council of governors · 7. membership strategy 2014/16 enclosure to approve the membership strategy...

COUNCIL OF GOVERNORS A meeting of the Council of Governors will be held at 10.00 am on Wednesday 19th November 2014, in Rooms 9 & 10, Education Centre, Queen Elizabeth Hospital Presentation: Gateshead Youth Assembly – Sarah Gascoigne, Appointed Governor

A G E N D A 1. Apologies for Absence: 2. To Sign the Attendance Register: 3. Chairman’s Business 4. Minutes of the Previous Meeting Enclosure

To approve the minutes of the previous meeting of the Council of Governors held on Wednesday 24th September 2014

5. Matters Arising from the Minutes 6. Chief Executive’s Briefing To Follow

To receive the Chief Executive’s routine briefing report Items for Decision:‐ 7. Membership Strategy 2014/16 Enclosure

To approve the membership strategy for 2014/16, presented by the Trust Secretary

Items for Discussion:‐ 8. Better Care Fund Presentation

To receive a presentation on the Better Care Fund presented by Dr D Cowie, Gateshead Clinical Commissioning Group

9. Membership Development Working Group Enclosure

To receive a progress report on the work of the Membership Group, presented by the Chairman of the Group

10. Governor Activities Enclosure

To receive a report on the activities of governors, presented by the Trust Secretary

11. Membership Feedback Verbal

For governors to feedback on events attended and activities undertaken, and to report any queries or comments received

Items for Assurance:‐ 12. Complaints, Litigation, Incident and PALS (CLIPA) Report Summary Enclosure To receive a summary report from the Head of Risk Management

on the Complaints, Litigation, Incident and PALS Report 13. Finance and Activity Performance Presentation

To receive a report on the Trust’s current performance, presented by the Director of Finance and Information

14. Monitor Q1 Return Enclosure

To receive the Q1 return and correspondence from Monitor presented by the Director of Finance and Information

15. Performance Report Enclosure

To receive the routine briefing report presented by the Strategic Head of Performance

16. Patient Led Assessment of the Clinical Environment (PLACE) Enclosure

Annual Assessment: To receive the results of the Place Visits presented by the Deputy Chief Executive

Items for Information:‐ 17. Election 2014 Update Enclosure

To receive an update on election process for 2014, presented by the Membership Co‐ordinator

18. Date and Time of Next Meeting The next meeting of the Council of Governors will be held on Wednesday 25th February 2015 at 10.00 am in Rooms 9 & 10, Education Centre 19. Exclusion of the Press and Public

To resolve to exclude the press and public from the remainder of the meeting, due to the confidential nature of the business to be discussed

COUNCIL OF GOVERNORS Minutes of a the Council of Governors Meeting held at 10.00 am on Wednesday 24th September 2014, in the Lecture Theatre, Education Centre, Queen Elizabeth Hospital Present: Mrs JEA Hickey Chairman Mrs E Adams Public Governor – Central Mr T Bryden Public Governor – Western Mrs F Butler Staff Governor Mr A Dougall Public Governor – Eastern Mrs A Ellinson Public Governor – Central Ms S Gallagher Public Governor – Central Mrs A Griniezakis Staff Governor Councillor J Hamilton Appointed Governor Mr B Hewitt Public Governor – Eastern Mr P Hopkinson Public Governor – Western Mrs M Jobson Public Governor – Eastern Dr F Kanu Public Governor – Central Mr A Kumar Appointed Governor Mrs J Lockwood Public Governor – Western Professor K McCourt Appointed Governor Mr M Pearce Appointed Governor Miss L Ritchie Public Governor – Western Mr A Sandler Appointed Governor Ms C Squires Public Governor – Western Mr I Stafford Staff Governor Mrs M Summers Public Governor – Western Mr R Thorold Appointed Governor Professor T Waring Public Governor – Central In Attendance: Mrs D Atkinson Trust Secretary Mr S Bowron Non‐Executive Director Mrs C Coyne Associate Director – Clinical Support and Screening Services Dr A Fairbairn Non‐Executive Director Mr K Godfrey Medical Director Mr P Harding Director of Estates and Facilities Mrs K Larkin‐Bramley Non‐Executive Director Mrs H Lloyd Director of Nursing, Midwifery and Quality Mr J Maddison Director of Finance and Information Mrs Y Ormston Deputy Chief Executive Mr J Robinson Non‐Executive Director Mrs J Williamson Membership Co‐ordinator 5 public members Apologies: Mr S Atkinson Associate Director – Surgical Services Mr J Bolam Public Governor – Central Mr M Brown Non‐Executive Director Dr J Bryson Non‐Executive Director Miss S Gascoigne Appointed Governor Mr M Henry Non‐Executive DirectorMs C Hesketh Associate Director – Medical Services Mrs S Pearson Associate Director – Strategic Transformation Programme

Agenda Item Discussion and Action Points Action

By G/14/38 CHAIRMAN’S BUSINESS:

The Chairman opened the meeting by asking if anyone present had any revisions to their declared interests. She informed the group that Mrs G Huthart, public governor and Mr S Dae, staff governor, had left the Council of Governors. She reported that the vacancies left by their departures will be filled at the next elections beginning in October 2014. The Chairman thanked both Mrs Huthart and Mr Dae for their support during their time with the Trust and wished them both well for the future. The Chairman continued informing the group that the recent FTGA ballot had resulted in them joining the Foundation Trust Network. She stated that this should ensure a more coordinated approach in general. She informed the group that Mr J Connolly, Director of Finance and Information, had left the organisation in June and Mrs G MacArthur, Director of Nursing, Quality and Midwifery, had retired. She welcome Mr J Maddison, newly appointed Director of Finance and Information, to his first meeting of the Council of Governors and informed the group that Mrs H Lloyd had been appointed as the Director of Nursing, Midwifery and Quality. The Chairman informed the group that this would be the last meeting for Mrs Y Ormston, the Deputy Chief Executive. Mrs Ormston is leaving the Trust to take up the role of Chief Executive at the North East Ambulance Service. The Chairman wished Mrs Ormston well in her new post and thanked her for her work with the Trust. She reported that interviews for the role of Director of Strategy and Transformation would be taking place the next day. In light of Mrs Ormston's departure, Mr P Harding, Director of Estates and Facilities, will take over the role of Deputy Chief Executive. The Chairman concluded her report by informing the group that the next workshop for governors will take place on Wednesday 8th October from 10.00 am to 12.00 noon.

G/14/39 MINUTES OF THE PREVIOUS MEETING:

The minutes of the Council of Governors Meeting held on Wednesday 21st May were agreed as a correct record subject to minor amendments.

G/14/40 MATTERS ARISING FROM THE MINUTES:

The action plan was updated to reflect matters arising from the minutes.

G/14/41 UPDATED DECLARATION OF INTEREST:

Mrs D Atkinson, Trust Secretary, presented an amendment to the Register of the Council of Governors Interests for 2014/15 for Mr R Thorold, appointed governor.


By

Name Position Interest Interest of Spouse Mr Richard Thorold

Appointed Governor

Owner and Director of Emarit Owner and Director of ICOVES

None

After further discussion, it was agreed: RESOLVED: to note and record Mr Thorold’s updated declaration of interests

G/14/42 CHIEF EXECUTIVE’S BRIEFING:

Mr ID Renwick, Chief Executive, presented his routine briefing report. He began by reporting that the completion of the new Emergency Care Centre continues and both the interior and exterior are starting to take shape. Mr Renwick stated that following some inevitable minor delays to the timetable the anticipated handover from Millers is expected on or around the 24th November 2014. Following this handover a period of five to seven weeks will be needed to install specialist equipment and to thoroughly clean the building and the process of staff familiarisation will begin in earnest. Mr Renwick stated that this should allow the building to become operational sometime between Christmas and early in the New Year, subject to service demands and pressures. He continued reporting that the Pathology hub has now opened with services for the three South of Tyne FTs now being provided. Mr Renwick stated that at the end of July, the CCG Alliance received formal confirmation from the Department of Health that its application to formally merge with effect from 1st April 2015 had been approved. He stated that the Trust will be working closely with CCG colleagues and he looks forward to relationships being developed further. He reported that the Trust has recently taken up a seat as a member of the Gateshead Health and Well Being Board. Recently Cllr L Caffrey has been appointed Chairman of the Board and Mr Renwick has met with Cllr Caffrey as part of her induction programme. Mr Renwick informed the group of the recent changes to the Executive Director team. He informed the group that Mrs H Lloyd is now Director of Nursing, Midwifery and Quality after Mrs G MacArthur’s retirement, and Mr J Maddison has replaced Mr J Connolly as Director of Finance and Information. He concluded his report by extending his good wishes to Mrs Y Ormston in her new role of Chief Executive of the North East Ambulance Service. He stated that he is looking forward to working closely with Mr P Harding in his new role as Deputy Chief Executive. After consideration, it was: RESOLVED: to receive the report for information


By G/14/43 ANNUAL REPORT AND ACCOUNTS 2013/14:

Mr ID Renwick, Chief Executive, presented the Annual Report and Accounts 2013/14 for information. He stated that the Trust is required to produce an Annual Report, which is a retrospective look back at the organisation’s performance. Mr Renwick stated that the Annual Report is a chance for the Trust to highlight its strong financial year and its excellent staff and achievements including those against core standards and targets set. He explained that the accounts show a technical deficit relating to asset valuation but that the underlying position is a small surplus. Mr Renwick gave an overview of the year’s highlights. He began by drawing attention to the Trust’s reduction in mortality and continued improvement in HCAI figures, which were driven by Mr K Godfrey, Medical Director and Mrs G MacArthur, Director of Nursing, Midwifery and Quality. The Trust maintained a relentless approach through the steering group and the task and finish group. He stated that once again a very good, healthy report card was achieved during the financial year, drawing attention to the unannounced CQC inspection and report that any hospital organisation would be proud of. The report concluded that there were no improvement actions and the comments from patients were incredibly positive and passionate. Mr Renwick continued focussing on the Trust’s achievement of CQC band 6 rating, reporting that the Trust is the only North East organisation that has achieved band 6 in all three ratings. He continued, reporting that the new Pathology laboratory and Emergency Care Centre will give opportunities for the new NHS, and they are already attracting interest from other geographically broader commissioners. Mr Renwick concluded his report by stating that the year’s set of results leave us in an incredibly good position to move forward. Professor T Waring, public governor, asked what impact the Better Care Fund (BCF) would have on the Trust going forward. Mr Renwick responded stating that the topic of the Better Care Fund is very relevant and was discussed at the previous day’s Board of Directors meeting, where the Trust Board signed off the submission for the Better Care Fund proposal for Gateshead. Mr Renwick stated that he will invite Dr D Cowie from the CCG to a future Council of Governors meeting to provide more information. He stated that the Better Care Fund is trying to reduce demand hospitals by handling patients outside of the hospital environment with the drive to be cared for in a different place. The CCG need to do a whole raft of things with the Better Care Fund and the need to support seven day working etc. Mr Renwick stated that there are risks but discussions with the Board of Directors and in the submission document have ensured that clarity has been gained and the operational

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By and strategic plans are much more prominent. There are risks but also opportunities to bring together better services for patients. Mrs A Griniezakis, staff governor, asked what the impact on staffing will be. Mr Renwick stated that seven day working will contribute to staff levels staying the same but there is no detailed plan as yet. The change will be in the delivery of care and the Better Care Fund will work differently but will be better covered. He reported that he feels there is clearly a drive to get more care delivered outside of hospital and an opportunity to re‐engineer more staff to be out in the community. Mrs A Griniezakis stated that other trusts are cutting staff massively. Mr Renwick stated that County Durham and Darlington Trust have reported they will be cutting 300‐400 jobs but stated that if this became an issue for Gateshead, the Trust will look to cut jobs through natural wastage in the first instance. Councillor J Hamilton, appointed governor, congratulated the Trust on an excellent report. He reported that he hears many positive stories from his constituents about the Trust. He stated that there are very big challenges ahead but the Trust is in a very strong position to lead the challenges. Mr P Hopkinson, public governor, asked if funding will move to other areas if patients are dealt with in other ways and at other places. Mr Renwick responded stating that this area is pretty much unknown and the level of detail is not yet available. He stated that the challenge is a broad one and the tariff and Better Care Fund will change the health service nationally. As an example of changing healthcare delivery, he reported that within the Trust, Dr Narayanan is working hard to change the pathways of care of diabetic patients to ensure that fewer people need to come into hospital for care and treatment. Miss L Ritchie, public governor, asked if the Better Care Fund plan could be shared with the Council of Governors. Mr Renwick stated that currently the document is confidential and has been submitted to NHS England. The Trust is awaiting 'blessing' and is going to test robustness of the process. He stated that the presentation from Dr D Cowie from the CCG will give an overview and information in the first instance. Mr R Thorold, appointed governor, asked if the asset impairment is reported every year. Mr Renwick stated that yes; it should be reported each year, however the large figure for the last two years has been driven by capital investments. Mr J Maddison, Director of Finance and Information, reported that the Trust has a requirement to revalue annually which has led to the impairment. Mrs A Griniezakis, staff governor, asked if the Trust is able to bid for outreach work. Mr Renwick stated that potentially yes the Trust could. We are expecting the community services tender to go out in the competitive market, and the Trust has an interest but as yet there is no specification on the service. South Tyneside will also have an interest and although there is a good working relationship between Trusts we would be competing against each other. Opportunities may also arise for some things that we don’t currently do but it is important that the work is smooth and streamlined and equally we will face risks through commercialisation.


By Professor T Waring, public governor, asked for clarification of the Challenging Behaviour Team. Mrs A Griniezakis, staff governor, reported that the service is run by the mental health team and they attend nursing homes to prevent patients coming to hospital who may have challenging behaviour. The team then keep patients in their care and help to make changes if necessary, if not the patient can be referred to a mental health ward. Mrs A Ellinson, public governor, stated that the impact of the merger of the CCG may have an impact on the health priorities which may not match between north and south. She stated that the voice of Gateshead still needs to be heard. Mr Renwick stated that the Health and Well Being Board have a public health team for Gateshead only and are looking to refresh of the Joint Strategic Needs Assessment to look at underlying health problems. The Board is still discussing the way forward. Mr P Hopkinson, public governor, asked if the Annual Report could be circulated to the Council of Governors in sufficient time to allow the full report to be read in detail. Mrs D Atkinson, Trust Secretary, agreed to take this forward from next year. After further discussion, it was: RESOLVED: to receive the Annual Report and Accounts 2013/14 for information

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G/14/44 ANNUAL MANAGEMENT LETTER 2013/14:

Mr J Maddison, Director of Finance and Information, presented the work on the Annual Audit for 2013/14 on behalf of KPMG. He began by giving an overview on the issues included in the audit approach including use of resources and the quality report. Mr Maddison reported that the financial statements audit resulted in an unqualified opinion. No unadjusted audit differences were identified and a number of disclosure changes were recommended and adopted. Overall, the audit provided a clean bill of health. He also reported that the Trust’s Annual Report is consistent with the financial statements. Five recommendations were also raised, all of which were graded as low or medium. Mr Maddison continued reporting that the use of resources looks at such things as governance arrangements and internal audit work. Three potential key risks were identified at planning but no significant issues were identified. Overall the Annual Governance Statement reflects KPMG’s understanding of the Trust’s operations and risk management arrangements. He then discussed the Quality Report and stated that the Trust achieved limited assurance opinion, which is a clean opinion, on the content of the report and limited assurance on the two mandated indicators (clostridium difficile and 62 day cancer). Mr Maddison stated that no opinion was required this year on the local indicator (incidents resulting in severe harm) and three recommendations were raised and agreed


By with management. After consideration, it was: RESOLVED: to receive the report for information

G/14/45 MEMBERSHIP DEVELOPMENT WORKING GROUP:

Mrs D Atkinson, Trust Secretary, gave an update on the work of the Membership Development Working Group. She reviewed the paper, agenda item 10, highlighting the membership totals and the recent work. Mrs Atkinson reported that a ‘roadshow’ type Medicine for Members has been arranged in Ryton. This has been requested so that members in the Western constituency can access the successful events. She stated that Mrs M Jobson and Mrs E Adams, public governors, continue to work hard to recruit members in the Trust’s Outpatient department. Mrs Atkinson reported that along with Mrs F Butler, staff governor, she attended a community event in Washington. The group was very interested in the work going on within the hospital and feedback was received including comments about food, car parking and the hospital environment. She encouraged governors to attend community events as these are an excellent opportunity to meet with members and inform them of the work of the Trust. Mrs Atkinson concluded by reporting that at the next meeting the group will be reviewing the terms of reference of the group along with the membership strategy before bringing to the next Council of Governors meeting for final approval. After consideration, it was: RESOLVED: to receive the report for information

G/14/46 GOVERNOR ACTIVITIES:

Mrs D Atkinson, Trust Secretary, presented to the group a report compiled from governors’ attendance at meetings and events. She stated that this report provides a useful tool for governors and the membership office to understand where governors have been and what they have achieved. This is also a useful report to record additional governor activity and highlight work and time taken and given to the role. Mrs Atkinson drew attention to the paper, agenda item 11, and the attached appendix which showed how governors are carrying out their role. Mr ID Renwick, Chief Executive, stated that the amount of work and input from governors is astonishing and gave thanks to the governors from the Board of Directors


By and Executive Team. After consideration, it was: RESOLVED: to receive the report for information

G/14/47 MEMBERSHIP FEEDBACK:

Mrs M Jobson, public governor, reported that she had recently attended visits to radiology and the bowel screening hub. She expressed her praise of the staff and their welcome and openness and stated that she really appreciates their dedication. Mrs J Lockwood, public governor, reported that she, along with a number of other governors, had recently visited the new pathology centre. She stated that she found the visit very interesting. Mr B Hewitt, public governor, stated that he had recently taken part in the 15 step challenge at Cragside Court. He stated that he was not only impressed with the building but particularly with the fantastic staff dealing with the patients. Miss L Ritchie, public governor, reported that she had recently attended a visit at the Tranwell Unit. She stated that she felt the visit was fantastic and certainly an eye opening experience. She was impressed with the improvements being made and level of detail e.g. rooms and activities. Miss Ritchie also stated that she had attended the pathology centre visit and asked for further information on the future plans and the marketing strategy for the centre. Mr ID Renwick, Chief Executive, stated that the Trust is currently pulling together business and marketing plans especially for pathology but will be happy to share this information, once completed, at a future meeting. He also reported that the Trust recently experienced some positive media coverage regarding the treatment of young people with dementia. Mr A Kumar, appointed governor, stated that he had recently attended visits to pathology and the bowel cancer screening hub. He was very impressed with bowel cancer screening department and the guide answered all questions in an all‐round excellent visit. Ms C Squires, public governor, stated that he had also attended the bowel cancer screening visit and found the experience excellent. She stated that seeing the process for samples gives insight to the question of whether people should take the test. Dr F Kanu, public governor, stated he had recently been involved in the PLACE exercises and passed his commendation of the excellent staff in putting things right and also the feedback of patients which was very inspiring. Dr Kanu also stated that a number of governors had attended Gateshead College to recruit new members. He informed the group that the event had been successful and a large number of students had been recruited. Mrs M Summers, public governor, gave her thanks to Mrs D Atkinson and Mrs J Williamson for their work in organising a Medicine for Members event in the western constituency. She stated that she had particularly asked for the event as it is hard for

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By members to come to QE so hopefully this will work well. Miss L Ritchie, public governor, asked for clarification on social media and role of governors. She stated that she had become aware of a community group on Facebook in her area and asked for guidance for governors in dealing with queries on social media. Mr ID Renwick, Chief Executive, suggested that Miss Ritchie talk to Mr R Wigham, Head of Communications, regarding this issue. Mr Renwick explained that recent use of social media had included work on recruitment of nurses for the ECC and had resulted in an excellent attendance. Mrs D Atkinson, Trust Secretary, agreed to organise for Miss Ritchie to speak to Mr Wigham.

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G/14/48 FINANCE AND ACTIVITY PERFORMANCE:

Mr J Maddison, Director of Finance and Information, presented the financial headlines. He explained that within the plan set at the beginning of the financial year the Trust were to have a £1.6m operational surplus at this stage. However, the current position shows a £1.6m deficit. This is due primarily to shortfalls in income and cost pressures, including on staffing costs. Mr Maddison stated that the ability to deliver £8.5m savings is increasingly difficult and challenging. He reported that currently the Trust is £3.2m away from plan both at the operational and overall level and at the end of month 5 the cash stood at £8.5m. This will continue to reduce as capital schemes progress. He stated that the under delivery on income has produced pressures on pay budgets and the challenge is to start to reverse the position. However, inevitably this will carry forward to the next financial year. Mr Maddison gave an overview of the on‐going risks. He explained that even though the economy is recovering, the current financial environment continues to be very difficult. However, the Trust has a good local agreement with Gateshead CCG through a cost envelope to provide certainty on income in the year. He also explained that delivering a 4% recurrent cost improvement programme is also increasingly challenging. The NHS Foundation Trust sector nationally is in deficit in Q1 for the first time and 80% of acute Trusts are in deficit. Mr Maddison concluded his report by stating that the main challenge is to maintain and develop quality, whilst driving cost reduction. Mr A Dougall, public governor, asked if the 4% recurrent cost improvement programme could be overturned in light of the general election. Mr Maddison stated that the plans are unknown however the Trust needs to work towards the 4% that is currently in place. Mr R Thorold, appointed governor, asked for clarification of the Trust’s risk rating of 2. He stated that he feels this is obviously of concern however Monitor’s website is confusing and doesn’t flag this up well. Mr Maddison replied stating that the system doesn’t generally flag early. The Trust’s current risk rating is a 2 but is expected to return to a 3 by the end of Q2, through cash management strategies. The income and expenditure position will continue, however,


By to put pressure on the rating going forward. He continued stating that Monitor have concerns around CRP and the ability of Trusts to deliver at 4%. This continues to be a problem year on year and there are achievements but also fixed costs, and the ability to drive savings becomes difficult. The Trust needs to develop how to become more efficient and will revisit the plans for 2014/15 and the next three years. Mr R Thorold, appointed governor, asked how much of the deficit is attributable to sickness cover. Mr Renwick responded stating that sickness cover is covered by bank staff so therefore uses very little of the £1.6m deficit. He also stated that there is a budget built in for an element of sickness levels. Mr J Maddison stated however, that if the Trust is able to greater manage the organisation’s sickness then the budget requirement could possibly reduce. Mr R Thorold, appointed governor, thanked Mr Maddison for a very simple and refreshing financial update report. After consideration, it was: RESOLVED: to receive the report for assurance and information

G/14/49 MONITOR Q4 RETURN AND 2014/15 ANNUAL PLAN REVIEW OF FOUNDATION TRUSTS:

Mr J Maddison, Director of Finance and Information, presented the results of Monitor’s review of the two year operational plan phase of the 2014/15 annual plan review (APR) as well as the Quarter 4 2013/14 monitoring cycle. Mr Maddison confirmed that based on this work, the current and forecast risk ratings are: Q4

13/14 (actual)

Q1 14/15 (plan)

Q2 14/15 (plan)

Q3 14/15 (plan)

Q4 14/15 (plan)

Continuity of service risk rating 4 3 3 4 3 Governance risk rating Green

The letter also highlights the risks from Monitor’s review of the Trust operational plan and Quarter 4 submissions which include the level of borrowing and the Trust’s cost improvement programme target. Following further discussion, it was: RESOLVED: to receive the report for assurance and information

G/14/50 PERFORMANCE REPORT:

Mrs Y Ormston, Deputy Chief Executive, provided an update on performance against national and local targets. She reported that the data relating to cancer performance measures is still subject to


By patch‐wide validation however the quarterly performance position in the Risk Assessment Framework represents an under‐performance in urological and gynaecological tumour sites. The 62‐day target remains under pressure and may be a red at the end of Q2. The Trust is compliant against the 4 hour A&E target in May 2014, with performance at 97.43% which is above the 95% threshold and for Quarter 1 to date; the Trust is fully compliant with this measure with performance reported as 95.51% for Type 1 activity and 96.68% for all types of activity. Mrs Ormston informed the group that despite ongoing data validation pressures, the Trust achieved trust‐level compliance against all three 18 week referral to treatment measures, with the reported red being revised to a green at 90.6%, however following concerns raised by the CCG around the volume of patients and clearance times, additional resources have been identified to resolve this. Pressures have also been experienced in the outpatient booking process with 18.5% of the Trust’s total outpatient bookings not being directly accessible to patients or GPs wishing to make an electronic appointment. Mrs Ormston highlighted the HR report stating that sickness has started to fall. The managing attendance policy is also being updated and in light of the changes it is hoped to see a reduction. She stated that bank usage has reduced by 3% from the previous month and attendance at corporate induction continues to improve. PDP targets also continue to improve and incremental pay is linked to having a PDP in place. Miss L Ritchie, public governor, asked if plans were in place to tackle the upward trend in delayed discharges. Mrs Ormston responded stating that in light of the Better Care Fund, it is hoped to see this start to decline. Regular meetings are in place with the local authority and actions are agreed on a weekly basis. Work is needed around an understanding of what is causing this. After consideration, it was: RESOLVED: to receive the report as assurance against the management governance

indicators in the Compliance Framework and local supporting measures of improvement management

G/14/51 ELECTION TIMETABLE:

Mrs J Williamson, Membership Co‐ordinator presented to the group a paper on the process to be undertaken for the next elections to the Council of Governors. The election process will begin on 15th October for eight governor positions available for election; two Western, two Central, three Staff and one Patient. Mrs Williamson stated that as with previous elections, anyone wishing to be nominated for election as a governor for the first time must attend a governor briefing event. The event is being held on Thursday 9th October 2014. She informed the group that current governors whose tenure ends on 4th January 2015


By will automatically be sent a nomination pack, unless they have stated that they do not intend to stand for re‐election. Mrs Williamson drew attention to the schedule of key dates included in the paper, agenda item 16. After consideration it was: RESOLVED: i) to note the key dates in the election process ii) to receive the report for information

G/14/52 AUDIT COMMITTEE ANNUAL REPORT:

Mrs K Larkin‐Bramley, Non‐Executive Director and Chair of the Audit Committee presented to the group the Annual Report of the Audit Committee. She drew attention to the paper, agenda item 17 and outlined the main points. Mrs Larkin‐Bramley explained that the Audit Committee is an independent committee made up of Non‐Executive Directors but experts are invited to attend e.g. Internal Audit and External Audit plus Executive Directors. The primary role of the Committee is to report on systems of internal control however, not all assurances can be monitored in detail by the Audit Committee therefore the Committee relies on assurances from other committees such at Patient, Quality, Risk and Safety Committee (PQRS) and the Business and Service Development Committee (BSDC). Mrs Larkin‐Bramley explained that the report sets out how the Committee’s role was fulfilled during the financial year ended 31st March 2014. She explained that the Trust is fully compliant with the registration requirements of the Care Quality Commission (CQC) and maintained its current status as registered without conditions through 2013/14. Mrs Larkin‐Bramley informed the group that in May 2014 the Committee received the Head of Audit Opinion for the financial year 2013/14 and this confirmed that significant assurance could be given that there is generally a sound system of internal control. She reported that the committee reviewed the Annual Governance Statement taking assurance from Internal Audit reports, the PQRS Committee, the Finance Committee and updates to the risk register, and there were no concerns reported. Mrs Larkin‐Bramley explained that Internal Audit and External Audit attend most meetings of the Audit Committee and that the Committee had received the annual report and accounts. She concluded her report by outlining the future plans for the Committee. Mrs JEA Hickey, Chairman, expressed her thanks to Mrs K Larkin‐Bramley for her hard work as Chair of the Audit Committee. After consideration, it was:


By RESOLVED: to receive the report for information

G/14/53 OPEN TO QUESTIONS:

Mr P Hopkinson, public governor, asked if any celebratory events would be planned for the Trust’s 10 year anniversary as an NHS Foundation Trust. Mr ID Renwick, Chief Executive, responded stating that he has spoken to Mr R Wigham, Head of Communications and Marketing, regarding this. He stated that the anniversary will be marked and also could be driven by official openings of new builds. Work will continue around this leading up to the date and governors will be kept informed. Mrs M Jobson, public governor, suggested that a TV item of what is happening could be good coverage. Mr Renwick stated that any media interest would be great for the Trust. Currently clinical staff do this regularly and are much better placed to talk passionately about their services. He stated that there has been some excellent coverage from the Trust regarding care of young patients with dementia and TV coverage of the hospital’s food.

G/14/54 CHAIRMAN’S CLOSING REMARKS:

The Chairman thanked everyone for their attendance and thanked staff for their presentations. She also expressed thanks to Mr ID Renwick, Chief Executive, the executive directors and all staff for delivering the projects and the on‐going work.

G/14/55 DATE AND TIME OF NEXT MEETING:

RESOLVED: that the next meeting of the Council of Governors will be held at 10.00

am on Wednesday 19th November 2014 in the Education Centre, Queen Elizabeth Hospital

Paper for Council of Governors Meeting 19th November 2014 Agenda Item: 7

G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T

Membership Strategy 2014/16

Introduction The Council of Governors has a key role in developing and maintaining an active and engaged membership. The purpose of the Membership Strategy is to define the membership community and outline the actions required to help Governors achieve objectives. It also describes how success will be evaluated in implementing the Strategy. Recommendation The Council of Governors is asked to receive and approve the updated Membership Strategy for 2014/16. Debbie Atkinson Trust Secretary

Foundation Trust Membership/Membership Strategies/Membership Strategy 2014/16

Membership Strategy 2014/16

Foundation Trust Membership/Membership Strategies/Membership Strategy 2014/16 2

Index 1 Introduction ................................................................................................................. 3 2 Overview ..................................................................................................................... 3 3 What membership means to the Trust ........................................................................ 3 4 Defining the membership community ......................................................................... 4 5 Membership recruitment ............................................................................................. 6 6 Resourcing the membership development ................................................................. 7 7 Building an active membership base ........................................................................... 8 8 Managing active membership ...................................................................................... 9 9 Membership Register ................................................................................................... 9 10 Communicating with members .................................................................................... 10 11 Playing a key community role ...................................................................................... 12 12 Working with other membership organisations .......................................................... 12 13 Evaluating success ........................................................................................................ 13 14 Looking ahead .............................................................................................................. 13 Annex A Governor’s work programme – objectives and actions ............................................... 14


Membership Strategy 2014/16 1 Introduction

This paper describes our strategy to maintain and develop an active membership. The strategy defines the membership community and sets out a series of actions to help us achieve our objectives. Finally, it outlines how we will evaluate our success in implementing this strategy. We recognise that the process of building a meaningful membership needs time and resources. We are committed to achieving the objectives set out in this document but recognise that this is an ambitious project requiring long term commitment and investment. The Council of Governors has a key role in developing and maintaining an active membership and they will continue to define new priorities and set target dates for completion.

2 Overview Gateshead Health NHS Trust became a Foundation Trust in January 2005 and is currently one of 150 Trusts to have achieved this status in the UK. Foundation Trusts are accountable to staff and local people through members and an elected Council of Governors, which works closely with the Trust’s Board of Directors to influence decision making and strategic planning.

3 What Membership means to the Trust

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

2005/06

2006/07

2007/08

2008/09

2009/10

2010/11

2011/12

2012/13

2013/14

2014/15

2015/16

Public MembershipExptect and Actual

Expected Actual


Becoming a member of the Trust provides new ways in which people, and in particular local people from Gateshead and the surrounding area, can contribute to the Trust’s success through a new form of social ownership. We seek to achieve this through an active public and staff membership and a Council of Governors that builds and sustains a wide consensus about the services provided at the Trust. Not all members will be able to or wish to serve on the Trust’s Council of Governors but many more will expect to have some tangible involvement in the affairs of the Trust. Our strategy seeks to ensure that members are enabled to participate at the level they feel is more appropriate. We hope to be able to show members how being involved has an effect on the hospital, our decisions, resources and services. Members will receive their three mailings per year of the membership newsletter “QE News” via post or email and annual reports and accounts if required. Membership means participation and responsibility – where local people, carers, staff and patients get involved in their local hospital, not for personal gain but for the benefit of the local community. Experience in other areas of public service shows that local people want to be listened to and that they want their views to be taken into account. Our users do not necessarily want to make decisions or manage their own services but they do want to have a say and expect us to act in response to what they have said. Patient, public and staff members will have a role in the way the hospital is governed. This means they can: • Have a say • Vote in the elections for the Council of Governors • Stand for election to the Council of Governors • Influence proposed changes to services and future plans for the development of the

hospital • Involve themselves

4 Defining the Membership Community Membership of Gateshead Health NHS Foundation Trust is made up of three constituencies; Public, Patient and Staff. Public Members: Those eligible to become public members are people over the age of 16 who live in Gateshead and the immediate surrounding area which is divided into three constituencies; Western, Central and Eastern Gateshead, and the Out of Area constituency which includes County Durham, Newcastle, North Tyneside, Northumberland, South Tyneside and Sunderland (other than areas within the Gateshead constituency).


The map above shows the boundaries for the public membership People over 16 years of age, living in these areas who wish to become a public member of Gateshead Health NHS Foundation Trust, must complete and have accepted a membership application form. Members can vote to elect governors for their constituency and can choose to be nominated to stand for election as a governor. Patient Members: In March 2009, the Trust’s constitution was amended to create an out‐of‐area patients’ constituency patient governor. In January 2011 a patient governor was elected. Patient members are those who live outside the area of Public Membership, who are over the age of 16 years and have at any time during the seven years immediately preceding the date of their application been a patient of the Trust. Carers of patients who meet these criteria are also eligible to become Patient Members.


Staff Members: Staff directly employed by the Trust are automatically members for the duration of their employment, unless they choose to ‘opt out’. Staff whose services are contracted for by the Trust, staff not employed by the Trust but who in effect work in and with the Trust for most of their time and volunteers are given the same status as staff, if they wish, provided they have worked with the Trust for a minimum of one year. Employees of the Trust cannot be public members. Membership Numbers: As at 31 March 2014 the total number of public members was 12,234, an increase of 83 members since April 2013. The total number of patient members was 280. The number of staff members was 3,500. The chart below shows the number of members per constituency:

5 Membership Recruitment

The Council of Governors Membership Strategy Subgroup was established in 2005 to:

• Agree a membership recruitment campaign.

• Review membership by number, age, ethnicity and gender by constituency.

• Actively recruit members to the Trust from their own constituency.

2245

6312

3601

280 76

3500

0

1000

2000

3000

4000

5000

6000

7000

Eastern Area Central Area Western Area Patient Out of TrustArea

Staff

Membership Totals(as at 31st March 2014)


• Attend meetings/functions to raise awareness of Gateshead Health NHS Foundation Trust.

• Report to the full Council of Governors the position statement of membership and the achievements of the recruitment campaign.

• Update the membership strategy and agree this with the full Council of Governors This group has undertaken a number of initiatives to ensure that it is representative of the public it serves in terms of age, ethnicity, socio‐economic profile and gender. As at 31 March 2014, our public membership was as follows:

PopulationDemographics

Membership Demographics

Gender Male 48.4% 39.0% Female 51.6% 60.9% Unknown 0.1% Age Under 16* 19.3% 16 – 19 4.9% 1.2% 20 – 29 11.4% 9.0% 30 – 59 41.6% 36.6% 60 – 74 15.2% 30.7% 75 and over 7.6% 21.3% Age unknown 1.1% Ethnic Breakdown White 98.4% 93.2% Other 1.6% 2.4% Unspecified 4.4%

*not able to become members

We are committed to ensuring that NHS Foundation Trust membership is representative of the whole community. We welcome membership applications from persons of any age (over 16), whatever their race, colour, religious beliefs, ethnic or national origin, gender, disability or marital status. Analysis of membership in the tables above shows that ethnic makeup is higher than that of the Gateshead demographics. The membership is over represented by people aged over 60 and is under represented in all other age groups.


6 Resourcing the Membership Development

The Trust recognises the need to adequately resource our membership functions and this requires a commitment to providing membership services and supporting skills development The Trust’s Membership Team consists of a full‐time Trust Secretary and a full‐time Membership Co‐ordinator. The following reflects the areas in which resource is committed: • Election management and membership management • Computer hardware and software • Expenses for governors • Communications • Postage • Training

7 Building an Active Membership Base Gateshead Health NHS Foundation Trust is a public benefit corporation and membership is open to all local people willing to accept the responsibilities of membership. We have a responsibility to develop the membership in order to: • Ensure the culture of membership is attractive to new members

• Increase the number of active, informed members who are representative of our

patients and local communities

• Increase the quality and level of participation in the Trust to ensure good governance

• Enable elected representatives to fulfil their roles and responsibilities so they may help develop strategy and policy

• Create a culture whereby members feel ownership of the Trust

• Ensure the composition of membership reflects the diversity of local communities To achieve our objectives we will need to: • Maintain an accurate and informative database of members to meet regulatory

requirements and to be a tool for developing membership

• Work with the Trust Board and Council of Governors to identify a strategy for extending membership

• Seek out best practice from other member‐based organisations and consider if they are appropriate for application at Gateshead Health NHS Foundation Trust


• Establish a working group of the Council of Governors to broaden the diversity of

membership, e.g. encouraging ethnic groups, people with disabilities and young people to join

• Identify initiatives for raising the profile of membership with employees of the Trust

• Review the use of staff communication mechanisms to promote membership 8 Managing active membership

Our aim is to increase the quality and level of public participation to enable the Trust to achieve its objectives and to ensure good governance. Objectives • To increase the number of active, informed members who are representative of our

patients and local communities

• To enable elected representatives to fulfil their designated roles and responsibilities

• To demonstrate a partnership approach between the Trust and its members. We will need to take the following steps to achieve our objectives: • Identify models for informal member groups and networks (looking at other

membership organisations) and examine alternative forms of involvement as opposed to traditional meeting structures

• Make meetings meaningful by examining current practice and reviewing whether improvements can be made in terms of publicity, format and content. Particular attention should be given to accessibility issues in order to promote equality of opportunity to participate.

• Examine and evaluate the electoral processes

• Organise election briefing events for groups of members who are potential candidates for the Council of Governors.

• Identify initiatives for widening the pool of candidates for the Council of Governors including strengthening links with other community sectors and like‐minded organisations

• Establish a programme for identifying and meeting with community groups to promote participation

• Continuously review channels for feedback on service quality issues between members and the Council of Governors/Trust Board


• Maintain a learning and development programme for current and newly appointed governors appropriate to their role

9 Membership Register

A register of public, patient and staff members will be maintained by the Trust. The membership information will be held on a secure and confidential database, which will be managed in accordance with the Data Protection Act 1998. The public and patient register will be managed by the Membership Co‐ordinator. The staff register will be maintained by the Trust’s Personnel Department through the Electronic Staff Record system (ERS). The registers will be used as the data sources for contacting members to provide them with information and opportunities to engage in the Trust’s activities. All contacts with members will be managed by the Trust’s Membership Office through the Trust Secretary and the Membership Co‐ordinator.

10 Communicating with Members Communication and consultation are central to engaging members of the Trust and making membership meaningful. They are also the basis for a successful partnership between the Trust and the community it serves. Currently we communicate through a membership newsletter, QE News, which is produced three times a year. Members can either receive a printed copy of the newsletter, a copy via email or view the newsletter on the Trust’s website. This is used to inform members about events and elections, give feedback on questions raised at member events and seek member’s view on the Trust’s future priorities. Members are also given the opportunity to receive QE Engage which is an on‐line bulletin of news and events within the Trust. In the future we will consult with our membership for ideas, guidance and feedback that will inform policy and decision‐making. Our governors will communicate with our membership through: • Public meetings • Regular newsletters • Trust open days • Community workshops • Web and email based communication A Single Point of Contact As part of our commitment to consultation and communication, the Trust has a Membership Coordinator whose function is to provide the governors and the membership with a single point of contact within the Trust. Medicine for Members Consultation is a reciprocal arrangement and for opinions to be meaningful they must be informed. The Trust will continue to hold Medicine for Members seminars which involve a


series of talks and seminars on clinical, public health and healthcare topics. Members are given the opportunity to learn about matters relating to their own health, the health of those around them and how their healthcare is being delivered and might be delivered in the future. These seminars are led by clinicians from within the Trust on topics of local and national interest. Topics during 2013/14 included: • Stroke • Organ Donation • Hip Replacements • Thyroid Disease • Lung Disease A total of 219 members attended the events during 2013/14 and feedback was, once again, extremely positive. Objectives • To seek to inform patients, staff, the public and local communities about the Trust’s

services and values in order to promote understanding, promote partnerships and attract new members.

• To ensure members receive appropriate communications to improve their understanding of the affairs of the Trust and its relationship with the local community.

• To ensure communications are used to stimulate active membership including encouraging new candidates for elected bodies.

• To ensure governors receive appropriate, user friendly and timely information about the Trust in order to make informed decisions.

Actions • Maximise the potential of the internet for information, communication and

involving members.

• Establish a clear brand for membership, reviewing materials and ensuring language is clear and modern.

• Explore ways of working with schools and the education sector to promote understanding of the Trust’s objectives

• Evaluate the membership’s response to different levels of information and methods of delivery.

11 Playing a Key Community Role

As one of the largest employers in Gateshead the Trust is a major contributor to the community as well as being in the front line of maintaining the health and well being of local people.


Objectives • To ensure that the Trust positively contributes to social inclusion

• To play a major role in the development and well being of the community we serve. • to maximise opportunities for membership and other relationships amongst all who

live in the communities in which the Trust operates • to identify groups or communities which are under‐represented in terms of the

diversity of the whole membership community Actions • Work to identify ways of improving services to local communities, particularly

where there is social exclusion or where residents are minority groups currently under represented in our membership

• Seek out partnerships with like minded organisations and key stakeholders in the community and pursue cooperative projects which resolve important local issues.

• Maximise opportunities for positive public relations in the local community 12 Working with other Membership Organisations

Aim We aim to develop a strong sense of shared purpose with other like minded organisations

Objectives • To work with other NHS Foundation Trusts and other partners to raise the profile of

community activity

• To share best practice with such partners and others on membership, cooperation and community relations

13 Evaluating Success

This membership development strategy is the property of the membership, operated on their behalf by their elected representatives. Everybody has a contribution to make but it is the governors who have a key role in monitoring the effectiveness of the strategy and ensuring that it remains meaningful and relevant as the membership of the Trust grows and matures. Specific tasks will be undertaken to evaluate the success of the strategy. The Council of Governors and the Trust Board will:


• Establish a working group of governors to broaden the diversity of membership, e.g. encouraging ethnic groups, people with disabilities, young people, to join and assess the Trust’s performance against its objectives annually

• Evaluate the membership’s response to different levels of information and methods of delivery

• Monitor active participation in the electoral and democratic processes and ensure that they are fair and protected from undue influences, internal and external.

14 Looking Ahead

Membership Development is an ongoing, evolving activity that needs to be responsive to new local conditions. As such, the plan will change to meet new circumstances and challenges. This strategy will be reviewed annually by the Membership Development Group and the Council of Governors of the Foundation Trust to ensure it properly targets and accurately reflects the needs and wishes of both the Trust and the wider community. The success of the strategy will ultimately be gauged by the membership: whether it is an active and engaged membership that feels a sense of pride and belonging in the Trust and whether that membership has grown in strength and size and acts as a support and partner to the hospitals while feeling valued and respected in return. All governors, the Membership Co‐ordinator and the Trust Secretary can be contacted via the Trust website www.gatesheadhealth.nhs.uk or via the switchboard on 0191 4820000


Annex A

Governor’s Work Programme – Objectives and Actions It is the Council of Governors responsibility to engage with the membership on behalf of the Trust. That includes communicating with the membership, ensuring that it is representative and its voice is heard. This strategy outlines how the Trust and the governors intend to do this with a series of objectives and actions needed to fulfil those objectives. Some aspects of the strategy are long‐term and will be reviewed annually, while others are more short‐term and will change, depending on circumstances. Key Aims & Objectives Action Detail Owner Status

Building an active Membership Base

Work with the Board of Directors and Council of Governors (specifically the Membership Strategy sub‐group) to identify a strategy for extending membership to individuals in all qualifying groups

Strategy to be agreed at Council of Governors meeting following approval at Membership Strategy sub‐group

Mrs D AtkinsonTrust Secretary

Ongoing and reviewed annually

Maintain an accurate and informative database of members to meet regulatory requirements and to be a tool for development of membership

Mrs J WilliamsonMembership Co‐ordinator

Ongoing

Identify initiatives for raising the profile of Membership with employees of the Trust to encourage them to become active members

Maximise existing communication methods including ensuring availability of contact details for staff governors.

Mrs D AtkinsonTrust Secretary

Ongoing

The Council of Governors, supported by the Membership Strategy sub‐committee will be responsible for evaluating the success of membership recruitment activities.

Council of Governors and Membership Strategy sub‐group


Key Aims & Objectives Action Detail Owner StatusUse direct contact from Governors to recruit members at key locations within the Trust’s constituencies.

Agreed at sub‐group

Membership Strategy sub‐group

Use appropriate advertising to recruit members


Managing Active Membership

Agree regularity and timings of recruitment campaigns

Agreed at sub‐group


Establish a programme for identifying and meeting with community and staff groups to promote participation

Agreed at sub‐group Membership Strategy sub‐group with involvement of the Staff Governors

Identify initiatives where members can be used as a source of feedback on patient and quality issues

Invite the Deputy Director of Nursing to Membership Strategy sub‐group


Communication with Members

Ensure all communication is clear and easily understandable

Trust Secretary/Membership Co‐ordinator

Develop and maximise the potential of the internet for information, communication and democratic purposes

The Membership Co‐ordinator continues to improve communication with members via the use of social media and the internet.

Trust Secretary/Membership Co‐ordinator

Provide all new members with relevant information about the Trust, the benefits of membership and the role of members

Membership Co‐ordinator


Key Aims & Objectives Action Detail Owner Status

Playing a Key Community Role

Target under‐represented groups or communities for membership recruitment

Trust SecretaryCouncil of Governors

Identify ways of making better links with community and increasing active membership


Identify and maximise opportunities for positive public relations in the local community to promote the role of the Trust

Trust Secretary

Increase partnership between Council of Governors and the Board of Directors

Maintain Governor and executive presence on each others committees Continue joint development days

Governors and Board members with Chair support

To be reviewed at Council of Governors meetings

Governor training

Devise a training programme using governors’ induction skills questionnaires

In 2014 work began with the OD & Training Department to pull together an improved training programme for Governors. This consists of a two year rolling programme which will be reviewed to take into account Governors feedback from each training session.

Governors with Trust support

To be reviewed at Council of Governors meetings

Evaluating the Strategy

The strategy will be reviewed on an annual basis by the Membership Strategy sub‐group on behalf of the Council of Governors


Annual


Key Aims & Objectives Action Detail Owner StatusA review on the success of the strategy will be presented to members on an annual basis

Presented to Members at the Annual General Meeting

Council of Governors



Membership Strategy Sub Group Update

1. Current Membership

Information on membership numbers is presented at each meeting and reviewed by the group. This includes breakdowns by age, gender and ethnicity. The total number of members at 31st October 2014 was 12,865; 12,586 public and 279 patient members. A graph showing membership totals is overleaf as Appendix 1.

2. Recent Work The next meeting of the group is scheduled for 27th November 2014. However, the group has continued to take part in the following activities: • organised a Medicine for Members event in the Western constituency • provide regular updates to the Council of Governors on governor activity and feedback

from online survey • continued with recruitment in OPD • began to attend local community groups • promoted membership in the Women’s Health Clinic

3. Next Steps/Future Plans The next steps/future plans for the group are to: • encourage all members of the Council of Governors to become involved in recruitment • continue to work with all governors towards the objectives and actions detailed in the

Membership Strategy • continue to promote membership in the QE Outpatients department • continue to attend local engagement events • review the terms of reference for the group

Mrs D Atkinson Trust Secretary

Appendix 1

2339

6474

3652

121 279

0

1000

2000

3000

4000

5000

6000

7000

Eastern Central Western Out of Area Patient

Membership by Constituency(as 31st October 2014)



Governor Activities

1. Introduction

Data for the report has been compiled from attendance at events and meetings and from the online feedback form.

The time period of the activities below covers 18th September to 11th November 2014 inclusive.

2. Governor Activities

During the period, 25 survey responses were received from governors after attending an event or meeting. The feedback was as follows:

1

3

5

1

9

3

0123456789

10

A pu

blic event

(external to Trust)

A pu

blic event

(internal e.g.

Med

icine for

Mem

bers)

Recruitm

ent /

Engagemen

t

A meetin

g or

conferen

ce(external to Trust)

A meetin

g or

conferen

ce(in

ternal)

A training

session

(internal)

What are you providing feedback about?

3. Recommendation

The Council of Governors is asked to note this summary and the activities report attached as Appendix 1.

Debbie Atkinson Trust Secretary

7

5

1

6

1

10

7

2

0

2

4

6

8

10

12

Talked

to peo

ple abou

t the

Trust informally

Recruited ne

w m

embe

rs

Gave a talk or p

resentation

abou

t becom

ing a

mem

ber/be

ing a governor

Contrib

uted

you

r views to a

discussio

n or con

sulta

tion

Learne

d more abou

t the

role of FT governors

Learne

d more abou

t the

Trust

Learne

d useful new

skills/know

ledge

Other

Please let us know if you did any of the following

1

4

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

0‐5 11‐20

If you were able to recruit new members, how many did you recruit?

Appendix 1

Governor Activities Public and Staff

Governor Name Activity Date

Eileen Adams

Visit to Pathology 25/09/2014 Visit to Pharmacy 30/09/2014 Recruitment at OPD 02/10/2014 Governors' Workshop 08/10/2014 Recruitment at OPD 16/10/2014 Recruitment at OPD 06/11/2014 Patient Experience and Dignity Group 10/11/2014

John Bolam Visit to Pathology 19/09/2014 Visit to Surgery Centre 30/09/2014

Tom Bryden Visit to Pathology 19/09/2014

Alan Dougall Visit to Pathology 19/09/2014 MSK Open Event 07/10/2014

Sheila Gallagher Governors’ Remuneration Committee Meeting 20/10/2014

Brian Hewitt 15 Steps Challenge 22/09/2014 Governors' Workshop 08/10/2014

Paul Hopkinson Visit to Pathology 19/09/2014 Governors’ Remuneration Committee Meeting 20/10/2014

Margaret Jobson

Recruitment at Freshers Week 22/09/2014 Visit to Bowel Screening 23/09/2014 Visit to Pathology 25/09/2014 Visit to Surgery Centre 30/09/2014 Recruitment at OPD 02/10/2014 Governors' Workshop 08/10/2014 Recruitment at OPD 16/10/2014 Medicine for Members 22/10/2014 Recruitment at OPD 06/11/2014 Patient Experience and Dignity Group 10/11/2014 Visit to Pathology 25/09/2014 Governors' Workshop 08/10/2014 Board of Directors’ Meeting 22/10/2014

Jacqueline Lockwood Visit to Pathology 19/09/2014 Governors' Workshop 08/10/2014 Board of Directors’ Meeting 22/10/2014

Lynn Ritchie

Visit to Pathology 19/09/2014 Community Engagement – Winlaton 02/10/2014 Governors' Workshop 08/10/2014 Meeting with Communications Teams re Social Media 17/10/2014 Medicine for Members 22/10/2014

Ian Stafford Governors’ Remuneration Committee Meeting 20/10/2014

Christine Squires

Visit to Bowel Screening 23/09/2014 Visit to Pathology 25/09/2014 Visit to Surgery Centre 30/09/2014 Governors' Workshop 08/10/2014 MSK Open Event 07/10/2014

Governor Name Activity Date

Mary Summers

Safeguarding Committee 19/09/2014 Recruitment at Freshers Week 22/09/2014 Visit to Surgery Centre 30/09/2014 Community Engagement – Winlaton 02/10/2014 Governors' Workshop 08/10/2014 Place Assessment 22/11/2014 Medicine for Members 22/11/2014 PEAG Meeting 06/11/2014

Teresa Waring Governors’ Remuneration Committee Meeting 20/10/2014 In addition, appointed governors have also been able to attend the following events:

Governor Name Activity Date Sarah Gascoigne Visit to Pathology Centre 28/10/2014

Ashok Kumar Visit to Bowel Screening 23/09/2014 Visit to Surgery Centre 30/09/2014

Paper for Council of Governors Meeting 19th November 2014

Agenda Item: 12


Complaints, Litigation, Incident and PALS (CLIPA) Report

Introduction It was agreed at the Council of Governors meeting in November 2010, that the group would receive regular Complaints, litigation, incident and PALS (CLIPA) reports. The attached report provides an executive summary and organisational learning report from 1st January to 30th June 2014. Recommendation The Council of Governors is asked to receive the report for information. Sue Winn Head of Risk Management

1

Complaints, Litigation, Incident & PALS (CLIPA) Report

Council of Governors

1st January – 30th June 2014

Robert Webber Risk Manager October2014

2

Contents Page

Introduction

3

Complaints

3

Litigation

5

Incidents

5

Patient Advice & Liaison Service (PALS)

7

• Compliments

7

Organisational learning

9

• Learning from complaints

9

• Learning from PALS

10

• Learning from incidents

11

3

Introduction The CLIPA Group was established in August 2006 to support the analysis of complaints, litigation, incidents and Patient Advice and Liaison Service (PALS) data and facilitate effective communication between these departments and to learn from experience. The Risk Management (CLIPA) Group develops quarterly aggregated reports which include data from each division so that trends can be identified, lessons learned and good practice can be shared across the organisation and across NHS organisations where appropriate. The CLIPA reports are reviewed by the PQRS Committee, SafeCare Committee and are to be reviewed by the Trust Board from December 2014. This report provides a summary of the CLIPA reports for the Council of Governors covering the period January – June 2014. This document has been compiled by Robert Webber risk manager from contributions from: Matt Baxter, Datix Manager Cherry Harvey, Legal Services Manager Shirley Hazeldine, PALS Manager Neil Gammack, Clinical Pharmacy Services Manager Hazel Rogerson, Complaints Manager Jacqui Edwards, Medical Devices Manager Complaints The Trust received a total number of 117 formal complaints between Jan –June 2014. This compares to 121 formal complaints received in the previous six months. Within the period there were 54 complaints that took longer than the Trust’s target time of 25 working days to respond fully to. The delays occurred because of the complexity of the complaint, absence of key members of staff or because meetings needed to be arranged with the complainant and this could not be convened within the 25 day time limit.

* 1 complaint subsequently withdrawn Individual Directorate Performance within the Quarter Individual Directorate/Departments are set a local target of completion of investigation and return of draft reply within 20 working days. Compliance with this target by department is shown in the following table. Increasingly meetings are being held with complainants to give full and open explanations relating to the issues raised. Generally this is in the more complex complaints and, as a result, the response times are more difficult to meet because of the difficulties of organising meetings involving a number of clinicians.

Month Number of Formal Complaints Received

Number Replied to Within 25 Working Days

Compliance with 25 day Target

January 20 10 50%February 21 14 66%March 19* 10 56%April 2014 23 14 61%May 2014 15 7 47%June 2014 19 8 42%Total 117 63 54%

4

Specialty/Department Number received

Number replied to within set target

Compliance with Directorate target

Emergency Medicine/A&E 21 12 57%Medicine 26 10 62%SCBU 1 0 0%Children’s Services 2 1 50%Surgery 16 9 56%Orthopaedics 21 12 57%Gynaeoncology 4 3 75%Anaesthetic/Pain 4 3 75%Maternity Services 7 5 71%Urology 2 2 100%Physiotherapy 1 0 0%Radiology 8 5 63%Pathology 3 2 67%Outpatients/appointments 3 3 100%Pharmacy 1 1 100%Endoscopy 3 3 100%Outpatients/ENT/Audiology 3 3 100%Colposcopy 1 1 100%TOTAL 128* 75 59%*NB ‐ this number is higher than actual number of complaints received in total as some complaints related to more than one Directorate. The Complaints that were received were in relation to the following reasons:

Main Reasons cited for Complaint Number Received Inadequate clinical assessment 40 Operation/procedure ‐ complications/unexpected outcome 15 Lack of Communication 10 Query regarding clinical assessment 5 Delay in undertaking clinical assessment 4 Delay in diagnosing condition 4 Failure to adequately diagnose condition 4 Cancelled appointment 3 Lack of concern for patient 3 Operation/procedure ‐ cancelled 3 Wait for appointment (i.e. Waiting list) 3 Information not being shared with carer 2 Disputed diagnosis 2 Discharge ‐ Inappropriate 2 Dispensing of mediation 2 Being offhand/dismissive 2 Operation/procedure ‐ delayed 2 Unhelpful 2 Unprofessional Behaviour 2 Verbal/Written Communication 2 Personal boundaries and space 1 Breach of confidentiality 1 Delay in admission to ward 1 Rudeness 1 Wait in clinic 1 Total 117

5

Litigation There were 46 new clinical claims and 10 non clinical injury claims from 1st January – 30th June 2014 compared to 42 clinical and 7 non clinical claims in the previous 6 months. It should be noted that these include requests for disclosure of records as well as letters of claim and may not necessarily result in a valid claim against the Trust once there has been the opportunity to investigate. Incidents There were 3097 incidents reported in the 6 monthly period compared with 2942 incidents reported in the previous 6 months. Number of incidents reported by business unit:

Jan 2014

Feb 2014

Mar 2014

Apr 2014

May 2014

Jun 2014 Total

Clinical Support & Screening 71 53 77 64 60 73 398Surgical Services 127 149 145 177 169 153 920Medical Division 250 275 293 279 263 272 1632Nursing, Midwifery & Quality 0 3 0 1 2 0 6Estates & Facilities 14 15 21 16 18 18 102Finance & IM&T 1 8 3 3 7 10 32Transformation & Compliance 1 1 0 2 1 2 7Total 464 504 539 542 520 528 3097

Severity of harm:

Incidents Jul – Dec 2013

Incidents Jan – Feb 2014

No harm 2118 2327Low 732 692

Moderate 70 64Severe 22 14Death 0 0

10 most common incidents reported:

Patient safety

incident Non‐patient

safety Total

Patient falls 853 (36.83%) 0 (0%) 853 (36.83%)Violence, abuse and harassment 45 (1.94%) 250 (10.79%) 295 (12.74%)Blood transfusion 245 (10.58%) 7 (0.3%) 252 (10.88%)Pressure damage 216 (9.33%) 0 (0%) 216 (9.33%)Medication 186 (8.03%) 0 (0%) 186 (8.03%)Staffing / resource issue 136 (5.87%) 0 (0%) 136 (5.87%)Delay / failure to treat / monitor 119 (5.14%) 0 (0%) 119 (5.14%)Equipment (Patient safety incident) 91 (3.93%) 0 (0%) 91 (3.93%)Security incident (theft / loss / damage) 0 (0%) 85 (3.67%) 85 (3.67%)Patient information 83 (3.58%) 0 (0%) 83 (3.58%)Total 1974 (85.23%) 342 (14.77%) 2316 (100%)

6

The security incidents can be broken down as follows. This demonstrates that not all incidents are theft/loss/damage. 30% of the incidents pertain to patient watch to support the clinical staff.

Total Patient Watch 25 Security incident ‐ Other 18 Loss ‐ patient property 12 Loss ‐ trust property 5 Theft or alleged theft ‐ patient property 5 Damage ‐ accidental damage to Trust property 3 Theft or alleged theft ‐ trust property 3 Damage ‐ accidental damage to patient property 2 Damage ‐ criminal damage to staff property 2 General security ‐ property left unlocked 2 General security breach ‐ intruder / unauthorised access 2 Loss ‐ staff personal property 2 Theft or alleged theft ‐ staff personal property 2 Damage ‐ accidental damage to staff property 1 Damage ‐ criminal damage to Trust property 1 Totals: 85

The following Pareto chart indicates the number of incidents reported by category alongside the cumulative percentage of all incidents. A Pareto analysis helps to focus efforts on the issues that offer the greatest potential for improvement by showing their relative frequency or size in a descending bar chart The tool will quickly identify the major causes of a problem so that resources can be focused on the cause of issues with the most potential for improvement. (NHS Institute for Innovation and Improvement.)

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%100.00%

0100200300400500600700800900

Patie

nt fa

lls

Bloo

d transfusion

Pressure dam

age

Med

ication

Staffin

g / resou

rce iss

ue

Delay / failure to

treat / m

onito

r

Equipm

ent (Patie

nt sa

fety…

Patie

nt inform

ation

Pathology sample iss

ues

Discharge or transfer issue

Results / investigations issues

Ope

ratio

ns / proced

ures

Patie

nt acciden

t (no

n‐fall)

Violen

ce, abu

se and

harassm

ent

Maternity / foetal / ne

onatal

Appo

intm

ent / list issues

Commun

ication failure

Infection preven

tion & con

trol

Inform

ation governance

Imaging iss

ue

Safeguarding

Patie

nt emergency

Ambu

lance transport issue

Facilities issue

Fire re

lated

Patrient Safety Incidents by category1 January to 30 June 2014

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Patient Advice and Liaison Service (PALS) The Patient Advice and Liaison Service (PALS) helps resolve concerns and queries raised by patients, relatives and visitors relating to Gateshead Health NHS Foundation Trust. It also provides health related information and advice to the public across the local health economy. The total number of issues dealt with was 1386 compared with 1046 in previous six months with 63% (876) of PALS enquiries for this period resolved within 24 hours. During the above period PALS received 162 enquiries requesting information, advice, and/or support across a wide range of areas. PALS were able to provide information/advice or refer to the most appropriate organisation for further support where needed. Issues ranged from assistance to locate patient’s lost property, advice on car parking concessions to general enquiries regarding hospital visiting times, information on services provided by the Trust and how to access health records. Top 5 issues by Department (excluding requests for information and advice) • Communication • Appointment issues • Clinic assessment (Inpatient) • Clinic assessment (Outpatient) • Attitude of staff Compliments 695 compliments were recorded for this period. Comments include: • Lady would like to compliment all staff involved in her care. She advises that she has had three stays in

the past six months here and each time she has come through A&E then to ward 9 then to the surgery centre. She comments that surgery centre stands out as being the most amazing place to be in the hospital. The care of the nurses and auxiliary staff is second to none.

• Thank you all for the great care and compassion you gave to patient and her family. None of the family thought that patient would linger on for six weeks but it was clear from the start that she was well cared for and that her wishes were always considered. We would particularly like to thank Carol for being there at the end and being so kind and thoughtful.

• A lady thanked us for the care she had received on ward one and left us with a gift of a basket of

flowers with a card enclosed for a great big thank you, yet again. The lady has sadly now passed away. • The care and service couple have received has been exemplary. The staff have been incredibly

supportive and have kept them informed every step of the way. IVF is a difficult and demanding process but the team set our expectations from the outset with an informative presentation evening where they explained in detail what was involved so we could make informed decisions and new what would happen and our chances of success. I could not ask for anything more from the team. From the front line nurses to the consultants couple comment that they are genuinely appreciative of their professionalism and their warm and caring nature and would like thank them all for their continued support in the journey they have taken.

• To the wonderful staff at St Bedes. Thank you so much for your kindness and support during the final

days of my lovely sister life. The care and compassion you all showed made her passing much easier for all the family and we cannot praise and thank you enough. We are a large close family and we appreciate the tolerance shown towards the number of visitors the patient had. This enabled everyone

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to say their goodbyes and surround her with love and laughter till the end. I would also like to say a special thank you to Rosie. Through all our tears and sadness you managed to bring some fun and laughter. Keep up the good work. God bless you all.

• Lady advises that she is really grateful to all the staff at Physiotherapy Bensham for the support and

care she received. • Thank you all for the great care and compassion you gave not only to my mother but to all of the

family. Family knew their mother would not be with them for much longer but it was clear from the start that she was being well cared for and that her wishes were always considered.

• Lady would like to say a massive thank you to everyone who had helped her, all of the nurses, doctors,

all the helpers and the cleaners, not forgetting the lady who took phone calls and padded all the messages on to me. Lady was scared of hospitals but was made to feel so welcome. She states that staff all took care of her and made her feel so at ease.

• Gentleman recently had a stint on level 3 (CCD) where they saved his life. He comments "The whole

team was amazing and the standards of care I received were amazing, within a few weeks after being in a coma and nearly dying now I feel better than ever" Gentleman further comments that his only issue was he felt a shower is needed on the CCU/HDU.

• Many thanks to all the staff on wd21 for all their kindness and expertise special thanks to two named

members of staff and the housekeepers for their time and encouragement • Lady was admitted for a planned section after having a dreadful time with her first baby at UHND. She

would like to thank all of the team for putting themselves out and making her feel valued and really looked after, she had a really good experience that she'll never forget. Lady states that she has a massive chunky and exclusively breastfed (it took some perseverance!) 15 week old who is lush! She would particularly like to thank named nurse and consultant as without the pair of them she states she would have cracked up!

Areas to receive compliments this period were:

A&E Department ICAR Sunniside Unit AN/PN wards Maternity Unit Ultrasound AAA Screening MAU Ward 1 Audiology MRI Ward 4 Breast Screening Old Age Psychiatry Ward 8 Chemotherapy OPD reception Ward 9 Cragside Unit Orthotics Ward 11 Critical Care Unit PALS Ward 12 Delivery suite Physiotherapy Department Ward 21 Domestics PIU Ward 22 Ellison Unit PODS Ward 23 Endoscopy Radiology Ward 24 EPAU Respiratory Ward 25 Escalation ward Rheumatology Ward 26 Fracture clinic Security Ward 27 Haematology Dept. St Bedes Unit

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Organisational Learning Learning from complaints (Jan – March) Case 1: Concerns were raised that there was a lack of empathy in relation to management of pain and that there was an animated conversation between the nurse and the doctor regarding the timing of medication. Outcome: It was acknowledged that a greater involvement of the Pain Team would have provided additional support as the patient did appear to have pain which was difficult to control and was also understandably extremely anxious in relation to potential pain when moving. As a result a Charge Nurse has been identified as the lead for the team to review pain management processes on the ward and to liaise directly with the Pain Team. Part of this will also include updates for ward staff in pain management and use of pain management tools which can be useful in monitoring and scoring individual’s pain and response to medication. Case 2: A complaint was raised in relation to an incident during a surgical procedure where part of a drain had not been removed. This was also recorded as a serious incident and root cause analysis (RCA) investigation was undertaken. The incident was reported to the Commissioners via the Strategic Executive Information System (STEIS). Outcome: It was not possible as part of the investigation to identify the cause of this incident. However, measures will be put in place to reduce the likelihood of something similar happening in the future. We have therefore identified three actions to reduce future risks: 1) Currently, when a drain is used in theatre, we do not record the manufacturer or batch number of this

equipment. In the event that we did confirm an equipment problem, this would make it difficult to trace the responsible batch/manufacturer. Therefore in the future we will be documenting the manufacturer and batch of all drains used during operations.

2) We will ensure that where a drain is inserted, we will record details of the drain in the patient’s notes, including whether there has been any purposeful amendments to the length of the drain. This will allow subsequent checking that the full drain has been removed.

3) In future, when drains are removed on the ward we will expect nursing staff to check the length of the removed drain against the length of the drain that was recorded as being inserted in theatre. Our intention is that this would provide a fail‐safe check to allow the immediate identification of any incidents such as this one where portions of the drain may have been inadvertently retained.

Case 3: A relative raised concerns that the patient was not given nutritional supplements despite the dietician advising that supplements were to be given twice a day. The investigation confirmed that there was a delay in the supplement being commenced as it needed to be written up on the drug chart by a doctor. Outcome: As a result of the complaint the matron met with the lead dietician to look at a protocol for the dietician to add supplements to the drug chart without the need for a doctor’s signature. In the future as soon as the dietician has decided a patient needs additional supplements they can be written on to the drug chart immediately and prevent a delay.

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Case 4: Patient raised concerns that after experiencing contractions at 28 + weeks and having being classed as high risks because of complex condition, staff did not ask her to come for an assessment. When the pains continued the patient was admitted but felt the midwife did not monitor her closely. The patient subsequently went on to deliver baby. This was also reported as an incident with RCA undertaken. Outcome: The RCA investigation confirmed that there were failings and the patient should have been invited to come in at the first point of contact. In addition it was highlighted that there was inadequate medical staff escalation which should have happened much more quickly than it did. As a result, a framework has now been developed for the escalation to medical staff and this is in place in the unit. A revised triage telephone document has also been developed to assess risk more accurately when patients are telephoning the unit. This will help the decision making process in relation to whether to invite mothers in to the unit or not. Case 5: Concerns were raised by a relative that a patient developed a grade 4 pressure sore whilst an inpatient. Outcome: RCA investigation findings concluded that documentation regarding positional changes was incomplete and there were gaps where it was not confirmed if the patient had been turned or repositioned. As a direct result of the complaint the ward team are developing new ways of working, including a positional change board and coloured stickers to go above the beds to highlight to the nursing teams the frequency of positional turns. Learning from PALS enquiries Issue 1: Lady felt that nurse removing her stitches did not have the necessary skills to carry out the procedure. Following several attempts another member of staff had to remove the stitches. Lady also felt that the lightening in the department was unsuitable to carry out this procedure. Outcome: Additional/refresher training has been arranged for all qualified nurses in the department and additional equipment has also been ordered to assist staff to remove sutures that are proving difficult to remove. Lighting levels have also been checked in department to ensure that it is adequate for fine work like removing stitches. Issue 2: Gentleman concerned that access to Women’s Health clinic is unsuitable for disabled or elderly patients. Gentleman also concerned that no information regarding location of Women Health clinic was included in his wife’s appointment letter and on contacting switchboard he was advised of the wrong entrance appropriate to access the department. Outcome: Appointment letters to be amended to include location and directions to access the department. Staff will also look at the current signage relating to the department and determine if additional signage is required. Apologies given if the wrong information was given by switchboard staff and gentleman’s concern will be shared to ensure lessons are learnt. Issue 3: Patient raised concerns at the lack of appropriate information in the clinic letter regarding the location of physiotherapy and orthotics department which caused his wife unnecessary distress. Outcome: Admin Manager is to arrange for clinic letters to be amended to advise patients of location of departments. Issue 4:

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Lady’s son has a number of problems and is being treated under CDT. The lady is extremely frustrated by the lack of progress and communication between the departments and organisations involved in his care. She feels that she has to constantly chase the associated parties involved in her son’s care to get results and appointments to ensure her son receives the appropriate treatment. Outcome: Apologies given to lady as department acknowledge that the poor communication and delays is unacceptable. Service line manager is to meet with commissioners to discuss how the current fragmented service is causing problems for both patients and parents. Issue 5: Lady concerned at the delay in receiving results and appropriate treatment following a biopsy of a growth on her abdomen. Lady is currently extremely unwell and on contacting the hospital she feels that she is passed from pillar to post. No one seems to care. Outcome: This episode highlighted there is a distinct lack of communication between the Gynaeoncology Multi‐Disciplinary Team (MDT) coordinator/secretaries and referring (internal) clinicians and or their secretaries. To ensure situations like this do not reoccur, Admin Manager has informed both of the Gynaeoncology MDT Coordinator/Secretaries that any correspondence should take place verbally between themselves and the referring clinician’s secretary which is also to be followed up/confirmed via email. Admin Manager has also confirmed that the patient’s notes are to be hand delivered to the referring clinician/secretary if required in order to ensure patients are not lost in the system. Learning from incidents Patient Falls Issue 1 Bed Sensors: The design of the bed sensors allows confused patients to turn them off which has contributed to two patient falls. Additionally members of staff have reported they have not been able to get bed/chair sensor when requesting them from the medical devices library. Action taken: Met with Medical Devices Manager ‐ It was agreed to remove the old metal type sensors and order 15 new sensors which will increase the current stock level by 10. Training will be provided by the bed sensor representative where needed. Issue 2: Anti‐slip socks: Following a Category 4 pressure sore incident it was decided trust wide to remove anti‐slip socks on all patients when they go to bed. Following this decision there have been four incidents where confused patients have woken during the night, got out of bed and slipped on the floor and fallen. Action taken: Discussed the decision with tissue viability staff and it was agreed that ward staff are to risk assess patients. Patients who are bed bound and at risk of developing pressure sores should not be wearing anti‐slip socks in bed. Patients who are confused and wandering and at little risk of developing a pressure sore should be issued anti‐slip socks to reduce the risk of them falling. The nurse should then document the reasoning for either leaving on or removing the anti‐slip socks in the patients care plan. Falls team advising ward staff to risk assesses patients when investigating falls. Falls Team Nurse also attended clinical practice lead meeting to inform them of about risk assessing patients.

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Issue 3: Treatment centre nurse call system: When the nurse cancels a nurse call alarm on wards 26 and 27, if more than one alarm is activated at the same time, all of the alarms are cancelled out and the nurse is not aware the alarm had been sounding in additional rooms. This has resulted in a patient falling. The patient wanted to use the toilet, as the nurse had not responded the patient got out of bed and fell. Action taken: Informed risk manager for surgery and health and safety officer about the problem. Health and safety officer has spoken with engineers who were aware of the issue. The problem is with the software and they are currently waiting for this to be upgraded to overcome this. Issue 4: Lack of Zimmer frames Incident investigation identified that patients have been sharing Zimmer frames due to a lack of Zimmer frames in the Trust. This poses the following risks. 1) Increased risk of falls as frame not readily available 2) Increased risk of falls as frame not tailored to individual needs 3) Cross infection 4) Indirect restraint Action taken: Meeting with physiotherapy managers and falls team identified issues causing reduced number of Zimmer frames available. Patients issued with a temporary frame have inadvertently been taking them home when being discharged from hospital. Hospital to purchase coloured frames which will help staff to identify frames belonging to the hospital. In addition, discharge lounge will screen Zimmer frames. Patients being discharged with a colour frame will have it replaced with a permanent issue from Gateshead Equipment Services Issue 5: Patient stood to get on to the porters trolley to go to x ray and fell. Action taken: Investigation has shown the porter was not acknowledged on arrival to the ward, went to the patient room asked the patient if they were able to get on to the trolley. Patient stated they were able to then on getting up fell to the floor and dislocated hip. Porters to ensure they check with the nurse looking after the patient there mobility status or if assistance is required before moving a patient.



Monitor Q1 Return

The Trust submits quarterly returns to Monitor and receives from Monitor an executive summary of the results. Attached are the results and correspondence for Quarter 1 – 30 June 2014 as follows:

• Monitor’s summary of foundation trusts performance The Council of Governors is asked to receive the report for assurance and information. Mr J Maddison Director of Finance and Information

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Performance Report

1. Purpose of the Report

This report provides an update on performance against national and local targets at the end of September and Q2 2014/15 providing a summary of: • Performance governance indicators measured in Monitor’s Regulatory Risk Assessment

Framework; • The position in relation to the Trust’s activity plan; • A summary of our current risks to performance, and • A summarised Care Quality Commission (CQC) performance dashboard, appendix A.

2 Performance Executive Summary 2.1 Risk Assessment Framework – Quarter 2 Performance Review

2.12 Access Referral to Treatment (18 Weeks) The Trust is compliant on aggregate with all 3 RTT measures in Q2. This is an outstanding achievement given the current NHS England initiative to clear elective backlog during the performance amnesty period. Service line pressures continue in the Surgical Business Unit. Business Units plans have delivered significant improvements in treating more patients during the amnesty period and therefore reducing the number of patients waiting for treatment. At the end of August the Trust reports 8,198 patients awaiting treatment representing a 12% reduction on the number of patients waiting in April 2014, and a 19% reduction in the number of patients waiting in the same reporting period last year. NHS England and the Area Team have taken a keen interest in reviewing RTT clearance times; the Trust is now reporting an overall clearance time of 12 weeks which is within expected performance levels for this measure of backlog clearance. A weekly Data Quality Task & Finish group continues to oversee the corporate recovery plan to rectify data quality and process issues which impact on the Trust’s ability to reduce the over‐all size of the Trust’s 18 week incomplete pathways. Additional data validation and re‐engineering data capture methods has demonstrated significant service line recovery in a number of pathways.

A&E Despite increased activity volumes and specific service pressures in July and August the Trust achieved the 4 hour A&E target in Q2. The on‐going need for locum cover in ED provides a transient work‐force which has in turn increased the risk of variation in A&E performance on a day to day basis. The Business Unit do have a recruitment plan in place to provide additional clinical resources during the winter period.

2

Service Line Managers are also currently implementing an action plan to improve patient flow through‐out non‐elective pathways and are also reviewing existing escalation plans. Recruitment remains a priority to the Business Unit in resolving workforce issues. Cancer Measures The data relating to cancer performance measures are still subject to patch wide validation and are therefore provisional at the time of writing this report. The projected quarterly performance position in the Risk Assessment Framework dashboard (figure 1) represents achievement in all cancer measures. Service specific pressures continue in Lung, Urological, Upper GI and Gynaecological tumour sites.

2.13 Outcomes

Clostridium Difficile There have been 6 incidences of Clostridium Difficile in Q2; this is equal to the quarterly allowance.

2.2 HR Quarterly Overview

At the end of September the Trust’s rolling 12 month sickness absence rate of 5.22% is higher than the internal target of 3.4%. Moving into Q2 the Trust has seen a slight reduction in the general overall trend; the Attendance Policy group continues to support clinical and non‐clinical Business Units with improvement strategies. The proportion of bank usage in has increased by 11% from Q1. The attendance policy group are reviewing the increases.

Corporate induction attendance rate compliance dropped from 93% to 89%, and Local induction compliance also deteriorated from 93% to 87% from the previous quarter. The proportion of Junior Doctors attending induction in Q2 has significantly improved on the previous quarter rising from 83% to 93%. The proportion of staff receiving mandatory training has improved slightly in Q2 from 83% to 84%. The Trust’s compliance rates against the number of staff eligible for PDP’s remained static at 83% at the end of the quarter.

Dementia awareness training continues to be rolled out across the Trust; at the end of September 59% of the workforce has received Barbara’s story training.

3 Summary At the end of month 6 the Trust is compliant with all measures in the Risk Assessment Framework. The Board to Board performance Framework and supportive management and transformational improvement reviews will continue to provide focus and support strategies to deliver in key performance areas experiencing pressures. Resolution of the issues and sustainability going forward remain a high priority to the Trust.

4 Recommendations

The Council of Governors is requested to receive this report as assurance against the management of the governance indicators in the Risk Assessment Framework and local supporting measures of performance management. Deborah Renwick Strategic Head of Performance

3

1 Risk Assessment Framework Dashboard Targets – weighted 1.0

Target/ Trajectory Quarterly Target Q1

2014/15 Q2

2014/15 Q3

2014/15 Q4

2014/15 ACCESS

Referral to Treatment Admitted 90% 90.6% 91.2%

Referral to Treatment Non‐Admitted 95% 97.55% 96.61%

Referral to Treatment Incomplete pathways 92% 94.65% 94.72%

Total time in A&E ‐ 4 hours All Types 95% 96.68% 96.09%

Maximum 62 day wait for first treatment

GP Referral 85% 86.9% 85.1%

Screening 90% 95.6% 93.1%

Maximum waiting time of 31 day subsequent treatments for all cancers

Drugs 98% 100% 99.3%

Surgery 94% 98.5% 98.1%

Maximum waiting time of 31 days from diagnosis to treatment for all cancers

96% 100% 99.7%

Maximum waiting time of 2 weeks from urgent GP referral for all urgent suspect cancer referrals

2ww 93% 93.5% 94.3%

Breast 93% 93.7% 95.0%

OUTCOMES Clostridium difficile Annual ceiling of 24 6 0 6

Minimising mental health delayed transfers of care (national reporting)

<=7.5% 0% 0%

Data completeness: identifiers 97% 99.0% 98.9%

Data completeness: outcomes for patients on CPA 50% 100% 100%

Certification against compliance for access to healthcare for people with a learning disability

Yes/No Yes Yes

Data Completeness: Community Dataset

RTT 50% 92.5% 93.5% Referral information 50% 100% 100% Treatment Activity 50% 100% 100%

(shadow monitoring) Patient ID 50% 93.1% 94.5%

4

INTERNAL MONITORING ONLY Quarterly Target

Q1 2014/15

Q2 2014/15

Q3 2014/15

Q4 2014/15

MRSA Objective Annual ceiling of 0

0

0 0

Figure 1 – Trust Risk Assessment Dashboard 2 Trust Activity Plan The table below sets out the Trust’s position in relation to September (month 6). Further in‐depth analysis can be obtained from the Finance & Activity Report. Clinical Activity by point of delivery Activity Plan

September Activity Actual September

% Difference

A&E attendances Day cases Elective –long stay Elective – Excess bed days Non elective Non elective – Excess bed days Outpatients – New Outpatients – Follow up Outpatients – Procedure

31,52712,3552,805504

13,6354,536

24,52566,0167,516

37,685 14,003 2,642 351

13,668 2,986

24,146 66,799 7,913

19.5%13.3%‐5.8%

‐30.4%0.2%

‐34.2%‐1.5%1.2%5.3%

Figure 2 – Trust Activity Plan Headlines at the end of September are:

• Elective activity has underperformed against the annual plan by 5.8%; • Day case activity has over performed against the plan by 13.3%; • Non‐elective activity is marginally above plan; • New outpatient activity is 1.5% below plan; • Outpatient follow up activity is slightly above plan by 1.2%, and • A&E attendances are above expected levels by 19.5%

3 Productivity & Efficiency The programme for Improving Clinical Performance continues to progress work in the following areas. Target 2012/13 2013/14 Q1

2014/15 Q2

2014/15 Q3

2014/15 Q4

2014/15 Elective Los 0.8 0.75 0.81 0.67 0.69 Non Elective Los 4.95 4.05 4.99 5.08 4.76 Day Case Rate 80% 79.12% 81.86% 83.95% 82.34% SDA Rate EL 75% 73.11% 78.5% 80.12% 80.57% SDA Rate NEL 48% 42.21% 44.18% 46.11% 50.32% Stroke Spelled Los Avg. 13 days 13.99 15.42 14.56 12.81

Stroke Los Median 5 7 5 8 6 Critical Care Beds 12 12 12 12 12 Paediatric Beds 9 16 16 8 8 Cardiology 21 21 21 21 21 New OP DNA Rate 8.06% 7.01% 7.82% 8.81% New to Review Ratios 3.04 3.01 3.19 3.13 Figure 3 – ICP Metrics

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4. Trust Performance 4.1 2 Week Waits ‐ Cancer Performance The White Paper ‘The New NHS – Modern, Dependable’ guaranteed that everyone with suspected cancer will be able to see a specialist within 2 weeks of their GP deciding that they need to be seen urgently upon requesting an appointment. Trusts are monitored monthly, quarterly and annually against this standard to ensure that no patient waits longer than necessary for access to specialist care. Our current performance of 93.9% for YTD is above the tolerance of 93% although at the time of writing this report this information is still subject to change via internal validation processes. 4.2 A&E The Trust reported Q2 performance for type I (QE site) activity at 94.95%, and all types of activity at 96.09%. Target /Trajectory Target Q1

2014/15 Q2

2014/15 Q3

2014/15 Q4

2014/15 A&E Clinical Quality: Total Time in A&E – 95th Percentile 4 hours 3 h 59 m 3h 59m

A&E Clinical Quality: Time to Initial Assessment ‐95th Percentile

15 mins 17 minutes 15 minutes

A&E Clinical Quality: Time to Treatment Decision – Median

60 mins 55 minutes 59 minutes

A&E Clinical Quality: Unplanned re‐attendance rate <5% 2.3% 2.0%

A&E Clinical Quality: Left Without being seen <5% 2.6% 2.8%

Figure 4 – A&E Quality Dashboard 4.3 18 Weeks ‐ Referral to Treatment 4.31 Measures & Performance These measures are assessed monthly (at specialty level), in the Local Contract with Commissioners and quarterly using aggregate Trust level data in the Risk Assessment Framework. The table below shows the national thresholds and GHNFT’s quarterly performance for 2014/15. Completed Inpatient Pathways (Admitted Adjusted) %

Median Wait

95th percentile

National Thresholds 90% <11.1 <27.7 Total GHNT (all specialties) – Q1 90.6% 11.21 20.87 Total GHNT (all specialties) – Q2 91.2% 11.04 22.44 Total GHNT (all specialties) – Q3 Total GHNT (all specialties) – Q4

6

Completed Outpatient Pathways (Non‐admitted) % Median 95th

percentile Wait National Thresholds 95% <6.6 <18.3 Total GHNT (all specialties) – Q1 97.55% 5.26 15.67 Total GHNT (all specialties) – Q2 96.61 % 6.01 17.86 Total GHNT (all specialties) – Q3 Total GHNT (all specialties) – Q4 Incomplete pathways (combined admitted and

non‐admitted) % Median Wait 95th percentile

National Threshold 92% <7.2 <36 Total GHNT (all specialties) – Q1 94.65% 6.16 18.5 Total GHNT (all specialties) – Q2 94.72% 5.70 19.05 Total GHNT (all specialties) – Q3 Total GHNT (all specialties) – Q4 Figure 5 – RTT Measures & Performance The table above demonstrates that Trust performance is achieving expected levels for all three 18 week standards which are assessed quarterly in the RAF, however these will continue to be validated until the submission date. Monthly performance data in Q2 to date indicates monthly achievement across all specialties, with service line exceptions in the following measures: Admitted: General Surgery, Urology and T&O; Non Admitted: General Surgery, Urology, T&O, ENT, General Medicine, Gastroenterology,

Rheumatology and Other; Incompletes: Urology, T&O, Plastics and Gastroenterology. RTT has become a national concern for NHS England, with more Trusts failing to deliver the Constitutional right for patients to receive treatment within 18 weeks. The Area Team have been asked to identify Trusts currently at risk. Gateshead was flagged ‘at risk’ in February last year because of the concern around the volume of patients on the waiting list and projected clearance times to clear the backlog. An action plan is in place to support PAS improvements and targeted training to ultimately prevent data quality issues. The graph below demonstrates the improvements made since February. Trust is now reporting an overall clearance time of 12 weeks which is within expected performance levels for this measure of backlog clearance.

Figure 6 – RTT Clearance Times

0.00

5.00

10.00

15.00

20.00

0

2000

4000

6000

8000

10000

12000

Clearance Times (w

eeks)

Coun

t

Trust Incomplete Pathways, Clock Stops and Clearance Times

Total Clock Stops Incomplete pathways Trust Clearance Times

7

The Business Units have also been given additional internal funding to increase resources required to validate the Patient Tracking List. The plans have delivered significant improvements in treating more patients during the amnesty period and therefore reducing the number of patients waiting for treatment. At the end of August the Trust reported 8,198 patients awaiting treatment, representing a 12% reduction on the number of patients waiting in April 2014, and a 19% reduction in the number of patients waiting in the same reporting period last year. Monitor requires all Trusts to report via UNIFY a weekly PTL and have issued a ‘performance amnesty’ against the 3 RTT measures during the summer period. 4.4 Cancer 62 Day Treatment Targets The Trust is compliant with this measure in Q2 with performance at 81.5%; YTD performance is also just above expected levels at 85.9%. 4.4.1 Pressures The quarterly performance position identifies Lung, Urological, Upper GI and Gynaecological tumour sites as having the highest level of breaches. 4.4.2 Mitigating Actions The cancer information team and the Business Units are proactively tracking ‘at risk’ patients to mitigate the risk of incurring further breaches. An action plan is in place to ensure remedial actions are timely and effective and we await RCA’s to understand the current service pressures. The recovery plans project tumour specific improvements to be realised in Q2 to prevent further breaches in Q3 and beyond. 4.5 Infection Prevention & Control 4.5.1 MRSA The Trust has reported no cases of MRSA so far in 2014/15 against a zero tolerance trajectory. This measure is excluded from the Risk Assessment Framework and is included in the CQC’s Intelligent Monitoring reports. 4.5.2 C.Difficile The Trust has reported 8 cases of C.difficile against a trajectory of 6 in Q2, however 2 of the cases were deemed unavoidable at panel. The Annual trajectory for C difficile is 24 and our YTD position is 6. 4.6 Slot Issues The NHS Constitution guarantee to patients to be seen within 18 weeks still stands, and our performance in areas such as Choose and Book and becoming a hospital of choice are still dependent on short wait times for outpatients and surgery. The patient booking system ‘Choose & Book’ publicise specialty level RTT waiting‐times to help assist the public in their choice of hospital. Patients usually access secondary care (for the first time in the pathway) in either one of two routes, either a manual GP referral via paper/fax etc. or via the national electronic booking system, Choose and Book. The electronic option remains the favoured route for referrals into our hospital, accounting for circa 75% of our initial referrals. Access to first appointments, therefore remains an influential consideration when choosing an acute provider for care and treatment.

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11

5.2 Turnover Turnover for the twelve months to 30 September 2014 was 11.37%, which is a slight decrease from 12.07% for the twelve months to the end of June 2014. As in all previous reports, this figure excludes medical staff, as the high turnover of staff changing jobs as part of their training distorts the information. 5.3 Sickness Absence Figure 11 shows a slight increase in sickness absence over the 12 months to 31 August 2014. It can be seen that the rate was 5.22% (an increase of 0.2%)

Figure 11 ‐ Sickness Absence For the period shown the main clinical Business Units reported absence figures above the Trust target figure, however two of the three business Units have managed to decrease their absence level over the period. Surgical Services reported 5.90% for the quarter (a decrease of 0.6%), Medicine recorded 5.0% (reduction of 0.1%), with Assessment & Diagnostic Services showing a slight increase on the previous quarter at 4.51% (increase of 0.3%). In terms of staff groups clinical support staff e.g. HCAs and Helpers continue to show consistently high levels of absence. The Attendance Policy has recently been revised in conjunction with Staff Side colleagues, and in response to feedback from managers has included tighter trigger points to help manage persistent absentees, and mandatory update training for managers and supervisors to ensure all managers are aware of their responsibilities in relation to attendance management. This years “Flu Campaign” commenced in the first week of October. The initial response has been very positive with around 700 staff across the organisation accessing their “jab” in the first few days. Again chasing a national target of vaccinating 75% of frontline staff the Trust is keen to encourage all staff to have the vaccination and avoid absence due to flu over the winter months. Regular updates will be published in “QE Weekly”.

12

Figure 12 – comparison of sickness absence rates Figure 12 gives a comparison of monthly Trust‐wide sickness rates for September 2012/August 2013 (blue/bottom line)and September 2013/August 2014 (red/top line). Although the rates were higher in the winter months of this year the position, compared to last year has become much more stabilised, with a small but steady decrease continuing from July onwards. Work is ongoing to maintain this position in the longer term. 5.4 Bank Usage The chart Nurse Bank Usage (figure 13) shows an increased usage with 43,126.93 hours worked over the quarter ending 30 September 2014, an increase of 4335.68 hours compared to the previous three months.

Figure 13 Bank Staff Hours Worked 01 October 2013 – 30 September 2014

13

5.5 Equality & Diversity Monitoring Percentage figures by ethnic origin for the population of Gateshead are shown in Figure 14 along with the Trust workforce profile.

Percentage of Population Ethnic Origin Gateshead Borough:

2011 census Trust staffing at 30 September 2014

A White – British 94.1 93.34 B White – Irish 0.3 0.45 White: other white 1.9 1.31 D Mixed – White & Black Caribbean 0.2 0.03 E Mixed – White & Black African 0.1 0.11 F Mixed – White & Asian 0.3 0.11 G Mixed – Any other mixed background 0.2 0.20 H Asian or Asian British – Indian 0.5 1.66 J Asian or Asian British – Pakistani 0.3 0.37 K Asian or Asian British – Bangladeshi 0.1 0.17 Asian: any other Asian background

0.5 0.56 M Black or Black British – Caribbean

0 0.06 N Black or Black British – African 0.5 0.62 P Black or Black British – Any other Black background 0 0.17 R Chinese 0.5 0.14 Other ethnic group 0.5 0..70

Figure 14 – Ethnic coverage Figure 15 shows the profile of the Trust workforce by broader categories.

Figure15 ‐ Ethnic Origin Percentage Workforce

14

The age profile of the workforce, as shown in Figure 16, has 20.14% of the workforce 30 years old or younger (which is a slight decrease this quarter compared to 20.55% at 30 June 2014) and 30.37% aged over 50 years (a very slight increase this quarter compared to 30.00% in June 2014). Retirement regulations mean it is increasingly difficult to manage this position as the Trust can no longer require people to retire when they reach a certain age. It is therefore important that this situation is constantly monitored to understand the resulting impact of the age drift.

Figure 16 – Workforce Age Analysis 5.6 Corporate and Healthcare Professional Induction The percentage for Corporate Induction has decreased to 87% (from 93% Sept 2014). The decrease is largely due to the appointment of 16 newly qualified nurses who were appointed in mid‐September and their Induction could only be accommodated over the months of September and October, so they have not yet been able to complete. There are also a few past individuals who still have parts of their induction outstanding. OD & Training are continuing to follow these up. Figure 17 shows the number of staff who have completed Corporate Induction and Healthcare Professional Induction (if applicable). Those not required to complete this induction are:

• Internal movers within the Trust • Secondary post holders (e.g. an existing nurse working on the Bank) • Declined the post (although were included in the new starters list) • Left the Trust • Employed for less than one month with the Trust (e.g. students, work experience)

Month Eligible Completed Within 8 Weeks % Completed % Within 8 Weeks

October 41 41 41 100 100 November 26 25 19 96 73 December 21 20 18 95 90 January 16 15 15 94 94 February 19 18 18 95 95 March 32 31 30 97 94 April 20 19 15 95 75 May 20 20 20 100 100

15

June 24 24 23 100 96 July 17 13 12 76 71 August 42 38 38 90 90 September 39 13 13 33 33 Total 317 277 262 87 83 Figure 17 ‐ Corporate and Healthcare Professional Induction 2013 ‐ 2014 5.6.1 Local Induction Local Induction has decreased to 81% from 93% (June 2014). The percentage completed within 28 days of starting has also decreased to 37% from 45% (June 2014). This decrease is due to a large number of new starters in September 2014 and local inductions have not been received yet for the majority of these staff. Many of these are the newly qualified nurses who have a longer induction programme and will not have arrived in their departments till October. Figure 18 shows the number of local induction sign off sheets returned. This figure covers from 01 Oct 2013 – 31 Sep 2014.

Division Eligible Completed Within 28 Days % Completed % Within

28 Days Assessment & Diagnostic Services 86 64 33 74 38

Chief Executive 2 1 0 50 0 Estates & Facilities 21 19 13 90 62 Finance & Information 12 11 4 92 33 Health Development 4 4 2 100 50 Medicine & Elderly 102 93 40 91 39 Nursing & Midwifery 4 4 0 100 0 Surgical Services 68 46 20 68 29 Totals 299 242 112 81 37 Figure 18 ‐ Local Induction Rates 5.6.2 Induction: Junior Doctors Figures 19 and 20 show the Trust intake of junior doctors from 01 Oct 2013 – 31 Sep 2014 and the percentage of those who have successfully completed their Trust and Local Induction. Junior Doctors Generic Induction has risen to 93% (83% Jun 2014). Local Induction has decreased to 72% (83% Jun 2014) for the most recent intake. To continue to drive improvement the Medical Education Team has implementing a new process for the 4th August 2014 intake, where no study leave will be authorised for Junior Doctors unless they have completed both Generic and Local induction.

16

Junior Doctors Generic Induction

Eligible New Starters 2013 ‐ 2014

Completed Within 8 Weeks % Completed % Within 8 Weeks

Oct ‐ Dec 11 11 11 100 100

Jan ‐ Mar 39 38 38 97 97

April ‐ June 12 10 7 83 58

July ‐ Sept 125 116 114 93 91

Figure 19 – Junior Doctors Generic Induction

Junior Doctors Local Induction Eligible

New Starters 2013 ‐ 2014

Completed Within 2 Weeks

% Completed % Within 2 Weeks

Oct ‐ Dec 11 7 7 64 64

Jan – March 39 24 24 62 62

April ‐ June 12 10 10 83 83

July ‐ Sept 125 90 87 72 70

Figure 20 – Junior Doctors Local Induction 7.5 Mandatory Training Mandatory Training continues to be offered on a face‐to‐face and e‐learning basis. The overall percentage of staff trained has remained high at 84% (83% Jun 2014). Figure 21 shows the current percentage of staff within the organisation who have successfully completed their Mandatory Training either face‐to‐face or via e‐learning in the last 12 months (01 Oct 2013 – 31 Sept 2014). The reasons that staff are not required or are unable to complete mandatory training include:

• Long Term Sick • Maternity Leave • External Secondment

However if a member of staff has been trained and is currently “Live” they will still be counted as “Eligible” and “Live MT” until their training expires, when they will be removed from “Eligible”

17

Figure 21 – Mandatory Training Compliance 5.8 Personal Development Plans The percentage of PDPs has remained strong at 83% (83% June 2014) Figure 22 shows the number of live PDPs reported to OD & Training from 01 Oct 2013 – 31 Sep 2014.

Figure 22 – PDP Compliance 5.9 Dementia Awareness – Barbara’s Story Training The Trust has been working towards all staff receiving dementia awareness training through the delivery of the Barbara’s Story training. 59% of staff have been trained. Figure 23 provides a breakdown of attendance.

Figure 23 – Dementia Awareness Training

Divisions Eligible MT Count Percentage

Assessment & Diagnostic Services 757 591 78.07Chief Executive 23 14 60.87Estates & Facilities 439 378 86.1Finance & Information 148 125 84.46Health Development 75 68 90.67Medicine & Elderly 765 641 83.79Nursing & Midwifery 75 61 81.33Surgical Services 700 624 89.14Total 2982 2502 83.9

Division Eligible PDPCount Lapsed No PDP Percentage

Assessment & Diagnostic Services 814 614 144 56 75.43Chief Executive 24 16 4 4 66.67Estates & Facilities 460 402 51 7 87.39Finance & Information 159 125 30 4 78.62Health Development 78 66 10 2 84.62Medicine & Elderly 852 757 75 20 88.85Nursing & Midwifery 82 63 17 2 76.83Surgical Services 748 627 86 35 83.82Total 3217 2670 417 130 83

Divisions Eligible Trained Percentage

Assessment & Diagnostic Services 813 424 52.15Chief Executive 23 11 47.83Estates & Facilities 455 250 54.95Finance & Information 163 147 90.18Health Development 77 72 93.51Medicine & Elderly 842 506 60.1Nursing & Midwifery 81 71 87.65Surgical Services 741 418 56.41Total 3195 1899 59.44

18

Appendix A CQC – Performance Indicator Director

Lead Monitor Risk Rating

Target 2014/15

Q1 Q2 Q3 Q4 Year 2014/15

Anticipated Year End

National Commitments Data Quality for Ethnic Group JM >=85% 86.73% 86.42% 86.57% Delayed Transfers of Care SW <=3.5% 2.23% 2.11% 2.17% 4 hour Maximum Wait (Type I)* CH >=95% 95.02% 94.95% 95.01% 4 hour Maximum Wait (All Types) CH >=95% 96.68% 96.09% 96.45% 2 Week Wait for RACP CH >=98% 99.4% 98.8% 99.1% Cancelled Operations – 28 days Admitted 28 days SA

<=0.8% 0.74% 0.77% 0.76% >=95% 100% 100% 100%

National Priority Indicators Breast Feeding Initiative SA DRAFT >66.2% 69.18% 70.51% 69.88% Smoking During Pregnancy SA DRAFT <16.78% 17.06% 18.55% 17.84% Experience of Patients HL Inpatient Survey/Friends & Family Test Participation in Heart Disease Audits HL To be confirmed Engagement in Clinical Audits HL To be confirmed Stroke Care 90% on stroke Unit CH DRAFT 80% 98.7% 86.7% 92.2% % Patients with TIA treated <24 hours CH DRAFT 60% 50% 66.67% 58.33% Maternity – Data Quality Indicators SA DRAFT <=15% 0.01% 0.03% 0.02% MRSA bacteraemia HL 1.0 0 0 0 0 MSSA HL 3 0 3 E Coli (Data collection started June 2011)

HL 40 41 81

Clostridium Difficile Incidence HL 1.0 24 0 6 6 18 Weeks Admitted within 18 weeks CH/CC/SA 1.0 > = 90% 90.6% 91.2% 90.9% 18 Weeks Non Admitted within 18 weeks

CH/CC/SA 1.0 > = 95% 97.55% 96.61% 97.08% 18 weeks Incomplete pathways within 18 weeks

CH/CC/SA 1.0 > = 92% 94.65% 94.72% 94.68%

2 Week Wait Cancers HL 0.5

>=93% 93.5% 94.3% 93.9% 2 Week Wait Breast Symptoms HL >=93% 93.7% 95.0% 94.3%

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CQC – Performance Indicator Director Lead

Monitor Risk Rating

Target 2014/15

Q1 Q2 Q3 Q4 Year 2014/15


31 Day diagnosis to treatment HL 0.5 >=96% 100% 99.7% 99.9% 31 Day diagnosis to treatment Drugs HL

1.0 >=98% 100% 99.3% 99.7%

31 Day diagnosis to treatment Surgery HL

>=94% 98.5% 98.1% 98.4%

62 Day Referral to treatment HL 1.0

>=85% 86.9% 85.1% 85.9% 62 Day Referral to treatment screening HL >=90% 95.6% 93.1% 94.6% 62 Day Referral to treatment upgraded HL Shadow >=94% 80.0% 64.7% 71.9% Time in A&E (95th percentile) CH 1.0 4 hours 3h 59m 3h 59m 3h 59m A&E Time to Initial Assessment CH 0.5 15 minutes 17 mins 15 mins 16 mins A&E Time to treatment decision CH 0.5 60 minutes 55 mins 59 mins 58 mins A&E Unplanned Re‐attendance Rate CH 0.5 <5% 2.3% 2.0% 2.1% A&E Left without being seen CH 0.5 <5% 2.6% 2.8% 2.7%

A&E Ambulatory Care Conditions CH

Cellulitis – 28.0% DVT – 29.2%

Cellulitis – 19.0% DVT – 22.2%

Cellulitis – 25.0%

DVT – 27.3%

Mental Health Data Completeness – identifiers CH 0.5 97% 99.0% 98.9% 99.0% Mental Health Data Completeness – outcomes CH 0.5 50% 100% 100% 100% Mental Health Delayed Discharges National Reporting CH 1.0 7.5% 0% 0% 0%

MRSA Elective Screening HL >100% 197.07% 195.93% 196.48% Community dataset Data Completeness – Referral to treatment SA 1.0 50% 92.5% 93.5% 93.0% Community dataset Data Completeness – Referral SA 1.0 50% 100% 100% 100% Community dataset Data Completeness – Treatment activity SA 1.0 50% 100% 100% 100%

20

Local Indicators Director Lead

Monitor Risk Rating

Target 2014/15

Q1 Q2 Q3 Q4 Year 2014/15


18 week RTT Admitted 95th Percentile CH/CC/SA <23 weeks 20.87 22.44 21.84 18 week RTT Admitted Median CH/CC/SA <11.1 11.21 11.04 11.12 18 week RTT Non Admitted 95th Percentile

CH/CC/SA <18.3 weeks 15.67 17.86 17.16

18 week RTT Non Admitted Median CH/CC/SA <6.6 5.26 6.01 5.65 RTT All specialties achieving % standards

CH/CC/SA

N/A All Specialties

Gen Surg, Urol, ENT, T&O and Gastro

Gen Surg, Urol,

ENT,Gen Med, T&O,

Plastics, Gastro , Rheum & Other

Gen Surg, Urol,

ENT,Gen Med, T&O, Plastics, Gastro , Rheum & Other

Patients Waiting > 26 weeks CH/CC/SA N/A

329 (0 over 52)

324 (11 over

52) 653

(11 over 52)

Diagnostics Waiting Times CC N/A 99% 99.88% 99.80% 99.83% Slot Issues CH/CC/SA N/A 4% 15.86% 20.45% 17.67% Mixed Sex Accommodation breaches CH/SA N/A 0 tolerance 0 0 0 * A&E Type 1 activity in Q1 was A&E only, in Q2 Type 1 activity became all activity on QE site.



Patient Led Assessment of the Care Environment (PLACE)

1. INTRODUCTION

This paper aims to update the Council of Governors on the outcome of the annual Patient Led Assessment of the Care Environment (PLACE).

2. BACKGROUND

The PLACE assessment process commenced in April 2013, the focus to strengthen and formalise the role of the patient in both determining the content and the delivery of inspections. This audit process is patient led; patient representatives make up at least 50% of the inspection team which also includes representatives from Estates and Facilities, Infection Prevention and Control and a Senior Nurse. The Trust wishes to thank the patient representatives for their invaluable contribution in undertaking what are often long and tiring PLACE audits The aim of PLACE assessments is to provide a snapshot of how an organisation is performing against a range of non‐clinical activities which impact on the patient experience of care – Cleanliness; the Condition, Appearance and Maintenance of healthcare premises; the extent to which the environment supports the delivery of care with Privacy and Dignity; and the quality and availability of food and drink. The specific areas to which the audit was focused included:

• Wards acute/community; • Emergency departments/minor injuries unit; • Out‐patients department; • External areas; Car Parks, Entrances, Grounds and Gardens • Internal areas; Public circulation areas, refreshment areas, public toilets • Food – including the availability of food and drink

A percentage score for the above areas are grouped into 4 main categories included:

• Cleanliness • Food • Privacy Dignity and Wellbeing • Condition Appearance and Maintenance

On completion patient representatives are required to complete their own review of the assessment process.

3. ASSESSMENT PROCESS The assessment of Cleanliness covers all items commonly found in healthcare premises.

The assessment of Condition, Appearance and Maintenance includes aspects of the general environment including décor, tidiness, signage, lighting, linen, access to car parking, waste management and the external appearance of buildings and the tidiness and maintenance of the grounds. The assessment of Privacy, Dignity and Wellbeing includes aspects such as provision of outdoor/recreation areas, changing and waiting facilities, access to television, radio, computers and telephones; and practical aspects such as appropriate separation of sleeping and bathroom/toilet facilities for single sex use, ensuring patients are appropriately dressed to protect their dignity. The assessment of Food and Hydration includes a range of questions relating to the organisational aspects of the catering service (e.g. choice, 24‐hour availability, meal times, and access to menus) as well as an assessment of the food service at ward level and the taste and temperature of food. As a change to last year the annual inspection process was completed over a number of weeks, audits were completed at agreed dates and times enabling assessment throughout the working day. External Validators were able to attend for most of the planned sessions to ensure good practice against the audit criteria. The program of assessments was decided each day with no prior notice given to Trust staff. The decisions on where to visit were left entirely at the discretion of the patient representatives who choose from a list of all areas. The Trust is required to include all units/sites with 10 in‐patient beds or more. The assessment criteria to included 10 Wards (or 25% whichever is the greater) and a similar number of Out Patient Facilities all covering buildings of different age and conditions. The Team were also able to sample and complete food assessments at the lunch and evening meal service at the QE and lunch at the ICAR Unit.

Queen Elizabeth Hospital

In‐patient areas (Wards) Non‐Ward Patient Areas Ward 2 Accident and Emergency Ward 8 Children’s Out Patients Ward 14 Colposcopy Ward 14a Discharge Lounge – Jubilee Wing Ward 20 Endoscopy Ward 22 ENT Out Patients Ward 23 Fracture Clinic Maternity Post Natal Main Out Patients Peter Smith Surgery Centre Level 2 Maternity Pre Assessment Unit St Bedes at Elmwood Physiotherapy Internal and External general areas

ICAR Unit at Houghton‐le‐Spring Ward Area

It was felt that the above included fair representation of Trust accommodation with a mix of services.

4. SCORING METHODOLOGY The outcome of the assessment is based on scores achieved to ‘Yes/ No’ answers and assessments against standards which can be scored as a Pass/Qualified Pass/Fail. In 2014 the calculation of the overall food score was changed with a weighting mechanism applied to the organisational questions of the food and hydration section.

The outcomes achieved in each of the four categories are presented in the form of a thermometer with a numerical percentage score against each area. Our scores achieved are at Appendix A. This also includes the National benchmarking score published on the 27th August 2014. PLACE assessment and scoring will be used by a range of public bodies such as; Care Quality Commission ‐ Information from the collection will be used in the CQC’s Intelligent Monitoring (IM) process. Department of Health and NHS England ‐ Information from the collection will be used for a range of purposes including: ‐ informing quality programmes including nutrition, compassion in practice implementation in relation to privacy and dignity. In overview it was considered by all involved that the assessments went very well. Constructive comments were received from the patient representatives who noted Queen Elizabeth Hospital “A hospital with a number of buildings of different ages where the standards of cleanliness were excellent and maintenance of the fabric of the buildings was consistently high throughout. The quality, presentation and delivery service of the food was excellent. We were impressed by the recently introduced pictorial menu book, a copy of which is on every Ward for the benefit of patients. For those patients on the dementia Ward there was a pictorial menu display which was changed on a daily basis. The assessors were particularly impressed by the friendly and caring attitude displayed by staff of all disciplines towards patients and Visitors.” ICAR Unit “An impressive, new, modern, purpose built 24 bedded rehabilitation unit which fulfils all the criteria. The dedication of staff and their commitment to the wellbeing of the patients generated an atmosphere of wellbeing.” Audit Findings During the process a number of general themes for improvement were considered.

• Environment Condition Appearance – Issues included areas of minor environmental damage, inappropriate storage, and temporary signage.

• Privacy, Dignity and Wellbeing ‐ Issues to consider, provision of Treatment Room, access to Private Rooms. This year also included questions around personal access to TV and radio with best practice indicating this should be provided at no cost.

• Food was sampled at the end of service on four Ward areas at the QE overall the food tasted was found to be of excellent quality, however it was felt that the temperature of the vegetable products could have be better. ICAR – The menu was felt to be limited, the menu information was confusing. The fish dish on the menu which was sampled during the audit was felt to be a little bland to taste the texture just acceptable. Further details are included in the action plan at Appendix B.

5. ACTION PLAN

Following on from the assessment and the feedback an action plan was produced. This is included at Appendix B. The action plan has been shared and will be followed up through our internal Patient Environment committee.

Mr P Harding Deputy Chief Executive

Appendix A

Site Cleanliness Food Overall Privacy and Dignity Condition

Appearance and Maintenance

QE Gateshead 2013 98.93 86.10 90.29 92.11 QE Gateshead 2014 99.68 89.62 90.99 94.51 ICAR* 98.61 76.92 85.71 89.71 National Average 2014

97.25 88.79 87.73 91.97

*ICAR Unit scores difficult to benchmark against other comparable sites. Scores appear slightly lower as some negative responses mainly to organisational questions in the Food, Privacy and Dignity and Condition Appearance and Maintenance sections had an enhanced effect on the overall outcome.(Small audit size) Notes ICAR Food Section marked lower Menu is more repetitive, less choice, patients required to choose 2 meal’s in advance fewer options for patient on a special diet etc Privacy and Dignity – Do patients have access to wifi, designated rooms for family visiting, can families stay overnight Condition Appearance – lack of high visability nosing to internal/external stairs, and high contrast marking on entrance doors. Has the Trust reviewed signs inside and outside the building. Has the organisation assessed the travel needs of patients

Appendix B

PLACE ACTION PLAN 2014/15

Topic Audit Result Action Responsible Officer Date

Cleanliness Overall the standard of cleanliness was agreed to be excellent throughout. There were minor failures which have been addressed as part of the process.

Continue regular monitoring of the environment.

S.Philipson On‐going

Environment Areas identified during the audit included– environmental damage, stained ceiling tiles, temporary signage. Ward 20/Suite 5 Main OPD – Damage to floor surfaces in 2 areas.

All areas identified during audit have been call logged for repair. Work continues to raise awareness and encourage all staff to be proactive in identify environmental issues ensuring they are reported proactively.

Internal PLACE Team

On‐going

Furniture/seating Seating in Ward 20 was identified as in need of replacement, seats were worn with loss of colour.

New furniture will be provided in ECC when department moves.

Matron Dec 2014

Lighting/Natural Light

Bathrooms in Jubilee Wards – lighting was inconsistent in some areas

Estates to review possibility to improve lighting.

Kevin Smeaton

Aug 2014

Linen All Linen was found to be clean and in good repair Linen storage areas were found to be tidy with appropriate storage

Continued monitoring Internal PLACE Team All Matrons

On‐going

Odours Areas were found to be fresh with good ventilation.

Continued monitoring Internal PLACE Team All Matrons

On‐going

Tidiness Storage remains an issue in the areas assessed 4 were marked as a qualified pass (minor issues) 1 area failed more significant concerns raised regarding the general tidiness of the environment.

Raised issue locally with wards.

Internal Place team

On‐going

Waste Management

No concerns raised. There was good evidence throughout the audit that waste is segregated and disposal effectively managed.

Continue to monitor Internal Place Team

On‐going

Dementia‐Friendly Ward Environment

Standards around consistent floor appearance, décor and signage. Currently the Trust does not comply with the standards described.

Ward 23 currently undergoing floor replacement programme and other minor works to comply with dementia friendly standards. New curtain selected for all patient areas in a dementia friendly design.

Internal Place Team / Ward 23

Oct 2014

Ward Hand Hygiene

It was noted during the audit that there was some inconsistency in provision, quality and location of hand hygiene information with access to clean hand wash stations and alcohol gel in all clinical areas.

A new edition printed leaflet with information on hand hygiene within the QE now available on the wards and departments a wipeable version agreed which can be fixed to wall surfaces. Work can commence as soon as posters costs agreed. Posters outside the hospital ward and department entrances which promote hand washing at the ward entrances for all – staff, patients & visitors.

Phil Pugh (IPC) John Simpson Estates

On‐going project to look at all hand hygiene products with a review to complete early 2015

Ward Safety All fire exits were found to be clearly identified and free of obstacles.

On‐going monitoring of all wards and areas as part of H & S process

All areas/ Internal Place Team

On‐going

Confidentiality No identified rooms on some Patient areas to ensure private conversations can take place

Matrons to ensure appropriate places are allocated in all patient areas

All Matrons Dec 2014

Ward Staff Appearance

It was pleasing to see excellent compliance with the ‘bare below the elbow’ policy throughout the audit. No concerns raised in this section

Continue to monitor All areas / Internal Place Team

On‐going

Privacy, Dignity and Wellbeing

Access to personal TV and Radio for each patient now part of assessment. No access to Treatment Rooms and Day Rooms

Standard new in PLACE 2014 assessment, to achieve compliance against best standard all patients would have personal access to a TV at no cost. Current patients have access to a personal TV at a cost.

Food QE ‐ Temperatures of some vegetable products scored at end of service could have been better. ICAR Unit – Patients menu was confusing layout did not make choices clear to patients.

ICAR ‐ Work commenced to improve choice. Catering Manager currently reviewing service with service provider.QE – Reduced container size of vegetable products and trained staff to bring vegetables to servery for a just in time service maintaining temperatures.

Ian Stafford On‐going

Embed PLACE Standards

Embed PLACE environmental standards across the organisation. Ensure the timely identification of repairs and remedial action

Develop weekly audit process to include multi‐disciplinary team and patient representation Implementation of standards for template ward (Ward 23)

Internal Place Team Ward 23/ Internal Place Team

On‐going Oct 14



Update Report – Elections 2014

Introduction The closing date for receipt of nominations for this year’s elections was 30th October 2014. 14 nominations were received for four constituencies; six for central, four for western, and four for staff. Unfortunately, no nominations were received for the patient constituency. Results Central Constituency six nominations received for two vacancies

Western Constituency four nominations received for two vacancies

Staff Constituency four nominations received for three vacancies

Patient Constituency one vacancy remains

Next Steps The voting packs will be distributed by the ERBS to all central, western and staff members on 19th November 2014. The closing date for receipt of ballot papers is 9th December 2014, with the results announced at 12.00 noon on 10th December 2014. Recommendation The Council of Governors is asked to receive for information the update report on the elections 2014. Mrs J Williamson Membership Co‐ordinator

council of governors · 7. membership strategy 2014/16 enclosure to approve the membership strategy...

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