to revenue transfer for the Trust of £18.6m, reducing the year end forecast to between (£41.7m) deficit and (£44.7m). This is a non-recurrent technical adjustment which has no cash backing and does not change the underlying run rate for the Trust.

2. Income & Expenditure

2.1 Year to Date Summary

The Trust’s year to date income and expenditure position as at the end of January is a (£56.0m) deficit against a plan of (£8.2m), an adverse variance of (£47.8m).

3

Table 1 below details the actual income and expenditure deficit compared to the planned trajectory produced at the start of the year.

Table 1: I&E - Actual vs Plan

(60.0)

(50.0)

(40.0)

(30.0)

(20.0)

(10.0)

0.0

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

£m

's

2015/16 I&E - Actual vs Plan

Cumulative Planned Trajectory Cumulative Actual

Table 2 below summarises the Trust’s income and expenditure position at the end of January with analysis of expenditure from section 2.3 and operating revenue from section 2.6 below.

Table 2: YTD Income and Expenditure Plan vs Actual

YTD Plan YTD Actual Variance

Jan Jan

£m £m £m

Operating Revenue 531.0 544.0 13.0

Operating Expenses (519.0) (580.6) (61.6)

EBITDA 12.0 (36.6) (48.6)

Depreciation (14.3) (14.3) 0.0

Interest Receivable 0.2 0.2 (0.0)

Interest Payable (0.2) (0.2) 0.0

PDC Dividend (5.7) (5.1) 0.7

Other Finance Costs (0.0) 0.0 0.0

Surplus/(Deficit) (8.0) (55.9) (47.9)

Gain/(Loss) on Asset Disposal (0.2) (0.1) 0.1

Total Surplus/(Deficit) (8.2) (56.0) (47.8)

2.2 Monthly Run Rate

The monthly deficit from the start of the financial year is demonstrated in table 3 below.

4

Table 3: Deficit by Month Compared to Plan

(8,000,000)

(7,000,000)

(6,000,000)

(5,000,000)

(4,000,000)

(3,000,000)

(2,000,000)

(1,000,000)

0

1,000,000

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

£'s

I&E Deficit versus Monitor Plan

I&E Actual Deficit Monitor Plan

The January in month deficit of (£4.6m) is an improvement on previous monthly deficits which have been an average of (£5.7m) in months 1 to 9. A key favourable movement in January is as a result of Birmingham Cross City suspending contractual fines for the last quarter of the financial year.

2.2.1 Ernst & Young Recovery Support

The first phase of the support provided by Ernst and Young (EY) was in identifying easy to implement, short term actions to deliver in year savings for the recovery process. These schemes delivered a worst case forecast of £15.6m for the 2015/16 financial year. This forecast is broken down as detailed in table 4 below.

Table 4: Delivery and Forecast Recovery Schemes at Worst Case

£m Mth 6 Actual Mth 7 Actual Mth 8 Actual Mth 9 Actual Mth 10

Actual

Mth 11

Forecast

Mth 12

Forecast

Total

Nursing 0.3 0.6 0.3 0.4 0.3 0.4 0.4 2.8

Medical Staff 0.0 0.1 0.3 0.3 0.4 0.3 0.3 1.8

NHS Clinical Income 0.3 0.4 0.4 0.9 0.5 0.7 0.7 3.9

Private Sector Usage 0.4 0.5 0.6 0.7 0.8 0.4 0.4 3.8

Other Non Pay (0.0) 0.2 0.2 0.3 0.3 0.4 0.4 1.7

Other Pay 0.1 0.1 0.1 0.2 0.2 0.2 0.2 1.2

Other Income 0.0 0.1 0.1 0.0 0.0 0.1 0.1 0.4

Total 1.1 2.0 2.0 2.9 2.6 2.5 2.5 15.6

The month 10 forecast was £2.5m so actual delivery was slightly better than anticipated.

5

The second phase of the support is in identifying longer term actions which will return the Trust to financial stability. These actions in turn will form the Financial Recovery Plan (FRP) over the next two to three financial years. A review of the following areas of productivity form part of this process:

Patient flow and average length of stay.

Operating theatres.

Outpatients.

Diagnostics.

Workforce productivity.

Non-pay expenditure.

Estates and facilities.

Depth of coding and income.

Corporate.

Initial in-depth pieces of work have been conducted within theatres for ENT, Ophthalmology and Urology and within the Radiology department and have highlighted some clear areas of opportunity. Detailed action plans are now being developed in order to identify expected delivery date. This work will continue to be extended across other specialty areas.

These workstreams and action plans will form part of the Annual Plan due to be presented to Board early April for submission to Monitor in mid-April.

2.3 Expenditure Analysis

The adverse expenditure variance of (£60.8m) against plan can be broken down as detailed in table 5 below.

6

Table 5: Breakdown of Variance against Plan

YTD Plan YTD Actual Variance

Jan Jan

£m £m £m

PAY

Medical Staff 94.4 105.6 (11.2)

Nursing 134.3 143.5 (9.2)

Scientific & Technical 48.1 49.1 (1.0)

Other 67.7 67.8 (0.0)

Total Pay 344.6 366.0 (21.5)

NON PAY

Drugs 57.6 55.9 1.6

Clinical Supplies & Services 53.6 58.8 (5.2)

Unidentified CIP (23.2) 0.0 (23.2)

Private Sector Usage 5.1 8.7 (3.6)

Other 101.6 110.6 (9.0)

Total Non Pay 194.7 234.0 (39.3)

GRAND TOTAL 539.2 600.1 (60.8)

The main areas of pay and non-pay variance are explored further in sections 2.4 and 2.5 below.

2.4 Pay Analysis

The drivers behind the pay variance are predominantly Medical and Nursing staffing.

2.4.1 Medical Staffing

Tables 6.1 and 6.2 below detail the monthly expenditure for medical staff split between consultant and non-consultant posts respectively.

Total medical expenditure in January was £10.1m, an improvement of £0.3m against the expenditure in December and £0.5m on the average monthly expenditure from April to December.

7

Table 6.1: Senior Medical Expenditure per Month

4,000.0

4,500.0

5,000.0

5,500.0

6,000.0

6,500.0

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

£0

00

's

Month

Senior Medical Expenditure per Month against Budget

Consultant Substantive Consultant WLIs Consultant Agency Consultant Locum Consultant Budget

Table 6.2: Non-Consultant Medical Expenditure per Month

3,000.0

3,200.0

3,400.0

3,600.0

3,800.0

4,000.0

4,200.0

4,400.0

4,600.0

4,800.0

5,000.0


£0

00

's

Month

Non Consultant Expenditure per Month against Budget

Non Consultant Substantive Non Consultant Agency Non Consultant Locum Non Consultant Budget

8

2.4.2 Nursing

Table 7 below details the monthly expenditure on nursing compared to the budget.

Table 7: Monthly Nursing Expenditure

11,000.0

11,500.0

12,000.0

12,500.0

13,000.0

13,500.0

14,000.0

14,500.0

15,000.0


£0

00

's

Month

Nursing Expenditure per Month against Budget

Substantive Expenditure Bank Expenditure Agency Expenditure Budget

Total nursing expenditure in January was £14.5m which is an increase of (£0.1m) on the expenditure in December and (£0.2m) on the average expenditure from April to December.

The cost of growth in unfunded capacity, above previous months run rates, for December and January was (£64k) and (£203k) respectively. The main movements in capacity are:

Ward 7 GHH – Remained open following removal of Vanguard unit for both December and January.

Ward 17 SHH – Opened 4 flex beds in both December and January.

Ward 7 BHH – Opened to 19 beds at end of December.

Ward 20A SHH – Opened 5 flex beds in January.

Ward 14 SHH – Usually closes over the weekend but has remained open for weekends throughout January.

9

2.5 Non Pay Expenditure

2.5.1 CIP Delivery

Table 8 below details the breakdown of the undelivered CIP target.

Table 8: Breakdown of Unidentified CIP

Mth 10 In Month Mth 10 YTD

£m £m

Unachieved CIP 2015/16 (0.1) (5.4)

Cash Releasing Run Rate Reductions 2015/16 (0.5) (3.7)

Unachieved CIP Prior Years (1.4) (14.1)

Grand Total (2.0) (23.2)

The CIP delivery and year end forecast will be analysed further in section 3 below.

2.5.2 Clinical Supplies and Services

The deficit on clinical supplies is largely driven by increased activity levels.

2.5.3 Private Sector Usage

The use of the private sector has now been eliminated in all areas with the exception of a couple of cases per week within Urology. These cases are expected to continue until alternative capacity can be identified for this patient cohort.

2.6 Income Analysis

2.6.1 Total Operating Income

Total operating income is £13.0m above plan at the end of January as shown in table 9 below.

Table 9 – Income against Plan

YTD Plan YTD Actual YTD Variance

Jan Jan

£m £m £m

Clinical - NHS (476.7) (491.6) 15.0

Clinical - Non NHS (8.6) (8.5) (0.1)

Other (45.8) (43.9) (1.9)

TOTAL (531.0) (544.0) 13.0

NHS Clinical Income currently indicates over-performance of £15.0m year to date, however, the contract payment challenges from

10

commissioners continue. Although the Trust disputes the majority of the challenges, a bad debt provision has been made where appropriate.

2.6.2 NHS Clinical Income/Activity - Inpatients

Table 10.1 below details the monthly admitted patient care (APC) spells against target to the end of January.

Table 10.1: Trust Inpatient Activity

5,000

5,500

6,000

6,500

7,000

7,500

8,000


Sp

ell

s

Month

Admitted Patient Care 2015/16 - Actual vs Target (PbR)

Emergency Spells - Actual Emergency Spells - Target Daycase & Elective Spells - Actual Daycase & Elective Spells - Target

The January in-month activity position reflects a 7.9% over-performance in emergency pathways (486 spells), taking the year to date over-performance to 1.4% (862 spells).

This is being driven by an increase in A&E activity which has shown 9.9% over-performance in January (1,997 attendances) bringing the year to date performance to 1.3% above plan (2,859 attendances).

The in-month planned elective and daycase activity was 1.1% above plan (76 cases) and 2.4% above the year to date plan (1,698 cases).

2.6.3 NHS Clinical Income/Activity – Outpatients

Table 10.2 below details the monthly outpatient attendances compared to target to the end of January.

11

Table 10.2: Trust Outpatient Activity

60,000

62,000

64,000

66,000

68,000

70,000

72,000

74,000

76,000

78,000


Att

en

da

nc

es

Month

Outpatients 2015/16 - Actual vs Target

Outpatient Attendances - Actual Outpatient Attendances - Target

Outpatient activity in month is (3.3%) below plan (2,281 attendances) which takes the year to date performance to (0.9%) below plan (6,562 attendances).

The top four areas of under-performance in Outpatients in month are Haematology Anti-Coag (1,307 attendances, 31.8%), General Medicine (96 attendances, 17.5%), Radiology (97 attendances, 13.3%) and Orthopaedics (466 attendances, 6.4%).

The top four areas of under-performance year to date against plan are Haematology Anti-Coag (7,581 attendances, 18.4%), General Medicine (916 attendances, 16.6%), Paediatric Surgery (125 attendances, 10.0%) and Radiology (639 attendances, 8.8%).

12

3. Cost Improvement Programmes

3.1 Current Year CIP Programme

The current year CIP performance by Division is detailed in table 11 below.

Table 11: CIP Delivery by Division

Division Target £000's Actual

Recurrent

£000's

Actual Non

Recurrent

£000's

Variance

£000's

Target £000's Actual

Recurrent

£000's

Actual Non

Recurrent £000's

Variance £000's Annual Target

£000's

Forecast Actual

£000's

Variance £000's

Heartlands Hospital 623.8 351.8 282.5 10.5 6,237.5 2,546.6 1,997.1 (1,693.8) 7,485.0 5,423.8 (2,061.2)

Corporate Directorate 117.3 5.2 64.1 (48.0) 1,172.5 524.9 64.1 (583.5) 1,407.0 696.4 (710.6)

Clinical Support Services 436.5 195.9 316.0 75.4 4,364.6 1,673.3 1,979.4 (711.9) 5,237.5 5,060.2 (177.3)

Trustwide Education Services 7.8 7.8 0.0 0.0 77.5 77.5 0.0 0.0 93.0 93.0 0.0

Facilities 116.7 118.9 2.1 4.3 1,166.7 1,134.9 20.8 (11.0) 1,400.0 1,397.8 (2.2)

Good Hope Hospital 183.3 161.2 0.0 (22.1) 1,833.3 956.9 5.9 (870.5) 2,200.0 1,352.2 (847.8)

Solihull Hospital 289.8 232.0 77.2 19.4 2,897.9 2,155.5 615.9 (126.5) 3,477.5 3,452.7 (24.8)

Womens & Childrens 225.0 34.5 31.2 (159.3) 2,250.0 654.6 183.6 (1,411.8) 2,700.0 1,000.5 (1,699.5)

GRAND TOTAL 2,000.2 1,107.3 773.1 (119.8) 20,000.0 9,724.2 4,866.8 (5,409.0) 24,000.0 18,476.6 (5,523.4)

January - In Month Year End ForecastYear to Date

The year to date target for CIPs is £20.0m against which £14.6m of schemes have been delivered (73.0%). This includes circa £3.7m of run rate reductions (schemes that have delivered a reduction in unbudgeted expenditure) which reduce costs but have no funding line to remove. Of this year to date delivery (£4.9m) is non-recurrent for which recurrent alternatives need to be identified going into 2016/17.

The delivery in the period of January shows under-performance against target of (£0.1m). The current year end forecast delivery is expected to be £18.5m, 77.0% of the target.

4. Statement of Financial Position

The Statement of Financial Position (Balance Sheet) shows the value of the Trust’s assets and liabilities. The upper part of the statement shows the net assets after deducting short and long term liabilities with the lower part identifying sources of finance. Table 12 below summarises the Trust’s Statement of Financial Position as at 31 January 2016.

13

Table 12: Statement of Financial Position

Audited Actual Plan Annual Plan

Mar-15 Jan-16 Jan-16 Mar-16

£m £m £m £m

Non Current Assets:

Property, Plant and Equipment 245.3 247.0 249.3 266.4

Intangible Assets 3.6 3.7 12.2 12.9

Trade and Other Receivables 1.1 1.5 1.1 1.1

Other Assets 4.2 4.1 4.0 4.0

Total Non Current Assets 254.2 256.3 266.6 284.4

Current Assets:

Inventories 8.5 9.8 8.5 8.5

Trade and Other Receivables 23.5 28.7 19.9 21.9

Other Financial Assets 0.0 0.0 0.0 0.0

Other Current Assets 8.5 15.2 8.5 8.5

Cash 87.7 41.6 65.1 49.1

Total Current Assets 128.2 95.4 102.0 88.0

Current Liabilities:

Trade and Other Payables (73.7) (94.6) (70.9) (79.1)

Borrowings (0.5) (0.5) (0.5) (0.5)

Provisions (8.7) (7.3) (7.3) (7.0)

Tax Payable 0.0 0.0 0.0 0.0

Other Liabilities (6.5) (12.9) (8.8) (6.5)

Total Current Liabilities (89.4) (115.4) (87.5) (93.1)

Non Current Liabilities:

Borrowings (4.0) (3.7) (3.6) (3.5)

Provisions (6.7) (6.4) (6.7) (6.7)

Other Liabilities 0.0 0.0 0.0 0.0

Total Non Current Liabilities (10.7) (10.1) (10.3) (10.3)

TOTAL ASSETS EMPLOYED 282.3 226.3 270.8 269.1

Financed by:

Public Dividend Capital 215.3 215.3 215.3 215.3

Income and Expenditure Reserve 19.4 (34.9) 12.9 11.8

Donated Asset Reserve (0.2) (0.2) (0.2) (0.2)

Revaluation Reserve 47.7 46.0 42.7 42.1

Merger Reserve 0.0 0.0 0.0 0.0

TOTAL TAXPAYERS EQUITY 282.3 226.3 270.8 269.1

5. Capital Expenditure (Non-Current Assets)

The approved capital plan for the 2015/16 year is £50.4m which includes £20.4m of schemes brought forwards from 2014/15. The capital forecast was revised as part of the financial recovery to £19.3m.

The expenditure in January 2016 was £0.4m, to take it to £15.8m year to date which is underspent against plan by £1.0m but is on track against forecast. The expenditure in month was predominantly £0.3m on site strategy for example the ED project and RSU lifts at Good Hope.

14

6. Current Assets

The Trust’s total current assets (excluding cash and inventories) amount to £43.9m at 31 January 2016, (£15.5m) higher than plan.

Table 13: Analysis of Current Assets (excluding Inventories and Cash)

YTD Actual YTD Forecast

January 2016 January 2016

£m £m

Trade Receivables 40.7 26.0

Bad Debt Provision (14.3) (8.4)

Other Receivables 2.3 2.3

Trade and Other Receivables 28.7 19.9

Accrued Income 3.8 2.5

Other Financial Assets 3.8 2.5

Prepayments 11.4 6.0

Other Current Assets 11.4 6.0

TOTAL 43.9 28.4

Analysis of the age profile of Trade Receivables (unpaid invoices issued by the Trust) is summarised in table 14 below.

Table 14: Aged Debt Analysis

0%

5%

10%

15%

20%

25%

30%

35%

40%

0-30 30-60 60-365 1 Year+

% o

f D

eb

t

Aged Trade and Other Receivables for Jan 2016

There remain 3 debts outstanding in excess of £1m:

Burton Hospitals Foundation Trust (£1.8m > 30 days, £2.1m total) – this has decreased by £0.1m in month due to receiving income for some services. There is still £1.8m outstanding in respect of maternity pathways debt.

Sandwell and West Birmingham Trust (£1.2m > 30 days, £1.5m total) – this has increased by (£0.2m) in month. The majority of this debt

15

(£1.4m) is for maternity pathways which are being escalated alongside other maternity debt. Other recharges for £0.1m have been put on hold until a purchase order number is provided, in line with the policy introduced at HoEFT.

University Hospitals Birmingham (£1.0m > 30 days, £1.3m total) – the majority (£0.9m) is due to maxillofacial services with a further (£0.2m) being for ministry of defence HIV services. These accounts continue to be discussed in order to reach a settlement.

In late December the approval was given to temporarily recruit additional debtors’ team members to increase the cash collection rates on a 3 month trial. If this does not produce improvements in cash collection an external agency will be used.

7. Cash Flow

7.1 Current Position

The cash balance at the end of January 2016 was £41.6m, a decrease of (£1.0m) in month. The variance to plan is (£23.5m) which is a £5.4m improvement on the December variance.

7.2 Forecast Year End Cash Balance

The forecast cash at the end of March 2016 is £17.9m with the increased costs in February and March being predominantly driven by PDC dividend.

The ongoing cash flow forecast is detailed in table 15 below with additional financing expected to be required from June 2016.

16

Table 15: Cashflow Forecast

50.3

42.6 41.6

33.2

17.9

15.9

9.2

0.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

End Nov 15 End Dec 15 End Jan 16 End Feb 16 End Mar 16 End Apr 16 End May 16 End Jun 16

£m

's

Month End Cash Flow Forecast

Actual Cash Forecast as at 29 Jan

8. Monitor Financial Sustainability Risk Rating

Monitor has replaced the previous Continuity of Services Risk Rating with a new Financial Sustainability Risk Rating (FSRR) from August 2015. The four criteria evaluated, the weighting placed on each of them and the scoring rationale is detailed in table 17 below.

Table 16: Scoring Mechanism for FSRR

Metric Weight 4 3 2 1

Capital Service Cover 25% 2.50 1.75 1.25 <1.25

Liquidity 25% 0.0 (7.0) (14.0) <(14.0)

I&E Margin 25% 1% 0% (1%) <(1%)

I&E Margin Variance 25% 0% (1%) (2%) <(2%)

FSRR

The Trust planned to achieve an FSRR of 2 as at both month 10 and the year end. However due to the large income and expenditure deficit, three of the four criteria are rated as 1 bringing the actual FSRR at month 10 down to a weighted average of 1.

This FSRR is not expected to improve by the end of the year due to the continued deterioration in the Trust’s net current liability position.

17

9. Conclusion

The Trust has reported an overall deficit of (£56.0m) for the first ten months (April – January) of the 2015/16 financial year, representing a (£47.8m) adverse variance against the Monitor plan of (£8.2m) deficit. The recovery process has yielded some improvement in the monthly run rate but the current position remains unsustainable and unaffordable in the longer term.

The latest forecast year end deficit is in the range of (£41.7m) and (£44.7m) deficit after an £18.6m benefit from the capital to revenue transfer recently agreed with Monitor. This is a non-recurrent technical adjustment and therefore the normalised forecast deficit remains in the range of (£60.3m) to (£63.3m).

The Trust’s cash balance as at 31 January 2016 is £41.6m which is (£23.5m) below the planned cash balance at this point in the year. Based on current trajectories the Trust would expect to require external cash support from June 2016.

10. Recommendations


Receive the contents of this report.

Note the range anticipated for the year end trajectories for 2015/16.

Julian Miller Interim Director of Finance 19 February 2016


BOARD OF DIRECTORS

WEDNESDAY 2nd MARCH 2016

Title: BOARD ASSURANCE FRAMEWORK

From: Sam Foster


The report is being provided for:

Decision: N Discussion: Y Assurance: Y Endorsement: Y

The Board is being asked to:

Review the updated BAF and identify any gaps in controls and assurances

Key points / summary: The BAF has been recently updated with the relevant leads as attached

The BAF continues to be work in progress and further work is underway to ensure that the corporate risk register is integrated further to ensure that operational risks are recorded appropriately, specifically for those risks that have been raised by the Board of Directors.

Once this revised process is fully established, it will also be cross referenced with the performance report. This will ensure that all risks are captured on the relevant Executive risk register

There are currently 3 red and 5 amber risks reported to the Board of Directors.

Recommendations:

Review the revised BAF and identify any gaps in controls and assurance.

Identify any Equality and diversity issues: None

Outline how any equality and diversity risks are to be managed: not applicable

Which other committee has this paper been to?

None

DRAFT

Heart of England NHS Foundation Trust

Board Assurance Framework 2015/16

Feb-16

Safe, Caring & Compassionate, Empowering and Effective

DRAFT

Note: for Q2 as this is the first report in the new format a trajectory has not been included

This assurance framework assesses the most important risks that the Trust faces and which have the highest potential

for external impact. These risks differ in magnitude and complexity to operational (day-to-day) risks and typically require

comprehensive risk mitigation plans which span a longer time than most operational risks. The Trust defines strategic

risk as a strategic control issue that could close down a service(s):-

1. Seriously prejudice or threaten the achievement of one or more of our strategic objectives.

2. Threaten the safety of service users.

3. Threaten the reputation of the Trust / the NHS.

4. Lead to significant financial imbalance and / or the need to seek additional funding to achieve resolution and / or

result in significant diversion of resources.

Strategic risk will be reviewed as part of the Trust’s annual business planning cycle and, if required, as identified during

the year. The risks are managed to minimise the potential impact and / or likelihood of the risk occurring. The purpose

of the BAF is to provide assurance to the Board of Directors that strategic risks are being fully and effectively identified,

managed, mitigated and reported with clear ownership and accountability within the organisation.

A risk score is attributed to each risk based on scores for impact (the effect the risk occurring would have on the

organisation) and likelihood (of the risk occurring). Successful mitigating actions should lead to a reduction in one or

both of these scores. The Trust uses the following matrix for scoring its risks.

DRAFT

Failure to have a sustainable, embedded organisational governance infrastructure for all divisions, set against the

Trusts quality and safety strategy and assurance frameworks12

Failure to deliver access standards owing to rising volume of routine secondary care work, delayed TOC, rising

ED attendances, gaps in community provision, lack of impact from better care fund and rapidly rising two week

wait

16

Breach of terms of the Monitor provider licence / material non compliance with external regulators, with particular

reference to capacity, finance and the CQC inspection action plan16

Failure to have appropriate leadership skills and capacity at all levels to deliver new ways of working and

appropriate ways of leading12

Failure to retain staff and the inability to recruit sufficient numbers of appropriately skilled, trained and competent

staff12

Lack of integration across the Birmingham health economy to deliver a fully integrated health and social care

service12

A lack of robust infrastructure: IT systems; metrics; workforce information system; financial modelling and

payment methods to allow the Board and management teams to deliver the required programme of change12

Significant deterioration of the Trusts underlying financial position resulting in the inability to deliver the Financial

Recovery plan20

Heart of England NHS Foundation Trust - Board Assurance Framework - Summary (Q4-2015/16)

DRAFT

Quarter 4 Board Assurance Framework Report

ObjectiveRisk

IDPrincipal Risk Risk Owner Key Controls Sources of Assurance

Current Assurance

LevelTarget Score Gaps in Assurance/Control Actions/Planned Updates Timescale

What is the Trust's objective? Risk

Ref

Describe the risk which threatens the

achievement of the objective

Individual

ultimately

accountable

for managing

the risk

What existing controls and processes that are in place to manage

the risk

Where can we gain evidence that

our controls/systems on which we

are placing reliance are effective

RAG

Rating

Target RAG

Rating post

mitigation plan

Where we are failing to pull

controls/systems in place. Where we are

failing in making them effective

What further action (if any) is necessary to address the

gap? Dates/notes on slippage or controls assurance

failing

1. CLINICAL QUALITY

Setting out our future clinical strategy through

clinical leadership in partnership with whole

system working to achieve continuous

improvement in the quality of patient care that

we provide

1.1

Failure to have in place a sustainable,

embedded organisational governance

infrastructure for all divisions set against the

Trusts quality and safety strategy and assurance

frameworks

CN

Good Governance Institute review

Key roles and responsibilities at divisional and directorate level

triumvirates

Divisional committee structure

Monthly performance framework reporting through divisional review

Trust Board reporting

CQC Action Plan

Board repotrs

Minutes of groups and committees

aligned to divisions and corporate

accountability

12 6

Current governance systems not fully

mature within Directorates and Divisions to

ensure the delivery robust clinical

governance.

No clear route of escalation for risk from

ward to Board

Sustained clinical engagement

Available information flow and analysis for

monitoring

Work force review of corporate governance services to

wrap round Directorates and strengthen the resilience and

capacity of the local governance arrangements.

To implement Executive-led risk group to ensure ward to

Board accountability

Divisional restructure

Feb-16

1.2

Failure to deliver access standards owing

to rising volume of routine secondary care

work, delayed TOC, rising ED

attendances, gaps in community provision,

lack of impact from better care fund and

rapidly rising two week wait

DoP

Capacity demand modelling undertaken to right size capacity.

Demand and capacity group involving all divisions and corporate

services.

Forecast activity for 2015/16.

Identified bed and theatre requirements overseen by business case

review group.

Activity, income and performance reviews

Trust Board Report.

Performance against national target

and waiting list size through

performance reports to divisional

meetings, exec meeting and Board of

Directors

16 9

No transformational programme in place

that is aligned to strategic objectives /

projected activity in terms of efficiency /

productivity / redesign

Divisions working to implement the capacity

requirements as identified via BCRG.

Alternative / collaborative (community) models of care for

ward based capacity

Divisional activity monitoring through range of forums.

Aligned to Quarterly reviews of activity and growth. All

plans presented to Exec Team.

Activity and capacity plan for 2016/17 to be presented

early February as year 1 to 5 of a sustainable plan (as

well as 16/17 Monitor planning guidance)

Transformation plan will be derived from this in response

to the capacity / financial requirement

On-going

1.3

Breach of terms of the Monitor provider

licence . Material non compliance with

external regulators, with particular

reference to capacity, finance and the

CQC action plan

DoFIIP and other regulatory frameworks

Monitor updateEMB, Trust Board and PMO 16 9

Mature governance systems and

processes

Trajectory to reduce datix backlog

Review of governance framework as described in 1.1 and

4.1On-going

2. WORKFORCE

We will be a great place to work with a highly-

engaged, motivated and skilled workforce who

are supported to deliver high-quality care

2.1

Failure to have appropriate leadership

skills and capacity at all levels to deliver

new ways of working and appropriate ways

of leading

DoW

Managed through the new executive team meetings and Trust

Board

Structures including accountability currently being worked on and

will be implemented early 2016.

Good Governance Institute commenced work with the Board

Weekly Execs

Minutes of and reports to the Board12 6

Leadership programmes for senior leaders

in the organisation have not been

identified

Discussions to be held with the new CEO aligned to the

financial envelope.Jan-16

2.2

Failure to retain staff and the inability to

recruit sufficient numbers of appropriately

skilled, trained and competent staff

DoW

Extensive recruitment activity has resulted in circa 160 nurses

joining the Trust in October and December 2015

Pastoral support is in place to support and improve attraction and

retention

Medical Efficiency Programme incorporating medical vacancies and

job planning

Weekly and monthly monitoring of

recruitment trajectories.

Weekly monitoring via Finance

Recovery Board

Trust Board

12 6

Sustaining an affordable integrated quality

workforce within the current financial

envelope set against clinical activity

To continue to evaluate the current workforce position set

against the Trust corporate objectives.Dec-15

3. INTEGRATION

We aim to provide care as close to home as

possible and patients will see a coordinated

seamless approach to their care

3.1

Lack of integration across the Birmingham

health economy to deliver a fully integrated

health and social care service

DMD

(Elderly)

Discussions taking place between HEFT and partners including the

GP Federations, East and North Birmingham

Service model discussions with UHB and City and Sandwell

The clinical model discussed and clarification sought with

Birmingham Community Healthcare using a shared approach to

post-acute care

Integrated Care and Social Services

(ICASS)Programme management

structure

Trust Board

Systems Resilience Group

12 6

Fully agreed vision at Executive level with

reference to short-term winter plan and

medium-term priorities

To monitor discussions through existing Governance

arrangements

Direct discussion with CEOs

Jan-16

4. AFFORDABILITY

We will make the best use of every pound,

developing services for the long term. Quality will

be the key driver to affordability4.1

Lack of a robust infrastructure: IT systems;

Metrics; Workforce information systems;

financial modelling and payment methods

to allow the Board and management

teams to deliver the required programme

of change

DOP

Solihull vanguard project to address the issues relating to the

infrastructure

Plans to roll this model out to Birmingham economy once

recognised

Additional resource provided to support the programme

Trust Board

ICASS systems resilience group

12 6

Gaining full assurance that BCF is fit for

purpose

Sustained collaborative working with the

CCGs

To continue to strengthen the programme and change

management capacity within the financial envelope and

work collaboratively with the key stakeholders

Feb-16

DRAFT

4.2

Significant deterioration of the Trusts

underlying financial position resulting in

the inability to deliver the Financial

Recovery Plan

DoF

Controls reviewed and updated

Financial Recovery Programme established

Financial Recovery Framework agreed and issued internally

External support with plan (Ernst & Young) now in place

Short term Financial Recovery Plan agreed by Trust Board and

Monitor

Longer term Financial Recovery Plan to be developed and

submitted April 2016

Directorate accountability through

divisional monitoring

Financial Recovery Tracking

Framework

Financial Recovery Programme

Board

Divisional recovery meetings

Weekly Ernst & Young Report

Monthly finance report to the Board

of Directors

20 12

Availability and transparency of financial

information

Unidentified savings within 2015/16 cost

improvement programme

Widespread communications strategy

Fully-implemented job planning (Demand

& Capacity)

Clarification of staff terms and conditions

Maximise transition to PBR (getting paid

for the activities performed)

Understanding of financial baseline /

robustness of the financial plan for

2015/16

Trustwide rapid cost reduction programme

Support from Ernst Young

Cash and capital expenditure review

Trustwide finance communications plan

Endoscopy 7-day working consultation

Nursing efficiency programme

Medical efficiency programme (focus on locums & job planning)

Workforce redesign

Trustwide activity and income entitlement project

(counting and coding)

SLR programme being tested and rolled out

On-going

Board Committee Minutes & Reports

14.1 Audit Committee (20.01.16) Oral 14.2 Donated Funds Committee (29.01.16) Enclosure 14.3 Monitor Standing Committee (29.01.16) Enclosure

Minutes of a meeting of the Donated Funds Committee of Heart of England NHS Foundation Trust

held in the Boardroom, Devon House, Birmingham Heartlands Hospital on 29 January 2016

PRESENT: P Hensel (Chair) A Jones

J Smith K Smith

16.001 APOLOGIES AND WELCOME

P Hensel welcomed Jacqui Smith to her first meeting of the Committee. It was noted that A Fletcher had attended earlier in the day but apologised for his absence having mistaken the start time of the meeting. E Hale was absent on sick leave.

16.002 MINUTES OF PREVIOUS MEETING

The minutes of the meeting held on 26 November 2015 were approved as a true record.

16.003 MATTERS ARISING

15.003 Trust-wide communication exercise. Carried forward (Action: EH). 15.037 Meeting with D Cattell. P Hensel reported that he had met with D Cattell regarding HEFT’s decision to terminate all agency staff in November, including most of the Fundraising team. He had pointed out that the Charity was funding the cost of these staff through the SLA and that the Committee felt this action was inappropriate without prior consultation with the Committee. D Cattell explained that it was a blanket decision that HEFT was entitled to take. P Hensel invited D Cattell to respond on how HEFT would fulfil the SLA. A Jones explained that D Cattell subsequently asked S Foster to respond given that she had operational responsibility for Fundraising; S Foster had indicated that any response would come after receipt of M Hammond’s report on the Charity. P Hensel noted that this action had swept aside any concept of the Committee holding the Fundraising team to account for its performance against targets. It was noted that the Charity had only paid half of the annual fee for the SLA and it now seemed unlikely that it would pay much more for the current financial year. P Hensel had also taken the opportunity to explain to D Cattell that the letter to fundholders asking for spending plans should have come from the Committee, not from D Cattell – D Cattell didn’t agree. 15.038 Proposal for the Charity to fund Christmas lunches. P Hensel confirmed that this proposal had fallen away. 15.042 Circulate spending plans. The first batch of spending plans for £252k of scopes and related equipment had been approved by circular e-mails and a written resolution during January 2016.

Page| 2

15.043 K Smith confirmed that the completed revised authorisation forms had been returned to Investec in November 2015.

16.004 FUNDRAISING REPORT

It was noted that there was no Fundraising Report due to E Hale’s absence.

16.005 FINANCE REPORT

A Jones outlined the key financial information for the 9 months to 31 December 2015 stating that total income received was £1,091k, £493k below plan, expenditure was £1,250k, £325k below plan, there was a loss on revaluation of £792k (estimate), resulting in a net deficit of £951k, £960k worse than plan. The value of the fund at 31 December was £7,257k. Donations were £60k below plan YTD, following sizeable receipts from the Friends of Solihull. Fundraising was £102k below plan and may be further adversely affected because of the lack of a Fundraising resource. Legacy income was £15k below plan but there were £224k of expected legacies that could reverse this position. Grants were £323k below plan but £200k was expected from Sutton Charitable Trust for equipment at Good Hope Hospital, although there were some operational discussions as to whether the equipment could be accommodated at the present time. Expenditure was largely below plan due to savings in buildings, fundraising expenses and fixtures, fittings and furnishings but this may reverse due to recent purchases of medical equipment. Administration costs were £62k higher than planned because of the use of agency staff to cover a secondment. Cash of £826k comprised £551k on deposit with RBS and £275k with Investec. The summary of spending plans was noted. A Jones explained that HEFT was required to submit a draft plan to Monitor by 8 February and that it was proposed that this would include a breakeven for the Charity before investment movements with income and expenditure planned at £1.5m in line with the current year’s performance. It was agreed that this seemed reasonable.

16.006 OPERATIONS COMMITTEE

K Smith commented on the Operations Committee Actions Log and noted that ‘go live’ for the new maternity scanning image equipment was still scheduled for March 2016. Monies had not yet been received from the ‘independent’ Good Hope League of Friends but K Smith was chasing this.

16.007 INVESTEC INVESTMENT REPORT S

K Smith referred to the pre-circulated reports from Investec and noted that the key measure was performance against benchmark, which was as follows:

Q3 12 months

HEFT 3.5% 3.5%

Benchmark 3.3% 2.8%

Page| 3

The market commentary was noted. There were no specific issues with Investec. P Hensel suggested the time was right to consider whether to continue the relationship with Marlborough, the Charity’s investment adviser, as it was felt that they added little value in terms of challenge to Investec. K Smith pointed out that there remuneration was around £2k per annum, so it was perhaps unreasonable to expect too much from Marlborough but they did provide some scrutiny of Investec’s performance against the benchmark and general commentary as to whether or not Investec’s performance was good or bad given prevailing market conditions; in K Smith’s experience, top class investment advisers tended to be significantly more expensive. K Smith undertook to check Marlborough’s terms of engagement (Action: K Smith). P Hensel undertook to ask M Hammond what the QEHB Charity does in this regard (Action: P Hensel).

16.008 HEFT REVIEW BY QEHB CHARITY CEO

The draft report had been received but was subject to checks for factual accuracy and a management response. P Hensel had met with M Hammond earlier in the week to receive his comments on the highlights. The most significant recommendation was that the Committee should have an appropriate substantive dedicated person in post running the Charity. P Hensel would start scoping for this (Action: P Hensel). K Smith would convene a meeting of the Committee to focus exclusively on the final version of the report (complete with any management feedback) as soon as possible (Action: K Smith).

16.009 ANY OTHER BUSINESS

P Hensel would frame a question for E Hale on the Etherington Review into self-regulation of charity fundraising following his attendance at the NHS Charities Group meeting on 10 March.

16.010 DATE OF NEXT MEETING

29 April 2016; Boardroom, Devon House, Birmingham Heartlands Hospital.

........................................ Chairman

Minutes of a meeting of the Monitor Standing Committee of the Board of Heart of England NHS Foundation Trust

held in the Board Room, Devon House, Birmingham Heartlands Hospital on 29 January 2016 at 8.00am

PRESENT: J Smith (by phone)

S Foster D Lock (by phone) J Moore (by phone)

(Chair)

IN ATTENDANCE: K Smith K Bolger D Burbridge A Fuller J Gould D Rosser

(Company Secretary)

16.01 APOLOGIES Apologies were received on behalf of J Miller (J Gould was in attendance on his behalf). The Chair noted that the meeting was quorate. S Foster explained that she had invited D Burbridge, Director of Corporate Affairs, University Hospitals Birmingham NHS Foundation Trust, to advise on governance matters.

16.02 MINUTES OF PREVIOUS MEETING The minutes of the meeting of 29 October 2015 were approved as a true record, save that A Foster was not present at the meeting.

16.03 APPROVAL OF MONITOR QUARTER 3 RETURN J Gould confirmed that the Monitor quarter 3 return had been completed in accordance with the Risk Assessment Framework and commented at a high-level on the current financial position of the Trust in terms of year to date deficit and cash. The meeting reviewed the pre-circulated papers. The Board was expected to sign the combined Governance Statement. This would confirm, or otherwise, four things: For finance, that: • The Board anticipates that the Trust will continue to maintain a financial

sustainability risk rating of at least 3 over the next 12 months. • The Board anticipates that the Trust's capital expenditure for the remainder of the

financial year will not materially differ from the amended forecast in this financial return.

For governance, that: • The Board is satisfied that plans in place are sufficient to ensure: ongoing

compliance with all existing targets (after the application of thresholds) as set out

2

in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.

Otherwise: • The Board confirms that there are no matters arising in the quarter requiring an

exception report to Monitor (per the Risk Assessment Framework, Table 3) which have not already been reported.

Governance The Trust had failed to achieve the four hour A&E waiting target for the fourteenth consecutive quarter. The Trust had agreed a system wide trajectory to achieve the target on a quarterly basis by quarter 1 2016/17. With increased demand on the urgent care pathway this trajectory would not be met. There would be further meetings with system wide stakeholders and a revised trajectory set in March 2016. In line with national reporting deadlines, the Trust’s performance against cancer targets had not yet been fully validated for the quarter. The results in the return were provisional and fully validated results would be notified in November. At this stage, however, it was known that the Trust would not hit the two week targets for both breast and other cancers. The Trust was committed to deliver the two week wait cancer targets and it had been agreed with stakeholders that this would be consistently achieved from Q4 2015/16. The Trust had recognised in year demand increases and recognised the potential for increased demand as a result of the latest NICE guidance which may provide further challenges. As disclosed in quarter one, the ‘Cancer 62 Day Waits for first treatment (from urgent GP referral) - post local breach re-allocation’ target would not be achieved. This was due to a flood in Endoscopy at Solihull Hospital during that quarter. This led to a loss in cystoscopy capacity, blocking the 2 week wait pathway in Urology and resulted in sharply reduced volumes achieving the 62 day pathway. Delivery of the standard was expected from January 2016. As also previously disclosed the Trust failed to hit the 18 week RTT target in the quarter. The Trust had agreed with a wider stakeholder group a trajectory to return to compliance with the RTT targets by quarter 1 2016/17. The Trust also provided supplementary governance Information to Monitor. Amongst other things it included information on serious untoward incidents (SUIs), contacts with the CQC, information governance breaches, dealings with the Coroner and exchanges with other regulatory organisations such as the Health and Safety Executive (HSE). Finance The Trust was subject to Monitor enforcement undertakings under section 106 and 111. The Trust had been working hard over the last several months to improve operational performance with trajectories, agreed with its stakeholders, to measure this improvement. The Trust had made many improvements in performance. This had come at a financial cost much greater than planned as significant investment in services had been made to meet these trajectory targets and improve clinical quality. The Trust was now in a financial recovery process with the support of Ernst and Young. Urgent work was in progress in order for the Trust to re-establish a sustainable financial position while maintaining improvements in operational performance. The Trust had produced a short term financial recovery plan for 2015/16 and must

3

produce a longer term financial sustainability plan for 2016/17 and beyond. In the third quarter of the financial year the Trust had reported a deficit of £15.7m, £17.3m adverse to the plan. The year to date deficit of £51.4m was £44.1m adverse to the plan. The Trust’s Financial Sustainability Risk Rating was now 1. While there has been a marginal improvement in financial performance in the quarter continuing significant operating losses meant that the Trust’s liquidity had continued to decline sharply. In quarter 3 overall operating income of £165.1m was £5.2m favourable to the plan, year to date income of £489.2m was £11.0m above plan. NHS Clinical Income of £150.3m outperformed the Monitor plan by £6.7m (this included a year to date switch of retinopathy income of £2.9m from non-clinical income) in the quarter. Year to date clinical income of £441.6m outperformed plan by £12.4m. In 2015/16 the Trust was recognising income under full Payment by Results (PbR) terms and conditions using the Enhanced Tariff Option (ETO). However, an impairment charge of £5.8m YTD was included in the position relating to ongoing payment queries from the CCGs and risks associated with moving to PbR. The modest favourable variance on operating income was offset by an overspend of £22.6m on operating expenses of £179.1m in the quarter. At the end of quarter 3 operating expenses of £536.0m were £55.8m over plan. Notable YTD overspends against plan were recorded on employee expenses £18.7m (unfilled vacancies, enhanced bank rates, additional WLI work, high levels of agency nurses and locum doctors), drugs, including pass through expenses £6.2m, clinical supplies £5.0m, non-clinical supplies £4.0m (extra capacity still open impacting on laundry, cleaning and security), consultancy £2.4m (including E&Y costs and project management office), impairment of receivables £6.8m (unplanned switch to PbR terms and conditions) and miscellaneous other operating expenses £13.9m (including extra internal audit and governance costs, unrealised planned savings and contingencies). There had been a further reduction in the Trust’s liquidity. Cash and investment balances of £42.6m were below plan by £28.9m. Lower than planned operational performance had resulted in adverse to plan cash flows of £14.2m for the quarter, £40.0m for the year to date. Changes in working capital balances were £20.8m better than planned for the quarter, £6.2m for the half year. Cash capital additions were £2.3m below plan for the quarter and £5.1m below plan for the year to date. More assertive cash preservation measures, actively managing working capital, had been in place during the quarter which had resulted in an improvement in cash balances from the low of £34.1m recorded at the end of quarter 2 despite the continued, significant operating losses being recorded. Mr Lock confirmed that there were no surprises in the return but questioned whether a statement could be added about the Trust’s plans to return to break even or surplus. J Moore explained that there were no such plans at the present time and confirmed that this had already been explained to Monitor. It was agreed that a statement should be added confirming that the developing position was being discussed regularly with Monitor in performance review meetings. Regarding Director changes, it was agreed to add that A Lord had resigned as a Non-executive Director effective from 31 January 2016, although this had occurred in quarter 4 and wasn’t strictly necessary. J Moore confirmed that Monitor was already aware of this resignation. K Bolger proposed to add language to the Governance statement clarifying that the Trust was continuing to take actions to mitigate the increased demand being experienced in A&E.

4

The Committee delegated authority to K Bolger and J Gould to make the changes described above. After due consideration and subject to the foregoing the quarter 3 return was approved and two directors were authorised to sign it on behalf of the Trust.

16.04

ANY OTHER BUSINESS S Foster questioned whether the Committee had the requisite authority to act and whether it was still necessary. After discussion, the Chair confirmed that the Committee served a useful purpose given the timing of Board meetings, the need for Monitor returns to be approved on behalf of the Board and the deadlines for certain Monitor submissions, such as quarterly returns. Furthermore, this had been contemplated in preparation of the paper on Board Structures that was approved by the Board on 6 January 2016.

15.21 DATE OF NEXT COMMITTEE MEETING 29 April 2016.

……………………………… Chair

POLICIES FOR APPROVAL

15.1 Celebrity and VIP Visitor Policy (SF)

Policies and Procedure – Celebrity and VIP Visitor Policy

©Heart of England NHS Foundation Trust Page 1 of 20

Celebrity and VIP Visitor Policy

There are no key changes from previous versions, as this is a new policy.

Ratified Date: Pending Ratified By: Chief Executives Group Review Date: January 2019 Accountable Directorate: Corporate Nursing Corresponding Author: Elaine Brewster, Interim Head of Communication and Maria Kilcoyne Head of Safeguarding

This policy is relevant to all staff at the Heart of England NHS Foundation Trust and should be circulated to and read by them.

Paper Copies of this Document

If you are reading a printed copy of this document you should check the Trust’s Policy website (http://sharepoint/policies) to ensure that you are using the most current version.

http://sharepoint/policies



Meta Data

Document Title: Celebrity and VIP Visitor Policy

Status Draft for ratification

Document Author: Maria Kilcoyne Head of Safeguarding and the Interim Head of Communications

Source Directorate: Corporate Nursing Patient Experience and Corporate Affairs

Date Of Release: TBC

Ratification Date TBC

Ratified by: TBC

Review Date: TBC

Related documents Safeguarding Adult Policy Safeguarding Children Policy Photographic Video and Mobile Device Consent and Confidentiality Policy

Superseded documents None

Relevant External Standards/

Legislation

Children Act 2004 CQC Regulation 13 Care Act 2014 Themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile (Lampard and Marsden 2015)

Key Words VIP, Celebrity, Visitor

Revision

HistoryVersion Status Date Consultee Comments

Action from

Comment

1.0 In

development

29.7.14 Safeguarding Unit

Paediatric Staff

Changes to wording in relation to

staff/ staff roles at HEFT

Document revised.

1.1 In

development

08.09.14 Head of Trust

Security

Corporate Nursing

Information

Governance



1.2 In

development

7.4.15 Safeguarding Team Reviewed and amended in light

of the publication of government

publication of Themes and

Lessons Learnt from NHS

Investigations into matters

related to Jimmy Savile (2015)

Document amended

1.3 In

development

May

2015

Safeguarding Adult

Committee

EIA to be completed Document to be

amended

1.4 In

Development/

final

May

2015

Safeguarding

Children Committee

Agreed pending EIA assessment. No further comments

1.5 FINAL version January

2016

Chief Executives

Group

For ratification



Contents

1 Circulation 5

2 Scope 5

3 Definitions 5

4 Reason for development 5

5 Aims and Objectives 5

6 Standards 5

6.1 Trust procedure for organising and managing celebrity/VIP visits 5

6.2 Consent 6

6.3 Confidentiality 7

6.4 Equality and Diversity 7

7 Responsibilities 7

7.1 The Trust 7

7.2 The Head of Communications 7

7.3 A member of staff from the communications and/or fundraising teams 7

7.4 General Managers / Heads of Nursing / Matrons/Ward Managers 8

7.5 Employees 8

7.6 Customer care and behaviour of staff 9

8 Training Requirements 9

9 Monitoring and Compliance 9

10 References 9

11 Method for Development 10

12 Appendices 9

12.1 APPENDIX A: Infection Control Guidance for Visitors 9

Hand washing 9

12.2 APPENDIX B: Safeguarding guidance for celebrity/VIP guests 12

12.3 APPENDIX C: Consent Form for photography/filming/interviewing for media purposes - VIP/Celebrity

Visits 13

13 Attachments 14

13.1 Ratification Checklist 15

13.2 Equality Impact Assessment 16

13.3 Launch and Implementation Plan 20



1 Circulation

This document applies to and should be read by all staff.

2 Scope

This policy applies to all Trust staff.

3 Definitions

This policy defines the agreed standards and responsibilities regarding celebrity and VIP visitors to the organisation.

4 Reason for development

As one of the largest NHS Foundation Trusts outside of London, the Heart of England NHS Foundation Trust receives a number of visits from celebrities and VIPs throughout the year to its Heartlands, Good Hope and Solihull sites.

Although the Trust aims to accommodate these visits wherever possible, it recognises its responsibility to protect the privacy of patients, families and staff.

It is a requirement for all NHS Trusts to have a policy in place to ensure that Celebrity or VIP visitors are escorted at all times and do not have unsupervised access to patients or visitors (Lampard and Marsden 2015).

5 Aims and Objectives

The purpose of this Policy is to inform staff and support providers of the Heart of England NHS Foundation Trust about procedures for organising and undertaking celebrity/VIP visits to the hospital and other Trust sites. The purpose of the Celebrity and VIP Policy is to:

Ensure robust procedures are in place to organise and conduct all celebrity/VIP visits professionally and respect the dignity and safety of our patients, staff and visitors

Ensure employees and other users are aware of the correct procedures for organising visits to any of the Trust’s sites

Build awareness amongst all staff in the organisation of their responsibilities in ensuring visits are handled efficiently

Ensure all visitors are aware of and abide by relevant Trust procedures such as Infection Control and Patient Confidentiality

Prioritise full consideration of patients, families and staff when arranging and undertaking visits.

6 Standards

6.1 Trust procedure for organising and managing celebrity/VIP visits



The Head of Communications or Senior Communications Officers must be made aware of any visits to ensure appropriate arrangements are made.

All visits by celebrities and VIPs are handled and managed by the Communications Team.

The decision for visits from politicians to visit the Trust lies with the Chief Executive (except during the election period when activity which could be perceived as political must not take place – often referred to as ‘purdah’).

Details of any visit must be cascaded to the Trust Communication Team, Directorate Management Team and Security (to gauge any potential impact on the rest of the Trust) as soon as details of the visit are known. If the Communications Team is approached less than 24 hours before a visit, then this cascade process must take place as soon as possible by phone and by email.

To arrange access to a ward area, the appropriate General Manager / Head of Nursing and/ or Matron must be contacted in advance of the visit to allow necessary arrangements at ward level to be made. The Head of Nursing and/or Matron should be contacted by phone or email at least 24 hours in advance.

To arrange access to a non-clinical area, the appropriate manager must be contacted in advance of the visit to assess appropriateness based on clinical priorities and allow necessary arrangements to be made. They must be contacted by phone or email at least 24 hours in advance.

If the Communications Team is approached less than 24 hours before a visit, then Matron must be contacted immediately before the visit to their area is agreed. Permission must be given by the General Manager / Head of Nursing and/or Matron before allowing any visit to take place to a ward area. The General Manager / Head of Nursing/ Matron or Clinical Lead should also advise if a visit should be postponed or cancelled due to clinical need.

Ward Managers and Ward Staff will be briefed by the Head of Nursing or Matron as appropriate and should support the Communications Team during the visit, in particular with obtaining consent or identifying/introducing patients and families.

All visitors to Trust sites must adhere to Trust procedures and protocol which guarantee the highest level of patient safety. ‘Infection Control Guidance for Visitors’ protocol can be found in Appendix A and Safeguarding guidance for the celebrity / VIP guest can also be found in Appendix C.

6.2 Consent

Appropriate media consent forms (Appendix C) must be completed for all patients, children and young people who are featured in any photography/media coverage. This includes anyone who may appear in shot even if visibility is minimal. Media consent for under 16s must be obtained from someone with parental responsibility.

Those over the age of 16 can give their own consent only if they are legally competent. A competent person is able to understand and retain information given to them, is able to use this information to make a decision and is able to communicate their wishes.

Media consent must be agreed verbally with staff for their involvement in the visit and any resulting media coverage.

The Communications Team is responsible for obtaining and retaining media consent.

Before giving consent, parents/carers must be fully provided with details about the use of any information or imagery that includes them or their children.

All consent forms must be fully completed, signed by the appropriate parent/legal guardian and returned to the Communications Team.



6.3 Confidentiality

All staff should understand that high profile visits must be treated confidentially and on a ‘need to know’ basis agreed by the Chief Executive and Head of Communications. This is to enable visits to take place as safely and smoothly as possible.

Staff will be notified of visits only where appropriate and should not divulge information on these visits to other colleagues, patients, families or external parties.

6.4 Equality and Diversity

Ensuring that patients, families, staff and visitors are treated with respect and dignity is central to the work of the Trust.

Communicating information is an essential part to ensuring that all staff, patients, children, young people and their families feel that they are informed about what is happening during any celebrity and VIP visits. As such, steps will be taken to ensure that where English is not the first language or there are difficulties with communication that people can understand and participate actively.

7 Responsibilities

7.1 The Trust The Trust will provide robust procedures for managing and handling visits to the Trust from celebrities and VIPs. These could be:

Invited guests

People who have requested to visit the hospital

7.2 The Head of Communications

has overall responsibility for ensuring that approval for the visit has been gained from the relevant manager, ensuring clinical priorities come first at all times.

will also ensure that all visits are handled responsibly and effectively, will act as the lead for such visits, reporting to Executive Directors when appropriate and providing support when necessary. This will include conducting a risk assessment in advance.

7.3 A member of staff from the communications and/or fundraising teams Will from time to time act as the lead contact for VIP visits on the day of the visit and ensure the correct procedures are followed and will:

Work closely with the Department of Health and commissioners in organising visits by Ministers, politicians etc.

Notify the Head of Communications about expected visits.

Brief Executive Team, Trust security and other appropriate audiences on visits and their potential impact.

Notify the General Manager/Heads of Nursing / Matrons/ Ward Managers and Facilities about the visit.

Provide briefings/key messages to Trust Spokespersons and those involved in the visits.

Accompany visitors and media on site where appropriate.



Oversee all associated media activity onsite, ensuring all appropriate consent is provided for all children involved in filming/photography at the hospital as well as hospital staff (a signed media consent form – Appendix B on page 10 is required in all cases), and that the Trust’s media policy is adhered to.

Draft and approve any related press releases and distribute appropriately.

Members of the communications/ fundraising team must adhere to all aspects of 7.5

7.4 General Managers / Heads of Nursing / Matrons and Ward Managers

Must support the Communications Team in organising visits to their areas; ensure all staff adhere to this policy and support families and patients during visits. Communications will alert the Facilities Department and a local security management specialist will be responsible for ensuring there is adequate security provision in place before and during a visit at the request of the Communications Team. Must be aware that celebrity visitors to the Trust must be escorted at all times and must not have unsupervised contact with patients or visitors and ensure that arrangements are in place to facilitate this. Adhere to the points in 7.5

7.5 Employees must:

Ensure they act in accordance with this policy and support visits to their areas and represent the Trust correctly by acting professionally at all times

Be aware of their safeguarding responsibilities and know what to do if they are a concerned about a child or young person.

Must be aware that celebrity visitors to the Trust must be escorted at all times and must not have

unsupervised contact with patients or visitors and ensure that arrangements are in place to facilitate

this.

Continue to listen to all concerns expressed or disclosures made by children and young people and

take appropriate action to safeguard them

Continue to remain vigilant, challenge and report all unauthorised visitors to clinical areas

Never use their position within the Trust to arrange unauthorised access for celebrities /VIP guests.

Be able to inform Senior Managers of any observed inappropriate behaviour or interaction by the Celebrity/VIP during their visit.

Follow the Child Protection Procedures and Trust Whistleblowing Policy when necessary.

Access further advice from the Trust Safeguarding Unit and follow normal safeguarding procedures to report concerns appropriately.

Contact the Communications Team if they are approached directly by a celebrity/VIP to make a visit to the hospital. The Communications Team will then take on the management of that visit.



7.6 Customer care and behaviour of staff

Staff are reminded that as employees they are representatives of the Trust and are expected to behave professionally at all times. During VIP/Celebrity visits, staff should continue in their roles as normal while supporting the management of the visit where appropriate.

Visitors to ward areas should always be greeted warmly by staff and treated respectfully throughout their visit.

• Staff must not approach celebrities or VIPs on wards, corridors or other areas on site unless advised to do so by the Communications Team as this can affect ongoing relationships with the guest. This includes asking for photographs or autographs.

• During visits, staff should not be present unless they are there as part of their jobs or are part of the visit. Any staff who are not supposed to be present during a visit will be asked to leave immediately.

• Staff must not invite their friends or family onto wards during visits and any unaccounted visitors of this nature will be asked to leave the premises immediately. Any staff involved in this practice may be reported to their Line Manager.

• Staff should be able to report any inappropriate conduct observed or remarks made to them or their colleagues by the celebrity / VIP during their visit to their line manager or the Trust’s Safeguarding Unit.

7.7 Staff dealing with complaints Staff dealing with complaints must report any complaint in relation to a celebrity/VIP visitor immediately to their manager and consider, as a priority, if the safeguarding team need to be alerted.

8 Training Requirements

There are no specific training requirements in relation to this policy.

9 Monitoring and Compliance Managed by the Head of Communications, compliance with this policy will be monitored on an ongoing basis after each celebrity / VIP visit. This will include an evaluation meeting post-event to assess its compliance with procedures outlined within this policy together with feedback from staff and those involved in the visit. Where deficiencies are identified, an action plan will be devised by the Head of Communications.

10 References There are no references however a number of Trust policies are relevant and related to this policy, including:

Information Governance Policy version 5 2013

Safeguarding Children Policy version 3 2013

Safeguarding Adult Policy version 9

Infection Control Policy

Raising Concerns (Incorporating Whistleblowing) Policy 2014 v 1



11 Method for Development

The following representatives have been consulted in the development of this policy, including:

The Trust Safeguarding Unit

Head Nurse for Paediatrics

Matron for Paediatrics

Information Governance Team

Communications Team

Trust Security Team



12 Appendices

12.1 APPENDIX A: Infection Control Guidance for Visitors

To reduce the risk of passing infection on to our patients, all visitors must be aware of the basic infection control procedures in place across the hospital. The below information should be provided to any celebrity/VIP and accompanying media on visits to the Trust. The Communications Team must ensure that all visitors are aware of and adhere to the following:

Hand washing

Alcohol hand sanitizers are available on the entrance to all Wards and Departments. Please clean your hands on entering or leaving every clinical area. Using the hand sanitizer kills any germs on your hands. Washing your hands with soap and water or using the hand sanitizer before you go into each patient’s bed space and then leaving their bed space is important as it reduces the risk of spreading infection to others. Bare below the elbow We ask all individuals who will have patient contact on their visit to remove any hand jewellery such as wrist watches, bracelets and stoned rings. They should also remove long sleeve clothing or roll up long sleeves to facilitate easier decontamination of the hands. If ties are to be worn, a tie pin should be used to prevent them coming into contact with the patient. Don’t sit on the bed We ask all visitors not to sit on a patient’s bed as they may pick up microorganisms on their clothing which they may then transfer to other patients. Infectious diseases If you have an infectious condition such as chickenpox, influenza or diarrhoea and vomiting, we ask that you don’t visit the Trust as these infections pose a risk to others. If you require any further advice please contact the Communications Team on 0121 424 3337 or [email protected] who can connect you with one of our Infection Control Nurses.

mailto:[email protected]



12.2 APPENDIX B: Safeguarding guidance for celebrity/VIP guests

Visitors to our hospitals bring excitement and joy to our children, young people and their families and we look forward to your arrival. To ensure the safety of our patients at all times and to ensure that your visit runs safely and smoothly, we politely request that you familiarise yourself with the guidelines below before you arrive:

The hospital’s Communications Team must be notified in advance of all visits from celebrities/VIPs on 0121 424 3337 and the purpose of the visit must be made clear.

When you come to the hospital you will be met by a member of the Communications Team who will escort you to your designated area. They will supervise all contact with children and young people during your visit as their safety is our priority. You will not be left alone with a patient at any time.

Gifts for children and young people are always welcomed as we know how much this means to them, but we ask that under all circumstances your kind donation is made via the hospital, not directly to a patient’s home address.

Photography and/or filming with a child or young person must be approved by the hospital Communications Team once a consent form has been signed by a parent/guardian.

For patient confidentiality reasons, you must not initiate further communication with the children and young people after your visit, i.e. through social networking sites. Approaches must be made via the Communications Team who will contact the child’s parents/guardian on your behalf.

Our staff are encouraged to be vigilant and confront and report all unauthorised visitors to the hospital, so please don’t be offended if you are challenged about your actions while you are onsite. They are helping to protect our children and young people.

Staff are also expected to report anyone they suspect to be using their position to help a celebrity/VIP visitor gain unauthorised access to children or young people.

The Trust recognises that all children and young people have equal rights to protection from harm, and that all adults have the responsibility to protect them from harm.

If you have any questions, concerns or comments about our guidelines above, please contact the

Communications Team on 0121 424 3337 who can assist you further.

Thank you for taking the time to read our guidelines. We look forward to your arrival at our hospital.



12.3 APPENDIX C: Consent Form for photography/filming/interviewing for media purposes - VIP/Celebrity Visits

We are asking for your permission for your child to help us in developing and sharing the work done at the Heart of England NHS Foundation Trust. As part of our communications and fundraising activity we work closely with members of the press and will always try to be sensitive to your situation. You are able to withdraw this consent at any time.

Event/Occasion/Location Date

Name of patient/child Date of birth

Ward

Name of parent/carer

Address

Email Phone

I have parental/guardian responsibility for and give my consent to the images of the child named above to be used in any of the following:

Please tick all that apply

Websites – use on Heart of England Foundation Trust website

Websites – use on external or partner websites

Radio interviews – to be broadcast on regional or national radio

Filming - to be shown inside or outside the hospital, including regional or national television

Publications – for use in regional or national media or Heart of England NHS Foundation Trust promotional material

I understand that the material to be produced is intended for public circulation and/or for publication the mass media. Where photographers and film makers are involved from outside of the Trust I understand that the Trust has no control over how these images may be used in the future. I understand that if I wish this consent to be withdrawn I should contact the Communications Team office in writing and their child will be removed from any database of images that is held. I accept the conditions of this agreement:

Signature Print Name Date

Patient

Parent/carer

On behalf of the Trust

This document can be made available in other languages and formats if requested.

I DO NOT WANT the images to be used for any of the above purposes. I understand any photographs taken are for my personal use and I agree not to publish these images without permission.

Please tick



13 Attachments

13.1 Ratification Checklist

Yes/No/Unsure Comments

1 Title: VIP and Celebrity Visitors Policy YES

Is the title clear and unambiguous?

Is it clear whether the document is a guideline, policy, protocol or standard?

YES

2 Rationale

Are reasons for development of the document stated?

YES

3 Development process

Is the method described in brief? YES

Are people involved in the development identified? YES

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

YES

Is there evidence of appropriate consultation with stakeholders and users?

YES

4 Content

Is the objective of the document clear? YES

Is the target population clear and unambiguous? YES

Are the intended outcomes described? YES

Are the statements clear and unambiguous? YES

5 Evidence Base

Is the type of evidence to support the document identified explicitly?

YES

Are key references cited? YES

Are the references cited in full? YES

Are supporting documents referenced? YES

6 Approval

If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?

NO

7 Dissemination and Implementation

Is there an outline /plan to identify how this will be done?

YES

Does the plan include the necessary training/support to ensure compliance?

YES

8 Document Control

Does the document identify where it will be held? YES

Have archiving arrangements for superseded documents been addressed?

9 Process to Monitor Compliance and Effectiveness

Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document?



Is there a plan to review or audit compliance with the document?

10 Review Date

Is the review date identified?

Is the frequency of review identified? If so, is it acceptable?

11 Overall responsibility for the Document

Is it clear who will be responsible for coordinating the dissemination, implementation and review of the document?

Policy Review Group Approval

If you are happy to approve this document please sign and date

Committee Approval

If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintain the organisation’s database of approved documents

Name

Date

Signature



13.2

14 Equality and Diversity - Policy Screening Checklist

Policy/Service Title: Celebrity and VIP Visitor Policy

Directorate: Corporate Nursing Patient Experience and Corporate Affairs

Name of person/s auditing/developing/authoring a policy/service: Maria Kilcoyne Head of Safeguarding and the Interim Head of Communications

Aims/Objectives of policy/service The purpose of this Policy is to inform staff and support providers of the Heart of England NHS Foundation Trust about procedures for organising and undertaking celebrity/VIP visits to the hospital and other Trust sites.

Policy Content:

For each of the following check the policy/service is sensitive to people of different age, ethnicity, gender, disability, religion or belief, and sexual orientation?

The checklists below will help you to see any strengths and/or highlight improvements required to ensure that the policy/service is compliant with equality legislation.

1. Check for DIRECT discrimination against any group of SERVICE USERS:

Question: Does your policy/service contain any

statements/functions which may exclude people from

using the services who otherwise meet the criteria under

the grounds of:

15 Response Action

required 16 Resource

implication

Yes 17 No Yes No Yes No

1.1 Age? √ √ √

1.2 Gender re-assignment? √ √ √

1.3 Disability? √ √ √

1.4 Race or Ethnicity? √ √ √

1.5 Religion or belief (including lack of belief)? √ √ √

1.6 Sex? √ √ √

1.7 Sexual Orientation? √ √ √

1.8 Marriage & Civil partnership? √ √ √

1.9 Pregnancy & Maternity? √ √ √

If yes is answered to any of the above items the policy/service may be considered discriminatory and

requires review and further work to ensure compliance with legislation.

2. Check for INDIRECT discrimination against any group of SERVICE USERS:


statements/functions which may exclude people from

using the services under the grounds of:

18 Response Action


implication


2.1 Age? √ √ √







2.6 Sex? √ √ √






TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING DIRECT DISCRIMINATION =

3. Check for DIRECT discrimination against any group relating to EMPLOYEES:


statements which may exclude employees from

implementing the service/policy under the grounds of:

21 Response Action


implication


3.1 Age? √ √ √





3.6 Sex? √ √ √






4. Check for INDIRECT discrimination against any group relating to EMPLOYEES:


conditions or requirements which are applied equally to

everyone, but disadvantage particular persons’ because

they cannot comply due to:

24 Response Action


implication


4.1 Age? √ √ √





4.6 Sex? √ √ √








TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING INDIRECT DISCRIMINATION =

Signatures of authors / auditors: Date of signing: 13.5.15

Equality Action Plan/Report

Directorate: Corporate Nursing

Service/Policy: Celebrity and VIP Visitor Policy

Responsible Manager:Maria Kilcoyne Head of Safeguarding

Name of Person Developing the Action Plan: Maria Kilcoyne

Consultation Group(s): Safeguarding Adult and Child Committees, Safeguarding Team, Communications team,

Paediatric Head Nurse/ Matron

Review Date: May 2018

The above service/policy has been reviewed and the following actions identified and prioritised.

All identified actions must be completed by: December 015_________________________________________

Action: Lead: Timescale:

Monitoring Head of Communications and Safeguarding

December 2015

Training/Awareness Raising/Learning to be incorporated into all exin Head of Safeguarding June 2015



all existing safeguarding training

Communications Trust wide at the time of the launch Head of Communications June 2015

When completed please return this action plan to the Trust Equality and Diversity Lead. The plan will

form part of the quarterly Governance Performance Reviews.

Signed by Responsible Manager:

Date: 13.5.15



26.1 Launch and Implementation Plan

Action Who When How

Identify key users / policy writers

Head Nurses, Communications, All Managers

January 2016

Via the Senior Nursing and Operational Networks

Present Policy to key user groups

All staff January 2016

Via Trust wide communications

Add to Policies and Procedures intranet page / document management system.

Communications Team

January 2016

Offer awareness training / incorporate within existing training programmes

To be included in all Safeguarding training – level 1-3

January 2016

Via delivery of safeguarding training

Circulation of document(electronic)

Communications Team/ Corporate Nursing Team

January 2016

Via existing cascade mechanisms and trust wide communications.

Consent for Examination or Treatment Policy

CATEGORY: Policy

CLASSIFICATION: Clinical Governance

PURPOSE To set out the agreed policy for

obtaining consent from patients

prior to examination or

treatment

Controlled Document Number: Version Number: 1

Controlled Document Sponsor: Dr David Rosser Deputy CEO

Corresponding Authors: Richard Steyn & Lorna Grinnell-

Moore

Controlled Document Lead:

Ratified By: Chief Executive

On: Review Date: Distribution

Essential Reading

for:

Information for:

All those who carry out

examinations or treatment on

patients. All those with

delegated responsibility to take

consent

Consent for Examination or Treatment Policy 1 Policy Statement 1.1 The purpose of this policy is to detail clearly the structures and procedures, both

Trust-wide and at specialty level, that apply to consent for Examination or Treatment.

1.2 The Department of Health has issued a range of guidance documents on

consent (see references section), and these should be consulted for details of the law and good practice requirements on consent. This policy sets out the standards for staff at the Trust taking consent to ensure they comply with the guidance, common law, Human Tissue Act 2004 and the Mental Capacity Act 2005. While this document is primarily concerned with healthcare, social care colleagues should also be aware of their obligations to obtain consent before providing certain forms of social care, such as those that involve touching the patient or client.

2 Scope 2.1 This Policy applies to all clinical services of the Trust and all clinical staff

employed by the Trust including contractors, volunteers, students, locum and agency staff and staff employed on honorary contracts.

2.2 The policy does not cover taking consent for the following:

2.2.1 consent for photographic images; this is detailed in the Trust Photographic, Video and Mobile Device Consent and Confidentiality Policy;

2.2.3 data protection or use of patient records; and 2.2.4 clinical trials

3 Framework 3.1 This section describes the broad framework for obtaining of consent for

examination or treatment. Detailed operational instructions for the implementation of this policy are contained in the associated Consent for Examination or Treatment Procedure. The procedure may be amended by authority of the Medical Director, provided that such amendments are compliant with this policy.

3.2 The Trust's framework for ensuring full participation in consent encompasses the

following: 3.2.1 All staff providing care or treatment to a patient will first ensure that the

patient has consented to receive treatment. 3.2.2 All staff who obtain consent to treatment will either:

a) be able to carry out the procedure; or b) be deemed competent to take consent for the procedure and have

delegated authority to do so in accordance with the Consent for Examination or Treatment Procedure.

3.3 FY1 Doctors should not obtain consent for the performance of a procedure or

examination by another practitioner.

If an FY1 Doctor is being supervised whilst performing a procedure the supervising practitioner should obtain consent. If FY1 Doctors are competent to perform a procedure unsupervised then the FY1 Doctor should obtain consent from the patient and where appropriate this should be evidenced by written consent.

3.4 If there is any suggestion that a patient lacks the capacity to consent then the

practitioner will undertake an assessment of the patient’s capacity, in line with the Mental Capacity Act 2005.

3.5 All staff making decisions on behalf of a patient who lacks capacity will, wherever

possible, consult with the patient's representative and or carers as appropriate and will ensure, based on all evidence available, that the care provided is in the patient's best interest and take account of any preferences previously expressed by the patient.

3.6 All staff will respect patient's refusal of treatment when the patient is considered

to have capacity to consent subject to 3.5. 3.7 When obtaining consent from a patient, information about what the examination

or procedure entails and the risks, benefits and alternatives must be communicated in a way that the patient can understand. Whenever possible this information should be supported with patient information leaflets.

3.8 Where tissue is to be taken during a procedure for storage or use, specific

consent must be taken and this must be recorded on the appropriate section of the consent form.

3.9 Training will be available to relevant staff Delegated Consent 3.10 Clinical Directors in each specialty must ensure that the protocol for obtaining

consent is followed and delegated consent competency is completed for each delegate. This will act as a guide to Junior Doctors and the Safety and Governance Department when undertaking any audit of consent.

4 Duties 4.1 Medical Director is responsible for ensuring there is a framework for reviewing

compliance with the Trust policy and procedure, ensuring that the policy remains fit for purpose and is reviewed as required and at least every three years. This may be delegated to the Safety and Governance Department.

4.2 The Deputy Director for Governance

4.2.1 is responsible for monitoring adherence to this Policy as set out in the monitoring matrix in Appendix A.

4.3 Clinical Director/Senior Nurse Senior Nurse refers to Matron or Sister/Charge Nurse Clinical Director or Senior Nurse are responsible for ensuring that:

4.3.1 staff who will be given responsibility for taking delegated consent are identified and registered within their specialty; 4.3.2 a local procedure specific training programme is in place for staff to whom the consent process is delegated, and who are not capable of performing the procedure; 4.3.3 the Consent Competency Protocol, or a local equivalent, agreed with the Safety and Governance Department, is completed for each individual, and will provide confirmation that staff taking delegated consent have been given appropriate training to take consent for specific procedures; 4.3.4 a list of all individuals identified as taking delegated consent, and all completed competency statements are sent to the Faculty of Education. 4.3.5 where the annual consent audit identifies staff who have obtained consent for a procedure without being authorised to do so according to the Competency Statement records held, , the staff member is immediately informed that they must not undertake such consent until they have been assessed as competent to do so;

a) the staff member is given the appropriate training and has an assessment of competency undertaken within 28 days; b) the competency assessment document is sent to Safety And Governance Department.

4.3.6 If the annual consent audit identifies consent being obtained by FY1 level doctors inappropriately (see paragraph 3.3) then they will immediately inform that Doctor to stop taking inappropriate consent and advise their Clinical Director and their Educational Supervisor. 4.3.7 Ensuring that action plans are produced within their specialty, when necessary, as a result of the annual consent audit.

4.4 Divisional Directors/Associate Medical Directors The Divisional Directors/Associate Medical Directors will

4.4.1 ensure Clinical Directors or Governance Leads identify where delegated consent is taken by staff not capable of performing the procedure, and maintain a register of those staff approved to obtain delegated consent and copies of their competency assessments. 4.4.3 maintain a record of which specialties undertake delegated consent, and contact Clinical Directors or Clinical Governance Leads and the Faculty of Education annually to ensure that this record is updated where required; 4.4.4 holding records of the individuals taking delegated consent, as identified by specialties; 4.4.5 holding records of all competency statements supplied by specialties. 4.4.6 monitoring compliance by conducting an annual consent audit, which will include checking that consent is being taken only by the appropriate staff in accordance with records of competency statements. 4.4.7 contacting the Clinical Service Lead where annual consent audit identifies staff who have obtained consent for a procedure without being authorised to do so according to the competency statement records held.

4.5 Medical recruitment Will send Divisional Directors/Associate Medical Directors and the Faculty of Education a list of all medical training grade new starters and start dates on a monthly basis.

4.6 Faculty of Education

4.6.1 The Faculty of Education will be responsible for ensuring that any delegated consent protocol or local guideline includes details of how nursing and other staff are identified for taking delegated consent in the specialty, the arrangements for training and competency assessment, and the monitoring and auditing arrangements to ensure that all staff who obtain consent are authorised to do so. 4.6.2 Ensure the protocol or local guideline is on the Intranet.

4 7 All Staff All staff providing treatment are responsible for ensuring:

4.7.1 that valid and effective consent has been provided by the patient and where written consent is required all Trust documentation has been completed as appropriate; 4.7.2 that where they are making decisions on behalf of a patient who lacks capacity they will, wherever possible, consult with the patient's representative and or carers and will ensure, based on all evidence available, that the care provided is in the patient's best interest and take account of any preferences previously expressed by the patient. 4.7.3 Will respect patient's refusal of treatment when the patient is considered to have capacity to consent subject to section 3.5 of the Procedure. 4.7.4 that they complete an incident form in line with the Incident Reporting and Management Policy and Procedure if there is any breach of this policy.

4.8 Consultant Staff

4.8.1 have an overall responsibility for the care of the patient and this will also extend to ensuring consent is appropriately obtained. 4.8.2 are to ensure that when delegating consent, delegates are fully trained and competent to obtain consent for the procedure in accordance with the Consent for Examination or Treatment Policy.

5 Implementation and Monitoring 5.1 Implementation

5.1.1 This policy will be communicated to all relevant staff via email. 5.1.2 The policy itself will be made available on the Trust intranet site.

5 2 Monitoring Appendix A provides full details on how the policy will be monitored

by the Trust. 6 References Department of Health (2009) Reference guide to consent for examination or

treatment, 2nd Ed. (online) available at www.dh.gov.uk UK Parliament (2004) Human Tissue Act UK Parliament (2005) Mental Capacity Act Dept. Constitutional Affairs (2007) Mental Capacity Act 2005 Code of Practice

(online) available at www.dca.aov.uk/leqal-policv/mentalcapacitv/mca-cp.pdf General Medical Council (2008) Consent: patients and doctors making decisions

together, (online) available at www.gmc-uk.org Nursing & Midwifery Council (2008) Consent, (online) available at www.nmc-uk.org

http://www.dh.gov.uk/

http://www.dca.aov.uk/leqal-policv/mentalcapacitv/mca-cp.pdf

http://www.gmc-uk.org/

http://www.nmc-uk.org/

Human Tissue Authority (2009) Code of Practice 1: Consent, (online) available at www.hta.gov.uk

NHSLA (2012/13) NHSLA Risk Management Standards 7 Associated Policy and Procedural Documentation

7.1 Consent for Examination or Treatment Procedure 7.2 Delegated Consent Policy 7.3 Photographic, Video and Mobile Device Consent and Confidentiality Policy 7.4 Incident Reporting and Management Policy and Procedure

http://www.hta.gov.uk/

APPENDIX A: Monitoring

Monitoring Of

Compliance

Monitoring Lead

Reported To

Person/Group

Monitoring

Process

Monitoring

Frequency

Adherence to this

policy will be

monitored by the

Safety and

Governance

Department via

an annual Trust

wide audit of

consent.

Deputy Director

of Governance

Medical Director,

Deputy Medical

Directors,

Divisional

Directors/

Associate Medical

Directors

This will involve

auditing a

random sample

of consent forms

from those taking

written consent in

the Trust to

ensure that

documentation is

being completed

and that consent

is being taken

only by the

appropriate staff.

Annually

The results of the

audit will be

disseminated to

specialty level

where an action

plan to improve

the completion of

the consent

forms will be

generated,

Deputy Director

of Governance

Clinical Directors,

exceptions will be

reported to the

Divisional

Directors/Associate

Medical Directors.

The responsibility

for producing and

implementing this

action plan will be

that of the

Clinical Directors

or Senior Nurses

depending on the

group of staff

involved.

The

implementation of

these action

plans will be

monitored by the

Safety and

Governance

Department and

exceptions

reported to

Medical Director,

Divisional

Directors/

Associate

Medical

Directors.

Annually

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