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Agenda item A8(i)a
TRUST BOARD
Date of meeting 31st January 2019
Title Consultant Appointments
Report of Andy Welch, Medical Director
Prepared by Jane Padget, Assistant HR Officer
Status of Report Public Private Internal
☒ ☐ ☐
Purpose of Report For Decision For Assurance For Information
☐ ☐ ☒
Summary The content of this report outlines recent Consultant Appointments.
Recommendations The Board of Directors is asked to note for information the decisions of the Appointments Committee.
Links to Corporate Objectives
Putting patients first; maintaining financial viability/stability
Links to Strategy and Clinical Risks
N/A
Impact
Tick yes or no as appropriate Yes No
Quality and Safety X
Legal X
Financial X
Human Resources X
Equality and Diversity X
Engagement and communication X
Sustainability X
If yes, please give additional information: N/A
Reports previously considered by
Consultant Appointments are submitted for information in the month following the Appointments Panel.
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Agenda item A8(i)a
____________________________________________________________________________________________________ Consultant Appointments Trust Board 31
st January 2019
CONSULTANT APPOINTMENTS
1. APPOINTMENTS COMMMITTEE – CONSULTANT APPOINTMENTS 1.1 An Appointments Committee was held on 14 December 2018 and interviewed one
candidate for the post of Consultant Urological Surgeon.
By unanimous resolution the Committee was in favour of appointing Dr Andrew David Moon. Dr Moon holds MBBS (University of Newcastle) 2009, MRCS (Edinburgh) 2012 and FRCS Urol (Edinburgh) 2017. Dr Moon is currently employed on behalf of the Lead Employer Trust, based at the Freeman Hospital.
Dr Moon is expected to take up the post in March 2019.
1.2 An Appointments Committee was held on 19 December 2018 and interviewed one
candidate for the post of Consultant Clinical Geneticist.
By unanimous resolution the Committee was in favour of appointing Dr Richard Martin. Dr Martin holds MBChB (Queens University) 2007, MRCP (Edinburgh) 2012 and a Diploma in Clinical Education (Newcastle University) 2013. Dr Martin is currently working as a Locum Consultant Clinical Geneticist with the Trust.
Dr Martin is expected to take up this post as soon as possible.
1.3 An Appointments Committee was held on 19 December 2018 and interviewed one
candidate for the post of Consultant Chemical Pathologist
By unanimous resolution the Committee was in favour of appointing Dr Purba
Banerjee. Dr Banerjee holds MB BS (Bangalore) 2000, MRCP (UK) 2009 and FRCPath
(UK) 2017. Dr Banerjee is currently employed as a Consultant Chemical Pathologist
with North Cumbria University Hospital.
Dr Banerjee is expected to take up the post of Consultant Chemical Pathologist in
March 2019.
1.4 An Appointments Committee was held on 10 January 2019 and interviewed one
candidate for the post of Consultant Interventional Neuroradiologist.
By unanimous resolution the Committee was in favour of appointing Dr Chee Gan. Dr
Gan holds MB BCh (University of Wales) 2007, FRCR (UK) 2012 and EDiNR (European
Board of Neuroradiology) 2016. Dr Gan is currently working as a Consultant
Interventional Neuroradiologist at the University Hospital of Wales.
Dr Chee is expected to take up the post of Consultant Interventional Neuroradiologist
in March 2019.
2
Agenda item A8(i)a
____________________________________________________________________________________________________ Consultant Appointments Trust Board 31
st January 2019
2. RECOMMENDATION 1.1 – 1.4 – For the Board to receive the above report.
Report of Andy Welch Medical Director 16 January 2019
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Agenda item BRP A8(i)a
TRUST BOARD
Date of meeting 31st January 2019
Title Honorary Consultant Appointments
Report of Andy Welch, Medical Director
Prepared by Andy Welch, Medical Director
Status of Report Public Private Internal
☒ ☐ ☐
Purpose of Report For Decision For Assurance For Information
☐ ☐ ☒
Summary The content of this report outlines recent requests for Honorary Consultant Contracts.
Recommendations The Board of Directors is asked to note the award of/ extension to the Honorary Consultant Contracts.
Links to Corporate Objectives
Continue to recruit and retain the very best staff.
Links to Strategy and Clinical Risks
Putting patients first and providing care of the highest standard focusing on safety and quality. Enhancing our reputation as one of the country’s top, first class teaching hospitals, promoting a culture of excellence in all that we do.
Impact
Tick yes or no as appropriate Yes No
Quality and Safety
Legal
Financial
Human Resources
Equality and Diversity
Engagement and communication
If yes, please give additional information: Award of Honorary Consultant Contracts
Reports previously considered by
Honorary Consultant Appointment requests are submitted for information as and when requests are received.
5
Agenda item BRP A8(i)a
HONORARY CONSULTANT APPOINTMENTS
1. HONORARY CONSULTANT APPOINTMENT REQUESTS 1.1 Dr Nithya Ratnavelu Dr Nithya Ratnavelu, MB BCh BAO, Belfast 1997 - 2003, BSc (Hons) Biochemistry, Belfast 2000 - 2012, is currently employed by Gateshead Health NHS Foundation Trust as a Consultant Gynaecological Oncologist. An Honorary Contract for Dr Ratnavelu is requested so that a joint operating service for 16-18 year olds in the Newcastle area can be provided. There will be no financial implication to the Trust. 1.2 Dr Christopher Duncan
Dr Christopher Duncan, BSc Med Sci Aberdeen 2001, MB ChB (with Hons) Aberdeen 2003, MRCP UK 2005, DTM&H 2007, DPhil Oxford 2014, MRCP (ID) 2016, currently has an Honorary Contract with the Trust as a Clinical Intermediate Fellow/ Honorary Consultant in Infectious Diseases until 28 February 2019 Dr Duncan has recently been awarded a Clinical Research Fellowship which has been added to his current post and this will take his post up to 4th November 2021. There is no cost to the Trust for the extension of his Honorary Contract. 1.3 Professor Stephen Jones Professor Stephen Jones, BMedSci, Newcastle 1987, MBBS Newcastle 1990, MRCP 1993, Dip BMedSci Newcastle 1994 FRCP 2006. Newcastle University has requested an Honorary Consultant Contract be awarded to Professor Stephen Jones. A Selection Committee held on 19th September 2018 resolved that Professor Jones be appointed Honorary Clinical Senior Lecturer (Consultant) in Dental Services. The Trust was represented on the Selection Committee by Mr B Cole, Clinical Director Dental Services. Professor M Thomason and Mr J Durham who supported the appointment. The post is fully funded by the University.
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Agenda item BRP A8(i)a
1.4 Miss Kate Elizabeth Carney Miss Kate Elizabeth Carney, MBChB Edinburgh 2007, BSc (Hons) Edinburgh 2004, MRCS Edinburgh 2010. ChM General Surgery Edinburgh 2015, FRCS Edinburgh 2016, is currently employed by Northumbria Healthcare NHS Foundation Trust as a Consultant Colorectal Surgeon. An Honorary Contract has been requested to allow Miss Carney to assist with patients from both Trusts on a regular basis. There is no financial implication to the Trust. 2. RECOMMENDATIONS The Board is asked to note:
1.1 Dr Nithya Ratnavelu will receive an Honorary Contract as a Consultant
Gynaecological Oncologist with immediate effect and for the duration of her involvement in the joint operating service.
1.2 Dr Christopher Duncan will receive an extension to his Honorary Contract as a Consultant in Infectious Diseases until 4th November 2021.
1.3 Professor Stephen Jones will receive an Honorary Contract as a Consultant Physician with immediate effect and for the duration of his post with the University.
1.4 Miss Kate Elizabeth Carney will receive an Honorary Contract as a Consultant Colorectal Surgeon with immediate effect. This should be reviewed in 2021.
Report of Andy Welch Medical Director 23rd January 2019
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Agenda item A8(ii)a – BRP AD JD Nov18 appendix
Executive Chief Nurse
Maurya Cushlow
Associate Director of
Midwifery
Elaine Blair
Associate Director of AHPs
Stella Wilson
Nurse specialists IM&T
Professional lead OPD/Dental
Procurement
Deputy Chief Nurse
Elizabeth Harris
Chief Nursing - Information
Officer
Associate Director of Nursing
Lisa Guthrie
(RVI)
Clinical Standards
Deteriorating patient
Clinical assurance Tool
Environmental
standards/PLACE
HCAI
Sepsis
Falls
Pressure Ulcers
Safety Thermometer
CAT
Tissue Viability
SAFER
Nutrition
Dementia
Care planning
Continence Care
Associate Director of Nursing
Ian Joy
(FRH)
Workforce & Practice Development
Workforce strategy
E Roster
Safe Staffing
Escalation
Succession Planning
Preceptorship
Competency Frameworks
New role development
Education
Research
Advanced practice & NP
development
SNCT development
Carter efficiency work
International Recruitment
Associate Director of Nursing
Peter Towns
(Community)
Prevention, Health promotion,
out of hospital care
Prevention & well being
Medicines management
Nurse consultants
Public Health
Out of hospital care
Clinical supervision
Parity of esteem
Diversity & inclusion
End of Life Care
Patient experience –
complaints/Patient
Involvement
OHS (operational)
Chaplaincy
Associate Director of Nursing
Helga Charters
(Trustwide) Children & Young People
Professional responsibility for nursing teams in designated children’s areas
Lead responsibility for children and young people cared for in adult areas across Trust.
Children and young people focused involvement alongside ADN adult posts – - Clinical Standards - Workforce & Practice Development - Prevention, Health promotion, out of
hospital care. NISR • Learning Disabilities
NISR
Hospital at night
Trustwide transformation/CIP/Business Planning (with LH)
H
9
Agenda item A8(ii)a – BRP AD JD Nov18 appendix
Associate Director of
Nursing
Prevention, Health
promotion, out of hospital
care
Associate Director of
Nursing
Clinical Standards
Associate Director of
Nursing
Workforce & Practice
Development
Matron Infection
Prevention and Control
Nurse Consultant –
Continence Care
Nurse Consultant
Tissue Viability
Nurse consultant
vulnerable older adults
Falls and Pressure Ulcer
Improvement Lead
Data Manager - Patient
Services
Associate Nurse
Consultant Vulnerable
Older Adults
Senior Nurse N&M
Staffing
Lead for Nursing
Midwifery & AHP
Research & Practice
Development
Senior Nurse - Practice
Development
Nursing Models of
Education Project
Manager
Senior Nurse -
International
Recruitment
Senior Nurse -
Specialist Palliative
Care/End of Life
Nurse Consultant
Cancer Services
Macmillan Lead
Head of Patient
Experience
Chaplaincy
Clinical service manager
OHS
Equality and Diversity
Lead
Nurse Consultant for
Paediatric Immunology
Senior Nurse - Hospital
at Night
Associate Director of
Nursing
Children and Young People
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Agenda item A8(ii)a – BRP AD JD Nov18 appendix
Lisa Guthrie
Royal Victoria
Infirmary Base
Matrons
Internal and Older Peoples
Medicine
Angela McNab, Chris Bill, Linda
Morgan, Barbara Goodfellow
EPOD
Sue Cook, Julie Graham
Neurosciences
Cheryl Teasdale
Clinical Research
Aileen Burn
Peri-Op and Critical Care (RVI)
Lisa Squires, Dawn Turley,
Lesley Scott
Women’s Services
Angela Barnes
Ian Joy
Freeman Hospital
Base
Matrons Community District Treacey Kelly Nursing (DN East, DN Central, DN West, ENNS), Care Home Support Team Alison Deagle Walk in Services (Molineux, Ponteland Road, Westgate Road, Lemington), Newcroft Sexual Health CRRT, Chronic Disease Monitoring, Community TB Service Kath Robinson Health Visiting (HV East, HV West, HV Central) School Health (SH West, SH East, SH Central)
Peter Towns
Community
Base
Matrons
Cardiothoracic
David Kinnersley, Fiona
Hindhaugh, Amanda Vickers,
Andrea Russell
Urology/Renal/IOT
Sally Ridley, Julia Ibbotson,
NCCC
Vacant Post
Surgery
Sam Rutherford, Diane
Henaghan
Orthopaedics
Ruth Saunders
Peri-Op and Critical Care
(FH)
Alison Gray, Sharon
Thompson, Emma McCone
Helga Charters
C&YP Lead
Matrons GNCH Jenny Palmer, Claire Riddell Louise Raine, Emma Willey, Vacant Post Cardiothoracic Rachel Patterson
Neonates Yve Collingwood
Site & Professional Leadership (Nursing)
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Agenda Item A8(ii)b – BRP
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
SAFEGUARDING COMMITTEE QUARTER 3 UPDATE 2018/19
1. INTRODUCTION
This paper provides a Quarter 3 update from the Safeguarding Committee to inform the
Board of Directors of implications emerging from new statutory national guidance, emerging
issues, and local practice developments.
Safeguarding activity for Quarter 3 in 2018/2019 evidences 1340 “Cause for Concerns” (CFC)
/ referrals across the safeguarding teams; 238 case discussions in the MASH by the
Children’s Nurse Advisor’s; 166 deprivation of liberty safeguards (DoLS) applications and 479
contacts with the LD team for advice and support.
Safeguarding training is a priority and continues to be delivered weekly at Trust Induction
for all new staff. Supplementary training is mandatory and is provided in line with national
requirements with additional bespoke safeguarding training on request. Safeguarding
supervision is provided to a range of staff across acute and community services. The teams
continue to review policies and complete audits to provide assurance regarding
safeguarding processes; they also contribute to a number of serious case reviews with our
local authority colleagues and support the work of both local Safeguarding Boards. Almost
50% of the work across the teams relates to out of area service users.
The Trust’s safeguarding teams continue to deliver a high quality service that serves to
promote the safety and well-being of adults at risk and vulnerable children. They are
extremely responsive to staff, providing advice and support to meet the demands of a
motivated and vigilant workforce. The teams respond to national guidance to improve
practice developments, undertake significant work to review processes to provide assurance
processes are robust and identify areas for development. The work of the safeguarding
teams continues to increase in relation to case numbers, complexity, training expectations
and the need to provide assurance; there are a number of risks they are working to
mitigate. This paper will summarise these issues, which have been raised and discussed with
the Safeguarding Committee.
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Agenda Item A8(ii)b – BRP
NATIONAL REPORTS AND REGULATORY UPDATE
The ‘Decision-making and mental capacity NICE guideline was published on 3rd October
2018 nice.org.uk/guidance/ng108 . This guideline covers decision-making in people 16 years
and over who may lack capacity now or in the future. It aims to help practitioners support
people to make their own decisions where they have the capacity to do so and to keep
people who lack capacity at the centre of the decision-making process.
The Care Quality Commission (CQC) estimates that around 2 million people may lack the
capacity to make certain decisions for themselves at some point due to illness, injury or
disability. The Mental Capacity Act 2005 was designed to empower and protect individuals
in these circumstances. However, the CQC identified serious issues with the practical
implementation of the Act.
It is in this context that the Department of Health commissioned this guideline, which makes
recommendations for best practice in assessing and supporting people aged 16 years and
older with decision-making activities. It helps to ensure that people are supported to make
decisions for themselves when they have the mental capacity to do so, and where they lack
the mental capacity to make specific decisions, they remain at the centre of the decision-
making process. The guideline supports the empowering ethos and principles introduced by
the Mental Capacity Act 2005 and explained in the Code of Practice. These are:
A person must be assumed to have capacity unless it is established that he lacks
capacity.
A person is not to be treated as unable to make a decision unless all practicable steps to
help him to do so have been taken without success.
A person is not to be treated as unable to make a decision merely because he makes an
unwise decision.
An act done, or decision made, under this Act for or on behalf of a person who lacks
capacity must be done, or made, in his best interests.
Before the act is done, or the decision is made, regard must be had to whether the
purpose for which it is needed can be as effectively achieved in a way that is less
restrictive of the person's rights and freedom of action.
The guideline focuses on:
advance care planning
supporting decision-making
assessment of mental capacity to make specific decisions at a particular time
The guideline does not cover:
decision-making activities and support for children under 16 years
the issue of deprivation of liberty and the Deprivation of Liberty Safeguards processes.
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Agenda Item A8(ii)b – BRP
The principles within this NICE Guidance are actively promoted throughout the Trust in
terms of advice and guidance to staff and MCA training to support clinical practice and
decision-making.
2. PRACTICE DEVELOPMENTS
There are a number of areas of safeguarding practice being developed, either to enhance
patients’ experience and ensure patient safety or to develop best practice especially in
relation to multi-agency working. Examples are outlined below.
i) SARC1 and CSE Mental Health Referral Pathway
A task and finish group has been set up to consider how children who have been subjected
to sexual abuse or sexual exploitation can have appropriate and timely access to mental
health services. The scope of this work will include areas covered by Northumberland,
Durham and Cleveland police forces. Provider services vary across the region and
commissioning arrangements are very complex. This often prevents timely access to
psychological support following trauma for children and young people who have
experienced sexual abuse. A second meeting is planned for January 2019.
iii) Learning Disability Champions
There was a meeting held in November with four consultants who expressed interest in the
opportunity to become a learning disability champion. A further two also expressed interest
but were unable to attend the meeting. It was agreed that all would become ambassadors
for LD and provide support to the LD nursing team by participating in mortality reviews,
chairing the quarterly mortality review meeting and to chair the LD Steering Group. This will
be reviewed after 6 months but it is very refreshing to have some key individuals who are
committed and motivated to provide this corporate leadership role.
iv) NHSI Learning Disability National Benchmarking Survey
The Trust has participated in a Learning Disability National Benchmarking Survey by NHSI. 80
consent forms were sent out to adult service users; 8 were returned within the time frame
and only 1 individual completed the survey. 20 staff surveys were distributed &
organisational data was submitted although there were some gaps due to the structure of
the survey. It is understood that NHSI will take the learning from this inaugural national
survey and consider how improvements can be made, as responses across the country have
generally been poor. Feedback from the survey will be shared at the National Learning
Disability Conference in March 2019.
1 Sexual Assault Referral Centres (SARC)
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Agenda Item A8(ii)b – BRP
v) Review of arrangements to use Special Care Baby Unit as a Place of Safety
A meeting has been held with CCG and Children’s Social Care to consider the issues of
utilising the special care baby unit (SCBU) as a place of safety for babies who are born where
the protection plan is for them to be discharged into foster care. Issues discussed:
Well babies being placed in SCBU as a place of safety until ICO (Interim care Order) is
obtained
Availability of court hearing dates for CSC to apply for ICO
Increased cot pressures for babies in SCBU
Inappropriate practice of placing well babies in SCBU as a place of safety
Cases where well babies have had to be transferred to local SCBU unit as place of
safety as RVI have no capacity to accommodate
Option of obtaining police protection order after delivery to place babies with foster
carer until ICO granted
A further meeting is being planned to include Northumbria Police and Legal Services to consider how a robust system can be established that ensures the safety of babies on a Child Protection Plan who cannot be cared for by the mother on postnatal ward until an Interim Care Order is obtained
vi) Children’s Social Care (CSC) and Maternity Services
A meeting has been held with CCG and CSC to address current issues in relation to maternity
services not receiving safeguarding information in a timely manner, iin particular:
Difficulties speaking to allocated social workers and not receiving a return call
Not receiving feedback regarding outcome of CSC referral
Birth plans not being completed and forwarded to RVI at an appropriate gestation
Delays in arranging pre-discharge meetings and obtaining ICO (interim care order)
No CSC representation at safeguarding forum meeting for last few months
Actions agreed:
The Safeguarding Core Group will complete the birth plan at the first meeting after
viability of the pregnancy has been reached and will send a copy to RVI. This content will
be reviewed at each subsequent core group.
CSC to identify birth plan templates currently in use and remove old versions.
CSC to identify two social workers to attend maternity safeguarding forum on
alternative months.
CSC to review the process for sending out letter to referrer to inform of outcome of
referral submitted.
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Agenda Item A8(ii)b – BRP
vii) Safeguarding Communication Forums
Safeguarding Communication Forums are well established across the Trust and have been in
place for a number of years. They take place quarterly and alternate across the Freeman
and RVI sites. The forums are well attended by a cross section of staff from a range of
different clinical and non-clinical roles. For 2019, the safeguarding Teams are going to
increase the number of forums and will hold them 6 times per year. Each forum will be
delivered on both sites within the same week where possible. This will enable more people
to attend the forums and for a range of external speakers to be invited. In February, a
speaker from the Rape Crisis service will deliver a presentation about sexual violence and
trauma; in April, another speaker from Community Safety will present a discussion about
substance misuse and drugs issues affecting our local communities.
viii) Human Rights in Health Care Conference
The Safeguarding Adults Team is leading on a Human Rights in Health Care Conference that
will take place on the 19 September 2019. The focus will be on the following articles with an
interwoven theme relating to the mental capacity act.
Article 2: Right to life
Article 3: Freedom from torture and inhuman or degrading treatment
Article 4: Freedom from slavery and forced labour
Article 5: Right to liberty and security
Article 8: Respect for your private and family life, home and correspondence Zoe Lodrick who is a well renowned expert in Sexualised Trauma has agreed to be a keynote speaker at the conference. Further information will follow in due course. viiii) Routine Enquiry for Domestic Abuse in Sexual Health The Adult safeguarding Team are undertaking a piece of work with Sexual Health Services to audit how routine enquiry for domestic abuse is undertaken in practice. An initial scoping exercise has been undertaken and a full audit will be completed by the end of June 2019.
3. INTERNAL ASSURANCE / POLICY COMPLIANCE
The Trust Safeguarding Committee has met quarterly as planned to ensure appropriate
scrutiny, challenge and assurance is in place.
Policies revised to date in Q3 2018/2019:
Prevent Policy (V1.0) approved at Safeguarding Committee November 2018
Safeguarding Clinical Supervision for Nurses, Midwives and Allied Health Professionals
who work with Children (V4.0) approved at Safeguarding Committee November 2018
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Agenda Item A8(ii)b – BRP
Was not Brought (at Hospital Out Patients appointments for Children) – V3.0
Restraint Policy (Adults) V7.0 approved at Safeguarding Committee November 2018
Audits completed to date in Q3 2018/2019:
Safeguarding Supervision for 0-19 service – presented to Safeguarding Committee
November 2018
Audits are reported to the Trust’s Safeguarding Committee and provide assurance that
policies and processes are being monitored and reviewed regularly.
4. TRAINING
Trust wide compliance with Safeguarding Mandatory Training is as follows:
Safeguarding Mandatory Training Compliance 2018/2019
March
2017
March
2018
2018/19
Q1
2018/19
Q2
2018/19
Q3
2018/19
Q4
Safeguarding Adults Level 1 95.7% 97.6% 87.1% 87.38% 87.30%
Safeguarding Children Level 1 95.7% 97.6% 87.1% 86.72% 86.65%
Safeguarding Adults Level 2 77.0% 83.2% 80.6% 82.56% 82.13%
Safeguarding Children Level 2 77.3% 81.9% 84.7% 85.89% 86.45%
Safeguarding Children Level 3 71.2% 73.2% 71.5% 71.47% 73.28%
TOTAL Prevent : 15.3% 40.2% 55.4% 64.85% 69.75%
BPAT n/a n/a 57.2% 66.00% 70.30%
WRAP n/a n/a 53.4% 63.60% 69.10%
Progress towards the 85% target for WRAP
training has slowed despite weekly
advertising and additional sessions for face-
to-face training across Freeman and RVI.
There have been multiple sessions offered in lecture theatres with very limited uptake.
Prevent training is advertised every week in ‘In Brief’ and reminders are also sent out to
Directorate Managers and Clinical Directors to disseminate across teams and services.
There has been a national issue with eLearning on ESR that was identified towards the end
of December that affected individual competencies to be pulled through to staff profiles on
completion of eLearning. This has still not been fully resolved and staff are temporarily
being advised not to complete eLearning by Workforce and Development.
Target Red Amber Green
end of Q1 40% 0-29% 30-39% 40%+
end of Q2 80% 0-69% 70-79% 80% +
end of Q3 90% 0-79% 80-90% 90% +
end of Q4 95% 0-84% 85-95% 95% +
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Agenda Item A8(ii)b – BRP
The same process for providing Directorate Managers with Prevent training data will be
implemented for the other levels of safeguarding training from January 2019.
The Trust is compliant with NHS England national requirement for the submission of
PREVENT assurance data. Quarter 3 data was submitted on the 08 January 2019.
The safeguarding trainer has worked with the safeguarding teams to review the training
matrix for mandatory safeguarding and Prevent training. This is in line with a Trust-wide
review of training needs. It has been a complicated process given the range of mandatory
safeguarding training and the publication of the Adult Safeguarding Roles and Competencies
for Health care Staff (2018). The latest version is attached (appendix 1) and will be discussed
at the January Safeguarding Committee for formal ratification. This document was
distributed across the Trust to Directorate Managers, Clinical Directors, Matrons, Clinical
Educators and a range of other staff. The feedback has been very positive in terms of how
easy the document is to follow.
The next stage of the process is to review the job roles in ESR to allocate the appropriate
level of training to each job role. Once completed, this will be sent to workforce
Development for them to amend ESR so that each individual member of Trust staff will be
able to clearly identify the level of training they require. For some staff, this may mean the
level of training will change, but it will prevent duplication and save time as staff that
currently have to complete level 1 or level 2 training will have the requirement to complete
level 1 removed. This has been warmly received and supports the recommendations within
the intercollegiate documents for both children and adults.
5. SAFEGUARDING ACTIVITY
Key points for the Safeguarding Committee to note in relation to activity up to the end of
Quarter 3 2018/19:
i) Women’s Services Safeguarding Activity
Safeguarding Maternity
March
2017
March
2018
2018/19
Q1
2018/19
Q2
2018/19
Q3
2018/19
Q4
Total number of cause for
concerns received 908 879 231 182 218
Number of FGM cases reported 56 28 9 13 10
Babies born on child protection
plans 260 108 19 25 22
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Agenda Item A8(ii)b – BRP
Babies discharged into foster care 52 52 7 15 6
Number of safeguarding
supervision sessions delivered 45 59 9 16 20
ii) Adult Safeguarding Activity
Safeguarding Adults
March
2017
March
2018
2018/19
Q1
2018/19
Q2
2018/19
Q3
2018/19
Q4
Total cause for concerns
received from staff 2094 2081 524 629 626
Case discussion 168 343 110 105 92
Discriminatory 1 4 0 1 1
DoLS Enquiry 192 87 11 24 29
Domestic abuse 317 311 76 107 113
Exploitation 14 * * * *
Financial abuse 93 94 24 25 35
Institutional 248 17 4 1 0
MARAC 48 55 8 15 18
MCA Enquiry 83 85 22 21 10
Modern Slavery 7 34 2 1 3
Neglect 141 367 112 105 123
Physical abuse 63 89 20 40 39
Psychological/
emotional 48 55 11 17 11
Radicalisation 5 7 1 4 3
Self-neglect 314 438 102 132 125
Sexual abuse 72 95 21 31 24
MAPPA Notifications 153 84 26 24 30
Violent Patient Notifications 59 72 11 25 27
The safeguarding adults’ team continue to be the single point of contact (SPoC) for Multi
Agency Risk Assessment Conference (MARAC) and MAPPA (multi-agency public protection
arrangements), PREVENT and violent patients on behalf of the Trust.
The team also attend safeguarding adult meetings and support the work of the Newcastle
Safeguarding Adults Board and sub-groups.
The Adult safeguarding Team would like to highlight some of the current safeguarding
concerns that are emerging in adults. These include:
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Agenda Item A8(ii)b – BRP
Homelessness, drug use – exploitation and assault
Concerns relating to self-neglect which can be profound and include risk of death
Increasing concerns about County Lines and Cuckooing
For further information, please follow these links:
http://www.nationalcrimeagency.gov.uk/publications/832-county-lines-violence-
exploitation-and-drug-supply-2017/file
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_
data/file/756031/Protecting_children_from_criminal_exploitation_human_trafficking_mod
ern_slavery_addendum_141118.pdf
iii) Learning Disability
Learning Disability
March
2017
March
2018
2018/19
Q1
2018/19
Q2
2018/19
Q3
2018/19
Q4
Total number of electronic alerts
present in patient records 2116 2298 * * 2624
Adults 1850 1984 * * *
Transition * * *
Young people 266 314 * * *
Referrals received for advice and
support
Adults
Transition
Young people
2055 1708
518
333
23
178
489
288
30
171
479
325
33
121
Inpatient episodes for people identified
with a learning disability 719 816 243 236 254
Day case attendances by people
identified as having an LD 540 513 120 118 93
Outpatient attendances by people
identified as having an LD 4961 5339 1508 1435 1454
Emergency Department attendances
involved a person with an LD. 786 974 251 209 225
People with LD who died whilst
receiving Trust care 16 10 10 3 0
21
Agenda Item A8(ii)b – BRP
iv) Deprivation of Liberty Safeguards
Trust applications for Deprivation of Liberty Safeguards (DoLS) 2018/2019
March
2017
March
2018
2018/19
Q1
2018/19
Q2
2018/19
Q3
2018/19
Q4
Total number of DoLS applications
made by the Trust 581 400 121 131 166
RVI 331 202 66 67 83
Freeman 192 142 39 62 83
CAV 58 56 16 5 N/A N/A
There has been a notable increase in the number of Deprivation of Liberty applications
made during December and this has continued into January. We would like to attribute this
improvement to the briefings to senior clinical staff, matrons and medics and the
programme of ward based audits to review patients who should have a DoLS application in
place. Additional training sessions will continue and there has been a meeting held to
discuss how a condensed 30 minute training could be implemented to target medical staff
specifically. This will continue to be monitored monthly in the Safeguarding Teams and by
the Trust’s MCA Steering Group / Safeguarding Committee.
v) Children’s Safeguarding Activity
Safeguarding Children
March
2017
March
2018
2018/19
Q1
2018/19
Q2
2018/19
Q3
2018/19
Q4
Total number of cause for
concerns received 2872 2446 643 714 496
Information sharing 1252 1171 284 292 185
Overdose/ alcohol or
substance misuse by
young person
313 326 106 95 55
Referrals to children’s
Social Care by Trust staff 204 224 67 92 71
Child protections medicals
were completed 148 130 47 30 36
Forensic medicals
completed 196 213 38 53 46
MASH case discussions 1284 816 328 323 238
22
Agenda Item A8(ii)b – BRP
6. RISKS AND RISK MITIGATION
There are a number of identified risks:
i) Safeguarding Mandatory Training including Prevent has been added to the Patient
Services Risk Register. The Trust did not meet the national target of 85% for staff
requiring WRAP (PREVENT) training by the end of March 2019; this remains a key
challenge. Compliance with all other levels of safeguarding training is below the target
of 90% by the end of Q3.
ii) Deprivation of Liberty Safeguard applications have been added to the Patient Services
Risk Register as the reduction in deprivation of liberty applications across the Trust
increases the risk the potential for unlawful detention of patients. This is being
scrutinised and ongoing audit and education is being progressed.
iii) Electronic record keeping and data management within the safeguarding teams is
reliant on storing documents and excel spreadsheets securely on shared drives. The
safeguarding teams need access to electronic record keeping systems to facilitate
improved documentation and data management.
iv) The Audit Cycle for the Safeguarding Teams is behind schedule for 2018/19 and this
will be subject to the development of an action plan for 2019/20 to ensure robust
review of practice and a continuous cycle of improvement is maintained within the
teams.
v) It is important that safeguarding is continuously embedded as “Everyone’s Business”
through training, education and sharing lessons learnt from case feedback to prevent
vulnerable children or adults at risk from being missed.
vi) The accumulative impact of these risks increases pressure on the Trust’s Safeguarding
Team to meet key performance requirements including audit, review of policies and
professional practice.
Work is ongoing to address these risks as detailed above.
23
Agenda Item A8(ii)b – BRP
7. SUMMARY
The safeguarding teams are wholly committed and strive to ensure Trust staff are fully
supported to fulfil their safeguarding responsibilities to promote the safety and well-being
of all patients who access Trust services. This update provides assurance that the Trust’s
Safeguarding Teams are pro-actively leading and contributing to work in response to a range
of complex and challenging issues.
8. RECOMMENDATION
To (i) note the content of this report (ii) support the on-going work of safeguarding teams
within the Trust to protect children and vulnerable adults (iii) note risks and risk mitigation.
Jo Gamble
Head of Safeguarding
11 January 2019
24
Agenda Item A8(ii)b – BRP
Level
Staff Groups
Safeguarding Requirement
Method & Frequency
Prevent Requirement
Method & Frequency
1
All non-clinical staff (e.g. board level execs and non-execs, admin staff, caterers, domestics, counter staff, senior managers/strategic professionals with no patient contact) All clinical staff who have NO patient contact (e.g. laboratory staff, technicians, healthcare scientists etc.) Clinical staff Bands 1, 2, 3 & 4 with patient contact (e.g. housekeepers, theatre orderlies, health care assistants, associate practitioners). Volunteers (all roles)
Adults Level 1
eLearning – every 3 years
000 Preventing Radicalisation - Basic Prevent Awareness
eLearning – every 3 years
Children Level 1
eLearning – every 3 years
2
Clinical staff - Bands 5 and above with any patient contact (adults and/or children) (e.g., radiographer/radiologist, allied health professionals, chaplains, registered nurses, medical staff, dental staff including consultants). + B4 dental nurses and B4 nursery nurses
Adults Level 2
eLearning – every 3 years
000 Preventing Radicalisation - Awareness of Prevent (Level 3)
eLearning – every 3 years
Children Level 2
eLearning – every 3 years
Mandatory Safeguarding Adults & Children and Prevent Training Requirements
Appendix 1
25
Agenda Item A8(ii)b – BRP
3
adult
Clinical staff Bands 5 and above with primarily adult patient contact who would assess and evaluate the needs of adults where there are safeguarding concerns. (e.g., District nurses, Community Staff Nurses, Mental Health Practitioners working with adults, registered nurses, AHP’s or medical staff with a lead role in adult protection as appropriate to their role).
Adults Level 3
eLearning or Face to face – annually
000 Preventing Radicalisation - Awareness of Prevent (Level 3)
eLearning – every 3 years
Children Level 2
eLearning – every 3 years
3
children
Clinical staff Band 5and above who work primarily with children who would assess and evaluate the needs of children / young people where there are safeguarding or child protection concerns (E.g. paed staff nurses, paed surgeons/ paed anaesthetists & intensivists/ dentists/ community children’s’ nurses, looked after children nurses, forensic nurses, mental health Practitioners working with children, radiologists/ radiographers, paed allied health professionals, paed specialist nurses, nursery managers etc.). Consultant Paediatric staff will receive training from the Named / Designated Doctor delivered by a series of lectures throughout the year.
Adults Level 2
eLearning – every 3 years
000 Preventing Radicalisation - Awareness of Prevent (Level 3)
eLearning – every 3 years
Children Level 3
Face to face – annually + eLearning option
26
Agenda Item A8(ii)b – BRP
3
combined
Clinical staff Bands 5 + who frequently work with children on a Child Protection Plan or CIN basis (e.g. health visitors, school nurses, midwives, safeguarding nurses, learning disability nurses, , lead professionals for safeguarding and child protection, psychologists, sexual health staff, substance misuse services, ED staff and Walk-in Centre staff etc.)
Adults Level 3
eLearning or Face to face – annually
000 Preventing Radicalisation - Awareness of Prevent (Level 3)
eLearning – every 3 years
Children Level 3
Face to face – annually + eLearning option
+ additional non-mandatory learning e.g. FGM / Domestic Abuse / Sexual Exploitation / Neglect / Self-neglect etc.
All staff are encouraged to attend multi-agency / multi-professional training relevant to their role in addition to the Trust’s core mandatory training as described above.
27
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28
Nursing Information DashboardThis report combines metrics from a number of sources to build an overall picture of each ward/clinical area. A key to each metric isbelow. This report should not be used to make judgements in isolation.
RN & Care Staff Fill Rates – actual nursing hours for the month as a percentage of the planned nursing hours for Registered Nurses andCare Staff. This includes day and night shifts. Fill rates above 100% indicate that more nursing hours were worked during the monththan was planned.
Funded establishment – the agreed nursing budget provided by Finance, expressed as whole-time equivalent.
SNCT establishment – using the Safer Nursing Care Tool methodology, this establishment has been calculated by taking the number ofpatients at each care level (as defined in the tool) and applying a multiplier. There is a lot of room for subjectivity in this measure,depending on who collected the data.
Registered Nursing Ratio (on shift) – the skill mix of the workforce on a ward that was Registered Nurse, expressed as a percentage ofthe overall nursing workforce. This is based on the actual hours input via the Nurse Day Count. Wards using HCA ‘specials’ will havelower RN ratios than planned.
Ward occupancy – the bed occupancy of the ward, occupied bed days expressed as a percentage of the available bed days.
Red flags – the number of nursing red flags (as defined by NICE) for each day and night shift. Most of these are for when the shortfall ofplanned vs. actual staffing is more than 15%.
Staff turnover – this is a 12-month figure showing the nursing workforce turnover, with the number of leavers for the period expressed asa percentage of the number of staff still in post at the end of the period. This was defined by HR.
Sickness absence – the whole time equivalent days lost to sickness absence as a percentage of the total available whole timeequivalent days. This figure is received once a month but is not currently updated to reflect any corrections made or late entries.
Vacancy rate – the whole time equivalent vacancies for all nurses (RNs and HCAs) expressed as a percentage of the budget whole timeequivalent.
Band 5 vacant Wte - the whole-time equivalent vacancies for Band 5 nurses.
Band 5 vacancy rate – as above, for Band 5 nurses only.
Bank fill rate – the number of filled bank/agency nursing shifts expressed as a percentage of the total number of shifts requested.
Bank & overtime – the whole time equivalent usage that was bank, agency or overtime, expressed as a percentage of the nursingestablishment.
C. difficile – the number of cases of C. difficile identified post-72 hours of admission to the Trust.
Datix staffing incidents – the number of Datix reports submitted because of shortages in nursing staff.
Fall per 1,000 bed days – the number of patient slips, trips and falls (all severities) expressed as a rate per 1,000 (occupied) bed days.
Pressure ulcers per 1,000 bed days – as above, for all Trust-acquired pressure ulcers.
Falls & Pressure Ulcers - the total number of falls and pressure ulcers added together.
Friends & Family Test response rate – the number of patients responding to the Friends & Family Test expressed as a percentage of thetotal number of patients who were eligible to respond.
SBR Sister – indicates whether the ward currently has a Sister/Charge Nurse who was recruited using the Strengths-Based Recruitmentprocess.
29
RN & Care Staff Fill Rates – actual nursing hours for the month as a percentage of the planned nursing hours for Registered Nurses andCare Staff. This includes day and night shifts. Fill rates above 100% indicate that more nursing hours were worked during the monththan was planned.
Funded establishment – the agreed nursing budget provided by Finance, expressed as whole-time equivalent.
SNCT establishment – using the Safer Nursing Care Tool methodology, this establishment has been calculated by taking the number ofpatients at each care level (as defined in the tool) and applying a multiplier. There is a lot of room for subjectivity in this measure,depending on who collected the data.
Registered Nursing Ratio (on shift) – the skill mix of the workforce on a ward that was Registered Nurse, expressed as a percentage ofthe overall nursing workforce. This is based on the actual hours input via the Nurse Day Count. Wards using HCA ‘specials’ will havelower RN ratios than planned.
Ward occupancy – the bed occupancy of the ward, occupied bed days expressed as a percentage of the available bed days.
Red flags – the number of nursing red flags (as defined by NICE) for each day and night shift. Most of these are for when the shortfall ofplanned vs. actual staffing is more than 15%.
Staff turnover – this is a 12-month figure showing the nursing workforce turnover, with the number of leavers for the period expressed asa percentage of the number of staff still in post at the end of the period. This was defined by HR.
Sickness absence – the whole time equivalent days lost to sickness absence as a percentage of the total available whole timeequivalent days. This figure is received once a month but is not currently updated to reflect any corrections made or late entries.
Vacancy rate – the whole time equivalent vacancies for all nurses (RNs and HCAs) expressed as a percentage of the budget whole timeequivalent.
Band 5 vacant Wte - the whole-time equivalent vacancies for Band 5 nurses.
Band 5 vacancy rate – as above, for Band 5 nurses only.
Bank fill rate – the number of filled bank/agency nursing shifts expressed as a percentage of the total number of shifts requested.
Bank & overtime – the whole time equivalent usage that was bank, agency or overtime, expressed as a percentage of the nursingestablishment.
C. difficile – the number of cases of C. difficile identified post-72 hours of admission to the Trust.
Datix staffing incidents – the number of Datix reports submitted because of shortages in nursing staff.
Fall per 1,000 bed days – the number of patient slips, trips and falls (all severities) expressed as a rate per 1,000 (occupied) bed days.
Pressure ulcers per 1,000 bed days – as above, for all Trust-acquired pressure ulcers.
Falls & Pressure Ulcers - the total number of falls and pressure ulcers added together.
Friends & Family Test response rate – the number of patients responding to the Friends & Family Test expressed as a percentage of thetotal number of patients who were eligible to respond.
SBR Sister – indicates whether the ward currently has a Sister/Charge Nurse who was recruited using the Strengths-Based Recruitmentprocess.
30
Nursing Information Dashboard - December 2018
Business and Development
Area MonthRN FillRate
CareStaffFill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Park Suite - RVI
Oct 2018 96.78% 59.85% 13.30 3.96 87.03% 59.88% 11 9.1% 4.8% 27.8% 2.37 25.5% 93.75% 12.41% 0 0 0.00 0.00 0 0.00% No
Nov 2018 100.22% 29.98% 13.30 4.55 93.26% 61.29% 6 9.1% 11.6% 27.8% 2.37 25.5% 100.00% 5.94% 0 0 0.00 0.00 0 0.00% No
Dec 2018 98.68% 68.18% 13.30 4.75 84.85% 32.12% 6 9.1% 3.7% 27.8% 2.37 25.5% 100.00% 6.39% 0 0 0.00 0.00 0 0.00% No
Page 131
Nursing Information Dashboard - December 2018
Cancer Services
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 33 -Freeman
Oct 2018 100.69% 100.62% 25.57 25.56 78.94% 93.14% 10 14.8% 0.8% 0.0% 0.00 0.0% 100.00% 10.25% 0 0 6.13 2.04 4 13.64% No
Nov 2018 100.27% 92.52% 25.57 21.82 80.23% 90.78% 12 16.0% 3.6% 11.7% 2.00 10.8% 92.31% 0.31% 1 0 8.64 2.16 5 23.68% No
Dec 2018 88.01% 110.54% 25.33 23.14 74.73% 95.01% 25 20.8% 6.8% 10.9% 0.76 4.4% 100.00% 0.59% 0 0 6.06 0.00 3 12.90% No
Ward 34 -Freeman
Oct 2018 90.25% 87.95% 30.01 31.73 68.86% 86.69% 16 3.7% 3.8% 13.1% 0.94 5.0% 63.04% 14.23% 0 0 7.17 1.43 6 19.83% Yes
Nov 2018 92.39% 95.67% 29.77 28.74 67.52% 77.44% 13 11.1% 4.4% 15.8% 1.70 9.7% 71.05% 3.43% 0 1 9.93 1.66 7 44.30% Yes
Dec 2018 86.97% 93.06% 29.77 28.69 66.68% 80.02% 20 7.4% 5.3% 16.9% 2.02 11.5% 48.57% 8.67% 0 0 4.65 1.55 4 6.30% Yes
Ward 35 -Freeman
Oct 2018 98.70% 92.93% 27.80 26.72 66.37% 76.86% 4 10.3% 8.6% 1.0% 0.00 0.0% 32.35% 12.73% 1 0 8.18 1.64 6 12.41% Yes
Nov 2018 95.09% 88.37% 27.25 21.72 66.60% 76.41% 8 10.7% 11.0% 2.6% 0.00 0.0% 67.61% 6.09% 0 0 11.74 1.68 8 17.91% Yes
Dec 2018 92.31% 86.89% 27.25 25.83 65.96% 75.19% 13 10.7% 9.6% 2.6% 0.00 0.0% 54.00% 4.81% 0 0 6.70 0.00 4 9.26% Yes
Page 232
Nursing Information Dashboard - December 2018
Cardiothoracic Services
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
PICU -Freeman
Oct 2018 98.06% 116.06% 98.12 92.69% 80.94% 26 3.7% 5.0% 2.5% 1.01 1.4% N/A 0.00% 0 0 0.00 0.00 0 N/A No
Nov 2018 93.89% 125.51% 98.12 N/A 91.82% 82.30% 38 3.7% 6.7% 2.7% 1.23 1.7% N/A 0.85% 0 0 0.00 3.58 1 0.00% No
Dec 2018 92.80% 106.45% 98.19 92.90% 85.81% 44 3.7% 8.0% 3.2% 3.62 5.0% N/A 0.35% 0 0 0.00 0.00 0 0.00% No
Ward 21 -Freeman
Oct 2018 92.24% 100.42% 130.92 92.53% 62.17% 43 12.4% 8.7% 2.8% 3.26 3.2% N/A 3.02% 0 0 0.00 7.08 3 N/A No
Nov 2018 96.02% 97.78% 130.92 N/A 92.97% 75.76% 34 11.6% 7.7% 2.7% 3.10 3.1% 100.00% 1.96% 0 0 0.00 6.00 3 N/A No
Dec 2018 94.27% 90.65% 130.92 93.28% 63.78% 39 10.9% 8.9% 0.2% 0.00 0.0% 66.67% 5.29% 0 0 0.00 13.79 6 N/A No
Ward 23 -Freeman
Oct 2018 93.10% 85.65% 48.45 30.48 78.76% 74.95% 52 1.8% 4.8% 0.0% 0.00 0.0% N/A 0.56% 1 0 0.00 0.00 0 27.69% No
Nov 2018 98.16% 95.02% 48.45 23.22 77.87% 68.82% 32 1.8% 5.2% 0.0% 0.00 0.0% N/A 1.09% 0 0 2.76 0.00 1 38.60% No
Dec 2018 93.20% 78.29% 48.45 27.92 80.69% 69.02% 37 1.8% 2.5% 1.7% 0.69 2.2% N/A 0.87% 0 0 0.00 0.00 0 0.00% No
Ward 24/24A -Freeman
Oct 2018 96.10% 63.40% 53.68 27.71 90.19% 72.49% 11 7.0% 4.4% 10.1% 1.09 3.3% 75.00% 6.86% 0 0 4.61 1.54 4 61.83% No
Nov 2018 96.29% 61.16% 53.68 24.63 90.47% 71.31% 14 7.3% 4.1% 11.3% 1.76 5.3% 91.67% 1.88% 0 0 1.62 3.23 3 0.00% No
Dec 2018 90.42% 42.01% 53.68 26.78 92.89% 66.94% 29 7.4% 4.7% 15.0% 3.76 11.3% 95.65% 3.99% 0 0 1.75 0.00 1 0.00% No
Ward 25 -Freeman
Oct 2018 97.52% 84.74% 24.80 21.41 68.16% 79.32% 11 12.0% 10.6% 5.8% 1.40 10.8% 82.46% 13.95% 0 0 0.00 2.05 1 23.94% Yes
Nov 2018 99.71% 95.17% 24.80 18.04 66.19% 75.33% 5 7.7% 6.5% 7.4% 0.79 6.1% 91.30% 3.23% 0 0 13.27 4.42 8 33.33% Yes
Dec 2018 96.84% 86.96% 24.58 18.35 67.73% 72.74% 4 7.7% 6.2% 6.9% 1.65 12.0% 81.82% 1.91% 0 0 4.43 2.22 3 42.42% Yes
Ward 27 -Freeman
Oct 2018 95.08% 88.92% 25.52 29.00 69.69% 81.82% 7 3.7% 2.5% 0.1% 0.00 0.0% 100.00% 4.78% 0 0 0.00 0.00 0 11.35% No
Nov 2018 89.33% 84.27% 25.52 31.10 69.56% 89.71% 13 7.7% 6.3% 0.1% 0.00 0.0% 100.00% 4.08% 0 0 0.00 0.00 0 37.33% No
Dec 2018 88.57% 73.46% 25.67 36.45 72.73% 76.59% 9 3.8% 6.8% 4.0% 0.00 0.0% 100.00% 5.88% 0 0 4.37 0.00 1 19.29% No
Ward 29 -Freeman
Oct 2018 94.64% 95.52% 31.36 32.11 59.32% 90.91% 28 9.4% 6.4% 23.5% 3.36 21.5% 62.89% 10.84% 0 1 10.00 3.75 11 1.12% No
Nov 2018 95.88% 99.66% 31.36 28.32 58.62% 88.81% 7 6.1% 3.2% 21.5% 2.36 15.1% 70.00% 4.94% 0 0 2.62 0.00 2 0.53% No
Dec 2018 90.66% 93.12% 31.36 33.58 58.49% 85.34% 24 6.1% 3.9% 18.3% 1.36 8.7% 71.19% 7.81% 0 0 6.13 1.23 6 2.30% No
Ward 30 -Freeman
Oct 2018 91.68% 132.21% 31.77 28.42 66.23% 76.59% 19 9.1% 5.6% 0.3% 0.00 0.0% 69.23% 3.43% 0 1 5.43 2.72 6 13.91% No
Page 333
Nursing Information Dashboard - December 2018
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 30 -Freeman
Nov 2018 89.06% 122.37% 31.77 25.36 67.29% 70.75% 22 9.4% 11.0% 0.3% 0.00 0.0% 75.00% 5.60% 0 0 7.60 1.52 6 22.22% No
Dec 2018 83.90% 94.69% 31.77 22.25 69.34% 59.73% 30 9.7% 9.8% 5.1% 0.61 3.4% 72.73% 5.76% 0 0 1.74 0.00 1 4.76% No
Ward 49 - RVI
Oct 2018 90.71% 98.39% 30.31 35.22 55.23% 85.87% 11 7.1% 8.1% 19.6% 2.08 14.9% 78.90% 25.57% 0 0 12.95 7.77 16 17.98% No
Nov 2018 95.52% 98.84% 30.31 29.62 56.44% 84.94% 4 9.7% 6.9% 9.7% 0.08 0.6% 84.78% 6.17% 0 0 6.77 4.06 8 0.00% No
Dec 2018 90.81% 100.71% 30.31 35.30 55.04% 88.54% 13 6.9% 10.0% 13.0% 1.08 7.7% 60.00% 7.39% 0 0 5.51 8.26 10 0.00% No
Ward 50 - RVI
Oct 2018 92.22% N/A 23.05 8.74 100.00% 70.43% 1 4.3% 1.0% 7.5% 1.00 8.7% 96.88% 12.45% 0 0 15.27 7.63 3 N/A No
Nov 2018 92.67% N/A 23.65 9.63 100.00% 68.89% 0 4.3% 2.3% 9.9% 1.00 8.7% 92.31% 2.66% 0 0 16.13 0.00 2 N/A No
Dec 2018 93.83% N/A 23.65 8.38 100.00% 82.80% 2 0.0% 1.9% 5.6% 1.00 8.7% 83.87% 4.52% 0 0 0.00 6.49 1 N/A No
Page 434
Nursing Information Dashboard - December 2018
Childrens Services
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 10 - RVI
Oct 2018 98.30% 103.11% 23.43 30.41 70.42% 83.01% 0 4.0% 12.2% 1.9% 0.00 0.0% 81.82% 17.07% 1 3 0.00 0.00 0 1.88% Yes
Nov 2018 98.31% 102.69% 23.43 30.07 70.51% 88.22% 0 3.8% 20.7% 0.0% 0.00 0.0% 93.75% 11.18% 0 1 0.00 0.00 0 0.00% Yes
Dec 2018 94.80% 94.43% 23.43 26.39 71.46% 68.03% 5 3.8% 17.1% 0.0% 0.00 0.0% 84.38% 5.63% 0 0 0.00 0.00 0 0.00% Yes
Ward 11 - RVI
Oct 2018 96.27% 85.91% 24.93 32.38 81.83% 76.37% 13 3.7% 1.8% 3.7% 0.33 2.0% 100.00% 0.92% 0 0 0.00 0.00 0 1.58% No
Nov 2018 93.01% 89.45% 24.93 32.51 80.61% 76.44% 16 3.7% 2.6% 3.7% 0.33 2.0% 100.00% 1.36% 0 0 0.00 0.00 0 0.00% No
Dec 2018 90.03% 87.44% 24.93 30.48 79.93% 66.07% 26 3.8% 3.1% 3.7% 0.33 2.0% 100.00% 2.17% 0 0 0.00 0.00 0 0.00% No
Ward 12 - RVI
Oct 2018 99.69% 98.62% 83.79 91.37% 84.16% 9 4.3% 6.4% 0.0% 0.00 0.0% N/A 0.74% 0 0 0.00 0.00 0 N/A No
Nov 2018 104.58% 101.21% 83.79 N/A 90.46% 96.56% 5 4.3% 6.3% 0.0% 0.00 0.0% N/A 0.97% 0 0 0.00 2.54 1 N/A No
Dec 2018 97.96% 97.55% 83.79 90.81% 72.21% 15 5.6% 3.4% 0.0% 0.00 0.0% N/A 4.00% 1 1 0.00 0.00 0 N/A No
Ward 1A - RVI
Oct 2018 92.61% 52.74% 34.76 34.87 93.15% 88.41% 25 0.0% 1.6% 11.5% 1.37 5.2% 60.00% 3.08% 1 0 0.00 0.00 0 39.13% No
Nov 2018 77.93% 44.31% 34.76 35.14 93.14% 93.24% 51 0.0% 4.5% 11.5% 1.37 5.2% 85.71% 2.13% 0 0 0.00 0.00 0 0.00% No
Dec 2018 77.27% 93.00% 34.76 26.85 86.83% 82.47% 101 7.4% 5.9% 11.7% 1.37 5.2% N/A 2.59% 0 0 0.00 0.00 0 0.00% No
Ward 1B - RVI
Oct 2018 97.24% 138.57% 23.60 28.05 83.09% 96.28% 7 4.0% 1.7% 7.7% 1.79 10.5% 92.59% 9.62% 0 0 7.73 0.00 3 0.00% No
Nov 2018 99.52% 188.84% 23.60 29.00 78.67% 97.44% 5 4.2% 1.1% 6.6% 0.56 3.3% 100.00% 1.23% 0 0 0.00 0.00 0 0.00% No
Dec 2018 98.92% 177.42% 23.60 28.42 79.60% 90.82% 2 4.2% 1.2% 6.2% 0.79 4.6% 97.06% 2.42% 0 0 0.00 0.00 0 0.00% No
Ward 2 - RVI
Oct 2018 90.99% 63.63% 33.89 33.26 86.18% 76.31% 32 14.7% 5.4% 7.2% 0.87 3.4% 80.00% 13.13% 0 0 2.22 0.00 1 0.00% No
Nov 2018 95.14% 72.31% 33.89 37.68 85.38% 81.12% 29 14.7% 2.8% 3.7% 0.66 2.6% 100.00% 7.94% 0 0 0.00 0.00 0 0.00% No
Dec 2018 96.19% 80.94% 33.89 31.77 84.66% 77.23% 15 21.9% 4.3% 6.2% 1.51 5.9% 100.00% 5.43% 0 0 0.00 0.00 0 2.38% No
Ward 3 - RVI
Oct 2018 82.40% 91.35% 43.28 22.26 78.30% 88.71% 91 16.7% 0.0% 8.7% 1.53 6.5% 100.00% 9.43% 0 2 0.00 0.00 0 0.00% No
Nov 2018 83.60% 94.69% 43.28 21.84 77.93% 89.00% 95 15.0% 2.8% 8.7% 1.53 6.5% 81.08% 6.79% 0 0 0.00 0.00 0 0.00% No
Dec 2018 85.75% 89.25% 43.28 21.48 79.35% 89.03% 117 15.0% 0.9% 6.4% 0.53 2.3% 93.55% 3.93% 0 0 0.00 3.62 1 0.00% No
Ward 4 - RVI Oct 2018 89.79% 96.60% 46.73 35.19 87.97% 78.71% 29 10.9% 2.7% 4.3% 0.39 1.2% 100.00% 3.51% 0 0 0.00 0.00 0 0.00% No
Page 535
Nursing Information Dashboard - December 2018
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 4 - RVI
Nov 2018 91.18% 69.83% 46.73 36.09 91.13% 88.24% 26 10.9% 3.0% 5.2% 0.84 2.5% 100.00% 1.48% 0 0 0.00 0.00 0 0.00% No
Dec 2018 89.33% 63.75% 46.73 38.44 91.68% 84.49% 41 11.1% 4.2% 7.0% 0.92 2.8% 62.50% 1.67% 0 0 0.00 0.00 0 0.00% No
Ward 6 - RVI
Oct 2018 N/A N/A 70.58 N/A 100.72% 10.4% 5.8% 10.8% 3.27 7.4% 80.00% 5.45% 0 3 0.00 0.00 0 2.58% No
Nov 2018 N/A N/A 70.58 N/A N/A 99.21% 9.1% 6.6% 9.1% 1.27 2.9% 86.21% 4.68% 0 0 0.00 0.00 0 0.00% No
Dec 2018 N/A N/A 70.58 N/A 92.35% 7.8% 5.9% 10.5% 2.27 5.1% 94.44% 3.10% 0 1 0.00 0.00 0 0.00% No
Ward 8A - RVI
Oct 2018 90.88% 95.45% 14.70 70.70% 70.04% 12 14.3% 1.3% 16.7% 2.38 27.4% 63.33% 22.31% 0 1 0.00 0.00 0 2.54% No
Nov 2018 102.43% 100.00% 14.70 72.31% 64.89% 2 14.3% 5.5% 16.7% 2.38 27.4% 76.19% 5.44% 0 0 0.00 0.00 0 0.00% No
Dec 2018 96.78% 65.85% 14.70 77.48% 42.59% 4 14.3% 7.9% 16.7% 2.38 27.4% 35.71% 4.08% 0 0 0.00 0.00 0 0.00% No
Ward 9 - RVI
Oct 2018 85.38% 126.40% 34.32 32.45 81.17% 93.35% 36 16.7% 1.0% 18.0% 3.96 15.8% 95.83% 11.36% 0 0 0.00 0.00 0 50.57% No
Nov 2018 81.95% 141.75% 34.32 33.98 79.18% 92.71% 44 16.7% 2.2% 18.0% 3.96 15.8% 83.87% 3.58% 0 0 0.00 0.00 0 0.00% No
Dec 2018 80.34% 129.53% 34.32 31.99 81.21% 91.13% 49 16.7% 4.4% 18.0% 3.96 15.8% 70.00% 4.84% 0 0 0.00 0.00 0 20.37% No
Page 636
Nursing Information Dashboard - December 2018
EPOD
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 10 -Freeman
Oct 2018 95.39% 101.16% 34.85 46.76 71.46% 70.54% 5 0.0% 3.7% 18.1% 3.03 14.1% 83.53% 12.05% 0 0 4.19 0.00 3 13.58% Yes
Nov 2018 92.01% 98.71% 34.85 38.85 71.22% 63.49% 10 0.0% 3.3% 23.2% 3.80 17.6% 100.00% 2.64% 0 0 6.54 3.27 6 12.93% Yes
Dec 2018 89.16% 101.12% 34.85 40.98 70.05% 58.96% 12 0.0% 2.7% 23.2% 3.80 17.6% 92.00% 3.47% 0 0 10.14 3.38 8 15.99% Yes
Ward 20 - RVI
Oct 2018 97.04% 77.72% 28.27 22.95 77.04% 59.76% 0 10.0% 4.9% 19.6% 1.12 6.4% 73.44% 8.03% 0 0 2.82 0.00 1 8.84% No
Nov 2018 98.75% 85.03% 28.51 24.07 76.04% 48.70% 0 10.3% 8.0% 22.6% 2.79 16.0% 81.13% 3.05% 0 0 0.00 0.00 0 0.00% No
Dec 2018 92.46% 85.43% 28.51 13.45 75.00% 49.65% 4 10.3% 2.9% 19.1% 2.79 16.0% 70.77% 4.35% 0 0 0.00 0.00 0 0.00% No
Ward 37 - RVI
Oct 2018 96.56% 39.81% 22.27 9.92 90.03% 0.00% 0 0.0% 6.7% 10.9% 0.42 2.9% N/A 6.06% 0 0 0.00 0.00 0 N/A No
Nov 2018 95.39% 56.49% 22.27 87.03% N/A 14 0.0% 4.1% 10.9% 0.42 2.9% N/A 0.00% 0 0 0.00 0.00 0 N/A No
Dec 2018 88.86% 37.99% 22.27 90.29% N/A 13 0.0% 3.3% 10.9% 0.42 2.9% N/A 0.31% 0 0 0.00 0.00 0 N/A No
Ward 47 - RVI
Oct 2018 91.41% 76.20% 33.08 25.60 79.35% 72.52% 25 3.4% 4.0% 15.1% 4.46 20.0% 75.00% 1.12% 0 0 4.94 1.65 4 8.43% No
Nov 2018 95.69% 78.17% 33.08 28.19 79.50% 79.88% 18 7.1% 0.8% 15.1% 3.46 15.5% 85.00% 0.48% 0 0 3.09 1.55 3 0.00% No
Dec 2018 90.88% 80.22% 33.08 25.85 78.17% 73.33% 24 7.1% 0.4% 16.6% 3.46 15.5% 72.73% 0.42% 0 0 1.63 4.89 4 0.00% No
Ward 5 - RVI
Oct 2018 96.77% 46.13% 16.01 N/A 87.24% 87.63% 0 0.0% 3.6% 13.6% 2.00 18.4% 100.00% 5.62% 0 0 3.07 3.07 2 0.88% No
Nov 2018 82.51% 51.87% 16.01 13.01 86.76% 89.44% 29 0.0% 3.7% 7.3% 1.00 9.2% 77.78% 0.00% 0 0 3.11 6.21 3 0.00% No
Dec 2018 98.00% 43.55% 16.01 8.51 90.26% 65.86% 1 11.8% 10.0% 7.3% 1.00 9.2% 80.00% 0.44% 0 0 0.00 4.08 1 18.57% No
Page 737
Nursing Information Dashboard - December 2018
Institute of Transplantation
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 38 -Freeman
Oct 2018 94.32% 105.16% 44.24 28.97 81.40% 85.77% 22 2.3% 2.6% 5.6% 2.47 8.3% 79.61% 14.15% 0 0 3.28 1.64 3 44.44% No
Nov 2018 95.22% 89.68% 44.49 26.61 83.85% 85.36% 14 2.3% 6.9% 6.2% 2.72 9.1% 77.78% 1.53% 0 0 3.47 0.00 2 0.00% No
Dec 2018 94.21% 93.88% 44.49 25.85 83.26% 80.65% 15 2.3% 3.9% 6.2% 2.72 9.1% 66.36% 0.27% 0 0 3.50 1.75 3 0.00% No
Page 838
Nursing Information Dashboard - December 2018
Internal Medicine
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
AssessmentSuite - RVI
Oct 2018 79.58% 127.02% 74.53 82.93 61.85% 69.81% 78 15.5% 4.8% 7.0% 1.55 4.4% 79.31% 10.16% 0 0 7.39 3.70 12 5.60% No
Nov 2018 90.92% 123.48% 74.63 79.62 65.58% 65.27% 48 15.5% 4.0% 0.0% 0.00 0.0% 78.70% 7.26% 0 0 7.15 4.09 11 0.00% No
Dec 2018 91.11% 107.44% 74.63 82.31 68.69% 66.97% 55 15.3% 5.4% 0.0% 0.00 0.0% 84.29% 4.46% 0 0 9.63 3.85 14 4.05% No
Cherryburn -CAV
Oct 2018 86.66% 93.70% 41.34 38.23 54.36% N/A 28 N/A N/A 22.1% 2.02 11.1% N/A 16.52% 0 0 0.00 0.00 13 N/A No
Nov 2018 83.73% 97.11% 41.34 39.40 52.57% N/A 28 N/A N/A 19.6% 2.02 11.1% N/A 2.49% 0 0 0.00 9 N/A No
Dec 2018 N/A N/A 41.34 38.67 N/A N/A N/A N/A 19.6% 2.02 11.1% N/A 3.82% 0 0 0.00 6 N/A No
Ward 13 -Freeman
Oct 2018 92.36% 129.75% 40.03 27.73 43.86% 87.08% 36 3.2% 7.6% 27.8% 4.90 30.6% 95.45% 12.34% 1 0 1.83 0.00 1 0.00% No
Nov 2018 100.12% 139.99% 40.03 26.21 43.98% 75.79% 19 3.0% 7.5% 27.8% 3.90 24.4% 100.00% 3.80% 0 0 9.51 3.80 7 0.00% No
Dec 2018 105.03% 142.62% 40.03 36.07 44.70% 94.69% 17 2.9% 5.6% 21.8% 2.90 18.1% 94.44% 7.77% 0 0 9.80 2.80 9 0.00% No
Ward 14 -Freeman
Oct 2018 80.16% 158.14% 41.87 35.31 39.57% 87.74% 32 10.0% 7.7% 27.8% 2.00 12.9% 96.10% 19.78% 0 0 2.45 3.68 5 0.00% No
Nov 2018 81.25% 163.90% 41.87 34.37 39.03% 91.77% 24 9.7% 6.1% 30.2% 2.00 12.9% 96.97% 2.58% 0 0 8.48 3.64 10 0.00% No
Dec 2018 83.89% 137.90% 41.87 37.80 44.00% 93.33% 25 6.7% 9.2% 30.2% 4.00 25.8% 96.69% 2.99% 0 0 8.06 4.61 11 0.00% No
Ward 15 -Freeman
Oct 2018 86.98% 155.75% 39.20 44.88 41.87% 97.74% 46 5.9% 4.7% 16.3% 1.79 12.3% 80.00% 14.92% 0 0 12.10 1.10 12 56.67% No
Nov 2018 90.27% 156.07% 39.20 41.61 42.73% 96.44% 29 5.9% 3.8% 15.3% 2.99 20.6% 88.10% 4.34% 0 0 17.28 2.30 17 17.86% No
Dec 2018 81.66% 169.46% 39.20 45.18 38.33% 95.81% 44 3.0% 8.3% 17.8% 3.99 27.5% 74.69% 5.28% 0 0 14.59 5.61 18 25.00% No
Ward 16 -Freeman
Oct 2018 91.50% 163.43% 39.50 37.00 41.83% 94.62% 6 14.3% 6.2% 24.3% 4.74 29.6% 85.58% 24.10% 2 0 3.41 1.14 4 0.00% No
Nov 2018 87.34% 158.06% 39.50 37.41 40.50% 93.18% 13 10.0% 18.0% 22.7% 4.90 30.6% 84.07% 3.04% 0 0 6.31 0.00 5 105.10% No
Dec 2018 90.93% 154.27% 39.50 21.95 38.91% 79.69% 10 10.0% 20.6% 25.0% 4.83 30.2% 76.45% 2.76% 0 0 5.39 1.80 4 0.00% No
Ward 18 -Freeman
Oct 2018 82.93% 177.77% 36.67 42.99 34.29% 96.89% 56 6.5% 1.8% 27.9% 3.29 25.7% 93.37% 25.69% 0 0 9.51 7.13 14 48.15% Yes
Nov 2018 86.76% 171.02% 36.67 43.40 36.70% 95.83% 21 6.1% 1.1% 25.1% 3.29 25.7% 95.58% 4.25% 0 0 8.70 9.94 15 32.61% Yes
Dec 2018 99.47% 161.22% 36.67 42.66 39.56% 93.32% 5 5.7% 2.2% 22.4% 3.29 25.7% 97.56% 3.95% 0 0 7.41 7.41 12 82.76% Yes
Ward 19 - RVI Oct 2018 135.50% 100.98% 24.65 15.95 69.88% 93.38% 1 8.7% 0.0% 10.0% 0.85 7.8% 40.00% 5.72% 0 0 2.62 2.62 2 67.86% Yes
Page 939
Nursing Information Dashboard - December 2018
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 19 - RVI
Nov 2018 105.84% 92.41% 24.65 23.45 66.42% 89.93% 1 8.7% 1.4% 5.9% 0.05 0.5% 69.23% 9.78% 0 0 10.37 0.00 5 0.00% Yes
Dec 2018 102.79% 99.96% 24.65 19.30 63.83% 87.28% 3 8.7% 2.0% 5.9% 0.05 0.5% 55.00% 0.57% 0 0 8.21 0.00 4 0.00% Yes
Ward 30 - RVI
Oct 2018 76.34% 99.52% 36.25 31.67 52.92% 96.13% 55 5.6% 2.4% 9.1% 4.87 25.4% 100.00% 4.44% 0 0 1.12 7.83 8 14.93% Yes
Nov 2018 78.82% 103.36% 36.25 31.18 52.79% 95.44% 47 5.6% 6.0% 3.6% 2.87 14.9% 94.29% 1.96% 0 0 11.64 1.16 11 0.00% Yes
Dec 2018 77.63% 101.11% 36.25 31.96 53.13% 92.47% 49 11.4% 5.1% 1.7% 2.20 11.5% 93.55% 0.61% 0 0 15.12 2.33 15 0.00% Yes
Ward 31 - RVI
Oct 2018 94.18% 63.35% 40.32 38.52 63.85% 97.78% 4 N/A N/A 26.0% 0.76 4.8% 98.36% 8.93% 0 0 11.38 6.83 16 16.67% Yes
Nov 2018 91.00% 63.69% 40.32 29.51 62.93% 97.70% 6 N/A N/A 29.0% 1.76 11.0% 93.22% 2.90% 1 0 10.59 8.24 16 0.00% Yes
Dec 2018 86.72% 64.86% 40.32 35.74 61.37% 93.55% 14 N/A N/A 26.6% 1.80 11.3% 92.73% 4.56% 0 0 14.27 2.38 14 0.00% Yes
Ward 41 - RVI
Oct 2018 79.15% 106.84% 43.35 34.40 59.70% 75.68% 48 5.6% 5.3% 21.5% 8.09 32.2% 92.31% 11.00% 0 1 4.92 4.92 6 11.19% No
Nov 2018 77.21% 119.43% 43.35 27.05 56.39% 69.10% 51 5.4% 9.3% 16.8% 6.09 24.2% 93.22% 6.37% 1 0 5.57 0.00 3 0.00% No
Dec 2018 79.56% 107.31% 43.35 26.96 59.72% 66.38% 51 8.1% 5.3% 14.5% 5.09 20.2% 89.06% 4.57% 0 0 0.00 1.87 1 0.00% No
Ward 48 - RVI
Oct 2018 96.40% 167.90% 40.69 33.93 40.18% 97.22% 0 8.3% 0.0% 27.9% 2.00 12.5% 100.00% 13.37% 0 0 8.01 1.14 8 33.68% No
Nov 2018 98.38% 160.82% 40.69 34.19 41.70% 92.83% 0 10.5% 0.7% 29.1% 3.00 18.8% 100.00% 3.64% 0 0 9.96 7.47 14 0.00% No
Dec 2018 94.23% 176.37% 40.69 37.62 38.39% 91.09% 2 7.9% 3.1% 24.2% 4.00 25.0% 100.00% 7.37% 0 0 6.11 3.67 8 0.00% No
Ward 51 - RVI
Oct 2018 81.87% 148.59% 11.60 9.31 69.00% 83.84% 35 0.0% 4.5% 0.9% 2.10 24.4% 85.92% 33.36% 0 0 12.05 18.07 5 0.00% No
Nov 2018 94.97% 129.14% 11.60 8.91 75.09% 77.25% 9 0.0% 1.0% 0.9% 1.10 12.8% 96.36% 1.21% 0 0 6.85 0.00 1 0.00% No
Dec 2018 98.33% 110.21% 11.60 8.91 76.89% 77.25% 6 0.0% 0.3% 0.9% 1.10 12.8% 79.37% 0.86% 0 0 0.00 0.00 0 0.00% No
Ward 52 - RVI
Oct 2018 101.06% 136.25% 41.54 42.79 56.50% 91.90% 3 4.5% 4.9% 0.0% 1.44 6.2% 91.67% 6.11% 0 0 3.04 3.04 6 6.73% No
Nov 2018 96.25% 125.04% 41.54 37.72 57.39% 88.67% 5 4.7% 6.9% 0.0% 2.64 11.2% 93.10% 2.05% 0 0 6.44 1.07 7 0.00% No
Dec 2018 98.05% 129.03% 41.54 44.16 56.98% 91.61% 6 0.0% 7.5% 0.0% 2.64 11.2% 94.00% 2.89% 0 0 3.02 4.02 7 0.00% No
Ward 9 -Freeman
Oct 2018 96.99% 123.67% 38.86 45.89% 93.14% 7 5.4% 8.0% 27.8% 3.58 25.6% 88.31% 16.01% 0 0 0.00 0.00 0 50.00% No
Nov 2018 91.89% 133.75% 38.86 42.63% 96.19% 12 5.4% 8.8% 25.2% 3.58 25.6% 94.94% 3.24% 0 0 0.00 0.00 0 27.27% No
Dec 2018 87.44% 85.76% 38.86 50.49% 95.05% 33 5.6% 6.4% 21.1% 3.58 25.6% 95.70% 7.10% 0 0 0.00 0.00 0 15.79% No
Page 1040
Nursing Information Dashboard - December 2018
Musculoskeletal Services
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 19 -Freeman
Oct 2018 93.23% 90.75% 31.56 28.72 56.77% 66.38% 9 0.0% 6.5% 7.9% 1.80 11.1% 69.57% 15.30% 0 0 1.43 1.43 2 5.07% No
Nov 2018 98.43% 95.34% 31.56 21.91 56.90% 46.27% 3 0.0% 7.4% 7.9% 2.00 12.1% 100.00% 2.31% 0 0 0.00 0.00 0 7.63% No
Dec 2018 92.87% 89.23% 31.56 29.06 57.15% 52.94% 6 0.0% 4.7% 12.1% 2.92 17.7% 85.71% 1.36% 0 0 1.79 1.79 2 12.82% No
Ward 20 -Freeman
Oct 2018 93.12% 75.02% 21.20 15.13 64.83% 47.66% 2 11.1% 9.1% 15.7% 3.11 28.8% 86.60% 12.97% 0 0 4.68 0.00 2 4.46% Yes
Nov 2018 89.60% 82.21% 21.20 14.45 61.84% 43.06% 13 11.1% 0.7% 20.4% 3.11 28.8% 90.32% 1.65% 0 0 16.13 0.00 6 28.23% Yes
Dec 2018 89.39% 83.62% 21.20 15.84 61.63% 34.55% 11 11.1% 2.8% 20.4% 3.11 28.8% 89.89% 1.27% 0 0 6.83 3.41 3 7.85% Yes
Ward 22 - RVI
Oct 2018 81.24% 113.49% 40.50 33.20 54.25% 75.50% 40 17.2% 11.1% 26.9% 7.32 34.3% 78.15% 37.43% 0 0 2.52 13.84 13 21.59% Yes
Nov 2018 86.24% 121.78% 40.50 37.74 53.98% 74.53% 30 16.7% 8.0% 24.4% 6.32 29.6% 87.77% 4.05% 0 0 6.60 6.60 10 0.00% Yes
Dec 2018 83.96% 110.07% 40.50 40.82 55.82% 68.13% 39 16.7% 5.6% 24.2% 5.32 24.9% 86.15% 2.81% 0 0 12.64 7.02 14 0.00% Yes
Ward 23 - RVI
Oct 2018 87.81% 97.08% 37.92 29.02 57.80% 73.03% 33 2.9% 10.0% 8.6% 1.07 5.7% 70.27% 24.02% 0 1 2.87 1.44 3 15.09% Yes
Nov 2018 92.34% 98.19% 37.92 5.86 58.75% 71.08% 27 6.1% 3.9% 6.0% 1.07 5.7% 88.24% 4.80% 0 0 12.10 3.03 10 0.00% Yes
Dec 2018 94.57% 87.13% 37.92 21.47 60.14% 56.58% 21 6.1% 5.9% 13.9% 1.07 5.7% 79.41% 5.72% 0 0 11.07 9.23 11 0.00% Yes
Ward 42 - RVI
Oct 2018 108.44% 102.10% 35.37 18.61 58.96% 55.32% 0 2.9% 1.8% 7.3% 2.28 12.7% 100.00% 8.09% 0 0 4.32 2.16 3 19.23% Yes
Nov 2018 104.98% 110.33% 35.37 17.42 56.23% 56.88% 1 2.9% 0.8% 7.3% 1.28 7.2% 73.68% 1.05% 0 0 4.36 0.00 2 0.45% Yes
Dec 2018 96.75% 104.06% 35.37 13.75 55.35% 38.85% 9 3.0% 2.5% 7.3% 1.28 7.2% 83.33% 1.19% 0 0 0.00 3.09 1 3.05% Yes
Page 1141
Nursing Information Dashboard - December 2018
Neurosciences
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 15 - RVI
Oct 2018 87.54% 83.03% 43.49 32.90 58.52% 89.75% 22 14.3% 2.3% 3.7% 0.90 4.0% 88.71% 12.26% 0 0 13.22 2.40 13 3.30% Yes
Nov 2018 94.41% 80.88% 43.49 35.98 61.10% 86.10% 7 14.3% 3.6% 8.3% 0.00 0.0% 92.98% 5.17% 0 0 5.17 1.29 5 0.00% Yes
Dec 2018 88.21% 77.03% 43.49 36.27 60.85% 81.27% 22 14.6% 1.1% 10.6% 0.90 4.0% 97.56% 1.89% 0 2 17.22 1.32 14 0.00% Yes
Ward 16 - RVI
Oct 2018 94.98% 131.42% 35.56 37.77 50.06% 94.80% 7 8.6% 4.7% 2.0% 0.64 3.5% 82.07% 19.66% 0 0 13.17 2.20 14 20.20% No
Nov 2018 99.57% 146.41% 35.56 40.17 48.55% 92.04% 0 5.9% 3.2% 8.4% 2.84 15.4% 88.81% 5.12% 0 0 0.00 3.50 3 0.00% No
Dec 2018 96.46% 133.78% 35.56 37.27 50.01% 88.24% 6 2.9% 1.9% 8.4% 2.84 15.4% 100.00% 2.17% 1 0 9.43 1.18 9 0.00% No
Ward 43 - RVI
Oct 2018 87.10% 124.02% 30.52 22.23 49.04% 73.30% 25 7.1% 1.7% 16.7% 2.02 14.7% 90.10% 18.61% 0 0 8.62 0.00 4 36.59% No
Nov 2018 96.54% 112.64% 30.52 19.77 54.06% 68.67% 9 14.3% 0.4% 12.4% 1.71 12.5% 95.45% 4.62% 1 0 16.55 0.00 7 0.00% No
Dec 2018 91.22% 116.74% 30.52 22.72 52.09% 70.62% 14 14.3% 0.3% 15.6% 2.24 16.3% 98.44% 6.65% 0 0 2.24 2.24 2 0.00% No
Page 1242
Nursing Information Dashboard - December 2018
Periop and Crit Care
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 18 - RVI
Oct 2018 95.70% 171.67% 109.46 90.94% 80.79% 20 14.7% 4.3% 5.4% 4.09 5.1% 80.17% 6.79% 0 0 1.81 9.07 6 N/A No
Nov 2018 96.20% 92.90% 109.46 N/A 94.91% 79.55% 26 15.7% 3.4% 6.0% 4.32 5.4% 76.36% 4.30% 1 0 0.00 7.62 4 N/A No
Dec 2018 109.68% 82.61% 109.46 95.98% 82.99% 26 14.0% 2.6% 7.9% 6.32 7.9% 81.37% 3.06% 0 0 1.77 1.77 2 N/A No
Ward 37 -Freeman
Oct 2018 93.50% 116.09% 116.60 87.88% 80.06% 54 7.0% 4.0% 0.0% 0.00 0.0% N/A 2.02% 0 0 0.00 16.48 9 N/A No
Nov 2018 91.43% 104.89% 116.60 N/A 88.69% 67.58% 50 6.2% 7.1% 0.0% 0.00 0.0% N/A 1.66% 0 0 2.24 11.21 6 N/A No
Dec 2018 94.35% 123.14% 116.60 87.34% 72.43% 42 7.1% 7.4% 0.0% 0.00 0.0% N/A 1.23% 0 0 0.00 12.15 6 N/A No
Ward 38 - RVI
Oct 2018 87.79% 59.35% 108.88 90.96% 80.81% 59 12.9% 4.5% 0.4% 0.00 0.0% N/A 1.36% 0 0 0.00 19.96 10 N/A No
Nov 2018 87.80% 69.33% 108.88 N/A 89.60% 67.00% 57 12.1% 4.3% 0.9% 0.00 0.0% N/A 1.32% 0 0 0.00 7.46 3 0.00% No
Dec 2018 90.79% 65.78% 108.88 90.37% 76.61% 54 11.3% 5.3% 0.0% 0.00 0.0% N/A 0.59% 0 0 0.00 16.84 8 N/A No
Page 1343
Nursing Information Dashboard - December 2018
Surgical Services
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 36 - RVI
Oct 2018 90.18% 107.04% 30.00 23.67 70.16% 86.45% 61 7.1% 0.0% 8.2% 2.39 12.5% 100.00% 5.90% 0 0 3.73 3.73 4 25.84% No
Nov 2018 91.12% 104.75% 30.00 19.14 70.58% 80.20% 51 7.1% 0.0% 8.2% 2.39 12.5% 95.65% 0.00% 1 0 2.09 2.09 2 0.00% No
Dec 2018 93.57% 100.90% 30.59 24.06 71.19% 78.39% 31 3.6% 1.5% 10.0% 1.00 5.6% 100.00% 0.23% 0 0 4.12 2.06 3 0.00% No
Ward 44 - RVI
Oct 2018 107.14% 90.92% 29.24 22.69 65.01% 65.22% 2 20.0% 6.4% 16.1% 1.50 9.3% 81.93% 18.19% 0 0 2.02 0.00 1 5.43% No
Nov 2018 106.22% 87.33% 29.24 25.93 65.72% 61.66% 4 20.0% 6.8% 19.5% 1.50 9.3% 89.36% 3.56% 0 0 3.84 1.92 3 0.00% No
Dec 2018 108.37% 96.10% 29.24 18.09 63.85% 58.59% 3 15.4% 5.3% 19.5% 1.50 9.3% 91.43% 2.26% 0 0 0.00 3.83 2 0.00% No
Ward 45 - RVI
Oct 2018 N/A N/A 16.52 N/A N/A 0.00% 0 5.9% 8.3% 4.6% 0.76 8.2% N/A 0.61% 0 0 0.00 0.00 1 15.24% No
Nov 2018 N/A N/A 16.52 N/A N/A 0.00% 0 5.9% 1.7% 4.6% 0.76 8.2% N/A 0.24% 0 0 0.00 0.00 0 26.62% No
Dec 2018 N/A N/A 16.52 N/A N/A 0.18% 0 5.9% 2.0% 4.6% 0.76 8.2% N/A 0.00% 0 0 0.00 0.00 0 36.68% No
Ward 46 - RVI
Oct 2018 94.64% 94.82% 33.58 34.69 66.34% 90.63% 14 0.0% 4.2% 3.0% 1.00 5.0% 100.00% 6.28% 1 0 4.87 0.00 4 86.21% No
Nov 2018 94.09% 86.39% 33.58 32.82 67.95% 88.20% 13 0.0% 5.3% 8.4% 2.80 13.9% 100.00% 5.00% 0 0 0.00 0.00 0 0.00% No
Dec 2018 89.62% 95.54% 33.58 35.08 63.89% 68.98% 24 0.0% 3.7% 8.4% 2.80 13.9% 86.67% 4.47% 0 0 7.97 0.00 5 0.00% No
Ward 5 -Freeman
Oct 2018 73.34% 105.57% 30.46 23.68 57.72% 97.74% 46 7.4% 0.5% 24.1% 4.99 28.6% 92.86% 12.80% 1 0 1.65 0.00 1 23.26% No
Nov 2018 80.59% 110.13% 30.46 24.38 60.23% 86.99% 35 7.1% 0.4% 18.2% 3.19 18.3% 95.65% 6.93% 0 0 0.00 1.68 1 32.61% No
Dec 2018 80.44% 115.79% 30.46 36.92 59.65% 87.07% 37 11.1% 0.7% 18.2% 3.19 18.3% 95.65% 8.93% 0 2 1.46 0.00 1 16.33% No
Ward 6 -Freeman
Oct 2018 101.16% 103.51% 29.17 31.37 59.36% 82.25% 3 8.0% 2.1% 8.0% 2.22 13.5% 74.29% 16.35% 0 0 1.46 0.00 1 44.44% Yes
Nov 2018 99.98% 97.44% 29.17 26.87 60.90% 72.82% 3 7.7% 3.2% 8.0% 2.22 13.5% 89.47% 6.00% 0 0 0.00 0.00 0 52.56% Yes
Dec 2018 98.48% 90.95% 29.17 28.68 63.34% 70.67% 10 7.7% 3.9% 4.5% 1.22 7.4% 93.18% 6.96% 0 0 0.00 0.00 0 39.76% Yes
Ward 7 -Freeman
Oct 2018 83.25% 157.36% 26.04 32.82 60.38% 88.71% 38 15.0% 0.2% 16.2% 4.19 24.6% 97.40% 28.99% 2 0 5.59 4.20 7 0.00% Yes
Nov 2018 85.48% 172.51% 26.04 29.17 59.25% 82.56% 37 15.0% 0.2% 20.0% 5.19 30.5% 97.06% 6.72% 0 0 4.66 0.00 3 65.43% Yes
Dec 2018 83.70% 171.90% 26.04 31.08 59.40% 84.04% 36 14.3% 0.0% 20.0% 5.19 30.5% 93.75% 10.71% 0 0 1.44 2.88 3 36.92% Yes
Ward 8 -Freeman
Oct 2018 93.37% 88.66% 30.98 27.70 54.16% 86.55% 7 8.3% 8.9% 31.6% 7.78 47.4% 70.64% 19.24% 0 0 8.97 1.49 7 73.02% Yes
Page 1444
Nursing Information Dashboard - December 2018
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Ward 8 -Freeman
Nov 2018 104.40% 94.74% 30.98 27.26 57.62% 79.26% 8 8.3% 9.5% 22.0% 4.82 29.4% 90.38% 10.33% 0 0 17.21 1.72 11 54.29% Yes
Dec 2018 83.00% 121.51% 30.98 30.39 55.29% 73.41% 36 8.3% 6.3% 22.0% 4.82 29.4% 98.70% 5.36% 0 0 14.17 3.15 11 53.62% Yes
Page 1545
Nursing Information Dashboard - December 2018
Urology and Renal Services
Area Month
RNFill
Rate
CareStaffFill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
EAS - Freeman
Oct 2018 N/A N/A 14.10 N/A 37.79% 11.1% 4.1% 9.4% 1.09 11.8% 70.59% 10.14% 0 0 0.00 0.00 0 N/A No
Nov 2018 N/A N/A 14.10 N/A N/A 30.95% 11.1% 1.9% 2.3% 0.09 1.0% 66.67% 4.26% 0 0 0.00 0.00 0 N/A No
Dec 2018 N/A N/A 14.10 N/A 16.59% 17.6% 3.1% 2.3% 0.09 1.0% 75.00% 0.00% 0 0 0.00 0.00 0 N/A No
Urology Clinic -Freeman
Oct 2018 N/A N/A 12.54 N/A N/A 7.7% 14.5% 16.9% 1.80 25.9% N/A 2.95% 0 0 0.00 0.00 0 N/A No
Nov 2018 N/A N/A 12.54 N/A N/A N/A 7.1% 13.6% 8.9% 0.80 11.5% N/A 4.55% 0 0 0.00 0.00 0 N/A No
Dec 2018 N/A N/A 12.54 N/A N/A 6.7% 9.5% 8.9% 0.80 11.5% N/A 1.83% 0 0 0.00 0.00 0 N/A No
Ward 1 -Freeman
Oct 2018 08.28% 85.58% 14.80 13.54 73.29% 49.33% 0 33.3% 0.0% 0.0% 0.00 0.0% 100.00% 7.50% 0 0 0.00 0.00 0 8.72% No
Nov 2018 02.37% 86.08% 14.80 17.39 71.51% 33.19% 0 33.3% 5.1% 11.7% 1.32 15.5% N/A 1.01% 0 1 0.00 0.00 0 11.11% No
Dec 2018 07.49% 101.36% 14.80 16.71 69.63% 59.17% 1 33.3% 0.8% 11.7% 1.32 15.5% N/A 0.88% 0 0 14.08 0.00 1 6.16% No
Ward 2 -Freeman
Oct 2018 01.60% 97.61% 31.38 27.42 61.56% 77.74% 2 3.3% 0.2% 6.4% 0.50 3.0% 85.19% 2.36% 0 0 5.53 0.00 4 24.14% Yes
Nov 2018 94.56% 101.24% 31.38 21.39 59.04% 72.61% 8 3.2% 4.0% 6.4% 0.50 3.0% 64.00% 0.22% 1 0 7.67 1.53 6 24.04% Yes
Dec 2018 96.49% 91.69% 31.38 24.70 62.04% 63.38% 5 3.3% 1.3% 1.7% 1.50 8.9% 50.00% 1.85% 0 0 8.94 0.00 5 28.65% Yes
Ward 32 -Freeman
Oct 2018 90.53% 72.57% 48.99 40.04 81.64% 96.11% 26 4.2% 4.8% 7.0% 4.02 12.0% 100.00% 9.57% 0 0 4.76 2.38 6 0.00% Yes
Nov 2018 89.07% 99.40% 48.99 35.30 76.14% 94.92% 30 4.2% 7.2% 7.0% 4.02 12.0% 93.88% 2.74% 0 0 9.95 0.00 8 13.75% Yes
Dec 2018 85.89% 88.01% 48.99 37.65 77.75% 82.62% 34 8.7% 8.4% 7.0% 4.02 12.0% 71.43% 3.65% 0 0 11.14 1.39 9 5.05% Yes
Ward 3 -Freeman
Oct 2018 89.64% 92.95% 30.74 24.99 59.67% 78.03% 15 30.8% 11.6% 14.8% 2.64 15.7% 75.86% 11.68% 0 2 1.39 0.00 1 12.50% No
Nov 2018 91.31% 99.51% 30.74 27.64 56.96% 70.94% 8 29.6% 10.6% 14.8% 2.64 15.7% 93.85% 1.24% 0 1 3.32 0.00 2 12.29% No
Dec 2018 91.59% 101.92% 30.74 25.15 57.38% 76.66% 12 30.8% 5.1% 17.8% 4.29 25.6% 96.97% 1.89% 0 0 2.99 0.00 2 8.92% No
Page 1646
Nursing Information Dashboard - December 2018
Womens Services
Area MonthRN FillRate
CareStaff Fill
Rate
FundedEstablish
ment
SNCTEstablish
ment
Registered Nurse
Ratio (onshift)
WardOccupan
cyRed
FlagsStaff
TurnoverSicknessAbsence
VacancyRate
Band 5Vacant
Wte
Band 5Vacancy
Rate
Bank &AgencyFill Rate
Bank &Overtime
C.difficile
DatixStaffingIncident
s
Falls per1,000beddays
PressureUlcers
per 1,000bed days
Falls &Pressure
Ulcers
Friends &Family
ResponseRate
SBRSister
Birthing Centre- RVI
Oct 2018 91.41% 99.39% 21.62 82.78% 50.54% 23 4.3% 3.8% 7.4% N/A 42.86% 2.54% 0 0 0.00 0.00 0 1.75% No
Nov 2018 96.03% 101.52% 21.62 N/A 83.18% 46.39% 15 4.3% 3.4% 10.2% N/A 45.24% 0.93% 0 0 0.00 0.00 0 104.21% No
Dec 2018 91.61% 101.17% 21.62 82.56% 39.25% 24 4.3% 5.3% 10.2% N/A 42.86% 0.93% 0 0 0.00 0.00 0 75.79% No
Delivery Suite -RVI
Oct 2018 99.44% 111.76% 156.45 82.01% 49.31% 20 3.3% 5.1% 2.0% 0.74 13.4% 38.60% 1.78% 0 0 0.00 0.00 0 0.00% No
Nov 2018 98.90% 110.89% 156.45 N/A 82.03% 43.57% 18 3.3% 5.5% 2.7% 0.74 13.4% 24.66% 2.99% 0 0 0.00 0.00 0 0.00% No
Dec 2018 93.86% 112.11% 156.45 80.97% 40.90% 38 1.7% 6.1% 2.6% 0.74 13.4% 18.75% 1.04% 0 0 2.82 0.00 1 0.00% No
Ward 32/33 -RVI
Oct 2018 97.97% 104.12% 54.43 49.01% 120.97% 16 6.6% 7.2% 10.9% N/A 53.25% 5.79% 0 0 0.63 0.00 1 0.00% No
Nov 2018 98.04% 99.69% 54.43 50.12% 114.37% 17 8.3% 10.2% 10.9% N/A 56.12% 0.04% 0 0 0.00 0.00 0 0.00% No
Dec 2018 96.05% 94.06% 54.43 51.10% 96.39% 14 8.6% 11.4% 10.5% N/A 38.89% 0.50% 0 0 0.00 0.00 0 0.00% No
Ward 32 - RVINov 2018 N/A N/A 0.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A 0 0 0.00 0.00 0 N/A No
Ward 33 - RVINov 2018 N/A N/A 0.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A 0 0 0.00 0.00 0 N/A No
Ward 34 - RVI
Oct 2018 99.43% 45.25% 20.64 81.95% 69.59% 1 0.0% 12.2% 6.3% N/A 73.47% 7.56% 0 0 0.00 0.00 0 N/A No
Nov 2018 97.73% 44.87% 20.64 N/A 81.84% 70.48% 4 0.0% 10.0% 5.9% N/A 61.70% 0.63% 0 0 0.00 0.00 0 N/A No
Dec 2018 91.02% 42.35% 20.64 81.82% 70.05% 0 0.0% 20.2% 10.7% N/A 41.79% 0.19% 0 0 0.00 0.00 0 N/A No
Ward 35 - RVI
Oct 2018 90.31% 77.34% 114.44 91.83% 83.32% 51 4.9% 3.4% 6.5% 6.99 9.4% 100.00% 1.55% 0 0 0.00 0.00 0 N/A No
Nov 2018 95.36% 75.04% 114.44 N/A 92.44% 85.73% 49 5.7% 6.2% 2.4% 2.26 3.0% 100.00% 2.80% 0 0 0.00 0.00 0 N/A No
Dec 2018 91.87% 70.37% 114.44 92.63% 83.35% 42 5.8% 5.5% 2.2% 2.08 2.8% 100.00% 1.72% 0 2 0.00 0.00 0 N/A No
Ward 40 - RVI
Oct 2018 98.42% 118.51% 41.73 15.05 68.35% 52.20% 9 8.9% 2.0% 12.4% 3.53 17.3% 90.00% 15.67% 0 0 0.00 2.81 1 10.53% No
Nov 2018 98.13% 126.55% 41.73 21.16 66.88% 43.03% 8 6.5% 1.8% 11.0% 2.53 12.4% 89.91% 4.43% 0 0 3.52 0.00 1 2.58% No
Dec 2018 92.67% 116.92% 41.73 21.92 67.55% 35.92% 11 6.5% 3.5% 11.0% 2.53 12.4% 80.77% 3.45% 0 0 0.00 0.00 0 3.80% No
Page 1747
THIS PAGE IS INTENTIONALLY BLANK
48
Appendix i
December 2018
Healthcare-Associated Infections Report
49
Healthcare-Associated Infection Report December 2018
0
10
20
30
40
50
60
70
2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
MRSA Yearly Trend
0
1
2
3
4
5
6
7
8
9
10
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
MRSA Bacteraemia - Cumulative Performance April 2018 to March 2019
Cumulative Actual
0
10
20
30
40
50
60
70
80
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
C. difficile - Cumulative Performance April 2018 to March 2019
Cumulative Local Objective Cumulative ActualCumulative Contract
Objective: ≤76
0
100
200
300
400
500
600
2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
C. difficile Yearly Trend
0.00
5.00
10.00
15.00
20.00
25.00
30.00
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
C.difficile Monthly Incidence Rates Per 100,000 Bed Days December 2018
HA C.diff per 100,000 Bed Days National Average/Trust Target
0
5
10
15
20
25
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Gram Negative Bacteraemia Month on Month Performance December 2018
E. coli Klebsiella Pseudomonas
0
10
20
30
40
50
60
70
80
90
100
110
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
MSSA Bacteraemia - Cumulative Performance Against Trajectory December 2018
2017/18 Cumulative 2018/19 Cumulative Local Target
0
5
10
15
20
25
30
35
40
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
C. difficile - Medicine December 2018
Medicine 2017/18 Medicine 2018/19
0
5
10
15
20
25
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
MSSA Bacteraemia - Cardiothoracic December 2018
Cardiothoracic 2017/18 Cardiothoracic 2018/19
Objective: zero tolerance
Page (1)
50
Agenda item: A8(iv)
IPC indicators (reported to DH)
MRSA Bacteraemia - non-Trust 0 0 0 0 0 0 2 0 1 3
MRSA Bacteraemia - Trust-assigned (objective 0) 0 n 0 n 1 n 0 n 1 n 0 n 0 n 0 n 0 n 2 n
MRSA HA acquisitions 3 5 4 4 4 4 2 4 2 32
MRSA Elective Screening Compliance (%) - - - - - - - - - -
MRSA Emergency Screening Compliance (%) - - - - - - - - - -
MSSA Bacteraemia - post-48 Hours Admission 15 n 10 n 5 n 9 n 6 n 12 n 9 n 3 n 7 n 76 n
E coli Bacteraemia - post-48 Hours Admission 20 20 18 16 9 14 10 13 19 139
Klebsiella Bacteraemia - post-48 Hours Admission 6 7 13 8 4 7 9 6 10 70
Pseudomonas Bacteraemia - post-48 Hours Admission 6 3 1 4 3 1 3 1 2 24
C.diff - Hospital Acquired (objective 76 or fewer) 5 n 4 n 6 n 8 n 10 n 7 n 11 n 7 n 2 n 60 n
C.diff - cases appealed 0 1 0 3 6 1 2 3 0 16
C.diff - appeals successful 0 1 0 3 6 1 2 3 0 16
C.diff related death certificates 1 0 0 0 0 0 0 0 0 1
Part 1 1 0 0 0 0 0 0 0 0 1
Part 2 0 0 0 0 0 0 0 0 0 0
Periods of Increased Incidence (PIIs)
MRSA Periods of Increased Incidence (PIIs) - - - 1 - - - 1 - 2
Patients affected - - - 4 - - - 2 - 6
C.diff Periods of Increased Incidence (PIIs) 1 - - 1 3 - 3 - - 8
Patients affected 5 - - 4 6 - 6 - - 21
Other Organisms Periods of Increased Incidence (PIIs) - - - - - - - - - 0
Patients affected - - - - - - - - - 0
Outbreaks
Norovirus Outbreaks 2 - - - - - - 2 4 8
Patients affected (total) 26 - - - - - - 24 20 70
Staff affected (total) 8 - - - - - - 11 11 30
Bed days losts (total) 138 - - - - - - 60 155 353
Other Outbreaks 4 2 - - - 1 - - - 7
Patients affected (total) 3 13 - - - 3 - - - 19
Staff affected (total) - 6 - - - 0 - - - 6
Bed days losts (total) 0 77 - - - 4 - - - 81
C.diff Transit and Testing Times Target <18hrs
Trust Specimen Transit Time 11:07 12:55 11:13 11:31 12:45 11:39 10:19 10:23 13:30 11:42
Laboratory Turnaround Time 03:02 03:52 05:01 05:03 04:50 04:15 03:58 02:37 02:53 03:56
Total to Result Availability 14:09 n 16:47 n 16:14 n 16:34 n 17:35 n 15:54 n 14:17 n 13:00 n 16:23 n 96.52% n
Hygiene Indicators/Audits (%)
CAT Trust Total N/A 96.50% n N/A 96.74% n N/A 96.29% n N/A 96.53% n N/A 96.52% n
Hand Hygiene Opportunity N/A 98.82% n N/A 99.88% n N/A 98.92% n N/A 99.40% n N/A 99.26% n
Hand Hygiene Technique N/A 98.58% n N/A 99.28% n N/A 98.44% n N/A 98.20% n N/A 98.63% n
Cleanliness audits N/A 97.57% n N/A 98.22% n N/A 97.45% n N/A 97.31% n N/A 97.64% n
Infection Control Mandatory Training (%)
Infection Control 83% n 83% n 84% n 86% n 87% n 87% n 88% n 88% n 89% n 86% n
Aseptic Non Touch Technique Training (%)
ANTT (M&D staff only) 26% n 26% n 33% n 34% n 36% n 35% n 47% n 48% n 49% n 37% n
Jan Feb Mar Cumulative
Feb Mar Average
Average
Feb
Feb
Cumulative
Sept Oct Nov Dec JanApril May June July Aug
June
MayApril
April
Healthcare-Associated Infection Report December 2018
June
June
April May June
May
May
June
April
July
JulyApril May
April May
July
June
Aug Sept Oct Nov
Oct
Sept Oct
Sept
Cumulative
Cumulative
Average
Jan
Nov
Nov
JanNov
Feb MarJan
Feb
Feb
Mar
Mar
Dec
Aug
Aug
DecSept
DecOct
Oct
Sept
July Aug JanDec MarNovSept
July MarJan
Dec
Dec
July
Nov
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Aug
Aug
Page (1)
51
Pages included WRES
APPENDIX Agenda item A10
52
Pages included Raising Awareness | Staff awareness sessions during 2017 - 2018
LGBT History Month | February 2017 – Staff and patient engagement points, Emotional Intelligence, Film
screening Losses sessions
Transgender Day of Visibility | March 2017– used social media too
raise awareness
Equality and Diversity Week 2017 | May
2017 – staff network drop in session, Bullying and Harassment Awareness Session, rainbow Flag raised, staff/patient engagement points
IDAHOBIT | May 2017, rainbow flag raised
Newcastle Pride| July
2017 – stall in the Market Place
Trans Lives Matter Conference | May 2017
–developed in partnership with local organisations supporting
trans people with the aims of creating partnerships across
Public Sector organisations to address trans inequalities.
53
Pages included Raising Awareness | Staff awareness sessions during 2017 - 2018
Black History Month | October 2017 – Multicultural ‘Lunch & Learn’ with the LGBT Fed – ‘How would it Feel?’,
Talk by Ranjana Bell, member of an Employment Tribunal and Chair of the CPS Scrutiny Panel for Racist and Religious hate
crime, screening of Hidden Figures and offered Tackling Racism Training by Show Racism the Red Card.
Transgender Day of Remembrance | November 2017 – Cannon Rachel Mann – ‘Respecting
Transgender People in a Prejudiced World’
UK Disability History Month | December 2017 – Screening of ‘Unrest’ and
talk by Professor Julia Newton about ME.
LGBT History Month | February 2018 – Count your
Losses sessions
Transgender Day of Visibility | March 2018
– ‘Say What?’ A session by Lewis Latimer on the use of
language, Trans Flag raised
International Day for the Elimination of
Racial Discrimination | April 2018 – Multicultural
‘Lunch & Learn’ and bullying and harassment awareness session.
54
Pages included Raising Awareness | Staff awareness sessions during 2017 - 2018
Equality and Diversity Week 2018 | May 2018 – Bullying and Harassment in the Workplace, Gender
Identity Awareness, HIV Awareness, Show Racism the Red Card – LGBT Hate Crime, Positive Prospective of Disability in the
Workplace, Multilingual Progressive Muscle Relaxation, staff engagement
Time to Change| May 2018 – Pledged to change the
way we think and act about mental health at work signed
Gender Identity Training for Senior
Mangers| June 2018 – facilitated by Be North providing an
overview of gender diverse people and communities and the
contemporary issues they face within the context of health care
Newcastle Pride| July 2018 – stall in the Market Place
.
IDAHOBIT | May 2018, rainbow flag raised
Black History Month | October 2018 – Chi Onwurah – BAME
Leadership Talk, Lyn Cole Challenges
and Reflections for minority ethnic
people working in England, staff
engagement points
55
Pages included Raising Awareness | Staff awareness sessions during 2017 - 2018
LGBT History
Month | February 2019 –
Count your Losses sessions, A
Day in the Life of a Chaplain,
Rainbow Flag, Role models
Better Health at Work| November 2018 –
Continuing Excellence Assessment
International Day of People with
Disabilities| engagement points for staff and patients
Trans Lives Matter Conference | November 2018 – 2nd Trans Lives Conference in partnership
with other NHS and third sector partners
Transgender Day of Visibility | November 2018 –
use of social media to promote and staff engagement points
Hate Crime Awareness Conference| October 2018 – representatives
attended the event organised by Northumbria Police
Medical School EDI Leads Conference| October 2018 – member of
the staff network presented date relating to WRES
56
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