public board meeting - wye valley nhs trust · public board meeting 04 july 2019, 13:00 to 14:30...

PUBLIC BOARD MEETING

04 July 2019, 13:00 to 14:30BOARD ROOM, TRUST HEAD QUARTERS

Agenda1. Apologies for Absence: 2 minutes

2. Declarations of Interest 2 minutes

3. Minutes of the Meeting held on 23 May 2019 5 minutes

Decision

Hardy Russell

3. PUBLIC BOARD MINUTES - JUNE - LF, HO.pdf (9 pages)

4. Matters Arising and Actions Update Report 10 minutes

Discussion

Hardy Russell

4. Public Action Log -JULY.pdf (2 pages)

5. ITEMS FOR REVIEW AND ASSURANCE 30 minutes

5.1. Chief Executive's ReportDiscussion

Glen Burley

5.1 4th July 2019 - Board public CEO Report V1 (1).pdf (6 pages)

5.2. Integrated Performance ReportDiscussion

Jane Ives

5.2 IPR FS.pdf (2 pages)

Copy of Board KPIS 201920 Month 2 v2.pdf (4 pages)

5.2.1. Quality

Discussion

Lucy Flanagan

Quality Report Month 2 2019 Board V2.pdf (5 pages)

5.2.2. Activity Performance

Discussion

Jon Barnes

JON - TB Report Month 2 2019-20.pdf (10 pages)

5.2.3. Workforce

Discussion

Susan Smith

5.2 Integrated Performance Report - Workforce draft v1.pdf (3 pages)

5.2.4. Finance Performance

Discussion

Howard Oddy

Month 2 FINANCE SECTION FOR LOADING INTO ADMINCONTROL.pdf (19 pages)

5.3. One Herefordshire - Urgent Care Programme Board UpdateDiscussion

Jon Barnes

5.3 Board Report - 1H UCPB update June 2019.pdf (7 pages)

5.4. Mortality ReportDiscussion

David Mowbray

5.4. Mortality Report FS.pdf (2 pages)

5.4a. Quality Committee Report - June 2019 - Mortality.pdf (9 pages)

5.4b. Monthly Mortality Report June - Outlier Crude Mortality.pdf (1 pages)

5.5. Digital Systems Development UpdateDiscussion

Howard Oddy

5.5 Digital Systems development update.pdf (1 pages)

5.5a Trust Board EPR and Fast Follower Report - June 2019.pdf (2 pages)

5.6. Board Assurance FrameworkDiscussion

Erica Hermon

20190627 Board Covering Report for BAF.pdf (2 pages)

20190627 - Board Assurance Framework.pdf (7 pages)

6. ITEMS FOR APPROVAL 10 minutes

6.1. Terms of Reference and Forward PlansDecision

Erica Hermon

6.1.1. Board of Directors' Forward Plan

Decision

Erica Hermon

20190627 - Covering Report Board of Directors Forward Plan 2019.pdf (1 pages)

20190627 - Board of Directors Forward Plan 2019.pdf (3 pages)

6.1.2. Audit Committee Terms of Reference and Forward Plan

Decision

Erica Hermon

20190627 - Covering Report - Audit Ctte TORs and Forward Plan.pdf (2 pages)

20190627 Updated Audit Committee Terms of Reference 2019 Version 2.pdf (6 pages)

20190613 Updated Audit Committee Workplan 2019-20.pdf (2 pages)

6.1.3. Executive Risk Management Meeting Terms of Reference and ForwardPlan

Decision

Erica Hermon

6.2 20190627 - Covering Report ERM TORs.pdf (2 pages)

6.2a ERM TOR 2019.pdf (4 pages)

20190627 - Risk Management Executive Forward Plan 2019.20.pdf (1 pages)

7. ITEMS FOR NOTING AND INFORMATION 15 minutes

7.1. Cyber Security ReportDiscussion

Howard Oddy

7.1 Board Report - Cyber-Security Report 7 - July 2019..pdf (3 pages)

7.2. Undertakings LetterDiscussion

Jane Ives

7.2 July - Undertakings Board Report - draft (3).pdf (10 pages)

7.2a WVT undertakings progress review v2.pdf (4 pages)

7.3. Committee Summary Reports

7.3.1. Quality Committee Summary Report 30 May 2019

Discussion

Christobel Hargraves

7.4.1a CQC Summary report May19.pdf (4 pages)

7.3.2. Audit Committee Summary Report 20 June 2019

Discussion

Andrew Cottom

7.4.2a AuditCttee-20June19 FS.pdf (1 pages)

7.4.2b AuditCttee-20June19.pdf (2 pages)

7.3.3. Foundation Group Strategy Sub-Committee 28 May 2019

Discussion

Humphries Richard

7.4.3.a Foundation Group FS.pdf (1 pages)

7.4.3 FGSSC Annual Report 2018-19 - Final - FOR PUBLIC BOARD.pdf (4 pages)

7.4.3a FGSSC Annual Effectiveness Self-Assessment 2019 Responses - Final - FOR JULY PUBLIC BOARD.pdf (6 pages)

7.4. Committee Minutes

7.4.1. Quality Committee - 25 April 2019

Discussion

Christobel Hargraves

7.5. CQC MINUTES APRIL.pdf (16 pages)

8. Any Other Business 5 minutes

9. Questions from Members of the Public 10 minutes

Discussion

10. Acronyms

Z Acronyms - updated 08.05.19.pdf (3 pages)

11. Date of Next Meeting 1 minutes

1 August 2019

WYE VALLEY NHS TRUST Minutes of the Board of Directors Meeting

Held on 23 May 2019 at 1.00 pm Board Room, Trust Headquarters, Hereford County Hospital

Present:

Russell Hardy RH Chairman Glen Burley GB Chief Executive Andrew Cottom AC Non-Executive Director Lucy Flanagan LF Director of Nursing Christobel Hargraves CH Non-Executive Director (NED) Richard Humphries RH Non-Executive Director (NED) Jane Ives JI Managing Director David Mowbray DM Medical Director Frank Myers, MBE FM Non-Executive Director (NED) Howard Oddy HO Director of Finance & Information Mark Waller MW Non-Executive Director (NED) In attendance:

Jon Barnes JB Chief Operating Officer Alan Dawson AD Director of Strategy and Planning Erica Hermon EH Associate Director of Corporate Governance Val Jones VJ Executive Assistant (For the minutes) Lisa Robinson LR Research & Development Chair – For Item 6.2 Mike Salmon MS Research Operations Lead – For Item 6.2 Sue Smith SS Director of Human Resources Jonathan Wren JW Associate Director of Finance – For Item 5.1 The Going the Extra Mile Award – Employee of the Month – This had been awarded

to Hamza Katali. The Chairman read out a precis of the reason why Hamza had been

put forward for this award.

The Going the Extra Mile Award – Team of the Month - was awarded to Dhanya

Prabhan, Abdul Khalil Aziz Khan and Teme Ward. The Chairman read out a precis

detailing the reasons why Dhanya, Abdul and the Teme Ward had been put forward

for this award.

The Chairman advised that due to Year-end, this meeting was slightly different to the

usual format. Some of the papers being presented in the Private Board would be

presented in the Public Board next year.

Minute Action

BOD01/06.19 Apologies for Absence

There were no apologies received.

BOD02/06.19 Quorum

The meeting was quorate.

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BOD03/06.19 Declarations of Interest

There were no new declarations declared.

BOD04/06.19 Minutes of the meeting held on 2 May 2019

Resolved – that the minutes of the meeting held on 2 May 2019 be confirmed as

an accurate record and signed by the Chairman.

BOD05/06.19 Matters Arising and Action Log

BOD19/07.18 – IM&T Strategy – The Director of Finance & Information (DFI) advised that he was meeting with the Group Director of IM&T Strategy the following week. BOD17/05.19 – Clinical Quality Committee Summary Report 28 March 2019 – The Director of Nursing (DON) advised that the Falls Lead at Wye Valley Trust (WVT) had already been in touch with South Warwickshire NHS Foundation Trust (SWFT) regarding falls learning, noting that SWFT had a higher number of falls prevention beds than WVT. The falls lead had reviewed the data from most recent falls to determine if the provision of more low profile beds could have reduced the number of falls. High level feedback was this was not felt to be the case but that more detailed analysis would be undertaken. The Medical Director advised regarding our mortality figures, that our SHMI was now 104 and HSMR 99.4. This put WVT the top Trust in the Country for our low mortality figures, with the second lowest mortality figures in the region.

Resolved – that the action log be noted.

BOD06/06.19 E-Rostering Business Case

The Director of Human Resources (DHR) presented the E-Rostering Business Case

and gave a presentation. The following key points were highlighted:

(a) The Chief Executive (CEO) questioned whether the Trust were getting a price

negotiation as this was the same system that was being implemented to other

parts of the Foundation Group. The DHR advised that this had occurred, with

the figures included within the report based on “worst case scenario”.

(b) The Medical Director queried the likelihood of the projected 10% savings

planned to be achieved. The DON advised that she had used this system

previously in two other organisations and that the impact achieved could not

be underestimated, especially with the current workarounds and lack of

interface with our Bank and agency provision. This enabled information to be

transparent and in “real time” with the visibility of staff skill mix enabling more

efficient deployment of staff. The Chief Operating Officer (COO) confirmed that

he had seen similar improvements following the use of these systems.

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(c) Mr Waller (NED) noted the difficulties of attributing the savings made and would

like to see more visible savings being made. The Chairman questioned

whether there was assurance that the benefits stream is totally dependent on

the system being implemented. The DHR confirmed that this was the case. A

breakdown of specific elements was linked to those headings with the

expectation that these would be factored into the CPIP. The Managing Director

advised that it was difficult to say whether we could achieve better results on a

paper-based system, but this system will enable direct savings. Mr Cottom

(NED and Chair of the Audit Committee) advised that this Business Case would

be presented to the Audit Committee to measure the points made.

(d) Mr Myers (NED) queried whether the opportunity regarding inaccurate PAs

calculated could provide savings. The DHR advised that this was the indicative

figure provided by the company with effective job planning along with Payroll

would enable the correct allocation of PAs.

(e) The Chairman advised that the Workforce Plans from NHSI included an

essential requirement of having an E-Rostering system.

(f) The DFI noted that NHSI had announced an extra amount of money available

to bid for in regard to E-Rostering systems. The DHR confirmed that the cost

was budgeted for in the first year. The DFI advised that the capital had also

been requested in our Emergency Capital bid, but this had not yet been

received. The Chairman questioned if the Business Case was approved today,

could this be put into place now. The DFI did not believe that this would be able

to be fully implemented at the current time unless there were changes to

priorities in the Capital Programme.

(g) The Chairman reiterated that the approval of this Business Case was subject

to the procurement process and final identification of where the finance was

being sourced. The DFI confirmed that this was £450k over two years, with the

first year’s revenue costs in this year’s budget.

(h) Revd Hargraves (NED) raised the positive impact of staffing being able to use

a mobile app and being able to view their booked shifts in advance.

(i) The Chairman questioned the timeframe to get E-Rostering up and running.

The DHR advised that following procurement, this would take around four

months. The Chairman summarised that for E-Rostering would be up and

running in six months and to be in place before Christmas, the capital needed

to be in confirmed in the next couple of months, and questioned how likely this

was. The DFI advised that our Emergency Capital Bid was problematic,

however NHSI were aware of our plight and had highlighted our urgent need,

but confirmation was often not received until September at the earliest. The

DHR felt that being prudent, it would take twelve months to get E-Rostering in

place.

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(j) Mr Myers (NED) questioned if an incentive to adopt and use this system had

been considered. The DHR advised that all staff were incentivised to using this

system.

(k) The Chairman summarised the discussions noting that a directive had been

received from NHSI for all organisations to have an E-Rostering system. The

Trust had reviewed different options and the preferred options was used

elsewhere in the Foundation Group. The cost would be £1.8m over five years,

with the benefits over this period at least £5.4m.

Resolved – that the E-Rostering Business Case be approved subject to capital.

BOD07/06.19 Clinical Quality Committee Terms of Reference and Workplan

The DON presented the Clinical Quality Committee Terms of Reference (TOR) and

Workplan and the following key points were noted:

(a) The TOR and workplan had been revised due to the evolution of the Clinical Quality Committee over the last twelve months. The DON had strengthened both to ensure that they were reflective of how the Committee currently operates and are aligned to Commissioners requirements. The TOR made more explicit those elements the Board delegate to the Clinical Quality Committee.

(b) The Clinical Quality Committee received the draft TOR and Workplan at their March meeting and had been approved subject to minor changes. The DON asked for the Board to approve the TOR and Workplan, acknowledging they may be subject to change once the Corporate Governance Review and review of the subcommittee structure had been completed by the Associate Director of Corporate Governance (ADCG).

(c) The committee would change its name to Quality Committee

(d) The CEO noted that there had been a lot of discussion on how to implement the new PLACE based models and would expect a further review following the system wide review.

(e) The Chairman noted that the Clinical Quality Committee was a subcommittee of the Board of Directors and its primary purpose was to provide assurance to the Board. It was not the purpose of the subcommittee to performance manage aspects of quality; this was the responsibility of the Executive Directors. The Chairman asked that it was made clearer that the Clinical Quality Committee were an assurance committee rather than a performance management committee.

(f) Mr Cottom (NED) felt that it would be useful to see the performance and management review that the ADCG was undertaking. The Chairman noted that a subcommittee was to provide assurance to the Board of Directors by the NEDs not to performance manage, with the Finance & Performance Committees chaired by an Executive Director with a NED present to enable performance management.

LF/CH

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Resolved – that:

(A) The Clinical Quality Committee Terms of Reference and Workplan were approved subject to the one amendment.

(B) A sentence would be added to the Terms of Reference for the Clinical Quality Committee to make it clearer that the Committee was an assurance committee rather than a performance committee.

LF/CH

ITEMS FOR NOTING AND INFORMATION

BOD08/06.19 Digital Systems Development Update

The DFI presented the Digital Systems Development Update and the following key points were noted:

(a) The roll out of the Pathology order comms continues to progress according to plan and has been adopted by colleagues. The roll out plan for Phase 2 was included within the report.

(b) Releases 14 (R14) – This was a major step forward by MAXIMS and had gone live this week. Some teething problems had been experienced, but it had broadly gone to plan.

(c) Electronic Prescribing & Medication Administration (EPMA) – The project had been launched and the internal demonstrations received. These had been well attended by Clinicians, Pharmacists and Nurses. The plan was to make a choice in two weeks’ time.

(d) EMIS – This continued to progress well, with the first phase launched in April. Staff were finding the system easy to use. The next phase was due to be realised week beginning 3 June. The Managing Director had met with the Hospital At Home Team who were very positive about the new system, although slight frustrated with the issues of data showing with GPs.

(e) The CEO questioned whether the issue around scheduling was being resolved. The Managing Director advised that the Trust had met with the SWFT team around this, noting that it may end up with both systems being needed.

Resolved – that the Digital Systems Development Update be received and noted.

BO09/06.19 Trust Research Strategy until 2021

The Research & Development (R&D) Chair and the Research Operations Lead presented the Trust Research Strategy until 2021 the following key points were noted:

(a) The Medical Director noted his disappointment that the R&D research was still national, and no localised research being developed. As there was no finance attached to this currently, Mr Myers (NED and Chair of the Charity Trustee) suggested using charity trustee monies.

(b) The R&D Chair advised that the Trust were part of a network with national wide

initiatives and an innovative IT system that reviewed the population and could target a study suitable for a particular area.

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(c) The Medical Director advised that some Trusts in Wales were working closely with Universities. The R&D Chair advised that the University of Worcester were involved in the R&D meetings.

(d) The R&D Chair advised that the main change she would like to see to research was to integrate it as a Trust wide commitment to ensure each Division has some accountability to deliver on our strategy and enter the required number of patients into the research. Currently the Trust only recruited five hundred people a year but according to our population, this should be one and a half times that figure. The R&D Chair advised that currently the savings made by trials was not calculated but this would be included in future trials. The CEO suggested looking at staff development in connection with R&D and other disciplines where national funding could be used. The R&D Chair advised that the Network was large enough to encourage local research to fund trials, with a number of opportunities available. Recruitment to the higher level of staff was required, with the more junior roles easier to recruit to.

(e) Mr Humphries (NED) queried whether the Trust was promoting a strong research culture. The DHR advised that links were being made in some projects. The Medical Director and R&D Chair would meet to discuss this area further.

(f) Mr Waller (NED) questioned how the structure chart of the Research Team compared to five years ago. The R&D Chair advised that there had been a number of temporary funded posts to deliver on particular projects, so little had changed in this time.

(g) Mr Myers (NED) queried how this could be aligned to our ethics. The R&D Chair advised that a number of the large studies were centrally focused, but she had not noticed any issues in this area. Mr Myers (NED) suggested that there could be weak spots when the projects were more local. The R&D Chair advised that the small projects were usually run through the Universities and felt that WVT should be able to pick a number of studies applicable to the Trust considering the number available.

(h) Mr Humphries (NED) felt that big research breakthroughs should not necessarily be difficult to achieve and questioned how to balance the need of trials against the possible impact of their findings. The R&D Chair advised that the Trust did not have the number of patients here required for many specific studies.

(i) Mr Humphries (NED) questioned what the Board of Directors could do to raise the profile of research. The R&D Chair advised that recruitment and Divisions being engaged with reporting of what studies they have and the details along with encouraging potential researchers to take on this role.

(j) The Chairman suggested having a research project presented to a Board Workshop twice a year to give more visibility. The Medical Director would review this suggestion.

DM/LR DM

Resolved – that:

(A) The Trust Research Strategy until 2021 be received and noted.

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(B) The Director of Human Resources and the Research & Development Chair would meet to discuss further promoting a strong research culture in the Trust.

(C) The Medical Director would consider having a research project presented twice yearly to a Board Workshop.

DM/LR

DM

COMMITTEE SUMMARY REPORTS

BOD10/06.19 Clinical Quality Committee Summary Report 25 April 2019

Revd Hargraves (NED and Chair of the Clinical Quality Committee) presented the Clinical Quality Committee Summary Report 25 April 2019 noting that the underline areas within the report were key for noting.

Resolved – that the Clinical Committee Summary Report 25 April 2019 be received and noted.

COMMITTEE MINUTES

BOD11/06.19 Clinical Quality Committee – 28 March 2019

Resolved - that the Clinical Quality Committee minutes – 28 March 2019 be received and noted.

BOD12/06.19 Any Other Business

There was no further business to discuss.

The Chairman asked the DFI how the finances were going in the new financial year.

The DFI advised that things were on plan at month 1.

The Chairman then asked the COO how performance was going in the new financial

year. The COO advised that there had been a good start to the year with urgent care

and flow better than the previous year.

BOD13/06.19 Questions from Members of the Public

Q1. Rostering – As Hereford County Hospital is a small hospital, it is a lot easier and

quicker to implement an E-Rostering package than a larger hospital. The cost however

to this Trust is a fixed price as for any other Trust. Can you negotiate a lower price for

less work?

A1. The DHR advised that the cost would vary according to the size of the hospital

and was therefore reflected in in our costs, but the Trust had also negotiated a reduced

cost as we are part of the Foundation Group. The Chairman noted that a smaller

hospital did not necessarily mean the system was easier to implement.

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Q2. Candour, Transparency and Pressure Ulcers - The figures reported for grade 3

and 4 pressure ulcers from the Public Board papers for January until April were quoted,

which were presumably including the Community Hospitals. However, in the minutes

of the Clinical Quality Committee held on 28 March it included the Pressure Ulcer

Update Report with a review of the increasing number of incidents of moisture

associated skin damage being undertaken with the DON advising that the vast majority

of the deep tissue injuries resolved with any acquired pressure ulcers treated and

reviewed as Serious Incidents. These statements seem to indicate a less favourable

scenario, would the Board care to clarify and comment?

A2. The DON advised that this was a complex area with acquired pressure ulcers, deep tissue injuries and moisture associated skin damage all different things with the latter two not necessarily progressing to a pressure ulcer. Our Commissioners require us to report all grade 3 pressure ulcers but after review, these may be found not to be acquired and therefore downgraded. This was a complex picture which was reported to the Board of Directors and via a deep dive to the Quality Committee. The DON would however take the detailed information away to check the figures.

Moisture associated skin damage (MASD) is a new ‘measure’ for Trusts to report from April 2019 (this year). However, we have been educating the staff to recognise early moisture associated skin damage and report this onto the datix system so that we can monitor the incidence. We have been doing this for over 12 months. What we have seen is an increase in reporting of MASD and a reduction in the incidence of grade 2 pressure damage. This tells us two things that our staff have been incorrectly reporting MASD as grade 2 – This is now rectified through good education of the staff. This also tells us that the interventions put in place once MASD is identified is working because we have seen a reduction in the overall incidence of grade 2, 3 and 4 pressure ulcers.

Deep Tissue Injuries (DTI) is also a new measure for trust to report from April 2019. However, again we have been reporting these for over a year and have seen an increase in incidence – this is to be expected as staff now recognise the key factors associated with DTI. Again the reduction in grade 3 unstageable pressure ulcers is also an indication that the interventions put in place when a DTI is recognised is working as a high proportion of reported DTI are resolved and skin integrity is returned.

The March information for pressure ulcers was a data inaccuracy and this is being rectified with the informatics team.

Q3. Research and Development Strategy – Page 70 - Would the Board care to clarify how the threat of clinical pressures on workplace/workforce will be overcome to enable the success of the Research and Development Strategy? A3. The Medical Director advised that numbers went down over the past years due to problems with vacancies, along with high vacancies amongst doctors with substantive staff having to cover vacancies which made it difficult to cover Research & Development as well. The Chairman advised that we have dedicated facilities but with staff having to work overtime to cover vacancies meaning was no spare time to cover Research and Development. The Medical Director noted that a significant recruitment plan was in place for medical staffing.

LF

Resolved – that:

(A) The Questions from the Members of Public be received and noted.

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(B) A more detailed response to the questions raised around pressure

ulcers, moister associate skin damage and deep tissue injuries would be

provided in the minutes.

LF

BOD14/06.19 Date of next meeting

The next meeting was due to be held on 4 July 2019 at 1.00 pm in the Board Room,

Trust Headquarters.

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WYE VALLEY NHS TRUSTACTIONS UPDATE: BOARD OF DIRECTORS, THURSDAY 4 JULY 2018

AGENDA ITEM ACTION LEAD COMMENTBOD11/03.19Finance Performance07.03.19

(B) The Director of Finance & Information would review the Nursing (overspends) & underspends graph as this was not ideal for identifying areas of concern.

HO Completed - Reflected in the Month 2 report.

BOD08/05.19Quality Report02.05.19

(C) A monthly update report on the performance measures against the Quality Priorities would be presented to the Board of Directors.

LF Completed – A brief narrative report for any exceptions against the agreed Board level performance indicators would be included in the Quality Report.

BOD12/05.19One Herefordshire – Urgent Care Programme Board Update02.05.19

A presentation would be given at the July Board Workshop on the plans and solutions for the coming winter period.

JB Completed – Board Workshop 04.07.19.

BOD07/06.19Clinical Quality Committee Terms of Reference and Workplan23.05.19

(B) A sentence would be added to the Terms of Reference for the Clinical Quality Committee to make it clearer that the Committee was an assurance committee rather than a performance committee.

LF/CH After discussions in the Private Board, a full review of the Terms of Reference for the Quality Committee would be undertaken in August.

BOD09/06.19Trust Research Strategy until 202123.05.19

(B) The Medical Director and the Research & Development Chair would meet to discuss further promoting a strong research culture in the Trust.

DM/LR Completed – Board Workshops to be arranged.

BOD13/06.19Questions from Members of the Public23.05.19

(B) A more detailed response to the questions raised around pressure ulcers, moister associate skin damage and deep tissue injuries would be provided in the minutes.

LF Completed – within minutes.

ACTIONS IN PROGRESSBOD19/07.18IM&T Strategy06.07.18

A timeline of when projects commenced would be included within future IM&T Strategy Reports.

HO Timeline to be included in next iteration of strategy – due in 2019.

BOD13/05.19Mortality Report02.05.19

The End of Life Survey results would be discussed at a future Board Workshop.

DM Due August 2019

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AGENDA ITEM ACTION LEAD COMMENTBOD15/05.19Summary Report on Safe Working Hours02.05.19

The Medical Director would invite the Junior Doctors to present a staff or patient story at a future Board Workshop.

DM Due August 2019

BOD16/05.19HSE Improvement Notices02.05.19

An update on the progress made against the HSE Improvement Notices would be presented to the August Board of Directors meeting.

EH Due August 2019

BOD09/06.19Trust Research Strategy until 202123.05.19

(C) The Medical Director would consider having a research project presented twice yearly to a Board Workshop.

DM Board Workshop dates to be confirmed.

ACTIONS REFERRED TO BOARD OF DIRECTORS SUB-COMMITTEESN/A N/A N/A N/A

REPORTS SCHEDULED FOR FUTURE MEETINGSN/A N/A N/A N/A

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Report to: Board of Directors Date of Meeting: 4th July 2019Title of Report: Chief Executive’s Update Report Status of report:(Approval, position statement, information, discussion)

For Information

Report Approval Route: Board of DirectorsLead Executive Director: Glen Burley, Chief Executive Author: Glen Burley, Chief ExecutiveAppendices:

1. Purpose of the reportTo update the Board on the reflections of the CEO on current operational and strategic issues.

2. RecommendationsFor information.

3. Executive Director OpinionAssurance can be provided that the information within this update report is accurate and up to date at the time of writing.

4. Please state (using ‘x’) which element of the Trust’s Objectives the report relates to:1. Quality Improvement: Continuously improve

quality of care by delivering on our quality priorities, focussing on our patients and the time they spend in our care.

X 6. Sustainability: Deliver improved efficiency as a Foundation Group of Trusts by collaborating on IT, procurement and identifying further benefits.

X

2. Quality Improvement: Improve urgent care by making a consistent improvement in delivering the A&E standard and increasing the range of services provided across 7 days.

X 7. Integration: Care for more people closer to home by integrating our community services with our One Herefordshire Partners.

X

3. Quality Improvement: Reduce patient waiting times by increasing our productivity, delivering our activity plans and taking a consistent foundation group approach to capacity planning.

X 8. Integration: Actively increase our role in health promotion and the prevention of ill health with our local communities.

X

4. Sustainability: Improve our financial sustainability by addressing our structural deficit.

X 9. Workforce and Leadership: Deliver our workforce plan, recruiting and retaining more staff and ensuring that they are enabled to work at their full potential.

X

5. Sustainability: Improve our effectives and efficiency by implementing our Digital Strategy.

10. Workforce and Leadership: Enhance our leadership potential through a joint Foundation Group approach to leadership and service improvement.

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1) Contract with Hereford CCG

Unfortunately we have still not yet been able to finalise a contract agreement for 2019/20 with Herefordshire CCG. Progress has been made over the past few weeks in a number of other disputed areas but we have not been able to reach agreement on the plans for elective care. Herefordshire has traditionally had very long waiting times compared to the rest of the NHS. This has been picked up by the CQC at each of their last three inspections of the Trust. Following their last inspection we agreed with the CQC, NHSI and the CCG that we would implement a plan to meet the national 92% constitutional standard over a two year period. This included a trajectory to end 2019/20 at a performance level of 86%. As the Board knows, we have made good progress on this but unfortunately the CCG now cannot afford to commission the activity levels in this financial year to meet the agreed plan.

We have offered a compromise, which would ensure that there are no 52 week waits over the year and would deliver a year end performance of 82.6%. This would be a slight improvement on our current performance of 80.2%. The CCG have proposed however that we should hold the current performance but we have explained that this could not be delivered without either wasting capacity or breaching the 52 week waiting time standard. Whatever position we reach, it appears that we will need to work carefully with the CQC to ensure that they are satisfied with a less ambitious plan. Hopefully this will be considered alongside the very many quality improvements that we have made.

It is important to note that the resolution of this issue will not impact on our financial plans for the year. If we are not commissioned to carry out this additional work then we will not incur the associated costs, so this is simply a disagreement on what level of elective performance is seen to be safe and appropriate.

In addition to the issues regarding our 2019/20 contract, we still have not resolved the final income position for 2018/19. As it currently stands, the Trust has undertaken around £8.5m of activity for the CCG without payment. This resulted in the Trust missing its financial control total and losing out on additional national funding.

We have asked NHSI and NHSE to arbitrate on these two issues.

2) Hutted Ward Replacement Business Case

We have submitted a further version of the Hutted Ward Replacement Outline Business Case to NHSI and await their feedback. Recently there has been a reassessment of capital schemes across the NHS. This review is in the context of more limited funds. So this is not the best time for the Trust to be asking for £23.6m of capital funding.

The national review of capital schemes has sparked some interest from the Heath Service Journal in our situation. By the time we meet as a Board, they may well have highlighted our plight. It would therefore be a really positive outcome if we can gain agreement from NHS Midlands to proceed.

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3) Shortlisting for CHKS Most Improved Hospital Award 2019

I am delighted to report that the Trust made this year’s shortlist of 5 organisations in the ‘most improved Trust’ category in the CHKS annual awards. CHKS are a national benchmarking organisation and unlike other awards where applicants apply for recognition, they examine the outcomes of all hospitals in the NHS. So, whilst we didn’t win, being shortlisted is a great achievement and is a further demonstration of our productivity and mortality improvements. The Chairman and I are recently met with the new Director of NHSI&E for the Midlands Region and he was very impressed with the Trust’s progress since he last focussed on the organisation during the difficult 2016/17 financial year.

4) Interim National Workforce Strategy

The Interim National Workforce Strategy has now been published. The intention to produce a new strategy was signalled in the NHS Long Term Plan. The reason for the ‘interim’ title is linked to the Comprehensive Spending Review and the need for appropriate funding to be awarded to Health Education England in order to meet the ambitions of the strategy. The Strategy addresses the aim for the NHS to reduce staff turnover by being a better employer as well as addressing leadership development, role redesign and increasing recruitment in clinical areas, particularly nursing. The HSJ recently reported on DHSC analysis which shows that if each trust achieved the mean level of international nurse recruitment we would still have a gap of just under 19,000 nurses by 2023/24. To address this it is believed that there will be much more national coordination of international nurse recruitment in the future if the funding request is met.

5) Proposed Legislative Changes to the NHS

The health and social care select committee has recently published its report on the legislative proposals set out by NHS England and NHS Improvement (NHSE/I) to accelerate the implementation of the NHS long term plan. This followed a consultation exercise which we responded to through NHS Providers. I previously reported on the response from NHS Providers which referenced some of our contributions.

The report is broadly supportive of the proposals but has asked for more clarity on practicalities and legal implications. It is particularly encouraging to see that that Committee have challenged the potential loss of local autonomy and accountability.

One of the key concerns that I raised in my response related to capital spending freedoms the power to direct Trusts on mergers. It is therefore encouraging to see that the Committee has challenged the potential loss of provider autonomy and accountability suggesting that the proposals are too centralising. The Committee is expecting to undertake formal pre-legislative scrutiny of any forthcoming bill. That said, it is unclear how or when parliamentary time could be made for this in the current political climate.

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Summary of report recommendations and conclusions

Collaboration and competition

The Committee welcomed in principle NHSE/I’s proposal to promote collaboration, especially the proposal to repeal section 75 of the Health and Social Care Act 2012 and revoke regulations made under it.

Procurement rules

The Committee supported the aims of NHSE/I in ensuring that commissioners can exercise discretion over when to conduct procurement process. The Committee recommended that DHSC and NHSE/I work with the NHS Assembly to co-produce a best value test.

Payment systems

The Committee supported NHSE and NHSI’s intention to provide greater local flexibility over the use of national tariff system. It requested that DHSC and NHSE/I outline how they plan to avoid and/or mitigate the concern that these changes could result in price competition.

Integrated care trusts

The Committee noted that there already exist different contractual and service options, permissible within existing legislation, that help to remove or reduce the barriers which organisational boundaries pose to integration.

The Committee supported the proposals to give the Secretary of State the power to create a new NHS trust to deliver integrated care in an area as long as this power is not used to impose a form of integration on local health and care services or as threat to incentivise organisations to collaborate.

Mergers and acquisitions, and capital spending

Local systems should be empowered to decide the most appropriate way to manage NHS resources. This includes being encouraged to resolve disputes between local partners about the best way to manage resources, including capital resources, within the system. However NHS England and NHS Improvement should have powers to deal with any disputes as a last resort.

Provider and commissioner joint working

The Committee agreed that the law should change to enable CCGs and NHS providers to establish joint committees. They also recommended that additional proposals should be developed that enable local authorities to participate as equal partners in such committees.

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Shared duties for providers and commissioners

The Committee welcomed the proposal to introduce a shared duty that requires CCGs and NHS providers to “promote the triple aim of better health for everyone, better care for all patients and the efficient use of NHS resources, both for their local system and for the wider NHS”. However, to avoid being ‘too NHS centric’ it recommended that the “triple aim” should be rephrased to include a specific reference to wellbeing.

National leadership

The Committee commended NHSE and NHSI for efforts they had made to work closer together and supported the principle of merging NHS England and NHS Improvement into a single body. However the Committee are concerned about the degree of central control that would result from this merger, especially in light of the other changes put forward.

Other areas covered

The Committee agreed that it is not advisable at this time to establish all integrated care systems as separate legal entities. In the absence of formal accountability for their collective decision-making, it expected STPs/ICSs to meet the highest standards of openness and transparency in the conduct of their affairs by holding meetings in public and publishing board papers and minutes. The Committee welcomed assurance from the NHS that holders of an Integrated Care Provider (ICP) contract are expected to be public statutory providers, but with the ability to subcontract with a range of other partners. The Committee strongly recommended that legislation should rule out the option of non-statutory providers holding an ICP contract.

6) Latest Going the Extra Mile Awards (GEM) Winners – May 2019

Employee of the Month – May – David Roberts

“Until recently David has given his time every Tuesday afternoon for many years to support the Occupational Therapy Team deliver a pre-op assessment knee replacement Patient Education Workshop. He performed an integral role in the delivery of the presentation that provided information about the joint replacement procedure, hospital stay and exercises following surgery.

After initial introductions and housekeeping, a slide showing David walking along Hadrian’s Wall has been an excellent introduction to set the scene for patient expectations following their joint replacement surgery. David explained that, following his 2 knee replacements he has gone on to walk the length of England but that this was made possible by his motivation to get through the pain after surgery and comply with the exercise regime recommended by physios in order to achieve the best possible outcome.

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He is able to answer specific patient questions directed at his experience, and through this has been able to reduce patients’ anxieties and fears around the surgery, whilst at the same time re-enforcing the professional therapy role and recognition that this surgery is initially painful but that with motivation and determination then patients can hope to have a good outcome.

Expert patient input into pre-op groups has been shown to be best practice in achieving the joint aims of reducing patient anxiety, managing expectations around length of stay and achieving a good functional outcome following surgery.

David is respectful of patients and their relatives and has worked well as a joint presenter along with qualified therapy staff and other volunteers. Written feedback from patients and relatives indicates that they find the sessions enjoyable, very beneficial, informative and worthwhile. They also help to create a very positive first impression of the hospital and its professional, supportive and caring workforce. The Trauma and Orthopaedic Enhanced Recovery Team wanted to acknowledge David’s contribution over the years and say a big thank you.”

Team of the Month – May – Plaster Room Team

“The plaster room team consistently work in a high pressure environment, reacting to urgent requests for intervention. In the case of diabetic foot, a very vulnerable caseload, they provide ‘gold standard’ total contact casts for high risk diabetic feet, often at risk of deterioration or amputation. They see patients weekly then fortnightly for 6-8 months, so diabetic foot referrals are a significant drain on team resources. I have recently seen one technician trying to manage multiple patients and just last week had to interrupt an audit session to ask for an urgent cast to be fitted that day to try to prevent critical foot damage. Two technicians attended to help my patient. They never decline to apply a cast despite other commitments / clinical pressures. They see patients very frequently and despite pressures, provide high quality treatments time and again. High quality care and adhering to the core/CARE values are critical to treating diabetic foot patients and the team do this by helping to prevent admissions and amputations, supporting patients through many months of casting therapy and repeatedly providing high quality, gold standard care in pressured clinics, sometimes singlehanded. This small but essential team covers wards, T&O, diabetes, A&E that I know of. They deserve to know how valued they are by this Trust.”

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Report to: Board of DirectorsDate of Meeting: 4 July 2019Title of Report: Integrated Performance Report & Dashboard – May 2019 Month 2Status of report:(Approval, position statement, information, discussion)

Information

Report Approval Route:Lead Executive Director: Jane Ives, Managing DirectorAuthor: Jane Ives, Managing Director

Lucy Flanagan, Director of NursingJon Barnes, Chief Operating OfficerSue Smith, Director of Human Resources and Organisational DevelopmentHoward Oddy, Director of Finance

Appendices: None1. Purpose of the report

To inform the Board of the performance of the Trust against a range of indicators, including operational performance against NHS Constitution targets, as at the end of May 2019 (Month 2).

2. RecommendationsFor the Board to consider performance against a range of Key Performance Indicators (KPIs) and to note the actions that are being taken to address areas of non-compliance.

3. Managing Director OpinionThere is a lot to be positive about in the first 2 months of the year, however a number of risks remain that need to be managed.

The system wide implementation of the ‘Respect’ documentation is an important integration project that will empower people to make decisions about their care in advance of an acute or emergency crisis. End of life care can then be tailored with compassion to meet individuals’ needs and wishes.

There is good early progress on a range of improvements to reduce avoidable mortality including NEWS training, intensive clinical practice weeks on wards and audits of care bundle compliance. This is adding to the already successful mortality reduction strategy that has seen Wye Valley deliver the most improved reduction in mortality in the England over the last 2 years.

Whilst there has been improvement in many areas in our quality performance the feedback we get from patients has remained broadly static and average. A more focussed approach to improving patient experience will be reported to the Board through a new quarterly patient experience report.

There are many positive indicators in urgent care pathways with more patients being treated as ambulatory, reductions in length of stay for patients being cared for the frailty assessment and acute medical units, reductions in the number of outlying medical patients and good performance in ambulance handover times in ED. This has improved despite the continued steep rise in ambulance conveyances and emergency admissions. The headline 4 hour performance at 85% is in line with our trajectory, but as demand has continued to increase in June our headline performance has started to reduce. We have encouraged the STP to take a more active role in managing emergency demand and the STP Director of Performance is leading a system project with WMAS on ambulance conveyance increases.

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The were no patients waiting over 52 weeks at the end of May and despite underperformance in elective activity plans we are on plan to deliver no 52 weeks waiting patients and improve RTT performance.In stroke care we have improved the SSNAP rating to a level B and there is a plan in place with Worcester to provide a networked consultant workforce that will be more resilient. Next month the board will receive an update on the medium term plan to improve stroke care in Herefordshire.

There are some encouraging improvements in staff metrics for turnover and sickness levels and whilst agency spend remains higher than planned the launch of the new nurse bank on July 1st is expected to increase the number of bank shifts at the expense of agency workers.

I have just completed this year’s series of staff engagement events which have been focussed on staff health and wellbeing in line with our quality priorities. The emerging themes will inform our plan and we will feedback to staff through a ‘you said….we did’ format.

By a very slim margin of £50k we are ahead of our financial plan and so are able to claim PSF and FRF performance funding to stay on plan to deliver our control total. There are risks to maintaining the position including the full delivery of the CPIP target and reduction in nurse agency and medical staffing costs.




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X 10. Workforce and Leadership: Enhance our leadership potential through a joint Foundation Group approach to leadership and service improvement.

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Page: 1 of 4 Information Services

Wye Valley NHS TrustTrust Key Performance Indicators (KPIs) - 2019/20

Regulatory Performance Measures Standard Targetset

Currentdata month

Monthactual

Trend(this

month vlast)

Year todate

Trend(April 2017 to

date)

Responsiveness Cancer 62 days urgent referral to treatment 85% N April 80,5% q 80,5%

Cancer 62 days urgent referral to treatment (38 day breach reallocation) 85% N April 81,7% p 81,7%

Cancer 62 day referral to treatment from screening 90% N April 100,0% p 100,0%

Referral to Treatment - Open Pathways (92% in 18 weeks) - English Standard 92% N May 81,1% p

Referral to Treatment - Open Pathways (95% in 26 weeks) - Welsh Standard 95% N May 83,2% q

Diagnostic waiters, 6 weeks and over - DM01 1% N May 0,5% p

A&E maximum 4 hour wait from arrival to departure 95% N May 85,3% p 82,2%

Financial Compliance Standard Targetset

Currentdata month

Monthactual(£k)

Trend(this

month vlast)

Year todate (£k)

Trend(April 2017 to

date)

Value for Money I&E surplus margin (NHSI oversight measure) Breakeven /Surplus N May -£1 691 p -£3 980

I&E surplus margin (actuals versus deficit plan)Fav / (Adv)Variance vs

PlanL May -£2 600 p -£5 781

I&E surplus margin (actuals versus plan) Actual v Plan N May -£69 q £49

Total income (actual versus plan) Actual v Plan L May £186 p £208

Pay expenditure (actual versus plan) Actual v Plan L May -£31 q £145

Non pay expenditure (actual versus plan) Actual v Plan L May -£224 q -£394

CIP (actual versus plan) Actual v Plan L May -£84 q -£165

Financialsustainability

Capital service capacity - Degree to which the provider's generated income covers its financialobligations

Actual N April - May = 4

Liquidity (days) - Days of operating costs held in cash or cash-equivalent forms including whollycommitted lines of credit available for drawdown


Financialefficiency

I&E margin - I&E surplus or deficit / total revenue Actual N April - May = 4

Financial controls Distance from financial plan - Year-to-date actual I&E surplus/deficit in comparison to Year-to-dateplan I&E surplus/deficit


Agency Spend - Distance from provider's cap Actual N April - May = 4

In Month

Activity Standard Targetset

Currentdata month Plan Actual

YTDVariance

(%)

Trend(April 2017 to

date)

Urgent Care Type 1 & Type 3 ED attendances (activity v plan) < Plan L May 5 805 6 009 1,4%

Non Elective Activity - Adult Acute < Plan L May 1 514 1 784 20,2%

Non Elective Activity - Paediatric Acute < Plan L May 372 356 -1,6%

Non Elective Activity - Obstetrics < Plan L May 172 195 3,5%

Total Non Elective Activity (Excl A&E) < Plan L May 2 058 2 335 14,8%

Planned Care -Acute &Community

Referrals (MAR - 2019/20 v 2018/19) L April -8,2%

Outpatient Activity - New attendances Plan L May 7 602 6 927 -9,6%

Outpatient Activity - Follow Up attendances Plan L May 19 776 18 507 -5,9%

Total Outpatient Activity Plan L May 27 378 25 434 -6,9%

Elective Inpatient Activity Plan L May 370 368 0,3%

Daycase Activity Plan L May 2 550 2 519 -1,4%

Total Elective Activity Plan L May 2 920 2 887 -1,2%

Community Contacts 2017/18Outturn L May 22 437 17 705 -18,9%

Community Bed Days 2017/18Outturn L May 2 460 2 254 -8,9%

Access Standard Targetset

Currentdata month

Monthactual

Trend(this

month vlast)

Year todate

Trend(April 2017 to

date)

A&E QualityIndicators

Ambulance turnaround within 30 minutes (WMAS) 98% L May 61,8% q 61,9%

Ambulance turnaround over 60 minutes (WMAS) 0% L May 0,9% q 1,2%

Time to be seen (average from arrival to time seen - clinician) < 15 minutes N May 1:19 q

A&E Quality Indicator - 12 hour trolley waits 0 L May 0 q 2

A&E - % of admitted patients admitted within 4 hours (arrival to discharge) 90% L May 62,9% p 59,7%

Cancer Cancer 2 week GP referral to 1st outpatient appointment 93% N April 95,3% p 95,3%

Cancer Urgent referrals for breast symptoms 93% N April 93,7% p 93,7%

Cancer 31 day diagnosis to treatment 96% N April 97,9% p 97,9%

Cancer 31 day second or subsequent treatment (drug) 98% N April 100% p 100%

Cancer 31 day second or subsequent treatment (surgery) 94% N April 92,3% p 92,3%

Cancer consultant upgrade (62 days decision to upgrade) 85% L April 90,6% p 90,6%

Cancer 62 day pathway: Harm reviews - number of breaches over 104 days L April 3 q 3

CancelledOperations

% Last minute non-clinical cancelled ops (elective) 0,80% N May 1,4% = 1,4%

Breaches of the 28 day readmission guarantee (%) 0% N May 11,1% p 9,3%

Breaches of the 28 day readmission guarantee (Numbers) 0 N May 3 p 5

Referral toTreatment

RTT 52(+) week waiters - All patients 0 N May 0 =

Target Type Performance Against Target (Status) Activity Performance OnlyN National Meeting Target Over 5% above Target

C CQUIN Not Meeting Target 5% above to 2% below Target

L Local More than 2% below Target to 5% below Target

Over 5% below Target

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RTT 40(+) week waiters - All patients L May 245 q

Responsiveness Delayed Transfers of Care (acute only; pts as % of occ beds) <3.5% N May 3,2% p

Delayed Transfers of Care (community only; pts as % of occ beds) <3.5% N May 11,5% q

Stroke Indicator - % spending >90% of their stay on a stroke unit 80% N May 89,5% p 82,5%

Stroke Admissions - Admitted to Stroke ward within 4 hours of presentation 65% L May 53,3% p 43,0%

Stroke Admissions - CT Scan within 12 hours 100% N May 94,4% q 94,7%

% of people who have a TIA who are scanned and treated within 24 hours 60% N May 50,0% p 26,1%

Local Performance Targets and Measures Standard Targetset

Currentdata month

Monthactual

Trend(this

month vlast)

Year todate

Trend(April 2017 to

date)

Inpatients Emergency 0 day LOS - General & Acute specialties (Adults only) 35% L May 28,3% q 29,6%

ALoS - General & Acute Emergency Inpatients (Acute episodes only) 4,5 L May 4,2 p 4,0

ALoS - General & Acute Elective inpatients 2,5 L May 2,5 q 3,0

Elective - Theatre Utilisation (Needle To Recovery Less Overruns) 90% L May 79,9% p 79,4%

Elective - Daycase Rate 85% L May 86,2% p 85,9%

BPT - Fracture Neck of Femur 80% N March 29% p 18%

Bed occupancy - G&A Wards (Acute Site) 90% L May 96,1% q 97,0%

Bed occupancy - Community Wards 90% L May 90,2% p 89,0%

Outpatients DNA Rate (Acute Clinics) 4% L May 6,0% q 6,1%

Clinic Utilisation - Consultant Led Clinics Only 95% L May 91,9% = 91,9%

% of patients waiting over 6 weeks without a date (month end snapshot) 0% L May 9,0% q

Number of patients waiting longer than 16 weeks over their due appt date 0% L May 5,7% q

Maternity -achieving the nationalambition to reducestillbirths, neonatal andmaternal deaths inEngland by 50% by 2030

Smoking at Delivery (6% by 2022) 11% N May 17,0% p 14,8%

% of women who have seen a midwife by 12 weeks and 6 days of pregnancy 90% N May 85,3% p 82,5%

% of women inititating breastfeeding 80% N May 79,6% q 81,0%

Caesarean section - Elective 13% N May 13,7% q 16,7%

Caesarean section - Emergency 15% N May 20,9% p 20,7%

Support people to improve their health outcomes

Contribute to thechildhood systemobesity reductiontarget

Breastfeeding initiation and 6 week target 50% N April 56%

Year 2 national measurement programme numbers participating April 99,7%

Year 6 national measurement programme numbers participating April 99,9%

Year 2 national measurement programme figures for obesity April 5,0%

Year 6 national measurement programme figures for obesity April 14,0%

Year 2 and year 6 national measurement programme follow up health promotion April 100%

Fit for Families programme - numbers participating April 5

Fit for Families programme - outcomes reported from June

Participation in dental health promotion April 78

Referral toTreatment

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Workforce Measures Standard Targetset

Currentdata month

Monthactual

Trend(this

month vlast)

Year todate

Trend(April 2017 to

date)

Workforce Turnover (rolling 12 months - Trust Level) 10% L Rolling 12 Months q 11,2%

Sickness Absence (%) 3,5% L May 4,1% q

Vacancy Rate 5% L May 7,3% q

Agency (agency spend as a % of total pay bill) 6,4% L May 10,2% p

Appraisal rate - all 90% L May 86,7% p

Mandatory Training 90% L May 89,7% p

Midwife to birth ratio - last 12 months 1:30 N May 1:30 =

Clinical Outcomes Standard Targetset

Currentdata month

Monthactual

Trend(this

month vlast)

Year todate

Trend(April 2017 to

date)

Quality - reduceavoidable death rates

Mortality - SHMI 100 N January to December 2018 q 104,81

Mortality - HSMR 100 N March 2018 to February 2019 q 98,0

Number of emergency calls L May 63 p 122

Number of cardiac 222 calls L May 77 p 153

Number of in hospital cardiac arrests L May 7 q 15

Out of hospital cardiac arrest L May 2 q 11

NCAR audit results (quarterly) Survival to discharge Quarterly from June

% compliance with NEWS e learning L May 84,1% p

% compliance with NEWS practical assessment L May 75,6% p

Number of Serious incidents relating to the deteriorating patient 0 N May 1 = 2

Sepsis Sepsis screening - A&E (% screened) 100% L April 100% =Antibiotics within 1 hour 100% L April 64,0% 64%

Septicaemia Mortality HSMR 100 N April 90,5 90,5

Septicaemia Mortality SHMI 100 N April 91,77 91,77

Reduce InfectionRates - to reduceinfection rates and toachieve the Gramnegative bacteraemiatarget reduction of 50%by 2021 (WVT target 9)

Number of hospital acquired bacteraemia (overall) n/a April 2

Number of >AD+1 MRSA Bacteraemia 0 N May 0 = 0

Number of MSSA Bacteraemia 0 L May 0 = 0

Gram Negative Bacteraemia 14 N May 1 q 3

Number of E.Coli Bacteraemia 0 L May 1 q 3

Number of Pseudomonas bacteraemia 0 N April 0 0

Number of Klebsiella 0 L April 0 = 0

Number of external reportable >AD+1 clostridium difficule cases 36 N April 1 q 1

Trust attributed Clostridium difficile infections (CDI) with lapses in care idenitifed 36 L May 0 = 0

Hand Hygiene 95% L April 95% q

Bare Below the elbow 95% N April 94% 94%

Cleaning Standards: Sodexo Contract 85% L May 91,0% = 91%

Cleaning Standards: Private Contract 90% L April 100,0% 100%

Cleaning Standards: Trust Contract (community setting) 90% L April 93,0% 93%

Cleaning Standards: Trustwide Clinical 90% L May 95,0% p 94%

Patient Experience Standard Targetset

Currentdata month

Monthactual

Trend(this

month vlast)

Year todate

Trend(April 2017 to

date)

Experience Complaints resolved within agreed timeframe 90% L May 87% q

Number of complaints <301 (2018/19)

L May 28 p 52

Number of complaints reopened <54 (2018/19)

L May 7 p 12

Number of complaints referred to Ombudsman 6 L May 1 = 2

Duty of Candour L May 4 q 9

Friends and Family Test - Response Rate (A&E) 25% C May 4,7% q

Friends and Family Test - Response Rate (Inpatients) 30% C May 27,4% p

Friends and Family Test - Response Rate (Community) 30% L May 45,8% q

Friends and Family Test - Response Rate (Maternity) 30% L May 27,0% p

Friends and Family Test Score - A&E recommended by Patients 95% N May 89% p

Friends and Family Test Score - Inpatients recommended by Patients 95% N May 98% =Friends and Family Test Score - Community recommended by Patients 95% L May 99% p

Friends and Family Test Score - Maternity recommended by Patients 95% L May 96% q

Staff Friends & Family Test % recommended - care 85% N Qtr 2 80% p

Reduce theproportion of nonvalue added timewhen patients are inhospital

Patient ward moves emergency admissions (Acute - more than 2 moves) L May 10,5% q 10,6%

Same Sex Accommodation Standard breaches 0 N May 14 q 33

% emergency admissions discharged to usual place of residence L May 85,6% = 85,6%

Emergency readmissions within 30 days of discharge (G&A only) 5,9% L April 8,0% p 8,0%

Number of people trained in Respect tool Due to be reported quarterly fomr quarter 1

Reducing Harm Standard Targetset

Currentdata month

Monthactual

Trend(this

month vlast)

Year todate

Trend(April 2017 to

date)

Safety Occurrence of any Never Event 0 N May 0 q 1

Safety Thermometer - Harm Free 95% N May 96,3% q

VTE Risk Assessment 95% N April 88,1% q

Number of hospital acquired thrombus L May 11 q 23

Number of hospital acquired thrombosis outstanding reviews L May 86 q 175

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Pressure ulcers (confirmed avoidable Grade 3,4) 0 N May 1 p 1

Total number of deep tissue injury L May 12 q 30

Total number of moisture associated skin damage L May 60 p 115

Number of patient falls in inpatient areas <535(2018/19)

L May 67 p 109

Number of patient falls in community hospitals <246(2018/19)

L May 20 p 37

Number of patient falls in inpatient areas (per 1000 bed days acute) 6,63 N May 6,3 p

Number of patient falls in inpatient areas (per 1000 bed days community) 8,6 N May 8,9 p

Number of falls with moderate harm and above 0 L May 1 p 1

Dementia assessment and referral: the number and proportion of patients aged 75 andover admitted as an emergency for more than 72 hours:

The proportion of patients aged 75 and over to whom case finding is applied within 72hours following emergency admission with a length of stay > 72 hours 90% N May 53,1% q

The proportion of those identified as potentially having dementia or delirium who areappropriately assessed, 90% N May 100% =The proportion of those with a diagnostic assessment where the outcome was positiveor inconclusive who are referred on to specialist services 90% N May 100% =

Sepsis screening - Inpatients (% screened) 90% L Qtr 3 100% =Number of SIs reported <75

(2018/19)L May 11 p 16

Medication Errors (with harm) <10% L May 10,8% q

% compliance with WHO checklist 100% N Jan-Mar 100,0% =

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Quality Report Month 2 2019/20

Maternity:

The trust has been accredited with level 3 baby friendly initiative which is a great achievement. The new perinatal mental health service has also been launched supporting women with mental health needs in pregnancy. This has been a gap in service provision to date and the new service is welcomed.

Reduce Infection Rates:

As part of the infection and prevention teams audit programme, during the last month the team have been focussing on clinical practice related to peripheral and urinary catheters. This review has included auditing of practice, completion of the associated documentation and care planning. The results of this will be presented to the infection prevention committee. There have been areas of good practice identified and the wider learning will be shared with all clinical areas. The team also ran a campaign throughout hydration week on 10th June. The campaign was designed to raise staff awareness of the importance to maintain hydration for our patients and indeed themselves. Maintaining hydration and managing urinary catheters will support the national ambition to reduce gram negative bacteraemia. The team have also been utilising the Surewash machine to assess staff competence in their hand hygiene technique. Infection prevention and control committee have approved a change in practice associated with MRSA screening; this aligns our practice to best practice and will also enable a greater focus on CPE screening in the emergency department.

Patient Experience:

The national guidance on friends and family test is still awaited. In the meantime, the deputy director of nursing is working with hospedia our provider of patient bedside TV's and the Picker Institute to enable more real time feedback from patients; this will include enabling the functionality on the bedside TV's and the provision of feedback kiosks in some areas including outpatients.

There has been an improvement in number of same sex accommodation breaches reported in month. All relate to delays with patients stepping down from ICU and CCU. New national guidance on mixed sex accommodation is awaited.

The national RESPECT document (figure 1 below), a document enabling patients to plan ahead for how they want their care to be managed in emergency situations is currently being piloted in parts of primary care in Herefordshire. The trust has begun to deliver training for frontline staff so that they are familiar with the document. Full roll out will commence in October 2019, the new form will come into operation at this time and will replace the current red DNACPR form (figure 2 below). Learning from the early implementation sites across the country is that it will take up to 2 years to fully phase out the red DNACPR forms.

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Figure 1 Figure 2

Reduce avoidable death rates:

Board will receive a separate update on mortality. The work to support the mortality project includes a number of priorities including;

Utilisation of the National Early Warning Score (NEWS) as a trigger for recognising the deteriorating patient

Recognising and responding to the deteriorating patient Sepsis management Compliance with care bundles

NEWS

Compliance with NEWS e learning and scenario based learning has improved in month, 84% of eligible staff have completed e learning and 75% have completed the practical training (this was only introduced in the last 12 months), the team will conduct a deep dive into the staff/areas who have not yet completed the training so that resource and effort can be targeted appropriately to help achieve compliance. A pilot of electronic observations and recording of NEWS has been conducted on the Acute Medical Unit. Lessons learnt from the pilot are currently being evaluated and a roll out plan for the wider organisation is under development.

The SBAR (situation, background, action, response) communication tool has been a key part of the training for staff. The tool is designed to improve situational communication when escalating a deteriorating patient to the clinical teams for review. The tool prompts you to communicate the essential information to the clinical teams to aid their decision making and response.

Recognising and responding to the deteriorating patient

As part of our drive to improve our management of the deteriorating patient and ultimately reduce avoidable death rates a number of teams have been supporting Clinical Practice weeks. These have been well received and provide clinical areas with the opportunity to identify what their learning/training needs are in order to improve clinical practice. Micro teaching sessions are then delivered in clinical areas and so far have included, SEPSIS, resuscitation skills and defib training,

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care of the dying patient, prevention of pressure ulcers, infection prevention and control related matters, NG feeding and lots more. All clinical areas will have experienced a clinical practice week by the end quarter 2.

The deteriorating patient group and Resuscitation Committee are combining and will be chaired by Dr Glancy; this group will bring together a number of work streams and will support the trust in improving practice and sharing learning. The first meeting of this group is scheduled to take place later this month.

Sepsis

The sepsis quality improvement project has seen a number of achievements in recent months including adding the sepsis six care bundle onto the electronic record in ED; this enables live reporting and auditing of all elements of the care bundle. Sepsis education is now added into the trust training schedule and a number of classroom and ward based teaching sessions have taken place. The post also supports the wider community and has piloted a training session in care homes and now plans to roll this out to over 20 care homes in the forthcoming weeks. We have seen a significant reduction in deaths attributed to sepsis, with the lowest ever reported rolling 12 months HSMR (March 18 – Feb 19) of 85.23.

Care Bundles

We have committed to improve compliance with care bundles in relation to Sepsis (see above), acute kidney injury (AKI) and the Gastrointestinal (GI) bleed bundle.

To support this work a number of junior doctors have audited practice and found our compliance generally poor, although the GI bleed bundle is the most utilised. Further work is required to improve the content and usability of the bundles and the AKI and GI bleed bundle are being redrafted. The ultimate aim is for all care bundles (like sepsis) to be electronic, recognising that this will require a cultural shift to be successful, given our recent experience of electronic VTE assessment.

Reducing Harm

VTE

VTE compliance remains a challenge for the trust and consideration is being given to reverting back to a paper based assessment until the electronic record is routinely used as a clinical record. Routine monthly audits of VTE are undertaken and these confirm that patients are receiving the appropriate prophylaxis despite the electronic assessment not being completed. We are in the process of strengthening our processes for reviewing cases of hospital acquired thrombosis to ensure there is maximum learning.

Serious incidents

There have been 11 serious incidents reported during May;

Diagnostic delay Infection incident 2 Maternity incidents (maternal deaths) Medication incident 2 pressure ulcers Fall

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Surgical incident 2 treatment delays

Each incident is subject to full investigation to ensure that lessons are learnt and the findings of the investigations are reported to Quality Committee. The two tragic maternal deaths both occurred in the early stages of pregnancy in the community and will be ultimately considered by the coroner. The initial review of each case has been considered by the medical director and in the first case the patient was cared for on the pregnancy of unknown location pathway, this appears appropriate given the clinical presentation but may require further review once the post mortem results are available. The second case was a very early pregnancy where the women’s risk factors had been appropriately identified and the midwifery team had made plans for referral to obstetrics to be seen on a high risk pathway at 12 weeks, unfortunately the woman died prior to her 12th week of pregnancy.

Falls

The total number of inpatient falls remains within normal variation, and below the national average.Community Hospitals has a higher average mean in comparison to the acute site, although the number of falls in community hospitals has reduced significantly since the closure of Hillside. Falls with harm remain low and below the national average. Following completion of the QSIR programme the Falls Lead will be commencing weekly falls data dissemination to clinical teams to improve real time awareness of trends and focus on high impact interventions. There has been a concentration of falls on Arrow Ward since its change of specialty in December 2018 (to frailty from respiratory), this is due to the case mix of patients. It is important that we are able to maximise independence and maintain their usual level of functionality for this group of patients. Although we have had the concentration of falls on Arrow ward the overall number of falls has not increased despite the acute site opening an additional 24 beds in December 2018.

Pressure Ulcers

There is a continued upward trend in terms of the total number of pressure ulcer related incidents, however the number of actual pressure ulcers developed or deteriorated whilst in our care does not have the same upward trend. There have been no reportable category 4 pressure ulcers developed or deteriorated in the Trust since March 2018. The number of category 3 pressure ulcers continues to fall: 23 reported during January to June 2018 compared to only 14 reported during the same period this year. During the period April 2018 to March 2019, 35 pressure ulcers were reported as serious incidents and were subject to investigation. After investigation and validation only 7 of these were deemed to be avoidable where lessons could be learnt and practice changed. Moisture Associated Skin Damage (MASD) is an area where we are seeing an increasing incidence, in particular in the community setting. The continence project which initially focussed on the acute site has seen successes in reducing the incidence of MASD, largely by standardising the approach to skin cleansing and continence products. The focus for the forthcoming months will be to standardise the approach in primary and community care settings.

Future Board reporting

Given discussions at Board last month the proposal is to take the following approach with future Board reporting. Each month, the Board will continue to receive a brief narrative report for any exceptions against the agreed Board level performance indicators, this report will also include a deeper dive into one of our 10 quality priorities on a rotational basis throughout the year. Board already receive annual reports for Safeguarding and Infection Prevention and Control and it is

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proposed that these continue. In addition, it is suggested a quarterly patient experience report is added. Finally, and given the discussion at the Board workshop regarding the Workforce Safeguards, Board needs to determine if it wishes to continue to delegate the authority for the monthly and biannual staffing reports to Quality Committee or to receive these directly.

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Activity Summary for May 2019:

3a. Acute activity: (RTT and non-RTT)

Contract Activity Monitoring

Year-on-Year Activity Variance(The following data excludes community and endoscopy cases to assess the activity demand across acute services)

‘Total elective’ (inpatient and day-case) activity this year to date is 6% over the same period in 2018/19. Total Outpatient activity is 4.1% over 18/19 with 1,586 more appointments to date.

Month 18/19 19/20 18/19 19/20 18/19 19/20 18/19 19/20 18/19 19/20 18/19 19/20 18/19 19/20Apr 1,740 1,878 1,478 1,519 262 359 67 89 17,977 19,450 5,740 6,270 12,237 13,180May 1,910 1,991 1,598 1,632 312 359 62 70 20,254 20,367 6,446 6,709 13,808 13,658JunJulAugSepOctNovDecJanFebMar

YTD 3,650 3,869 3,076 3,151 574 718 129 159 38,231 39,817 12,186 12,979 26,045 26,838Variance

Total Elective Day Case OutsourcedElective

6.0% 2.4% 23.3%25.1%

Total Outpatient New Follow Up

4.1% 6.5% 3.0%

Section 2 - Chief Operating Officer, Performance Exceptions

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‘Daily Triggers’

ED Attendances

ED Conveyances

(Day In Arrears)

Bed Occupancy (%) - Incl

Escalations From Capacity

Bed Occupancy (%) - Excl

Escalations From Capacity

Stranded (7 Day) - Acute

Stranded (21 Day) - Total DTOC - Total

31/05/19 Fri 180 59 87.0% 92.7% 92 56 24

30/05/19 Thu 187 49 90.1% 95.9% 101 60 16

29/05/19 Wed 173 69 93.3% 101.2% 103 58 19

28/05/19 Tue 216 56 93.2% 100.0% 100 57 21

27/05/19 Mon 188 75 93.6% 101.6% 98 53 14

26/05/19 Sun 207 86 93.9% 99.6% 87 51 15

25/05/19 Sat 198 60 91.0% 94.7% 83 47 15

24/05/19 Fri 207 54 94.7% 102.0% 77 45 16

23/05/19 Thu 182 69 91.7% 98.8% 79 45 16

22/05/19 Wed 230 63 92.4% 98.8% 89 48 18

21/05/19 Tue 218 82 95.5% 102.4% 92 50 25

20/05/19 Mon 253 66 93.6% 95.5% 93 55 26

19/05/19 Sun 193 59 90.0% 91.1% 77 53 18

18/05/19 Sat 163 55 88.0% 89.4% 72 51 19

17/05/19 Fri 215 46 89.7% 95.5% 81 56 23

16/05/19 Thu 200 63 90.8% 95.9% 85 56 22

15/05/19 Wed 201 54 95.5% 102.8% 88 54 28

14/05/19 Tue 196 70 97.4% 107.3% 99 60 32

13/05/19 Mon 227 80 96.2% 103.7% 101 63 24

12/05/19 Sun 201 48 92.8% 100.0% 94 63 24

11/05/19 Sat 140 69 88.2% 93.9% 88 58 24

10/05/19 Fri 194 59 88.0% 92.7% 89 64 28

09/05/19 Thu 185 65 91.6% 97.6% 88 66 26

08/05/19 Wed 187 63 93.2% 100.4% 94 60 28

07/05/19 Tue 239 73 93.9% 100.4% 94 61 26

06/05/19 Mon 169 72 92.2% 96.7% 80 56 18

05/05/19 Sun 198 58 93.7% 95.9% 74 54 19

04/05/19 Sat 147 61 90.4% 91.5% 70 48 19

03/05/19 Fri 176 42 89.9% 94.3% 82 48 19

02/05/19 Thu 162 63 93.5% 99.6% 95 53 22

01/05/19 Wed 177 55 96.2% 103.7% 108 55 24

Date

NHS England Measures

25 of 31 (80.6%) days in May were red rated for ED attendances as the Trust saw high demand for front door services. April had 16 days with a red rating. 12 days in May had attendances of 200 or more which included 2 separate instances of 3 consecutive days.

22 days (71%) had a red rating for ambulance conveyances in month including every Monday in the month.

Acute Medical Unit (AMU)

AMU opened in December 2018, the average length of stay on the ward was 1.57 days in January, reducing to 1.39 days in May.

Medical outliers:

‘Medical outliers’ are patients under the care of ‘medical’ specialties cared for on ‘non-medical’ wards because no space is available on the medical ‘base’ wards. With the improvements in ‘patient-flow’ delivered over the last 6 months we have seen a significant reduction in the number of medical ‘outlier’ patients.

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3b. A&E standard:

85.3% of A&E attendances [5,124 of 6,009] achieved the 4 hour target against a national standard of 95% as the Trust recorded its best performance since June 2017. The recovery trajectory was 83.2%.

‘Minors’ performance continues to perform well with 98.19% of patient being treated within 4 hours.

The two graphs below demonstrates the continued pressure on both the Emergency Department and acute inpatient bed base.

ED Attendances

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Emergency Adult admissions

(adult admissions with a length of stay of one or more nights)

Ambulance Conveyances

May saw the second highest volume of conveyances ever with 1,954 which was 15 less than December 2018 (1,969). 91.5% of all WMAS conveyances had a hand-over time of under 30 minutes which is the second best result in WVT history (March – 91.8%). 9 Conveyances took over an hour for their hand-over to be completed which was the most since January (22).

The complete programme of work overseen by the One Herefordshire Urgent Care Programme Board (UCPB) is discussed in more detail later in these Board papers.

The UCPB continues to work on the Ambulatory Care pathways and protect the Trust’s emergency assessment areas from escalation, despite the increase in attendances and admissions there has been a steady increase in the number of 0-day Length of Stay (LOS) patients

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

Spells 1388 1354 1368 1461 1476 1278 1307 1365 1520 1578 1437 1662 1667 16550 LOS 332 314 291 376 366 333 327 378 422 432 367 447 484 471% 24% 23% 21% 26% 25% 26% 25% 28% 28% 27% 26% 27% 29% 28%

Measures2018/19 2019/20

Trendline

Trust Total Emer.

Work in on-going to look at the Ambulatory Emergency Care conditions and understanding ‘lost opportunities’ to maximise the number of patients cared for in the most appropriate clinical areas.

The Frailty Assessment Unit has increased its throughput, bed occupancy and reduced its Length of stay significantly over the past few months. This is mainly due to the Front Door Frailty teams input; ward reconfiguration and improvements within patient flow.

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May JunAvailable 480 496 480 496 496 480 496 480 496 496 448 496 480 496 320Occupied 433 468 426 469 464 463 484 466 469 477 409 452 420 438 273

Occupancy 90% 94% 89% 95% 94% 96% 98% 97% 95% 96% 91% 91% 88% 88% 85%Days Delayed 8 63 45 41 27 22 39 43 35 79 40 29 11 17 0

% Of Bed Days 2% 13% 11% 9% 6% 5% 8% 9% 7% 17% 10% 6% 3% 4%Admissions 65 61 82 62 79 60 63 76 71 67 80 83 72 99 50

Discharges 60 53 83 60 67 39 52 69 53 35 73 86 69 77 41Transfers In 18 23 24 25 15 13 17 14 14 10 33 60 44 41 29

Transfers Out 26 29 22 28 28 32 27 23 31 42 42 58 46 67 34Deaths 8 5 4 2 5 2 2 4 5 0 3 5 6 6 2

Avg Spell LOS 6.0 8.6 4.6 5.9 6.6 5.1 5.8 6.1 5.8 5.9 6.7 4.0 3.8 3.4 3.3Avg Ward LOS (Charted) 4.7 5.9 4.2 5.4 4.9 5.6 5.8 5.8 5.5 4.8 4.9 3.0 3.6 3.3 3.6

Measures2018/19 2019/20

Trendline

Gilw

ern A

ssessm

ent

Unit

Bed Days

DTOC

Activity

3c. RTT 18 week standards:

English commissioned performance:

The Trust’s (English) performance for the month was 81.1% (80.5% - April) against an agreed trajectory of 81.4% and standard of 92% of incomplete pathways waiting under 18 weeks.

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Welsh commissioned performance:

The Trust’s performance for May was 83.2% against a standard of 95% of incomplete pathways waiting under 26 weeks. This represents a 1.1% (84.3%).reduction against last month’s performance

Patient’s waiting for treatment over 40 weeks:

The graphs below show the number of patients (English and Welsh) waiting over 40 weeks since April 2017. 352 patients are waiting 40 weeks or more at month end in May which is a reduction of 747 against the Trust’s highest point of 1,110 in August 2018.

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Patient’s waiting for treatment over 52 weeks:

0 patients were waiting over 52 weeks for treatment at month end for the second consecutive month.

3d. Diagnostics:

The Trust achieved the Diagnostic standard of less than 1% of patients waiting over 6 weeks at month end with performance at 0.47% after reporting 14 breaches. There were 10 breaches in Cardiology, 3 in Neurophysiology and 1 in Respiratory Physiology.

3e. Cancer standards (April 2019):

The Trust achieved the following ‘Cancer targets’:

Cancer ‘Two Week Waits’ Two Weeks ‘Breast Symptomatic’ Cancer ‘31 days 1st treatment’ Cancer ‘62 days screening’ Cancer ‘62 days upgrades’

The Trust failed the following ‘Cancer Target’:

Cancer ‘62 days’ Cancer ‘31 Days Subsequent Treatments’

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Cancer ‘62 days’

47.5 out of 59 patients in total were treated for their cancer within 62 days in April. There were 11.5 breaches as the Trust failed to meet the 85% standard (82.7%).

‘62 day cancer’ target breaches as follows:

Breast 2 Haematology 1 Lower GI 1Lung 0.5 Sarcoma 1 Skin 1Upper GI 0.5 Urological 4.5

The Trust continues to struggle to achieve its 62 day target. Meetings with the 3 teams that are causing the most breaches are continuing and each have developed recovery plans to improve compliance. This picture is replicated across the Cancer Alliance.

Cancer ‘Two Week Waits’ & Cancer Two Weeks ‘Breast Symptomatic’

Cancer ‘Two Week Waits’ performance for April was 95.3% as the Trust achieved this standard. December 2018 was the last time that the threshold was met (95.9%).

The Cancer Two Weeks ‘Breast Symptomatic’ position for April was 93.7% marking the first time that the standard has been achieved since December 2017.

Cancer ’31 Days First Treatments’

93.3% of patients were treated within 31 days of a decision to treat (target 96%). The 2 breaches were from Lower GI (1) and Skin (1).

RCAs and Harm Reviews

RCAs & Harm Reviews - 62 and 104 day breaches:

RCA and Harm Review position Dec 2018 - Feb 2019:

Month 62 day breaches – RCAs104 day breaches – RCA +

harm reviewHarm outcome

February 11 7No harm -1, Harm – 1 (datix

completed), Awaiting outcome – 2, tertiary - 3

March 14 9No harm – 2, awaiting outcome – 6, tertiary - 1

April 12 4No harm – 1, awaiting

outcome – 2, tertiary - 1

Total 37 20

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Site 62 days 104 days Breach reasons Actions

Breast 3 0 Theatre capacity – 2 and complex - 1 Nil

Colorectal 6 2 Mix of theatre capacity, WVT diagnostics (endoscopy and radiology), pathway processes, tertiary and patient instigated delays

Team have developed an action plan to address current issues and implemented a new straight to test pathway.

Dermatology 3 0 1 biopsy capacity, 1 patient instigated and 1 general pathway capacity

Capacity being reviewed on an ongoing basis

Gynaecology 1 0 Tertiary Nil

Head & Neck 2 3 Complexity of pathway, processes within pathway + tertiary

Working with Worcester to improve pathway

Haematology 0 1 Complexity

Lung 7 2 Complexity of pathway, patient instigated delays + tertiary

Reviewing faster diagnosis pathway

Sarcoma 1 0 Tertiary Nil

Upper GI 4 1 4 tertiary + 1 complex None

Urology 10 11 Diagnostic capacity (template biopsies, radiology, pathology), processes, OP capacity, patient instigated delays and radical prostatectomy capacity at Cheltenham

Agreed process to improve pathway timing starting to show an improvement from December. Increased robotic time at Cheltenham agreed.

3f. Cancelled Operations:

28 of 1,908 (1.42%) operations were cancelled at the last minute in March as the Trust ‘under-achieved’ the standard of 0.8%. 3 operations were not rebooked within 28 days (11.1%) which also ‘under-achieves’ this measure. Failures are determined by being over 1.5% and 15% of each standard respectively.

3g. Stroke/TIA:

Stroke performance (% of time spent on Stroke Unit) is calculated using national SSNAP data.

89.5% (34 of 38) patients spent 90% of their time on a Stroke ward in month as the Trust achieved the 80% standard. Performance for the financial year is currently at 82.5%.

45.5% (10 from 22) of ‘high-risk’ TIA patients were scanned and treated within 24 hours of referral in month which is a failure of the 60% threshold. 2019/20 performance is 24%.

The Sentinel Stroke National Audit Programme [SSNAP] data is collected by the Trust to provide timely information to clinicians, commissioners, patients, and the public on how well stroke care is being delivered and can be used as a tool to improve the quality of care that is provided to

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patients. This is submitted nationally and Trusts are graded from A to E (A being the highest performing) based on multiple quality parameters across the stroke pathway. The trust has been rated at a ‘B’ for quarter 4 2018 -19

3h. Delayed Transfers of Care (DTOC) (May 2019)

513 bed days were lost to delayed transfers of care in May 2019 which is 30 more than April’s performance. 242 days were lost in the acute setting and 271 in the community. 224 days were lost to patients out of the county with 161 attributed to Welsh patients.

‘Care Packages in Own Home’ (E) has remained the largest delay reason in each month since May 2018 following 172 reported in May. Further Non-Acute NHS Care (C) routinely makes up the second largest share of delay reasons (136 actual) with Residential Home (D i) and Nursing Home (D ii) also contributing greater than any other cause.

Key Actions:

The Bank holidays in May resulted in spikes in both LOS and DTOC, which have now been reversed. Teams are looking at improving notification processes to get ahead of the batching that such periods cause.

The Trust’s 7 day LOS review is now conducted weekly and is achieving improving ward and divisional engagement across all areas.

21-day LOS community review started mid-June in line with new regional reporting requirements, and confirms the positive findings with LOS remaining around 14 days, and good turnover of patients in month

The fully integrated Discharge team (Hospital Liaison and Complex Discharge) is becoming more established and actively engaging with ward based teams.

The Integrated care division are monitoring any impact the WMAS ‘intelligent conveyancing’ policy may have on delayed discharges– early indications suggest that the policy is not contributing to delays in discharge.

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1

5.2 Integrated Performance Report - Workforce

16/17 17/18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19Rolling

12 Months Average

Target Threshold

Budgeted Establishment 2911.2 2932.1 2918.8 2929.5 2876.9 2872.8 2858.7 2852.6 2865.2 2862.1 2876.6 2915.1 2930.1 2929.4 2951.6 2954.1

Substantive Staff in Post 2638.3 2707.8 2681.4 2667.7 2662.4 2659.2 2668.1 2694.1 2711.4 2708.3 2696.4 2711.2 2719.5 2743.6 2732.6 2738.5

Vacancy 272.9 224.3 237.4 261.7 214.5 213.6 190.6 158.4 153.9 153.8 180.3 203.9 210.5 185.8 219.1 215.6

Starters 589.6 498.2 23.0 18.3 25.8 45.5 86.0 70.5 42.3 33.1 25.4 39.3 47.2 41.9 36.3 35.0 40.7

Leavers 372.7 346.0 34.4 28.8 30.0 94.5 30.3 44.8 19.5 35.3 39.1 19.9 32.9 44.3 29.8 24.5 36.3

Turnover 14.6% 12.9% 13.0% 13.2% 12.0% 12.6% 12.6% 11.7% 11.3% 11.4% 11.9% 11.8% 11.5% 11.6% 11.4% 11.2% 11.9% <=10% >15%

Vacancy Rate – Total 9.4% 7.6% 8.1% 8.9% 7.5% 7.4% 6.7% 5.5% 5.3% 5.2% 6.1% 6.9% 7.0% 6.3% 7.4% 7.3% 6.8% <=5% >10%

Agency Spend % Pay Bill 14.9% 12.8% 10.6% 11.2% 9.7% 10.2% 10.9% 9.5% 8.0% 9.3% 8.4% 10.0% 8.9% 9.4% 8.7% 10.2% 9.6% <=6.4% >11.4%

Sickness Absence Rate 4.2% 4.6% 4.6% 4.2% 4.3% 5.0% 4.7% 4.7% 5.1% 4.9% 4.8% 5.5% 5.2% 4.6% 4.6% 4.1% 4.7% <=3.5% >8.5%

Appraisal – All 90.1% 89.4% 88.8% 91.3% 92.3% 92.7% 88.3% 86.1% 86.0% 87.0% 87.0% 85.5% 83.1% 83.2% 83.0% 86.7% 87.2% =>90% <85%

Core Skills 85.8% 88.5% 88.3% 90.1% 90.1% 90.0% 87.0% 85.4% 85.9% 85.6% 85.6% 86.2% 86.6% 87.7% 89.2% 89.7% 87.7% =>90% <85%

Where in-month performance is rated as RED an exception report wil be produced.

Training (% - In Month)

Staff Numbers (FTE)

Turnover (% - Rolling 12 Months)

Vacancy (% - In Month)

Agency Spend (% - In Month)

Sickness (% - In Month)

Appraisals (% - In Month)

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2

There is an overall improving position across the majority of workforce key performance indicators this month, with the exception of agency spend, and no requirement for exception reports. However, a considerable amount of work has been taking place across the Trust to support this position, highlights of which are outlined below:

Recruitment: the international recruitment campaign to fill Band 5 Registered Nurse vacancies is gaining considerable traction, with a planned 92 international nurses scheduled to join the Trust by the end of December 2019. These nurses will predominantly work within the Medical and Surgical divisions once they have completed their two month orientation programme. Lessons learned from this successful initiative are now being applied to other hard to recruit staff groups such as medical & dental, radiology, and cardiac physiologists.

Retention: this continues to be addressed through a variety of staff engagement and recognition initiatives: the Staff Friends & Family Test for this quarter will be asking our medical and dental workforce about working and delivering care at the Trust; save the date cards have been distributed to employees eligible to attend the next Long Service Awards event scheduled to take place on 27th September 2019, and short films have been made to showcase the winners of the 2019 Employee of the Year, the Team of the Year, plus the winner of the Chairman’s Award for Innovation and will be shown at the Annual General Meeting on 11th July 2019, at which the winners will receive their prizes.

The four annual staff engagement events have now concluded – four hundred staff were invited to meet the Managing Director and members of the executive team during June. Each session started with a thank-you to staff for their hard work over the past year and some highlights about what has been achieved, with a focus on two key principles – (1) improvement is everyone responsibility and (2) valuing patient’s time. The remainder of the session then focused on group work to address the following two areas:

How can we make Wye Valley NHS Trust a great place to work? What can we all do to support our health and wellbeing?

A huge amount of positive feedback has been generated by each of these sessions and already shared with participants, with the expectation that we sustain momentum and pull out key themes and actions in support of a refreshed “You said … We did” action plan by the end of July 2019.The staff survey contract has also been agreed for the autumn of 2019 and this year a mixed mode sample approach is being undertaken. This means that staff selected to participate will be able to access their survey document using their work email rather than receive paper copies. By adopting Group approach to the procurement of this contract we have also secured a discounted price.

Temporary Staffing: the Bank Office has launched the new Bank rate for Registered Nurses and this will go live on 1st July 2019. Overall, there has been a positive response and the new rate is regarded as fair and equitable. In support of the new rate, consideration has been given to how we make this group of staff more aware of the shifts available to be worked – a range of plans are being put in place involving a refresh of the intranet site, a review of the texting service, and a screen at the entrance to Spires. Ultimately, though, the newly approved business case for e-rostering will be a tremendous help when implemented due to the ability to access and book shifts remotely.

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3

The team area also working on the implementation of a new direct engagement model which goes live on 1st July which will secure VAT savings on medical and “other” agency shifts, plus preparing for the implementation of the new Master Vend contract which goes live on 5th August 2019.

Leadership: the Group approach to leadership is now live and the first Mary Seacole programme to be run at the Trust is fully recruited, with twenty participants due to commence the course on 15th July 2019. The second course scheduled to run on site will take place in the autumn and the twelve off-site places allocated this year are being filled as they become available. The People Management Toolkit has been launched and there will be a particular focus throughout the remainder of this year on people management skills in support of effective sickness absence management and crucial conversations – both these areas have been identified through the staff engagement sessions as priorities.

Work is also ongoing to identify nominations for 360’ feedback facilitator training and ILM Level 7 Coaching and Mentoring, plus participants continue to undertake their ILM level 3 and 5 Leadership & Management training and the first two participants from the Trust have been accepted onto the STP procured Senior Leaders Master apprenticeship programme which starts in November 2019. In the interim, work is ongoing to ensure teams across the Trust have access to Insights profiling, so they can better understand how they might work together effectively.

Health & Wellbeing: Planning is now taking to place to ensure a successful flu campaign in the autumn. The target set by CQUIN is an 80% take-up of the flu vaccination by front line staff and this year the campaign will involve both the Health @ Work team and peer vaccinators across the Trust to obtain maximum coverage. Training for peer vaccinators and the purchase of additional kit to ensure the safe transportation and storage of the flu vaccinations across the wider Herefordshire site has been scheduled to take place over the summer months.

Changing how we work: The Trust have recently been successful in obtaining £115,000 additional funding from Health Education England – West Midlands (HHE) to support the training and development of our workforce. Following the initial submission against the HEE criteria, details plans are now being developed with the divisional teams and professional leads to ensure this money is prioritised to support key service developments and transformation.

This piece of work is being overseen by the Strategic Workforce Committee, which Chris Woods, Workforce Transformation Manager at HEE, attended on 5th June 2019 where he outlined a best practice approach to workforce planning – supply, up-skilling, new roles, new ways of working, and leadership and how HEE monies to support the training and development of the workforce can support this process.

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`

I&E Performance against Budget Plan YTDThe Trust’s control total, prior to PSF and FRF performance funding, is a deficit of no more than £35.246m. Available PSF and FRF funding totals £17.993m, which therefore results in the net deficit control total of £17.254m.

The Trust was £50k ahead of the financial plan at the end of May and therefore accrued £1.798m of the performance funding (NB this is payable quarterly).

Individual variances against income and expenditure are shown in the table (left). After adjusting for timing differences on the cost neutral items of Excluded Drugs and Private Sector outsourcing, there was a £56k adverse income position, a £145k underspend against pay and a £139k overspend against non-pay budgets.

The table above records the rolling run rate used to monitor high level trends. Please note that the contractual dispute with Herefordshire CCG distorted the month 12 position; however, when viewed over a 12 month period, the relative position of monthly income and expenditure can still be observed.

The table also highlights the critical favourable impact of achieving the performance fund.

Section 5 - Director of Finance, Performance Exceptions

All values in £000's M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M1 M2 TotalIncome 15,278 15,325 18,053 16,026 16,280 16,474 15,636 16,289 16,232 9,580 16,963 17,215 34,178

Pay 11,245 11,603 12,273 11,626 11,659 11,594 11,570 12,053 11,722 12,605 12,328 12,066 24,394Non Pay 4,678 4,885 4,798 5,049 5,288 4,964 5,131 5,045 5,101 4,039 5,109 5,223 10,332Excluded Drugs 1,221 1,166 1,385 1,111 1,530 1,157 1,207 1,084 1,226 1,344 1,519 1,323 2,842

EBITDA (1,866) (2,329) (403) (1,760) (2,197) (1,241) (2,272) (1,893) (1,817) (8,409) (1,993) (1,397) (3,390)

Depreciation & Interest 1,074 1,068 1,073 1,088 1,069 1,070 1,074 1,073 1,094 1,844 1,188 1,203 2,391Donated Assets Adjustment (11) (11) 19 202 (24) (25) (26) (25) (24) (16) 7 (10) (3)Net impact of fixed asset revaluations and impairments (359) 0

Deficit Prior to PSF (2,929) (3,386) (1,495) (3,050) (3,242) (2,286) (3,320) (2,941) (2,887) (10,596) (3,188) (2,590) (5,778)PSF 0 0 0 0 0 0 0 0 0 1,141 899 899 1,798Deficit Including PSF (2,929) (3,386) (1,495) (3,050) (3,242) (2,286) (3,320) (2,941) (2,887) (9,455) (2,289) (1,691) (3,980)

Rolling Run Rate18/19 19/20

STATEMENT OF COMPREHENSIVE INCOME - To Month 2 - 31st May 2019 - 2019/20

CURRENT MOVEMENTANNUAL INBUDGET CURRENT

PLAN BUDGET ACTUAL VARIANCE MONTH

£000 £000 £000 £000 £000

Contract & PbR Income 167,787 27,522 28,945 1,423 835Contract Overperformance 5,396 894 0 (894) (306)PbR Excluded Drugs 18,383 3,064 2,908 (156) (209)Non Contracted Activity (NCA's) 1,767 287 287 (0) (0)Other Income for Patient Care 7,478 1,246 1,249 3 3Donations For Non Current Assets 400 67 67 0 0Other Non Patient Income 5,320 893 723 (171) (138) Total Operating Income 206,531 33,974 34,178 204 184

Pay Expenditure 147,668 24,539 24,394 145 (31)Non Pay Expenditure 61,760 9,871 10,332 (461) (432)Excluded Drugs 17,955 2,993 2,843 150 173

Total Operating Expenditure 227,383 37,402 37,568 (166) (290)

EBITDA (20,851) (3,428) (3,390) 39 (106)

Depreciation 5,278 880 873 7 35Gain or loss on asset disposal 0 0 0 0 0Interest Receivable 57 10 13 3 1Interest Payable on Loans 3,413 569 569 0 0Interest Payable on PFI 5,778 963 963 0 0Dividends on PDC 0 0 0 0 0

Operating Surplus/ (Deficit) (35,263) (5,830) (5,781) 49 (69)

Technical Adjustments

Donated Assets - Additions 400 67 67 (0) (0)Donated Asset Depreciation (417) (69) (70) 1 1Donated Assets Adjustment (17) (2) (3) 1 1

Net impact of asset impairments 0 0 0 0

Adj. financial performance retained Surplus/ (Deficit) (35,246) (5,828) (5,778) 50 (69)

PSF 3,186 318 318 0 0FRF 14,807 1,480 1,480 0 0

Additional PSF Funding 17,993 1,798 1,798 0 0

(17,254) (4,030) (3,980) 50 (69)

YEAR TO DATE

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Outturn

As at the end of May (month 2), the Trust is forecasting achievement of its financial plan.

However, it must be stressed that there are a number of risks facing the Trust which are not yet mitigated.

The most material risks at present are as follows:

1. Satisfactory resolution of the 2019-20 contracting dispute with Herefordshire CCG, ie. securing an outcome that enables the Trust to achieve the income assumed in the budget plan at £142.1m (versus the indicative contract value of £136.5m);

2. Closing the current reported gap of £1.8m against the £6m CPIP expectation;3. Managing the reduction in agency nursing to match the scale of overseas nurse investment/recruitment (90 wte);4. Managing medical staffing costs to the budget plan (as an adverse variance has developed year to date, particularly in the medical division);5. Controlling and reversing the overspending in relation to non-pay expenditure.

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Income Performance and Contracting – Point of Delivery

2019-20 Income PlanINCOME - BY PATIENT CLASS

2019-20 ANNUAL BUDGET

MOVEMENT IN CURRENT

MONTH

FORECAST OUT TURN

FORECAST OUT TURN

BUDGET ACTUAL VAR. % VAR. VAR.£ 000's £ 000's £ 000's £ 000's Var £ 000's £ 000's £ 000's

Contract IncomeDaycase 18,915 3,134 2,907 (228) -7% (175) 0 18,915Elective 12,974 2,151 2,438 287 13% 313 0 12,974Emergency 51,415 8,137 8,943 806 10% 636 0 51,415Outpatients 23,202 3,775 3,513 (262) -7% (93) 0 23,202Accident & Emergency 10,800 1,826 1,829 3 0% 10 0 10,800Pathology 3,415 569 576 7 1% 7 0 3,415Diagnostics 3,554 592 462 (130) -22% (130) 0 3,554Critical Care 4,201 700 672 (28) -4% (28) 0 4,201PbR Excluded Drugs 12,443 2,074 1,825 (249) -12% (227) 0 12,443Other Variable & Blocked 10,694 1,856 2,214 358 19% 273 0 10,694Community Contract 37,581 6,264 5,980 (284) -5% (284) 0 37,581HCCG Pace of Change (2,000) (333) (333) 0 0% 0 0 (2,000)Any Qualified Provider 229 38 38 0 0% 0 0 229

Non Contract IncomeInter Trust SLAs - Cross Charges 6,457 1,076 1,127 51 5% 1 0 6,457Central Funds 4,522 754 754 0 0% 0 0 4,522Business Unit Service Income 5,290 888 717 (171) -19% (139) 0 5,290Named Patient Panel Drugs 2,440 407 451 44 11% 19 0 2,440Donations For Non Current Assets 400 67 67 0 0% 0 0 400Radiology MES 0 0 0 0 0% 0 0 024 Bedded Ward 0 0 0 0 0% 0 0 0

Total Operating Income 206,531 33,974 34,178 204 1% 184 0 206,531

FRF, PSF 17,993 1,798 1,798 0 0% 0 0 17,993

TOTAL OPERATING INCOME INCLUDING STF 224,524 35,772 35,976 204 1% 184 0 224,524

INCOME

YEAR TO DATE

At the end of month 2, there was a favourable variance of £204k with an in month favourable movement of £184k.

The favourable variance related largely to the volumes of emergency and elective activity undertaken that were above contract.

Community activity is now being funded under a cost per case regime. At the end of month 2, a significant adverse variance was reported. The variance was primarily due to staff vacancies, leave and data entry backlogs. Corrective action taken by the Division should improve the position in future months.

It is important to note that the volume of private sector activity exceeded the budget. If the level of expenditure continues at the current run rate, it is estimated that the annual budget £1.7m for private sector sub-contracted work will have been fully utilised by mid-August.

As a result of the overall income and expenditure position at month 2, the Trust has accrued for the FRF/PSF funds.

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Income Performance and Contracting – Contract Analysis2019-20 ANNUAL BUDGET

MOVEMENT IN CURRENT

MONTH

FORECAST OUT TURN

FORECAST OUT TURN

BUDGET ACTUAL VAR. % VAR. VAR. ACTUAL£ 000's £ 000's £ 000's £ 000's Var £ 000's £ 000's £ 000's

CCG Commissioning SLAsNHS Herefordshire CCG - Current MOU 136,500 22,351 23,608 1,258 6% 691 0 136,500NHS Herefordshire CCG Over Performance 5,396 894 0 (894) -100% (306) 0 5,396NHS Shropshire CCG 5,577 907 956 49 5% 49 0 5,577NHS Worcestershire CCG 2,892 471 540 69 15% 69 0 2,892NHS Gloucestershire CCG 1,334 219 270 51 23% 51 0 1,334NHS Telford & Wrekin CCG 181 30 29 (1) -3% (1) 0 181Non Contracted Activity (NCA's) 1,767 287 287 (0) 0% (0) 0 1,767Any Qualified Provider (AQP) 229 38 38 0 0% 0 0 229

LHB Commissioning SLA'sPowys LHB 16,900 2,754 2,754 0 0% (0) 0 16,900Aneurin Bevan LHB 2,054 337 345 8 2% 8 0 2,054Welsh Specialised Commissioning 135 22 23 0 2% 0 0 135

Other Commissioning SLA'sNHSE - Specialised 5,465 910 874 (36) -4% (36) 0 5,465NHSE - Local Area Team 3,915 650 647 (4) -1% (4) 0 3,915NHSE - Armed Forces 258 42 43 1 2% 1 0 258Public Health 2,465 411 411 0 0% 0 0 2,465MRET 1,433 239 239 (0) 0% (0) 0 1,433Commissioner QIPP/Overperformance 921 220 0 (220) -100% (220) 0 921Contract Variations 0 0 (0) (0) 0% (0) 0 0

Inter Trust SLAs (Cross Charge)NHS Herefordshire CCG 0 0 0 0 0% 0 0 0Gloucestershire Hospitals FT 5,002 834 885 51 6% 1 0 5,002Overperformance Excluded 0 0 0 0 0% 0 0 0Powys Trust 959 160 160 (0) 0% (0) 0 9592gether MH Trust 250 42 42 0 0% 0 0 250Other Cross Charges 246 41 41 0 0% 0 0 246

Central Funding & TrainingNational & Regional Funding 0 0 0 0 0% 0 0 0Education & Training 4,522 754 754 0 0% 0 0 4,522

OtherBusiness Unit Service Income 5,290 888 717 (171) -19% (139) 0 5,290Named Patient Panel Drugs 2,440 407 451 44 11% 19 0 2,440Donations For Non Current Assets 400 67 67 0 0% 0 0 400

Total Operating Income 206,531 33,974 34,179 205 1% 185 0 206,531

FRF & PSF 17,993 1,798 1,798 0 0% 0 0 17,993

TOTAL OPERATING INCOME INCLUDING STF 224,524 35,772 35,977 205 1% 185 0 224,524

INCOME

YEAR TO DATE

Contract Summary

At the time of writing, there were only two contracts signed for 2019/20, namely NHS Specialised Commissioning and Herefordshire Council for School Nursing and Health Visiting.

Negotiations with Welsh commissioners are ongoing. A previous reported financial risk regarding tariff payments by Welsh LHBs is close to resolution. This would resolve the £1.5m HRG4+ risk identified in the 2019/20 financial plan.

There is a material dispute with the Trust’s main commissioner HCCG which is preventing agreement. (The agreement of the host contract would also resolve all the English associate agreements with CCGs that border Herefordshire.) Although the indicative contract value is planned at £136.5m for the year, in year growth and improvements required in Referral to Treatment times (to 82.6%) is expected to generate income from HCCG at £142.1m, ie £5.6m more than the contract value.

There are no material disputes with other commissioners. Work on agreeing Service Level Agreements continues.

.

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Performance against Cost Budgets

Pay

Pay was £145k underspent moving adversely by £31k in month.

A significant overspend on Medical Staffing costs was offset by delays in recruiting to new AHP posts to support AMU and in the Community. Medical Staffing overspends were largely due to vacancies and pressures in ED, but there were also issues in Women’s & Children’s, Geriatrics, and Gastroenterology.

Overall nursing costs were to budget, but moved adversely following a particularly high cost month on nurse agency (the highest cost value in 12 months and the highest volume in the last nine months). There was an increased usage of Thornbury nurses, particularly within the Children’s Ward due to the clinical need for RMN nurses for CAMHS staff. This has resulted in an increased average price and therefore no further master vend savings have been delivered in month.

Non-pay

Non pay was £311k overspent (however this included a £308k ‘overspend’ on private sector outsourcing and £150k ‘underspend’ on Excluded Drugs). Both of these items have an equal and opposite effect with income categories and are largely a factor of phasing. With an outsourcing budget of £1.658m, it will be crucial to deliver to this budget (and secured income), over the course of the financial year.

Given the current overspending that has emerged, all non-pay variances, including activity related costs of clinical supplies, will be closely monitored over forthcoming months.

Specific overspends relating to Trust Overheads (£18k adverse movement in month) were due to high postage costs across the Trust (£16k adverse movement in month), and printing and stationery costs (£9k adverse movement across the Divisions).

To Month 2 - 31st May 2019 - 2019/20

MOVEMENTANNUAL IN

CURRENTBUDGET BUDGET ACTUAL VARIANCE MONTH

£000 £000 £000 £000 £000Pay

Directors & Sen. Managers =>Band 8 4,477 759 743 15 (2)Medical & Dental 41,625 7,014 7,169 (155) (91)Nurses & Midwives 59,167 10,073 10,039 34 (69)AHPs 11,846 2,014 1,889 125 63Pharmacists 1,554 297 279 18 5Professional, Technical, Scientific 7,618 1,276 1,226 50 16Managers/Technical >Band 5 2,936 505 495 10 13Clerical <=Band 5 14,171 2,393 2,358 35 26Other Pay 673 116 104 12 8Apprenticeship Levy 502 91 91 0 0Redundancy Pay 0 0 0 0 0Unallocated CPIP - Pay (1,276) 0 0 0 0Earmarked Reserves - Pay 4,375 0 0 0 0

147,668 24,539 24,394 145 (31)Non Pay

Drugs 3,725 623 637 (14) (17)Excluded Drugs 17,955 2,993 2,843 150 173Excluded Devices 1,173 193 225 (31) (20)Med & Surg Supplies 11,488 1,921 1,950 (28) (8)Implants & Accessories 1,996 333 372 (39) 3Other Clinical Supplies 1,630 284 284 (0) (6)Clinical Services contracts 5,372 873 883 (10) (39)Private Sector Sub-Contracting 1,658 442 749 (308) (369)PFI Contract 10,592 1,765 1,766 (0) 1Transport & Travel 1,502 259 248 11 21Establishment expenses 5,167 841 852 (10) 8I.T. 2,061 328 357 (29) (21)Trust Overheads (inc. Insurance) 6,931 1,169 1,212 (42) (18)Other Non Pay 3,739 646 607 39 31Hoople 1,156 193 191 2 1Unallocated CPIP - Non Pay 0 0 0 0 0Earmarked Reserves - Non Pay 3,571 0 0 0 0

79,715 12,863 13,175 (311) (259)Depreciation 5,278 880 873 7 35(Gain) or loss on asset disposal 0 0 0 0 0Interest Received 57 10 13 3 1Interest Payable on Loans 3,413 569 569 0 0Interest Payable on PFI 5,778 963 963 0 0Dividends Payable 0 0 0 0 0Sub Total 14,412 2,402 2,392 10 37

GRAND Total Expenditure 241,795 39,804 39,960 (155) (254)

YEAR TO DATEHEADING

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Directorate Performance – Variance against £22.8m Budget Plan

This table summarises the distribution of the variance from budget plan and the resulting performance by area.

Income - Current issues relate to activity recording (now under PbR) within Community areas and also to Road Traffic Accident insurance claims (which always have a volatile profile based on the progress of the external claim management process), which were £113k behind plan.

Pay - The table shows all the Medical Staffing overspend was in the Medical Division and this is thus one of the main financial risks for the Division to manage.

Non-Pay – As discussed above, there are a number of material variances which are being reviewed (NB Private Sector and Excluded Drugs are not key items of concern at present). There were also a significant number of smaller variances which require close management and monitoring.

DIRECTORATE POSITIONS - To Month 2 - 31st May 2019 - 2019/20

Surgical Medicalintegrate

d CareClinical

Support

Estates and

Facilities PFI Corporate£000 £000 £000 £000 £000 £000 £000

Income NHS Income 289 576 (232) (131) 8 0 (12)Non NHS Income 7 (107) 1 5 (3) 0 (40)PbR Income 0 0 0 0 0 0 1Excluded drugs (4) (269) (1) 118 0 0 0

291 199 (232) (8) 5 0 (51)

Pay Directors & Sen. Managers =>Band 8 3 (5) (1) (0) 1 0 18Medical & Dental (17) (182) 2 39 0 0 3Nurses & Midwives 29 (83) 51 (4) 0 0 42AHPs 8 (2) 69 52 0 0 (2)Pharmacists 0 0 0 13 0 0 6Professional, Technical, Scientific (2) 13 (0) 39 (2) 0 2Managers/Technical >Band 5 6 (2) 0 (1) 1 0 7Clerical <=Band 5 4 (10) 5 (2) 1 0 37Other Pay 0 0 0 0 12 0 0Cost Pending Capitalisation 0 0 0 0 0 0 0Redundancy Pay 0 0 0 0 0 0 0Unallocated CPIP - Pay 0 0 0 0 0 0 0Earmarked Reserves - Pay 0 0 0 0 0 0 0

30 (270) 126 135 12 0 114

Non Pay Drugs (6) (26) 4 12 0 0 2Excluded Drugs 362 (78) (0) (134) 0 0 0Excluded Devices 1 (32) 0 0 0 0 0Med & Surg Supplies (33) 9 (30) 26 3 1 (5)Implants & Accessories (39) (0) (0) 0 0 0 0Other Clinical Supplies 3 1 (5) 0 (0) 0 0Clinical Services contracts (15) (2) (0) 7 0 0 (0)Private Sector Sub-Contracting (303) (4) 0 0 0 0 0PFI Contract 0 0 0 0 0 (0) 0Transport & Travel (1) 2 1 7 (1) 0 3Establishment expenses 8 1 (12) 1 (12) 1 1I.T. (10) (2) (1) (10) (0) 1 (7)Trust Overheads (inc. Insurance) (13) (8) (10) (2) (2) 0 (7)Other Non Pay 8 5 (4) 1 3 0 27Hoople 0 0 0 0 0 0 2Interest Received 0 0 0 0 0 0 3Interest Payable on Loans 0 0 0 0 0 0 0Depreciation 0 0 0 0 0 0 7

(38) (135) (58) (92) (9) 4 26

Subtotals 283 (206) (163) 35 9 4 89Total Variance from Plan Prior to PSF and Donated Dep'nDonated AssetsImpairmentA&EFinancial ControlTotal PSF FundingTotal Variance from plan

205

Variance from Plan £000's

1

50

145

(301)

50

0

00

0

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Agency Ceiling Controls

The Trust has an agency ceiling cap which has remained at £8.39m for the current year. The graph above shows a rolling 12 month view of monthly expenditure levels for commercial agency. In the first two months of the year, the Trust has spent £2.3m on agency which exceeded the capped level of expenditure by £0.9m.

The most significant change in month was the expenditure level on nurse agency which rose to its highest level in the 12 month period shown above. This was an exceptional month, with much more significant use of Thornbury as an off framework supplier.

Of the £685k spent during month 2, £148k (22%) was spent with Thornbury and of this, 50% related to specialist RMN nurses required to support CAMHS patients on the Children’s ward.

Volume was at the highest level for nine months and areas of particularly high volume use were A&E (11.14 WTE) and Frome ward (10.59 WTE).

Master Vend savings are now being measured as incremental on top of the £1.038m of price savings achieved during the prior year. The high usage of Thornbury has pushed the average unit price up to a level where no further additional marginal savings are currently being achieved.

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Nursing Cost Run Rate

M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M1 M2 YTD TotalsCommercial Agency 538 616 620 558 537 516 522 649 534 608 570 685 1,255Bank 292 313 350 291 265 254 247 256 251 258 237 231 468Substantive & Overtime 3,684 3,737 4,094 3,878 3,804 3,830 3,860 3,993 3,901 3,961 4,286 4,030 8,316Nursing Expenditure 4,514 4,666 5,064 4,727 4,606 4,600 4,629 4,898 4,686 4,827 5,093 4,946 10,039

Nurses & Midwives £'000s2018/19 Run Rate 2019/20 Run Rate

The table above shows the rolling run rate of nursing costs by month. The cost is currently averaging £5m/month

The graph to the left maps overall agency cost and volume and clearly shows the spike in month 2 has changed the pattern of the trend.

The table shows key areas of financial variance in terms of the year to date, overall cost of nursing (substantive, sickness, agency, overtime) against the budgeted cost of a fully substantively staffed establishment, including funded time-out.

Further budget is held by each Division to fund (less CPIPs) the prior year outturn marginal (premium) cost of agency. A significant part of this agency premium

budget, set for the second half of the year, is to be used to fund the invest-to-save initiative of the recruitment of overseas nurses. This budget is planned not to be required once all 90 wte overseas nurses are in place and will have eliminated the need for a corresponding number of agency nurses.

Key variances from Substantive Budgeted EstablishmentA & E (144,741)Arrow Ward (89,713)DC Overspill (53,554)AMU (Acute Medical Unit) (52,418)Frome (42,782)Bromyard - Nursing (36,047)CAU (33,867)A & E Overspill (33,460)Wye Ward (32,791)Lugg Ward (32,617)Redbrook Ward (29,964)McMillan Renton Unit (24,379)Other (13,954)SW - Ross 11,902Virtual Ward - Hospital at Home 12,547Theatres - Recovery 12,624Maternity Continuity of Care 12,779CNS Gastroenterology 13,754Hereford - Health Visiting 16,191CLRN - Research & Development 17,099NW - Leominster 17,844City Locality Team - City 21,518

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Key variances from Substantive Budgeted EstablishmentMS - A & E (331,688)MS - Medicine (85,765)MS - Gen Surg (84,485)MS - Obs & Gynae (75,816)MS - Acute Medicine (71,421)MS - Geriatrics (52,174)MS - Paediatrics (38,636)MS Acute AMU (38,347)MS - Discharge Registrar (33,254)MS - Ear/Nose/Throat (32,566)Other 14,926MS - Breast Surgery 17,697A & E GP Streaming 18,131Podiatric Surgery 18,924MS - Diabetes 20,930PDS - Gaol Street 24,289

Medical Staffing Cost Run Rate

M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M1 M2 YTD TotalsCommercial Agency 454 484 609 403 431 444 460 443 418 484 425 439 864Substantive, locum and extra hours 2,844 3,065 2,927 3,130 3,203 3,129 3,110 3,251 3,189 3,415 3,148 3,156 6,304Medical Expenditure 3,298 3,549 3,536 3,533 3,634 3,573 3,570 3,694 3,607 3,899 3,573 3,595 7,168

Medical Staffing £'000s2019/20 Run Rate2018/19 Run Rate

The table above shows the rolling run rate for Medical Staffing costs by month. The cost is continuing to be significantly higher than budgeted with localised (but material) cost pressure points.

The graph to the left shows the trend line of agency cost reducing and substantive costs and extra payments in total increasing.

The table to the right shows the full costs against approved budgeted establishement (at substantive rates).

The Divisons centrally hold a separate budget to fund the marginal (premium) cost of commercial agency based on prior year outturn less CPIP.

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Substantive Medical Staffing Additional Payments

WLI capacity (and cost) is expected to fall as a result of national changes to personal tax and pension arrangements (resulting in capacity risk to the Trust). The impact of this is not yet showing in the year-to-date costs, which are marginally higher than for the same period last year. It is highly likely this position will reverse over future months. The large areas of WLI spend remain as Radiology (£60k in month), Anaesthetics (£24k in month) and General Surgery (£13k in month).

Other cover payments to medical staffing are also higher than experienced during the prior year. Both these factors, combined with successful recruitment into vacancies, support the evidence of the graph (above) showing reduced agency and increased substantive costs. ED spend of £80k in month is due to cover for A&E rotas including annual leave and sickness; there were also 3.2 WTE consultant vacancies in Acute Medicine (£43k cost in month), 2.35 WTE consultant vacancies plus middle grade vacancies in Anaesthetics (£37k in month), training rota vacancies in General Surgery (£33k in month), cover for a middle grade not performing plus a consultant on sick leave in Obstetrics and Gynaecology (£28k in month), and 2.00 WTE consultant vacancies in Rheumatology (£20k in month).

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Cost & Productivity Improvement Plan (CPIP)

This table shows the Trust currently has a gross value of £4.7m of individual CPIP lines which it is actively managing. Currently, the most likely risk adjusted outturn against these values is £4.2m

The above creates a gap of £1.8m against the £6m budgeted requirement and assumption for delivery.

A number of further opportunities are currently being worked through by the Divisions and corporate departments. These, and further, schemes will be required to close the current position and prevent a forward phased CPIP plan from adversely impacting on financial performance (and therefore the Trust’s ability to secure performance funding).

Each management area of the organisation is given a target as shown in the bottom section of the table. The distribution of the forecast outturn shows the extent of the challenge by area to close the current gap to plan.

CIP Performance By Programme£000's

Curr

ent

Plan

ned

Valu

es

Curr

ent

Fore

cast

O

uttu

rn

Fore

cast

De

liver

y Sh

ortf

all

Cum

ulat

ive

Pla

n

Cum

ulua

tive

Deliv

ery

YTD

Varia

nce

Apprentices 77 77 0 16 16 0Best Practice Tariff 68 23 (46) 0 0 0Bowel Screening Increase 110 110 0 18 18 0Contract reduction 94 94 0 19 19 0Cost Reduction 92 81 (11) 11 7 (4)Demand reduction 97 97 0 0 0 0Drugs reduction 89 60 (29) 13 8 (5)EMIS Savings 50 50 0 0 0 0Energy 80 41 (40) 13 0 (13)Full cost recovery of service provided to Gloucester FT 90 90 0 15 15 0Hold Recruitment 106 106 0 18 18 (0)IT System 6 5 (0) 1 0 (0)JB Admin Review 10 10 0 2 2 0Ledbury Shaw Healthcare 50 50 0 8 8 0Master Vend 402 292 (110) 67 0 (67)Med and Sug red 24 24 0 4 4 0Mobile Phone Review 3 3 0 1 1 0Post removal 28 28 0 5 5 0Prior Year 649 649 0 137 137 0Procurement 262 98 (163) 24 8 (16)Rates review 76 63 (13) 13 11 (2)Recruitment 1,753 1,727 (26) 166 166 0Reduction in Price through controls 13 12 (1) 2 1 (1)Restructure 17 17 0 3 3 0Retire & Return 18 18 0 0 0 0SLA 115 115 0 17 17 0Subsidy of software licence 6 6 0 1 1 0VAT Optimisation 336 269 (67) 56 0 (56)GP rental 3 3 0 0YTD Plan Gap (1,277) 0 = Planning gap x YTD delivery

Totals 6,000 4,723 4,218 (1,782) 630 464 (165) 0

CIP Performance By Area£000's

Annu

al

Targ

et

Curr

ent

Plan

ned

Valu

es

Curr

ent

Fore

cast

O

uttu

rn

Curr

ent

Shor

tfal

l

Cum

ulat

ive

Plan

Cum

ulua

tive

De

liver

y

YTD

Deliv

ery

Varia

nce

YTD

Plan

ning

Ga

p Re

leas

ed

in p

ositi

on

YTD

Varia

nce

Surgical Division 2,003 1,561 1,519 (484) 245 215 (29) (29)Medical Division 1,379 1,793 1,602 223 175 106 (69) (69)Integrated Care Division 629 383 377 (252) 38 34 (4) (4)Clinical Support Services 978 352 339 (639) 57 51 (7) (7)Corporate 454 415 216 (237) 49 8 (41) (41)Estates 558 218 166 (392) 65 50 (16) (16)

Totals 6,000 4,723 4,218 (1,782) 630 464 (165) 0 (165)Variances (165) 0

planning Gap (1,277) Delivery Planning

1920 Current Forecast Performance Month 2 Year To Date Performance

1920 Current Forecast Performance Month 2 Year To Date Performance

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The graph below illustrates the overall delivery/planning gap from the £6m CPIP target.

April May June July August September October November December January February MarchPlanning Gap 28 85 170 284 426 596 795 1022 1274Delivery Gap 81 166 208 251 299 346 352 391 429 455 481 507Actuals/Forecast 233 465.00 750 1040 1325 1626 2048 2466 2898 3348 3784 4219

0

1000

2000

3000

4000

5000

6000

7000

CPIP Monthly Profile

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Sche

me

Type

Scheme Name

19-20 Capital

Plan value

(£k) Cash

b/f

wd

(Led

Rd

sale

+

unsp

ent P

DC)

Pre-

appr

oved

Loan

s (1

8/19

Capi

tal +

EPR

C/f

wd

fr 1

7/18

)

New

Em

erge

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capi

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oan

(yet

to b

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prov

ed)

Oth

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et to

be

appr

oved

Tota

l Loa

ns

PDC

- app

rove

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PDC

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be a

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Tota

l PDC

Dona

ted

Tota

l Fun

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YTD Actual

M2 (£k)

Backlog maintenance 400 200 200 400 0 400 14HDU/ Endoscopy development 1,000 150 850 1,000 0 1,000 0Repair lifts at Leominster and Ross 238 0 238 238 0 238 0Capital Estates PM 250 250 0 250 0 250 26SCBU transitional care project 100 0 100 100 0 100 0Improve traffic flow outside ED 60 0 60 60 0 60 0Completion of second lift at Ross (part donated) 55 55 0 55 0 55 27Estates - other 269 188 81 269 0 269 103Hutted Ward Replacement 9,283 0 0 9,283 9,283 0 9,283 0Total Estates 11,655 0 843 1,529 9,283 11,655 0 0 0 0 11,655 170

Rolling Instrument replacement in Theatres 200 171 29 200 0 200 0Ophthalmology microscope replacement 141 141 0 141 0 141 0Respiratory lung function module 125 0 125 125 0 125 0Bladder scanners - trust wide 102 0 102 102 0 102 0Endoscopy rolling replacement 101 0 101 101 0 101 0Faxitron DAAX replacement 76 0 76 76 0 76 0Rolling Instrument replacement in Podiatric surgery 52 52 0 52 0 52 0Clinical Equipment - other 368 32 336 368 0 368 0Total Clinical Equipment 1,165 0 396 769 0 1,165 0 0 0 0 1,165 0

Windows server 2008 & SQL 2008 537 537 0 537 0 537 0Data centre phase 2 380 0 380 380 0 380 0E-rostering & E-job-planning implementation 358 0 358 358 0 358 0Device replacement 850 850 0 850 0 850 2Windows 10 & ATP Implementation 150 150 0 150 0 150 0OPMAS replacement 122 122 0 122 0 122 0Community Scheduler (Malinko) 74 8 66 74 0 74 10IM&T other 163 20 143 163 0 163 0Community EMIS implementation 1,029 42 0 237 237 750 750 1,029 70EPR phase 2 development and implementation 4,139 2,463 340 2,803 1,336 1,336 4,139 164EPMA purchase and implementation 1,590 124 0 0 0 1,466 1,466 1,590 42Total IM&T 9,392 166 4,150 1,524 0 5,674 2,802 750 3,552 0 9,392 288

Donated assets 400 0 0 0 400 400 0

Total Capital Expenditure planned 22,612 166 5,389 3,822 9,283 18,494 2,802 750 3,552 400 22,612 458

Shortfall on PFI, capital loan and finance lease principal repayments 2,416 710 1,706 1,706 0 0 2,416 561

Capital Financing required 25,028 876 7,095 3,822 9,283 20,200 2,802 750 3,552 400 25,028 1,019

Planned funding Source (£k)

Esta

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Capital - Overview

Capital Summary

During the first two months of this financial year, the Trust has spent £458k on capital schemes, as detailed in the YTD Actual column.

£103k of expenditure against ‘Estates – other’ included the urgent purchase of health records cabins of £66k.

The shortfall in depreciation covering PFI, capital loan and finance lease principal repayments during this period was £561k. This brings the total capital financing cover required, at the end of May 2019, to £1.019m.

The planned sources of financing for this year’s schemes are shown in the table [left]. A significant amount of the financing (£3.8m) for ‘core’ capital schemes (as opposed to major schemes such as EPR/ EPMA and Hutted Ward replacement) is not yet approved.

The Trust has submitted an emergency financing application for the £3.8m but, due to continued constraints on national capital, there is no guarantee when, or if, this will be approved.

The Provider sector has been warned that additional borrowing requests should be minimised to absolutely urgent and critical expenditure that needs to be incurred in 2019/20.

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Core capital schemes

Due to the uncertainty of new financing being approved during 2019/20, the Trust has prioritised which schemes need to progress now and which will need to wait until approval is given for the additional £3.8m. This is in the process of being finalised through the Capital Planning and Equipment Committee (CPEC) with the Trust’s risk register being updated, if necessary, for those schemes which are currently unable to progress.

Hutted Ward Replacement scheme

A revised Outline Business Case (OBC) was submitted to NHSI/E on the 7th June which, at the time of writing, NHSI/E are in the process of reviewing. This version of the case included more depth and quantification of benefits which this scheme can enable.

EMIS

Implementation is continuing and a number of pilot areas have now gone live. After receiving £500k in 2018/19, the Trust is having to re-apply for the 2019/20 element of the Health Service Led Investment (HSLI) PDC funding (£750k). The national HSLI programme is awaiting the outcome of national capital prioritisation for final confirmation of the amount of funding available in 2019/20.

Global Digital Exemplar – Fast Follower schemes (EPR and EPMA)

The financing for this is agreed based upon the three year Fast Follower agreement the Trust has with NHS Digital (NHSD). However, access to this PDC financing is based upon; a) proof of matched funding, and, b) delivery of agreed project milestones. The Trust has used existing EPR funding for the matched element. At present, both the project milestones and financial phasing are being re-negotiated with both NHSD and the main EPR supplier (IMS) via Contract Change Notices (CCNs). Once the CCN has been agreed with NHSD, the Trust will be able to draw down financing upon delivery of the first milestone.

Capital Programme Risks

The fundamental risk to the Trust this year is the increased uncertainty of receiving capital financing which is not already approved. This risk is being managed through CPEC and escalated up to the Trust Management Board as and when appropriate.

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Cash Flow Position

Actual Actual Plan Plan Plan Plan Plan Plan Plan Plan Plan PlanCashflow Analysis Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 2019/20

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000Surplus / (Deficit) from Operations (2,247) (218) (1,731) (955) (1,255) (1,054) (118) (224) (411) 94 (363) 478 (8,004)Adjust for non-cash items:Depreciation 400 473 400 400 400 400 400 400 400 400 400 397 4,870Income recognised in respect of capital donations 0Impairments 0 0 0 0 0 0 0 0 0 0 0 0 0Provisions (33) (34) (33) (33) (33) (33) (33) (33) (33) (33) (33) (37) (401)Operating Cash flows before working capital (1,880) 221 (1,364) (588) (888) (687) 249 143 (44) 461 4 838 (3,535)Working capital movements:(Inc.)/Dec. in inventories 0 126 0 0 0 0 0 0 0 0 0 0 126(Inc.)/Dec. in current assets (2,939) (2,391) (901) 1,500 (1,199) (1,200) 1,798 (1,800) (1,798) 3,299 (2,099) (2,100) (9,830)Inc./(Dec.) in trade and other payables 0 (306) 813 131 131 131 131 131 131 131 131 131 1,686(Inc.)/Dec. in current provisions 0 (11) 0 0 0 0 0 0 0 0 0 0 (11)Net cash inflow/(outflow) from working capital (2,939) (2,582) (88) 1,631 (1,068) (1,069) 1,929 (1,669) (1,667) 3,430 (1,968) (1,969) (8,029)Capital investment:Capital expenditure (250) (277) (1,019) (1,375) (1,100) (1,740) (2,018) (2,739) (2,360) (2,813) (2,092) (2,878) (20,661)Capital receipts 33 34 33 33 33 33 33 33 33 33 33 37 401Net cash inflow/(outflow) from investment (217) (243) (986) (1,342) (1,067) (1,707) (1,985) (2,706) (2,327) (2,780) (2,059) (2,841) (20,260)Funding and debt:Interest Received 5 7 4 5 5 4 5 5 4 5 5 5 59Interest Paid (766) (766) (766) (766) (766) (766) (766) (766) (766) (766) (766) (766) (9,192)PDC Received 0 0 251 430 202 317 382 435 218 393 56 580 3,264DH loans - received 3,092 2,197 3,628 4,190 4,241 4,542 4,645 5,417 4,582 5,517 5,387 4,348 51,786DH loans - repaid 0 0 0 (2,699) (659) (634) (3,598) (859) 0 (5,398) (659) (195) (14,701)Capital element of finance lease rentals 0 0 0 0 0 0 0 0 0 0 0 0 0PFI/LIFT etc capital (861) 286 0 (861) 0 0 (861) 0 0 (862) 0 0 (3,159)Net cash inflow/(outflow) from financing 1,470 1,724 3,117 299 3,023 3,463 (193) 4,232 4,038 (1,111) 4,023 3,972 28,057Net cash inflow/(outflow) (3,566) (880) 679 0 0 0 0 0 0 0 0 0 (3,767)

Cash at Bank - Opening 4,767 1,201 321 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 4,767Cash at Bank - Closing 1,201 321 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000

The table summarises the cash flow position reported to NHSI for the year to date and the forecast for the remainder of 2019/20. It identifies in-year cash movements including the impact of the deficit on cash, together with movements in working capital and capital expenditure. It also includes repayments of capital loans and loans taken out to enable the Trust to maintain liquidity.

The first two months have seen an operating deficit, capital expenditure and working capital improvement totalling £7.6m, funded by borrowing from DHSC of £3.2m, and a reduction in cash balances of £4.4m.

In future months, operating deficits and capital expenditure will be funded by loans including revenue support and capital loans. In addition, the Trust has a facility to draw down additional working capital loans to reflect the variance between last year’s planned outturn and the final actual position. The difference reflects a pressure on cash that has not been funded to date.

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Board Resolution required to support DHSC revenue loans

Revenue Loans

In order for the Trust to continue to operate whilst incurring a deficit, it is necessary to draw down loans from the DHSC in order to enable sufficient cash availability. The Trust’s annual financial plan identifies revenue loans to be drawn on a monthly basis.

In order to draw down monthly loans, the Trust Board is required to provide a resolution to confirm their agreement to the loan. The resolution detailed identifies borrowing requested for May 2019 and also identifies the requirement for loans to be taken in June 2019.

The loan is made up of the following elements:

May deficit support, £2,157k May PSF/FRF Advance, £899k

The Trust Board is requested to note and approve the loan.

Board Resolution

Statement from the Managing Director and Director of Finance of Wye Valley NHS Trust regarding the Trust Board approval of loan reference DHPF/ISUCL/RLQ/2019-05-03/A

Due to the need to take an urgent decision on the 2nd May 2019 and submit the relevant paperwork to the Department of Health, we have acted on behalf of the Trust Board. This is in accordance with the Trust's Standing Orders.

We recommend that a loan totalling £3,056,000 is taken, repayable in full on 18 May 2022, and approve the loan on behalf of the Board.

In line with Schedule 1 of the loan documentation, we also:

• approve the terms of, and the transactions contemplated by, the Finance Documents to which it is a party and resolving that it execute the Finance Documents to which it is a party;

• authorise the Director of Finance to execute the Finance Documents to which it is a party on its behalf; and

• authorise the Director of Finance to sign and dispatch all documents and notices including the Utilisation Request.

• Confirm our undertaking to comply with the Additional Terms and Conditions.

It is also anticipated that further loans to support the revenue deficit will be required in June 2019 in accordance with the annual plan. Trust Board is requested to authorise the Managing Director and Director of Finance to take action to execute those loans.

Jane Ives, Managing Director, Wye Valley NHS Trust

Howard Oddy, Director of Finance, Wye Valley NHS Trust3 May 2019.

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Board Resolution required to support DHSC revenue loans

SoFP (Balance Sheet)

Revenue Loans

In order for the Trust to continue to operate whilst incurring a deficit, it is necessary to draw down loans from the DHSC in order to enable sufficient cash availability. The Trust’s annual financial plan identifies revenue loans to be drawn on a monthly basis.

In order to draw down monthly loans, the Trust Board is required to provide a resolution to confirm their agreement to the loan. The resolution detailed identifies borrowing requested for June 2019 and also identifies the requirement for loans to be taken in July 2019.

The loan is made up of the following elements:

• June deficit support, £2,110k

• June PSF/FRF Advance, £901k

• June additional deficit support 18/19, £2,000k

The Trust Board is requested to note and approve the loan.

Board Resolution

Statement from the Managing Director and Director of Finance of Wye Valley NHS Trust regarding the Trust Board approval of loan reference DHPF/ISUCL/RLQ/2019-06-06/A

Due to the need to take an urgent decision on the 28th May 2019 and submit the relevant paperwork to the Department of Health, we have acted on behalf of the Trust Board. This is in accordance with the Trust's Standing Orders.

We recommend that a loan totalling £5,011,000 is taken, repayable in full on 18 June 2022, and approve the loan on behalf of the Board.

In line with Schedule 1 of the loan documentation, we also:

• approve the terms of, and the transactions contemplated by, the Finance Documents to which it is a party and resolving that it execute the Finance Documents to which it is a party;

• authorise the Director of Finance to execute the Finance Documents to which it is a party on its behalf; and

• authorise the Director of Finance to sign and dispatch all documents and notices including the Utilisation Request.

• Confirm our undertaking to comply with the Additional Terms and Conditions.

It is also anticipated that further loans to support the revenue deficit will be required in July 2019 in accordance with the annual plan. Trust Board is requested to authorise the Managing Director and Director of Finance to take action to execute those loans.

Jane Ives, Managing Director, Wye Valley NHS Trust

Howard Oddy, Director of Finance, Wye Valley NHS Trust11 June 2019.

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Statement of Financial Position

2018/19Month 2 Accounts M2 Plan M2 YTD M2 Var. Plan Actual Variance

£000s £000s £000s £000s £000s £000s £000sNON-CURRENT ASSETS:Property, Plant and Equipment 78,205 85,277 80,234 5,043 92,954 89,026 3,928Intangible Assets 11,091 9,761 8,791 970 18,221 18,221 0Trade and Other Receivables 264 0 0 0 0 0 0TOTAL Non Current Assets 89,560 95,038 89,025 6,013 111,175 107,247 3,928CURRENT ASSETS:Inventories 3,028 3,212 2,902 310 3,212 3,212 0Trade and Other Receivables 10,677 14,464 16,271 (1,807) 18,964 18,964 0Cash and Cash Equivalents 4,767 1,000 321 679 1,000 1,000 0TOTAL Current Assets 18,472 18,676 19,494 (818) 23,176 23,176 0TOTAL ASSETS 108,032 113,714 108,519 5,195 134,351 130,423 3,928CURRENT LIABILITIESTrade and other payables (25,551) (22,776) (20,816) (1,960) (22,776) (25,788) 3,012Borrowings: PFI obligations (3,445) (3,445) (3,445) 0 (3,445) (3,445) 0Borrowings: finance leases (76) 0 0 0 0 0 0Borrowings: DH revenue loans (38,172) (27,850) (37,603) 9,753 (27,850) (35,850) 8,000Borrowings: DH capital loans (3,425) (3,265) (2,566) (699) (3,265) (3,265) 0Other financial liabilities 0 0 (4,421) 4,421 0 0 0Provisions (44) (50) (50) 0 (50) (50) 0Total Current Liabilities (70,713) (57,386) (68,901) 11,515 (57,386) (68,398) 11,012NET CURRENT ASSETS/(LIABILITIES) (52,241) (38,710) (49,407) 10,697 (34,210) (45,222) 11,012TOTAL ASSETS LESS CURRENT LIABILITIES 37,319 56,328 39,618 16,710 76,965 62,025 14,940NON-CURRENT LIABILITIES:Borrowings: PFI/LIFT obligations (41,786) (40,922) (41,212) 290 (38,338) (38,338) 0Borrowings: finance leases (861) 0 (1,506) 1,506 0 0 0Borrowings: DH revenue loans (91,749) (101,070) (93,899) (7,171) (117,743) (117,743) 0Borrowings: DH capital loans (13,964) (18,135) (17,962) (173) (33,258) (30,724) (2,534)Other financial liabilities 0 0 0 0 0 0 0Provisions (989) (958) (983) 25 (958) (983) 25Total Non-Current Liabilities (149,349) (161,085) (155,562) (5,523) (190,297) (187,788) (2,509)ASSETS LESS LIABILITIES (112,030) (104,757) (115,944) 11,187 (113,332) (125,763) 12,431TAXPAYERS EQUITYPublic dividend capital 26,617 26,873 26,617 256 30,137 30,137 0Revaluation reserve 14,092 17,520 14,161 3,359 17,520 14,092 3,428Income and expenditure reserve (152,739) (149,150) (156,722) 7,572 (160,989) (169,992) 9,003TOTAL (112,030) (104,757) (115,944) 11,187 (113,332) (125,763) 12,431

2019/20 Year to Date 2019/20 Full Year

Non-Current AssetsThe year to date position differs from the plan due to the impact of impairments and reduced capital expenditure in 2018/19 on the outturn position.The forecast position incorporates the impact of the planned capital programme for 2019/20.

Current AssetsTrade receivables have increased due to a rise in NHS debtors.The cash position at the end of May was very tight in line with the Trust's challenging working capital position.

Current LiabilitiesThe Trust's trade payables position from the year-end outturn is at a similar level to the month 2 position. The month 2 analysis separates out monies owed for Tax, NI and Superannuation and shows them as Other Financial Liabilities.

Borrowing/LoansRevenue and capital loans have increased by a total of £4.7m in the first two months of the financial year. This includes £4m of revenue loans repaid following the receipt of £4m of capital loans relating to the 2018/19 capital programme.

Taxpayers EquityA small amount of PDC has been drawn down in relation to PDC funded capital schemes. The revaluation reserve has also been amended to account for equipment indexation. The movement in I&E reserve reflects the deficit incurred in the first two months of the year.

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Debtors and Creditors

BETTER PAYMENT PRACTICE CODE

NHS Non-NHS NHS YTDNon-NHS

YTD NHS Non-NHS

Number of Invoices paid in Period 102 5481 153 9548 1,334 50,547% of Invoices paid within target 14.71% 29.76% 22.88% 33.76% 25.94% 44.44%

Value of Invoices paid in period (£000s) 868 14,456 1,475 21,264 10,204 105,205% of value paid within target 63.36% 62.66% 75.80% 58.58% 55.95% 57.06%

OUTSTANDING DEBTS

Host Other Welsh Non-NHS Private Total£000s £000s £000s £000s £000s £000s £000s

Current 9,492 2,456 223 25 3 12,199 3,6611 Month 916 117 67 43 11 1,154 5,7782 Months 47 647 1,468 66 1 2,229 1,642Over 3 Months 321 823 1,109 608 4 2,865 6,255Unallocated Credits (5) (455) (401) (5) 0 (866) (1,368)Total Value Outstanding 10,771 3,588 2,466 737 19 17,581 15,968

Last Month 9,853 2,976 2,341 768 30

Age of Debt

2018/19

Debt outstanding as at end of the Month Previous Month

BPPCDue to on-going financial challenges, the Trust struggles to achieve the 95% target for payment for goods and services within 30 days.Performance in the first two months of the year was marginally improved compared to 2018/19.

Aged DebtsThe total value of outstanding debtors as measured by invoices raised increased from £16m to £17.6m. Over three-month old debt is £2.9m compared to £6.3m in month 1. This mainly relates to outstanding debts with other NHS bodies and Welsh NHS bodies.

The overall increase in accounts receivable is £0.9m with Herefordshire CCG, £0.6m with other NHS organisations and £0.1m with Welsh NHS bodies.

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Report to: Board of DirectorsDate of Meeting: 4 July 2019Title of Report: One Herefordshire - Urgent Care Programme Board UpdateStatus of report:(Approval, position statement, information, discussion)

Position statement / Information

Report Approval Route:Lead Executive Director: Jon Barnes - Chief Operating OfficerAuthor: Jon Barnes - Chief Operating OfficerAppendices:

1. Purpose of the reportTo provide an update on the work of the One Herefordshire - Urgent Care Programme Board and progress against the work streams it supports.

2. RecommendationsTo receive the report and discuss the collective actions being taken to deliver a recovered position against the A&E 4 hour standard.

3. Executive Director OpinionThis paper provides an overview of the One Herefordshire Urgent Care Programme Board’s (UCPB) progress to date.

Work continues within the Urgent Care Programme Board to carry out a ‘deep dive’ on all projects within the programme.

The #WyeValleyWay workshops continue with the third planned for start of July. At this workshop the implementation of the #WyeValleyWay will be mutually agreed and plans put in place to launch this in September.

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6. Sustainability: Deliver improved efficiency as a Foundation Group of Trusts by collaborating on IT, procurement and identifying further benefits.


7. Integration: Care for more people closer to home by integrating our community services with our One Herefordshire Partners.

X


8. Integration: Actively increase our role in health promotion and the prevention of ill health with our local communities.


9. Workforce and Leadership: Deliver our workforce plan, recruiting and retaining more staff and ensuring that they are enabled to work at their full potential.



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Report to: Board of DirectorsDate of Meeting: 4 July 2019Title of Report: Mortality ReportStatus of report:(Approval, position statement, information, discussion)Report Approval Route:Lead Executive Director: David Mowbray, Medical DirectorAuthor: Chris Beaumont, Mortality Project ManagerAppendices: None

1. Purpose of the reportFor information and to provide an update on the implementation of the mortality strategy. The report includes performance in relation to mortality rates with analysis of trends and variation. In addition it includes the number of mortality reviews undertaken for the previous month with key learning derived from the process.

2. RecommendationsThe Board of Directors are asked to note:

1. Monthly Headlines• Further reduction in the Trust’s overall rolling 12 month HSMR (March 2018 – February 2019) to 98.0. Overall, there were 11 less deaths than the expected 706 for the 12 month time period defined. • Due to a delay in the update of ONS data, the SHMI (January 2018 – December 2018) remains at 104.8.• Crude Mortality has continued to remain low for emergency admissions (4.95%) and all admissions (1.73%).• Lowest ever reported rolling 12 month HSMR (March 2018 – February 2019) for deaths attributed to Pneumonia and Acute Bronchitis, at 87.87 and 94.94 respectively. • Medical Examiners are now capturing all their reviews electronically on the newly developed Mortality Review System, which will allow for in-depth analysis of any key themes or patterns. • Significant reduction in deaths attributed to Sepsis, with the lowest ever reported rolling 12 month HSMR (March 2018 – February 2019) of 85.23. This equates to 15 less than the expected number of deaths.• Development of a business case to support an additional trauma theatre session on the weekend, with the aim of addressing the issue of the increasing time to surgery for #NOF patients.

3. Executive Director Opinion



x 6. Sustainability: Deliver improved efficiency as a Foundation Group of Trusts by collaborating on IT, procurement and identifying further benefits.



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Wye Valley NHS Trust Mortality Report 2018-19

Introduction

This monthly report aims to provide an update on the progress of implementation of the mortality strategy. The report includes performance in relation to mortality rates, focussing on trends and variation identified, which includes the number of mortality reviews undertaken for the previous month with key learning.

1. Monthly Headlines Further reduction in the Trust’s overall rolling 12 month HSMR (March 2018 – February

2019) to 98.0. Overall, there were 11 less deaths than the expected 706 for the 12 month time period defined.

Due to a delay in the update of ONS data, the SHMI (January 2018 – December 2018) remains at 104.8.

Crude Mortality has continued to remain low for emergency admissions (4.95%) and all admissions (1.73%).

Lowest ever reported rolling 12 month HSMR (March 2018 – February 2019) for deaths attributed to Pneumonia and Acute Bronchitis, at 87.87 and 94.94 respectively.

Medical Examiners are now capturing all their reviews electronically on the newly developed Mortality Review System, which will allow for in-depth analysis of any key themes or patterns.

Significant reduction in deaths attributed to Sepsis, with the lowest ever reported rolling 12 month HSMR (March 2018 – February 2019) of 85.23. This equates to 15 less than the expected number of deaths.

Development of a business case to support an additional trauma theatre session on the weekend, with the aim of addressing the issue of the increasing time to surgery for #NOF patients.

1. Trust-wide Mortality Strategy Implementation Update

This section outlines the areas within the Mortality Strategy where progress has been delayed or inhibited, and the mitigations put in place to continue to support the implementation.

Earlier this month, the key leads held a meeting to review the progress of actions for the development of a High Dependency Unit. This include actions to deliver a short and a long term plan.

Standard Operating Procedure for the use of Theatre Recovery has been completed. Mobile screens have been ordered. A draft Standard Operating Procedure will be developed to support patient

management, admission criteria and escalation of patients managed on CCU. This will aim to support the CCU / HDU hybrid model.

Initial ‘mock-up’ plans for the dedicated HDU have been completed, with a final review by Infection Control. The finalised plans, including the costing, will go to the Trust Management Board for approval.

All other work streams are progressing within the time scales indicated.

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2. Mortality Outlier Groups – Update

Respiratory:

Acute Bronchitis: Rolling 12 month March 2018 – February 2019 HSMR – 94.94 (↓ 9.77)

Pneumonia: Rolling 12 month March 2018 – February 2019 HSMR – 87.87 (↓1.26)

COPD: Rolling 12 month March 2018 – February 2019 HSMR – 108.29 (↓ 2.89)

Lowest ever reported rolling HSMR for Pneumonia and Acute Bronchitis 4th consecutive reduction in the rolling HSMR for COPD. 120 deaths against an expected 137 deaths for Pneumonia.

Key Actions:

Continued progress with the WMQRS and Mortality Improvement plan, with a continued focus on primary and secondary care integration.

#NOF: Rolling 12 month March 2018 – February 2019 HSMR – 165.14 (↑ 2.72)

34 deaths against an expected 21 deaths (March 2018 – February 2019). Increase of 2.72 in the latest rolling 12 month HSMR.

Key Actions:

Since the meeting last month, which aimed to improve the trauma capacity in theatres for more timely surgery on #NOF patients, there has been a review of the current theatre scheduling and investigation as to the potential options to maximise theatre efficiency. Based on the expert opinion, resources, and data modelling, the current schedule was found to be the most suitable option. However, there will be a business case for an additional theatre session on Saturday to be run as a trauma list. The Theatre General Manager will be leading on the development of the business case, and updates will be reported through the monthly mortality report.

Anaesthetic engagement for the timely review of patients and attendance at the 8am Trauma meeting.

Capturing of detailed information regarding any theatre delays for #NOF patients.

There has been an agreement for the ortho-geriatrician post to be funded from the orthopaedic budget, as opposed to the current medical allocation. In addition to this, the current locum ortho-geriatrician has been extended for a further six months.

A review of the physiotherapy provision at weekends, which is linked with a project to support Early Supported Discharge.

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Appointment of two Advanced Clinical Practitioners, in the Surgical Directorate who will be based in ED, to further support the management of #NOF patients.

CCF: Rolling 12 month March 2018 – February 2019 HSMR – 86.81 (↓ 1.09)

Lowest ever reported HSMR for CCF. 9th consecutive reduction in the rolling 12 month HSMR. 34 deaths against an expected 40 deaths (March 2018 – February 2019).

Key Actions:

A meeting has been arranged for the 25th June with key leads from Primary Care and Secondary Care to discuss opportunities for a pilot to support the management of heart failure patients in Herefordshire. The outcomes of the meeting will be updated through the monthly mortality report.

The draft version of the ‘Heart Failure Discharge Checklist’ has been completed, and is currently being reviewed by the specialist Consultants. This will aim to ensure that heart failure patients receive all the appropriate clinical advice and follow up care is booked prior to discharge.

3. Community Hospitals – Ross, Bromyard and Leominster

Bromyard: Rolling 12 month March 2018 – February 2019 HSMR – 101.42 (↓ 28.00)

Ross: Rolling 12 month March 2018 – February 2019 HSMR – 237.67 (↓ 3.78)

Leominster: Rolling 12 month March 2018 – February 2019 HSMR – 150.37 (↑5.28)

Following this month’s Community Hospital steering group, there has been further refinement of the initial improvement plan to support the reduction in mortality in the Community Hospital setting. The keys areas of focus for the coming months include:

A development programme for the GP’s, which will start with an initial scoping exercise to understand their needs.

An initial draft of the Community Hospital Admission protocol, including the supporting documentation for the transfer of patients, has been developed. The division will review these documents later this month.

Feedback mechanism to Community Hospital staff and GP’s, through the development of a clinical dashboard. This process will include the process for feeding back findings from Structured Judgement Reviews conducted in the trust.

Plan for applying the Structured Judgement Review methodology to Community Hospital deaths.

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4. Learning from Deaths

During May, there were 95.6% (65) of 68 deaths reviewed, in accordance with the Wye Valley Mortality Review process, with a further 21 in-depth second stage mortality reviews. The learning and outcomes of these reviews can be seen in the Learning from Deaths Dashboard.

As of this month, all of the mortality reviews (Medical Examiner Screening and 1st stage Structured Judgement Reviews) conducted will be captured electronically through the newly developed web-based system. The transition to electronic data capture will provide a deeper analysis to fully understand any key themes or patterns. Reporting will commence in next month’s report.

5. Alerts and Audits (Internal and External) Summary

This section aims to summarise the current activity of Wye Valley NHS Trust for mortality alerts and audits. The table below includes both internal and external alerts with a short summary of the current actions.

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Indicator Description/Notes Data month Deaths in Month Trend ChangeDirection of

TravelTrend - April 2016 to latest

reported month

First Look

Crude Mortality-all % of Deaths by Admissions 69

Crude Mortality-Emergency % of Deaths by Emergency Admissions 69

Latest StaticTrend (No. of deaths)

Change (Rate %)

Direction of Travel

Trend - April 2016 to latest reported month

Crude Mortality-all % of Deaths by Admissions 68 0.00%

Crude Mortality-Emergency % of Deaths by Emergency Admissions 66 0.08%

Indicator Description/Notes Data month Month Actual Acute Trust rank Trend ChangeDirection of

TravelTrend - April 2016 to latest

reported month

SHMI Dec-18 104.81 96 of 137 -1.2

SHMI Weekday Dec-18 105.71 100 of 137 -2.03

SHMI Weekend Dec-18 106.9 77 of 137 1.32

HSMR 98.0 47 of 135 -1.73

HSMR Weekday 95.7 NA -2.41

HSMR Weekend 104.74 NA 1.19

Data month HSMR SHMIObeserved/Expected Deaths

HSMR

Actual Deaths SHMI

Trend (HSMR)

Change (HSMR)

Direction of Travel HSMR

Trend - April 2016 to latest reported month

108.29 120.15 27/25 44 -2.89

87.87 91.46 120/137 168 -1.26

94.94 105.18 10/11 24 -9.97

86.81 98.82 34/40 45 -1.09

85.23 91.77 89/104 128 -5.27

94.14 106.98 11/12 19 -3.82

165.14 151.09 34/21 42 2.72

123.04 101.92 15/12 26 -11.27

Data month Value Peer MeanTrend - April 2016 to latest

reported month

13.87 12.33

5.79 5.62

16.99 14.45

5.51 5.01

0.30 0.25

* Direction of Travel is based on 3 month average vs previous 3 months average

Rolling 12 month Standardised Hospital Mortality Indicator (inc. post 30 days

discharge patients)

Mortality Dashboard

Mortality Indicators

May-19

Observed/Expected Deaths

Month Actual

1.7%

5.1%

Apr-191.73%

4.95%

Rolling 12 month Hospital Standardised Mortality Ratio

Feb-19

Obs. 187 v exp. 179

Fractured Neck of Femur (Internal)

Feb 2019 (HSMR), Dec 2018 (SHMI)

Palliative Care Coding 72 of 131

Obs. 1207 v Exp. 1140.5

Obs 897 v Exp 865

Obs 310 v Exp 286

Obs. 695 v Exp. 706

Obs. 508 v Exp. 531

Urinary Tract Infection (CQC Alert)

Coding

Indicator Acute Trust rank

Depth of Coding - Deceased Patients

Feb-19

56 of 131

Cusum/External Alerts

Outlier Alerts

(Please note this is first look data and subject to change - Static position is below)

46 of 131

Co-morbidity Scores - Live patients 18 of 131

Co-morbidity Scores - Deceased Patients

Outlier Groups - HSMR,Rolling 12 months

CCS Group/Origin of Alert

Chronic Obstructive Pulmonary Disease (Outlier)

Pneumonia (Outlier)

Acute Bronchitus (Outlier)

Congestive Heart failure (Outlier)

Septicemia (Outlier)

Gastrointestinal Bleeds (Outlier)

Depth of Coding - Live Patients 62 of 131

0

50

100

150

200HSMR(56)

HSMR (all)

HSMR (Weekdays)

HSMR (Weekends)

SHMI

SHMI (Weekdays)

SHMI (Weekends)Chronic Obstructive Pulmonary

Disease (HSMR)Pneumonia

Acute Bronchitus

Congestive Heart failure

Septicemia

Gastrointestinal Bleeds

Urinary Tract Infection

Fractured Neck of Femur

Wye Valley All Acute Trusts

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

Apr-1

4

Jun-

14

Aug-

14

Oct-1

4

Dec-

14

Feb-

15

Apr-1

5

Jun-

15

Aug-

15

Oct-1

5

Dec-

15

Feb-

16

Apr-1

6

Jun-

16

Aug-

16

Oct-1

6

Dec-

16

Feb-

17

Apr-1

7

Jun-

17

Aug-

17

Oct-1

7

Dec-

17

Feb-

18

Apr-1

8

Jun-

18

Aug-

18

Oct-1

8

Dec-

18

Feb-

19

Apr-1

9

Crude Mortality - SPC Chart, April 2014 to date

Total Mean UCL LCL

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Mortality Rates by Wye Valley NHS Trust Sites:

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Mortality Outlier Metrics

Fractured Neck of Femur: Overall Performance Run Chart

The 'Overall Performance' run-chart shows:

• Mean time to surgery: The chart shows the average number of hours between admission to A&E and surgery, for all patients operated that month. The graph also shows the national average for comparison. NICE guidelines recommend that surgery should take place on the day of admission to hospital or the following day. This is because it is uncomfortable, undignified and distressing to be confined to bed with a hip fracture and patients are unable to get up out of bed until they have had the operation. This recommended time for surgery may not be possible for some patients – for instance if they have medical problems which need other treatment first to make them well enough for surgery.

• Crude 30-day mortality: The graph shows the proportion of patients who died in the first 30 days. It takes time to cross-check these figures so this graph cannot show the last few months. We also show a national average line for reference. However, some hospitals have patients who are older or frailer than those in other parts of the country. These hospitals might expect a slightly higher number to die after hip fracture, so the ‘crude 30-day mortality’ graph may not be reliable when comparing different hospitals’ performance.

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This Month(May 19)

Last Month(Apr 19)

This Month (May 19)

Last Month(Apr 19)

This Month (May 19)

Last Month(Apr 19)

68 60 65 (95.6%) 56 (93.3%) 21 1

This Quarter Last Quarter This Quarter Last Quarter This Quarter Last Quarter

128 213 69 ( 95.8%) 183 (86.5%) 22 39

Outcomes:

Score 1: Definitely Avoidable 0

Score 2: Strong Evidence of Avoidability 0

Score 3: Probably Avoidable 0

Score 4: Possibly Avoidable 0

Score 5: Slight Evidence of Avoidable 1

Score 6: Definitely not Avoidable 18

Avoidabiity awaited on two cases

Summary of May Second Reviews:

Seven cases required rapid reviews from ITU, ED, General Surgery, Urology and Respiratory.Two cases identified no learning, with a futher two outstanding with learning from the other cases:• Lack of ITU beds• Missing documentation• Completion of MCCD

The learning from these cases is circulatged through the Mortality Newsletter and directly to the teams involved.

During May , 21 reviews were conducted in accordance to the agreed Wye Valley Mortality Review process. The panel, consisting of clinicians from a wide range of specialties, engaged positively with the process and through broad discussion were able to pull out good relevant learning.

Learning from Deaths Dashboard

Total Number of Deaths (In Hospital Deaths)

Total Deaths Reviewed Total Deaths with a Second Review

Summary of the total number of deaths and total number of cases reviewed under the Structured Judgement Review Methodology.

0

20

40

60

80

100

120

Number of Deaths (In Hospital) Number of Reviews

Number of Second Reviews Target - 75% Review

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Herefordshire Child Death Overview Panel (CDOP) 2018 – 2019 Reported Deaths:

April 2019: 3 deaths

May 2019: 0 deaths

June 2019 (To 17/06): 1 death

MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries):

LeDeR – Learning Disabilities Mortality Reviews

May 2019 – LeDeR review update:

Completed reviews – 0

Notification of death – 1

Reviews in progress – 7

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Mortality Outlier Metrics

Crude Mortality (per diagnostic outlier groups):

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Report to: Board of DirectorsDate of Meeting: 4 July 2019Title of Report: Digital Systems development updateStatus of report:(Approval, position statement, information, discussion)

Information

Report Approval Route: Digital Programme BoardLead Executive Director: Howard Oddy – Director of Finance & InformationAuthor: EPR Programme Manager and Associate Director of ITAppendices: None

1. Purpose of the reportTo provide an update on the current status of the EPR, EPMA and community IT programmes.

2. RecommendationsThe Board is asked to note the contents of the report.

3. Executive Director OpinionThe three major projects that are currently being progressed within the Trust continue to make progress in line with the plans, though the very recent indication of later delivery dates for MAXIMS releases is a cause for some concern. This matter will be receiving a great deal of attention over the next month and the Board will be updated at its next meeting regarding the outcome of ongoing discussions.











X 10. Workforce and Leadership: Enhance our leadership potential through a joint Foundation Group approach to leadership and service improvement.

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5. Electronic Patient Record (EPR) ProgrammePathology Order Communications (OCS)The rollout of Pathology OCS across the Trust will complete this week, finishing with the Community Hospitals. This has been a significant undertaking in terms of resource but also in terms of the business change for Trust clinicians. The phased rollout has provided tangible user support, and this approach is likely to be the model adopted for future initiatives.

Radiology Order Communications (OCS)This remains a key clinical and administrative objective; but, as part of the Managed Equipment Service project, the Radiology Department have been considering the future of their scheduling system (RIS). The plan for RIS is now more fully formed, (and should see a replacement RIS going live in early 2020) which in turn means that initial activities can commence for implementing Radiology OCS.

EPR Phase 2 Development planIMS have indicated that the next three scheduled releases of MAXIMS will each potentially take six to eight weeks longer to deliver than previously advised. This matter is being further explored with the Supplier, but may mean that the contingency period at the end of the Programme is reduced.

EPR Phase 2 Deployment (Implementation) planAhead of a meeting with the Nursing and Medical Directors, a further iteration of the rollout plan for Outpatients is being created. Trauma and Orthopaedics are amongst the Specialities who have expressed their desire to be early adopters of clinical noting in MAXIMS.

Nurse eOBS (electronic observations)Two pilots of four days each using MAXIMS to record patient observations have been undertaken on the Acute Medical Admissions unit. The objectives of the pilots were to;

o Trial some different mobile devices (both Apple and Android equipment)

o Configure MAXIMS with NEWS configuration of scores and local clinical advice

o Identification of SOPS/ amendment of policies required

o Gain Initial staff engagement and feedback

There have been problems with the devices themselves (which were also encountered by Taunton), but, once working, the feedback from the staff has been very positive. Again, a meeting with the Nursing and Medial Directors has been arranged to review the pilot results and agree next steps.

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6. Electronic Prescribing & Medication Administration (EPMA)

Work is continuing to procure an EPMA solution for the Trust. Site visits to Wolverhampton and Taunton have taken place to ratify and review the shortlisted products. A product recommendation of OPENeP from Better by Marand has been submitted to, and approved by, the Trust Management Board. Better by Marand and EMIS Health have been formally notified of this decision and the next stage of procurement is to assess re-seller opportunities with the five suppliers put forward by Better by Marand. All five interviews have been scheduled, with one already complete. Project Team resourcing is also in progress, with two Pharmacy roles currently out for advert. The EPMA Nurse role will be advertised shortly. Additional work streams to prepare for project start-up are continuing, including As-is process mapping and the start-up of Risk and Issue management processes.

7. EMIS Community & Malinko Scheduler

Phase 2 of EMIS community went live, ahead of schedule, on 4th June 2019. The implementation was a success with no major issues. The next phase of the implementation consists of about 220 end-users spread across the county.

In light of lessons learned from the implementation of Phase 1 and Phase 2, an updated programme plan is being presented to the EMIS Programme Board on 28th June. The main factors which have driven the need to revise the plan are the support needs of staff who have not previously used IT in their jobs and the level of business transformation and process change associated with implementing the electronic system.

Read Only Access to the EMIS viewer in acute is dependent on the Data Sharing Agreement (DSA). The wording of the “indemnity clause” in the DSA has been agreed by the LMC. A final copy of the data sharing agreement is currently being circulated to key stake-holders for signature. Once the DSA is in place, the project team will implement the Care Record Sharing request and EPR Viewer request documents. Patient comms will be issued by the CCG with the required consultation period. It is anticipated that all remaining DSA activities will be completed by September with a potential go-live date in mid-September.

Malinko was successfully upgraded to V2 on 28th May 2019. The ongoing EMIS rollout has exposed an increasing tension in the decision to use Malinko as the scheduler of choice. Future planned roll outs of Malinko to other teams in the community have been suspended while an options appraisal is developed on the future of Malinko. The options appraisal will be presented to TMB.

8. Health System Led Investment (HSLI) programme

The funding agreement for 2019-20 HSLI funding is nearly ready for submission ahead of a 5th July deadline.

9. Appendices

None

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Report to: Board of DirectorsDate of Meeting: 4 July 2019Title of Report: Board Assurance FrameworkStatus of report:(Approval, position statement, information, discussion)

Discussion

Report Approval Route: Executive Risk, Board of DirectorsLead Executive Director: Jane Ives, Managing DirectorAuthor: Erica Hermon, Associate Director of Corporate GovernanceAppendices:

1. Purpose of the reportTo review the updated 19/20 Board Assurance Framework (BAF) and consider the risks to the delivery of the Trust’s strategic objective.

2. RecommendationsTo approve the BAF, identifying any gaps in risk to the delivery of the Trust’s strategic objectives.

3. Executive Director OpinionThe Board Assurance Framework has been updated to identify those risks (existing and new) that impact on the strategic delivery of the Trust’s objectives. Significant changes to the 2019/20 BAF include:

Deletion of the mortality riskInsertion of the pension riskInsertion of the Responsible Officer riskInsertion of a capital funds risk




x


x 7. Integration: Care for more people closer to home by integrating our community services with our One Herefordshire Partners.

x


x 8. Integration: Actively increase our role in health promotion and the prevention of ill health with our local communities.

x


x 9. Workforce and Leadership: Deliver our workforce plan, recruiting and retaining more staff and ensuring that they are enabled to work at their full potential.

x

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x 10. Workforce and Leadership: Enhance our leadership potential through a joint Foundation Group approach to leadership and service improvement.

x

2/2 84/166

BOARD ASSURANCE FRAMEWORK

Wednesday, 05 June 2019

NU

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JB 3 5 15 10 1. A&E Delivery Board2. Nurse staffing element of

remodelled workforce complete

3. Revised 7-day stranded review process in place.

4. Front-door frailty team in place.

5. Rapid assessment area in place to mitigate against losses and improve upon GP Streaming.

6. Urgent Care Programme Board in place

7. Flow academy in place8. Agreed temporary staffing

solution in place9. Implemented improved

professional standards (as approved by TMB 5 Oct 18).

10. ED staffing reviewed daily at control meeting.

1. Urgent care programme board.

2. Output of Silver week (17 Sep 18).

3. Monthly performance report and staff report presented to the Board of Directors

4. Monthly update on Urgent Care Programme Board presented to Board of Directors with progress on work streams.

5. Fortnightly reviews of all medical vacancies and impact on rotas discussed at Medical Agency Review Group

6. Urgent Care Programme Board actions reported monthly to the Board of Directors

2 5 10 1.Inability to recruit and retain medical and nurse staffing or find consistent agency cover.

2.Unable to significantly improve ambulatory emergency work due to workforce gaps in acute medicine and pressure on assessment areas.

3.Poor out of hours and weekend performance in relation to inconsistent clinical capacity and leadership due to recruitment issues.

4.ED process management on daily basis is inconsistent

5.Absence of clinical lead and clinical director vacancies within med division impacts on the ability to lead this piece of work.

Allocation of clinical lead with responsibility and oversight to ensure rotas are fit for purpose within each area.

1. GAA has limited operational capacity but is awaiting completion of refurbishment

2. Revision of site management with ECIST support arrangements to free up capacity for out of hours and complex discharge team.

3. SAA move to Redbrook Ward

4. Recruitment to 7-day service and ED Business Case

5. Fortnightly review of actions with each of the work streams within Urgent Care Programme Board and their respective project leads and the Chief Operating Officer.

6. Implement blended workforce approach

7. Improved operational escalation through ED pathway required, supported by ECIST.

8. Transfer of rota management to divisional teams to ensure improved scrutiny and over view of annual leave and study leave.

9. Delivery of workforce plan to mitigate loss of GP streaming.

JB

JB

JB

SS

JB

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DM

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Jun 19

Jul 19

Jun 19

Ongoing

Ongoing

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Jul 19

Apr 19

Aug 19

1/7 85/166



23.

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AD 5 4 20 15 1. Escalation Policy and use of escalation areas

2. Investment in Community Services to prevent admissions and reduce hospital length of stay

3. Development of business case for acute hospital beds as part of Trust's Estate Strategy (hutted ward replacement).

4. Right sizing plan has been agreed to optimise current medical beds.

5. Modular 24-bedded interim unit operational on 21 Dec 18.

1.Escalation policy reviewed and approved with use of escalation areas reported.

2.Review of number of operations cancelled and bed occupancy numbers.

3.Investment agreed as part of business planning. Increases in community staff monitored

4.STP states that an additional 34 beds are required at the County Hospital. The additional beds are a capital priority for the STP.

5.A business case has been approved by the Board of Directors and funding is being sought both as an emergency capital bid and STP capital bid.

6.Capacity plan completed and approved by the Board

7.Implemented 'right sizing bed plan' on 21 Dec 18.

5 3 15 1. No emergency decant plan internally or externally with commissioner / agencies

2. No alternative decant space.

3. Emergency demand has increased to the point that all escalation areas are occasionally used

4. Funded bed capacity plan not yet agreed

1. Due to their age and condition, there is a risk of critical failure of the Hutted Wards ahead of the necessary funding being secured and the completion of a new build.

2. NHSE approval of current business case plans for hutted ward replacement.

1. OBC approved and with NHSI and will need updating with costs and planning permission for funding application.

2. NHSI have requested an updated OBC with latest layout included which reduces derogations. These are agreed in principle with NHSI and work underway to complete and resubmit case.

3. Finalising the outline business case for the hutted ward replacement and additional capacity with NHSI.

4. Develop full business case, subject to NHSI approval of Ser 1 (above).

5. Refresh of capacity plan to understand latest bed resource requirements.

AD

AD

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Jun 19

Sep 19

Jul 19

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JI 3 5 15 15 1. Job planning policy and AMD for productivity plan to deliver systematic and standardised job planning

2. F&PE committee reports on activity impact

3. Divisional Risk registers4. Medical Agency Reduction

Project (MARP) board.5. Workforce strategy

1. Board Integrated Performance report

2. Workforce improvement report

3 5 15 Job planning progress by divisional team

Action plan include an action for external audit on job planning in quarter 4.

SS

2/7 86/166



43.

Qua

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Impr

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JB 4 4 16 12 1.Outsourcing elective work to recover position

2.Harm reviews being undertaken on long waiters (over 52 weeks) and cancer 62 days and 104 days.

3.Submitted trajectories and proposals to NHSI

1.Monthly report to Board of Directors on RTT position

2.Monthly report to Clinical Quality Committee on harm reviews

3.Revised harm review process discussed at Clinical Quality Committee

4 3 12 Contract p positionTax tax positionTheatre capacity

1.Delivered the agreed annual elective activity within plan

2.Resolve contractual position with HCCG.

JB

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HO 4 3 12 12 1.CPIP Programme with robust governance arrangements

2.CPIP Programme Managers3.Vacancy Panel4.Budget holders have control

totals5.Finance and Performance

Executive6.CPIP Delivery Meeting

1.Twice monthly reporting to CPIP delivery on CPIP identified and progress of delivery of project

2.Monthly review of Divisional performance in Finance and Performance Committee

3.Board of Directors receive monthly report on financial position and CPIP achievement

4.Deep dive reviews with Divisions and Corporate to discuss financial recover and achievement of CPIP targets.

4 3 12 Approx £1.3m gap 1.Continue to identify opportunities to develop into projects to meet CPIP targets at fortnightly meeting.

2.CPIP delivery for 19/20 being developed to bridge the gap in delivery.

HO

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SS 3 5 15 15 1.Recruitment & Retention Plan2.Workforce Strategy3.Flexible working policy in

place 4.Improvement plan in place for

management of Master Vendor and Direct Engagement contracts.

5.Detailed recruitment plan lists a number of initiatives to address the vacancy gap and deliver sustainable workforce.

1.F&PE and Board of Directors receive monthly performance report on workforce

2.Check and Challenge Boards undertaken on establishment

3.Renewed contract to deliver more robust outcomes.

4.Nurse staffing establishment reviewed

6.Nurse Agency and Medical Agency Programme Boards.

7.Strategic Workforce Committee

3 5 15 1. Nurse and medical recruitment plans not delivering the numbers required.

2. Consortium approach to agency bookings and cost.

3. Visibility of rostering process to employees to allow bank engagement

1. Ability of master vendor contract to meet required agency fill rates which leads to use of higher cost tiers within the contract and other agencies.

2. Revised HMRC policy relating to VAT recovery with potential impact on ability to fill current rota arrangements.

1. Targeted local and international recruitment taking place

2. NHSI action plan following the deep dive visit.

3. E-Rostering business case pending approval by Board

4. Updated nurse recruitment and retention plan for 19/20 in development.

5. Relaunch of bank on 3 Jun with new rates and weekly pay.

SS

SS

SS

SS

SS

Mar 19

Jun 19

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74.

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al d

efic

it

Ther

e is

a ri

sk th

at th

ere

is in

suffi

cien

t cap

ital

fund

s to

sup

port

exi

stin

g pr

ojec

ts.

Fina

ncia

l Org

anis

atio

nal HO 4 5 20 20 1. Capital planning and

equipment committee.2.Capital expenditure controlled

and approved by capital accountant.

Monthly report to Board.Monthly submission to NHSI.

4 5 20 1.Projects requiring £8m with only £5m of capital funds.

Submitted bid for the additional monies

HO Sep 19

8

5. S

usta

inab

ility

: Im

prov

e ou

r ef

fect

ives

and

effi

cien

cy b

y im

plem

entin

g ou

r Dig

ital S

trat

egy

Ther

e is

a ri

sk to

the

deliv

ery

of

the

Dig

ital S

trat

egy

due

to th

e sc

ale,

num

ber a

nd c

ompl

exity

of

indi

vidu

al p

roje

cts

and

the

chan

ge/tr

ansi

tion

requ

irem

ents

of

the

wor

kfor

ce.

Info

rmat

ion

Gov

erna

nce/

ITHO 4 3 12 12 1. Digital Strategy

2. Programme Team3. IT Project Managers4. Digital programme.

1. Digital programme board.

2. Capital Planning and Equipment Ctte.

3. Monthly Board paper to Trust on digital progress.

4. Ensure clinical acceptance and clinical engagement in any proposed solutions

4 3 12 Change managementTrainingCultural change and professional buy-in to projects.

1. Agree digital programme for 19/20 cognisant of resource requirements.

2. Publication of Group Digital Strategy by appointed Group Director.

3. Programme Board to develop overarching overview of projects to determine critical path, overlap and staff impact.

HO

HO

1st quarter

Jul 19

9

7. I

nteg

ratio

n: c

are

for m

ore

peop

le c

lose

r to

hom

e by

inte

grat

ing

our

com

mun

ity s

ervi

ces

with

our

One

Her

efor

dshi

re P

artn

ers.

If th

e In

tegr

ated

Car

e A

llian

ce B

oard

doe

s no

t ena

ble

prog

ress

to b

e m

ade

suffi

cien

tly q

uick

ly to

cre

ate

an in

tegr

ated

wor

kfor

ce a

t loc

ality

leve

l to

man

age

dem

and

for u

rgen

t car

e an

d co

unty

-wid

e se

rvic

es th

at a

re re

spon

sive

eno

ugh

to

mee

t dem

and

for s

tep

up a

nd s

tep

dow

n ca

re fo

r pat

ient

s at

hom

e, th

ere

will

be

dela

yed

tran

sfer

s of

car

e an

d hi

gh le

vels

of e

mer

genc

y de

man

d. In

add

ition

ther

e is

a ri

sk o

f des

tabi

lisin

g M

SK a

nd p

harm

acis

t wor

kfor

ce if

the

new

prim

ary

care

w

orkf

orce

is n

ot im

plem

ente

d as

a O

ne H

eref

ords

hire

app

roac

h.Pa

tient

Exp

erie

nce

SS 4 3 12 12 1. ICAB with independent chair and scrutiny

2. Primary care networks3. Managing Director SRO for

One Herefordshire Integrated Care Programme

4. Operational Delivery Group5. Integrated discharge team

established

1. Integrated Care division objectives and performance management through F&PE

2. Board integrated performance report

3. Home First integration plan agreed by ICAB

4 3 12 1. Finance and performance and quality forum reporting to ICAB yet to be established

2. Lack of integrated BI and KPIs for localities

3. Pathways 3 D2A – lacking robust GP cover

1. No locality based reports yet available

2. Workforce implementation plan for primary care pharmacists not yet agreed

3. Long term approach to FCP (MSK) not yet agreed

1. WVT support of home first recruitment

2. Integration of out of hours teams including hospital at home

3. Proposals to integrate co-ordination of hospital at home and home first capacity

SS

DF

DF

Ongoing

4/7 88/166



109.

Wor

kfor

ce a

nd L

eade

rshi

p: D

eliv

er o

ur w

orkf

orce

pl

an, r

ecru

iting

and

reta

inin

g m

ore

staf

f and

en

surin

g th

at th

ey a

re e

nabl

ed to

wor

k at

thei

r ful

l po

tent

ial.

Due

to th

e in

abili

ty to

recr

uit a

nd re

tain

con

sulta

nt

appr

aise

rs a

nd re

spon

sibl

e de

puty

offi

cer t

o ov

erse

e th

e pr

oces

s, th

ere

is th

e ris

k th

at th

e Tr

ust

will

fail

to e

xerc

ise

its d

uty

unde

r the

Med

ical

Pr

ofes

sion

(Res

pons

ible

Offi

cers

) Reg

ulat

ions

201

0 (r

espo

nsib

le o

ffice

r rev

alid

atio

n an

d ap

prai

sal)

Insp

ectio

ns a

nd s

tatu

tory

dut

y.

DM 3 5 15 9 1. Widened the appraiser pool to GPs.

2. Increased number of appraisers.

3. Appointed appraisal lead/deputy RO.

1. Annual appraisal and revalidation audit – presented to Board of Directors.

2. Monthly meetings with appraisal lead and revalidation officer.

3 3 9 1. Risk that pension situation leads to critical reduction in number of appraisers.

1. Consultant Volunteers and GP appraisers being sought locally and across the group.

DM Ongoing

11

9. W

orkf

orce

and

Lea

ders

hip:

Del

iver

our

wor

kfor

ce p

lan,

recr

uitin

g an

d re

tain

ing

mor

e st

aff a

nd e

nsur

ing

that

they

are

ena

bled

to w

ork

at

thei

r ful

l pot

entia

l.

Ther

e is

a ri

sk o

f poo

r clin

ical

per

form

ance

due

to b

eing

una

ble

to

recr

uit t

o co

nsul

tant

vac

anci

es re

sulti

ng in

the

use

of lo

cum

sta

ff, a

la

ck o

f cap

acity

to d

eliv

er n

atio

nal s

tand

ards

and

ser

vice

frag

ility

Patie

nt e

xper

ienc

e

SS 3 5 15 10 1. Active recruitment project plans in place at consultant level

2. Continue to book locum agency doctors to fill gaps

3. Recruited Band 5 team leader to oversee medical recruitment

4. STP clinical reference group devoted to fragile services

5. New innovative job plans for consultants for fragile services.

6. External delivery partners.

1. Board of Directors review KPI in relation to vacancies

2. Medical establishment report provides clarity on recruitment progress

3. Monitoring of performance reports through MARP, F&PE and Board of Directors

4. Clinical incidents and Datix reported to Serious Incident Panel and Clinical Quality Committee on a monthly basis

5. A list of fragile services has been compiled and passed to STP: stroke, medicine, community paediatricians, neurology, oral surgery, plastic surgery and renal.

2 5 10 1.Clear medical workforce plan that addresses opportunities within STP

2.Funded capacity doesn’t meet demand in specific areas e.g. neurology, community paediatrics (LAC) has long waiting times

Ongoing assessment of future fragility and associated business continuity planning.

1. Discussions around alternative models are ongoing for the vulnerable services at STP level.

2. Fragile services list under continual review.

3. Assessment of future fragility with medical, strategic and operational directors.

DM

AD

DM

Ongoing

Ongoing

5/7 89/166



129.

Wor

kfor

ce a

nd L

eade

rshi

p: D

eliv

er o

ur w

orkf

orce

pla

n,

recr

uitin

g an

d re

tain

ing

mor

e st

aff a

nd e

nsur

ing

that

they

are

en

able

d to

wor

k at

thei

r ful

l pot

entia

l.

Failu

re to

hav

e a

com

preh

ensi

ve ro

ster

sys

tem

(bot

h fo

r m

edic

al a

nd n

ursi

ng) i

n pl

ace

impa

cts

upon

the

abili

ty to

pr

oact

ive

book

sta

ff an

d un

dert

ake

repo

rtin

g of

effe

ctiv

enes

s re

sulti

ng in

an

inab

ility

to in

terf

ace

with

ext

erna

l age

ncie

s in

th

e tim

ely

and

effe

ctiv

e pr

ovis

ion

of a

genc

y st

aff.

SS 3 4 12 12 1. Detailed manual reporting systems which address rostering practice and effectiveness

2. Manual systems supporting agency interface

3. Senior clinical lead appointed to temporary staffing office.

4. Centralised bank and agency bookings in the temporary staffing office.

5. Review of payments and incentives for bank staff.

1. Master Vendor contract performance meeting which reviews management information

2. Challenge Board with Divisional Director of Nursing which reviews management information in support of rostering practices

3. Agency as a % of spend against payroll is a KPI reviewed at Board of Directors

4. Twice daily staffing meetings between clinical lead for temporary staffing office, level 2 nurse and master vendor.

5. Weekly challenge meetings with Director nursing, finance and MD.

3 4 12 1.A budgeted overarching e-rostering system.

2.Emergency capital was approved but reallocated.

1. Management information not yet embedded in challenge Boards.

2. Revised HMRC policy relating to VAT recovery with potential impact on ability to fill current rota arrangements.

1. Approval of emergency capital

2. Fully utilise existing smart rostering system for all staff.

3. Recruit to nursing and medical posts.

SS

SS

SS

Jun 19

Ongoing

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139.

Wor

kfor

ce a

nd L

eade

rshi

p: D

eliv

er o

ur w

orkf

orce

pla

n, re

crui

ting

and

reta

inin

g m

ore

staf

f and

ens

urin

g th

at th

ey a

re e

nabl

ed to

wor

k at

thei

r ful

l pot

entia

l.

Ris

k of

con

tinue

d hi

gh tu

rnov

er o

f nur

ses

and

supp

ort s

taff

due

to in

flexi

ble

wor

king

pr

actic

es, l

ack

of e

ngag

emen

t and

lead

ersh

ip re

sulti

ng in

hig

h co

st a

genc

y an

d di

fficu

lty

recr

uitin

g

SS 3 4 12 12 1. Staff engagement programme for 18/19 in place

2. Staff retention working group

3. NHSI Retention Project4. Leadership Development

Programme5. Leadership Charter6. Workforce Strategy7. Revised flexible working

policy approved 8. Staff engagement events9. Communications campaign

in relation to flexible working

1. Board of Directors receive monthly workforce report

2. JNCC and Equalities group receive quarterly update on workforce issues

3. Vacancies monitored and reported to Strategic Workforce Committee

4. Undertaken 'deep dives' into areas of high turnover at F&P.

5. New nurse agency programme board introduced of which recruitment and retention is a key work stream.

6. Understanding of reasons for leaving provided monthly through F&PE and workforce section of the integrated report to Board of Directors

7. Group leadership development programme agreed for 2019/20

8. Recruitment and retention strategy and associated action plan for nursing staff implemented as part of workforce strategy.

3 4 12 Ability of master vendor contract to meet required agency fill rates.

1. Revised approach to induction, competency assessment and retention for support staff

2. Implement Leadership Development Programme action plan, linked to succession planning and talent management.

SS

SS

Mar 19

Apr 19

7/7 91/166

Report to: Board of DirectorsDate of Meeting: 4 July 2019Title of Report: Board of Directors Forward PlanStatus of report:(Approval, position statement, information, discussion)

Approval

Report Approval Route: Board of DirectorsLead Executive Director: Jane Ives, Managing DirectorAuthor: Erica Hermon, Associate Director of Corporate GovernanceAppendices:

1. Purpose of the reportTo provide the Board of Directors the opportunity to review and approve the forward plan for the Board of Directors.

2. RecommendationsTo approve the forward plan for the Board of Directors.

3. Executive Director OpinionThe forward plan will enable the necessary focus and assurance required of the Board to meet Trust Standing Orders and Standing Financial Instructions.




X



X



X



X


x 10. Workforce and Leadership: Enhance our leadership potential through a joint Foundation Group approach to leadership and service improvement.

x

1/1 92/166

BOARD OF DIRECTORS FORWARD PLAN 2019/20

02-May

23-May

04-Jul

01-Aug

05-Sep

03-Oct

07-Nov

05-Dec Jan Feb Mar Apr

A = Approval D= Discussion I = Information

Exec Lead

Monthly Reports CEO Report GB D D D D D D D D D D D

Integrated Performance Report: (a) Quality(b) Finance/CPIP(c) Activity(d) Workforce

JILFHOJBSS

D D D D D D D D D D D

One Herefordshire Urgent Care Programme Board JB D D D D D D D D D D DMortality Report DM D D D D D D D D D D DCommittee Summary Reports:(a) Quality Committee(b) Audit Committee(c) Remuneration and Terms of Service Committee(d) Charity Trustee(f) Foundation Group Strategy Sub-Committee

CHACRHFMRH

I

II

II

I

I

I

I

IIII

I

I

I IIIII

I I

I

I

Electronic Patient Record Update HO I I I I I I I I I I IOther ReportsIntegrated Business Plan AD A Capacity Planning 2019/20 AD/JB D IMT Strategy HO A Risk Management Strategy EH A Board Assurance Framework EH D D D DGuardian of Safe Working DM I I I IAudit Findings Report HO A Annual Report and Annual Governance Statement EH A

1/3 93/166


02-May

23-May

04-Jul

01-Aug

05-Sep

03-Oct

07-Nov


Final Accounts HO A Quality Account LF A Infection Prevention and Control Annual Report LF A Child Safeguarding Annual Report LF A Adult Safeguarding Annual Report LF A Freedom to Speak Up SS A A Health, Safety and Wellbeing Annual Report EH A Equality and Diversity (bi annual) SS D D Standing Orders and Financial Regulations EH/HO A Well Led Framework EH A

Confidential SectionStaff Suspensions and Employment Tribunals (by exception) SS I I I I I I I I I I I I

Claims Annual Report 2018/19 EH A Fit and Proper Persons Compliance/Trust Declarations EH A

Workforce Improvement Plan SS D D D D D D D D D D DBusiness Cases:HDUEndoscopy

A

A

Freedom to Speak Up - Annual Report D

GovernanceMinutes of Board of Directors EH A A A A A A A A A A ADeclarations of Interest EH I I I I I I I I I I I I

2/3 94/166


02-May

23-May

04-Jul

01-Aug

05-Sep

03-Oct

07-Nov


Minutes of other Committees of the Board:(a) Quality Committee(b) Audit Committee(c) Charitable Funds Committee(d) Foundation Group Strategy Sub-Committee

I I

I

II

I IIII

I I IIII

I I I

Action Log EH A A A A A A A A A A AWork Plans:(a) Board of Directors(b) Quality Committee(c) Audit Committee(d) Remuneration and Terms of Service Committee(e) Charity Trustee(f) Trust Management Board(g) Risk Management Executive(h) Group Strategy Committee

EHLFEHEHEHEHEHEH

A

A

A

A

A

Terms of Reference:(a) Quality Committee(b) Audit Committee(c) Remuneration and Terms of Service Committee(d) Charity Trustee(e) Trust Management Board(f) Risk Management Executive(g) Group Strategy Committee

LFEHEHEHEHEHEH

A

A

A

A

AAA

Annual Reports:(a) Audit Committee(b) Remuneration and Terms of Service Committee

EHEH

AA

3/3 95/166

Report to: Board of DirectorsDate of Meeting: 20 June 2019Title of Report: Audit Committee - Terms of Reference and Forward PlanStatus of report:(Approval, position statement, information, discussion)

Approval

Report Approval Route: Audit Committee, Board of DirectorsLead Executive Director: Andrew Cottom (NED)Author: Erica Hermon, Associate Director of Corporate GovernanceAppendices:

1. Purpose of the reportTo provide the Board of Directors the opportunity to review and approve the terms of reference and forward plan for the Audit Committee

2. RecommendationsTo approve the terms of reference and forward plan for the Audit Committee.

3. Executive Director OpinionThe terms of reference for Audit Committee and the Trust’s Standing Orders require that an annual review of the terms of reference is undertaken. This is to ensure that any changes to legislation which may have taken place are captured but an annual review is also considered to be best practice and good governance. The terms of reference were approved at the Audit Committee on 20 June 2019.




X



X



X



X

1/2 96/166


x 10. Workforce and Leadership: Enhance our leadership potential through a joint Foundation Group approach to leadership and service. Improvement.

x

2/2 97/166

WYE VALLEY NHS TRUST

AUDIT COMMITTEE

TERMS OF REFERENCE 2019/20

1. Purpose

1.1 The Audit Committee’s prime purpose is to keep an overview of the systems and processes that provide controls assurance and governance within the organisation as described in the Annual Governance Statement on behalf of Trust Board and that these systems and processes used to produce information taken to Trust Board are sound, valid and complete. This includes ensuring independent verification on systems for risk management and scrutiny of the management of finance.

1.2 The Audit Committee is a Non-Executive Committee of the Board of Directors and has no executive powers, other than those duties and decisions delegated by the Board through the Scheme of Delegation.

1.3 The Audit Committee shall provide an independent and objective view on internal control, probity and embedded systems of assurance in line with Department of Health Guidance.

1.4 The Audit Committee will provide proactive oversight on the governance arrangements of the Trust and will not infringe on management’s responsibility to deliver the arrangements.

2. Membership

2.1 The Committee will comprise three nominated Non-Executive Directors who shall be approved by the Board from amongst the Non-Executive Directors of the Trust and shall include a member with significant, recent and relevant financial experience.

2.2 Neither the Chair of the Trust or the Chief Executive attends this Committee unless invited to do so by the Committee Chair.

2.3 The Chair of the Committee is a Non-Executive Director appointed by the Board of Directors. If the Chair is not present, then members present will agree which of the remaining Non-Executive Directors will chair the meeting.

2.4 The following will be in attendance:

The Director of Finance and Information (as lead Executive Director);

The Managing Director and Executive Directors are expected and will be invited to attend when the Committee is discussing areas of risk or operation that are the responsibility of that Director.

Internal and External Audit representatives

Associate Director of Corporate Governance and Company Secretary (as secretary to the committee) whose duties will include:

1/6 98/166

Advising the Committee on pertinent areas relating to governance and risk management arrangements.

Supporting the Chief Executive as Accountable Officer on issues in relation to internal controls, governance and risk management particularly providing assurance on such systems through the drafting of the Annual Governance Statement.

The development of an annual programme of work for the Committee to approve.

The development of each Audit Committee agenda based upon the annual programme of work for agreement with the Director of Finance and Information Agreement and the Committee Chair

Ensuring that the agenda, reports and corresponding minutes reflect confidential items.

Ensuring the collation & distribution of the Committee papers at least 5 working days in advance of the meeting.

Ensuring the minutes accurately reflect the business of the meeting & keeping an accurate record of matters arising and issues to be carried forward is maintained.

Ensuring that minutes and actions are circulated to the Chair for comments within 5 working days of the meeting and circulated to the other members for comments within 10 working days.

Executive Assistant, whose duties will include:

Collation and circulation of papers Taking the minutes and agreeing these with the Chair Keeping a record of matters arising and seeking updates on action points

2.5 In exceptional circumstances, deputies may be nominated to attend prior to the meeting, with the Chair’s approval.

2.6 The Chair of the Committee may also extend invitations to other personnel with relevant skills, experience or expertise as necessary to deal with the business on the agenda.

2.7 Other Non-Executive Directors may attend the meeting at the invite of the Committee Chair or where a nominated Non-Executive Director has arranged for another Non-Executive Director to attend on their behalf.

2.8 The Audit Committee, supported by the Director of Human Resources and Organisational Development, will ensure that all members are suitably trained and have continuing appropriate training to enable them to be effective.

3. Quorum

3.1 A quorum shall be two Non-Executive members, to include the member with significant, recent and relevant financial experience/ Chair of the Committee. In the unusual event that the Chair is absent from the meeting, the Committee will agree another Non-Executive Director to take the chair.

3.2 A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee.

4. Frequency of Meetings

2/6 99/166

4.1 Meetings shall be held not less than four times a year. The External Auditor or Head of Internal Audit may request a meeting if they consider that one is necessary.

4.2 At least once a year, but preferably routinely, the Committee shall meet privately with the External and Internal Auditors.

4.3 It is the responsibility of the Lead Director to ensure items are identified for the Committee’s agenda in line with the Committee’s terms of reference, its work programme agreed at the beginning of each year and the current risks facing the organisation, and to agree these with the Chair of the Committee.

5. Notice of Meetings

5.1 Meetings of the Audit Committee, other than those regularly scheduled as above, shall be summoned by the Secretary to the Audit Committee at the request of the Chair of the Audit Committee.

5.2 Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed and supporting papers, shall be forwarded to each member of the Committee and any other person invited to attend, no later than 5 working days before the date of the meeting via AdminControl.

6. Authority

The Committee is authorised by Trust Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed by Trust Board to co-operate with any request made by the Committee. The Committee is also authorised by Trust Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

7. Duties

The duties of the Committee can be categorised as follows:

a. Governance, Risk Management and Internal Control

The Committee shall review the establishment and maintenance of an effective system of governance, risk management and internal control, across the whole of the organisation’s activities that support the achievement of the organisation’s objectives.

In particular, the Committee will review:

• all risk and control related disclosure statements (i.e. the Governance Statement, Accounting Policies, Quality Accounts), together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to endorsement by the Board

• the underlying assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks, the Board Assurance Framework and the appropriateness of the above disclosure statements

3/6 100/166

• The procedures for ensuring compliance with relevant regulatory, legal and code of conduct requirements

• The procedures for all work related to fraud and corruption as set out in Secretary of State Directions and as required by the Counter Fraud and Security Management Service

• The procedures for monitoring compliance with Standing Orders and Standing Financial Instructions;

• Schedules of losses and compensations and making recommendations to the Board.

• Schedules of debtor/creditor balances greater than £5,000 and over 6 months

• The annual financial statements prior to submission to the Board.

In carrying out this work, the Committee will primarily utilise the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these audit functions. It will also seek reports, policies and assurances from directors and managers as appropriate, concentrating on the overarching systems of governance, risk management and internal control, together with indicators of their effectiveness.

This will be evidenced through the Committee’s use of an effective Assurance Framework to guide its work and that of the audit and assurance functions that report to it.

b. Internal Audit

The Committee shall ensure that there is an effective internal audit function established by management that meets mandatory Public Sector Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Chief Executive Officer and Board.

This will be achieved by:

• Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and dismissal

• review and approval of the Internal Audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organization as identified in the Assurance Framework

• Consideration of the major findings of internal audit work (and management’s response), and ensure co-ordination between the Internal and External Auditors to optimise audit resources

• ensuring that the Internal Audit function is adequately resourced and has appropriate standing within the organisation

• Annual review of the effectiveness of internal audit

c. External Audit

The Committee shall review the work and findings of the External Auditor and consider the implications and management’s responses to their work. This will be achieved by:

4/6 101/166

• consideration of the appointment and performance of the External Auditor, in line with the requirements of the 2014 Local Audit and Accountability Act and in accordance with any codes, rules and guidance issued by the National Audit Office and NHS Improvement.

• discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the Annual Plan, and ensure coordination, as appropriate, with other External Auditors in the local health economy.

• Discussion with the External Auditors of their local evaluation of audit risks and assessment of the Trust and associated impact on the audit fee.

• review all External Audit reports, including agreement of the annual audit letter before submission to the Board, together with the appropriateness of management responses.

• review the procedures for the provision of non-audit services, ensuring the effectiveness of the process and the independence of the external auditors.

Ensuring that the External Audit tenure of appointment conforms with ethical rules regarding rotation of key audit personnel and the provider as a whole.

The Committee shall ensure the cost effectiveness of External Audit.

d. Other Assurance Functions

The Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation.

These will include, but will not be limited to, any reviews by Department of Health, Arm’s Length Bodies or Regulators/Inspectors and professional bodies with responsibility for the performance of staff or functions.

In addition the Committee will review the work of other committees within the organisation, whose work can provide relevant assurance to the Audit Committee’s own scope of work. This will particularly include the Clinical Quality Committee and the Risk Management Executive.

In reviewing the work of the Clinical Quality Committee, and issues around clinical risk management, the Audit Committee will wish to satisfy itself on the assurance that can be gained from the clinical audit function.

The Committee will receive an assurance report on the process for the Quality Accounts prior to final approval by the Trust Board.

e. Suspension of Standing Orders

The Committee shall review every Board decision to suspend Standing Orders.

f. Management

5/6 102/166

The Committee shall request and review reports and positive assurances from Directors and managers on the overall arrangements for governance, risk management and internal control.

They may also request specific reports from individual functions within the organisation (e.g. clinical audit) as they may be appropriate to the overall arrangements.

The Audit Committee will provide a clear expectation of professional competency and feedback on the Trust’s Director of Finance and Information and senior financial management staff to the Chief Executive Officer and Workforce and Development Committee on request.

g. Financial Reporting

The Committee should ensure that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the Board.

h. Counter Fraud

The Committee shall satisfy itself that the organisation has adequate arrangements in place for countering fraud and shall review and signoff counter fraud documents and proposals in support of the Trust. the outcomes of counter fraud work.

8. Reporting Responsibilities

8.1 Trust Board will receive the minutes of Committee at the Trust Board meeting following the Committee meeting.

8.2 The Committee will also report to the Board annually on its work and include commentary on its support of the Annual Governance Statement, the effectiveness of assurance systems, the work of internal and external audit and the annual accounting process.

9. Review

These Terms of Reference will be reviewed annually or sooner if required and recommendations made to the Trust Board for approval.

10. Approval

Date of approval: Approving Body: Board of Directors

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AUDIT COMMITTEE PROGRAMME OF WORK 2019/20D=Discussion A=Approval I= Information Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20Audit CommitteeGovernanceReview Risk Management and Board Assurance Framework D DAnnual Report and Annual Governance Statement Timetable DReview draft Annual Governance Statement DReview the Trust’s annual report DReview of other reports and policies as appropriate – for example, changes to standing orders DReview Register of Declarations of Interest D IAppointment of Internal Auditors DLosses and Special Payments DStanding Orders and Standing Financial Instructions DFinancial FocusAgree final accounts timetable and plans for 2018/19 AReview of accounting policies for production of final accounts DReview of unaudited annual accounts and financial statements prior to recommendation to theBoard DReview of systems and accuracy of financial reporting to the Board, including budgetary controls DLosses and Special Payments Quarterly Report D D D DInternal AuditApproval of internal audit plan for 2019/20 AInternal Audit tracking I I I IProgress report and technical update I I I IReceive Head of Internal Audit Opinion 19/20 DReview and approve internal audit plan 2020/21 D AReview and approve internal audit terms of reference AReview the effectiveness of internal audit DReceive internal audit reports:Data Quality Review - Cancer Waiting Times DHutted Wards Project DTemporary Staffing Usage - Medical Locums DOutpatients Clinic Capacity and utilisation DTheatre utilisation DSickness Absense Management DEstates - Contract Management DCost Improvement Programme DAgency Spend DGoverance - Quality Improvement Priorities DBAF and Risk Management DFinancial Systems D DExternal AuditExternal audit plans 2020/21 AExternal audit fees letter 2019/20 AReview the effectiveness of external audit DReceive the External Auditor’s report to those charged with governance and draft Vfm Opinion2019/20 DReceive the External Auditor’s annual audit letter 2018/19 DReceive opinion on Quality Accounts 2018/19 DAudit findings report 2018/19 DCounter FraudReceive and approve annual counter fraud plan 2020/21 A

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Review counter fraud progress reports I I I IReview the effectiveness of the Local Counter Fraud Specialist DReceive counter fraud annual report 2018/19 DClinical AuditReview terms of reference DMedical equipment IQuality Improvement IReview Clinical Audit plan DAudit CommitteeReview Committee Effectiveness DReview Committee’s terms of reference DApprove annual Audit committee report 2019/20 APrivate discussions with internal and external audit D D D DApprove the minutes of the Audit Committee meeting A A A AA+A1:M61pprove Committee Work plan A

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Report to: Board of DirectorsDate of Meeting: 4 July 2019Title of Report: Executive Risk Management - Terms of Reference and Forward

PlanStatus of report:(Approval, position statement, information, discussion)

Approval

Report Approval Route: Executive Risk Management, Board of DirectorsLead Executive Director: Jane Ives, Managing DirectorAuthor: Erica Hermon, Associate Director of Corporate GovernanceAppendices:

1. Purpose of the reportTo provide the Board of Directors the opportunity to review and approve the terms of reference and forward plan for the Executive Risk Management Meeting

2. RecommendationsTo approve the terms of reference and forward plan for the Executive Risk Management Meeting

3. Executive Director OpinionThe terms of reference will allow for the appropriate management of the Executive Risk Management Meeting which in turn will enable assurance to be provided to the Board of Directors.

These Terms of Reference will be reviewed every 12 months or sooner if required

The terms of reference were approved at the Executive Risk Management Meeting on 5 May 2019.




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x 10. Workforce and Leadership: Enhance our leadership potential through a joint Foundation Group approach to leadership and service. Improvement.

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Wye Valley NHS Trust

Executive Risk Management

Terms of Reference

1. Purpose

The overall purpose of the Executive Risk Management is to ensure the effective implementation of the Risk Management Strategy and there are core processes in place to manage risks across the organisation.

The Executive Risk Management will report on any issue where the Board of Directors may require additional assurance or where a Board of Directors decision is required.

2. Membership

Managing Director Director of Finance and Information Chief Operating Officer Director of Nursing Medical Director Director of Human Resources Associate Director of Corporate Governance / Company Secretary Director of Strategy and Planning Deputy Director Quality Governance Patient Safety and Risk Manager Divisional Operations Director/or equivalent – (Surgery, Medicine, Integrated

Head, Clinical Support) Divisional Nurse Directors/or equivalent (Surgery, Medicine, Integrated Head,

Clinical Support) Associate Medical Directors – by exception Head of Midwifery

Other staff of the Trust may be requested to attend for specific matters.

3. Attendance

The expectation is for 100% attendance at meetings. Members unable to attend should inform the administrator and nominate a deputy, except in extenuating circumstances of absence. In normal circumstances, any members who are unable to attend should nominate a deputy who is appropriately briefed to participate in the meeting.

Where a member is unable to attend routinely an appropriate deputy who will attend on a regular basis should be nominated and notified to the Chair.

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4. Chair

The Managing Director will Chair the meeting. The Deputy Chair will be the Director of Nursing.

5. Quorum

A quorum shall be 3 members with a minimum of 2 Executive Directors one of whom must be the Managing Director or their Deputy

6. Frequency of Meetings

The Executive Risk Management shall normally meet monthly.

7. Notice of Meetings

Agenda and papers will be circulated one week prior to the meeting.

8. Administrative Support

An Executive Assistant will provide administrative support.

9. Duties

Promote a culture within the Trust which encourages open and honest reporting of risk with local responsibility and accountability.

Provide a forum for the discussion of key risk management issues within the Trust.

Coordinate the identification of all risks; Clinical, Health & Safety, IT, Finance, Human Resources, Workforce and Estates and ensure risk assessments are undertaken Trust-wide, and that all risks are appropriately evaluated.

Ensure appropriate actions are applied to both clinical and non-clinical risks Trust-wide.

Enable risks which cannot be dealt locally to be escalated, discussed and prioritised.

Through the Divisional Risk Registers review new risks rated Red (15-25) and Amber (12) to consider whether they have been appropriately rated and agreeing action plans to control them.

Through the Divisional Risk Registers review and monitor risks rated Red (15-25) ensuring action plans are being implemented to control the risks. In addition the Executive Risk Management will review risks rated Amber (12), on a quarterly basis, to consider whether they have been appropriately rated.

Review the risks on the Divisional Risk Registers to determine whether any of them will impact on the Trust’s Strategic Objectives, and if so, the risk will be added to the Board Assurance Framework.

Review the Board Assurance Framework prior to its presentation to Board of Directors.

Advise the Board of Directors of exceptional risks to the Trust and any financial implications of these risks.

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Monitor the effectiveness of the agreed action plans. Recommend priorities for resources to manage risks. Oversee the work of the Divisional Risk Governance Groups, the Corporate

Division Risk Committee and the Health, Safety & Wellbeing Committee Review and monitor the implementation of the Risk Management Strategy Ensure that all appropriate and relevant requirements are met to enable the

Chief Executive to sign the Annual Governance Statement Approve documentation relevant to the implementation of the Risk

Management Strategy

10. Reporting Requirements / Responsibilities

Executive Risk Management will receive monthly risk registers from each of the Divisions (Surgical, Medicine, Integrated Care and Clinical Support) showing all high level risks (15 and above)

Risk Management Executive will undertake a deep dive, on a quarterly basis, of all the Divisions (Surgical, Medicine, Integrated Care and Clinical Support) Risk Registers to include risks scoring Red (15-25) and Amber (12).

Executive Risk Management will receive minutes from Health, Safety and Wellbeing Committee and a verbal update from the Chair as necessary.

Executive Risk Management will received risks from the Corporate Division Risk Committee which are rated high (15 and above)

The Company Secretary will provide a quarterly report to the Board of Directors on the Risk Register (All risks 15 -25) and the Board Assurance Framework (Strategic Risks 15 -25).

Exceptionally, where a newly-identified high risk becomes known to the Executive Risk Management, the Company Secretary will provide a written report to the next Board of Directors meeting.

Quality Committee will receive all clinical risks rated Red (15 -25) twice yearly from the Divisional Risk Registers.

Health, Safety & Wellbeing Committee will receive the Divisional Health & Safety risk register at each meeting.

The Divisional Governance Groups will receive their risk registers on a monthly basis.

Internal Audit will report to the Audit Committee, at least once a year, on the effectiveness of the management of the risks on the Board Assurance Framework.

The Executive Risk Management, established as part of the risk management arrangements approved by the Board of Directors, is accountable through the Managing Director to the Board of Directors.

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11. Compliance and Review

These Terms of Reference will be reviewed annually or sooner if required and recommendations made to Board of Directors for approval.

12. Approval

Date of approval by Executive Risk Management:

Approving Body: Board of Directors:

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RISK MANAGEMENT EXECUTIVE FORWARD PLAN 2019/20D=Discussion A=Approval I= Information Exec / Lead Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20Routine ReportsSurgical Division Risks 15 and above DOD D D D D D D D D D D D DMaternity Risks 15 and above HNMMedical Division Risks 15 and above DOD D D D D D D D D D D D DIntegrated Care Divisision Risks 15 and above DOD D D D D D D D D D D D DSupport Services 15 and above DOD D D D D D D D D D D D DCorporate Service Functions Risks 15 and above CS D D D D D D D D D D D DBoard Assurance Framework CS D D D D D D D D D D D DHealth and Safety Minutes CS I I I I I IHealth & Safety Annual Report 17/18 CS AQuarterly Deep Dive ReviewsSurgical Division Risks 12 and above DOD D D DMedical Division Risks 12 and above DOD D D DIntegrated Care Divisision Risks 12 and above DOD D D DSupport Services 12 and above DOD D D DMaternity Deep Dive 12 and above HNM D DGovernanceMinutes CS A A A A A A A A A A A AAction Log CS D D D D D D D D D D D DRisk Management Executive Terms of Reference CS A A

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Report to: Board of DirectorsDate of Meeting: 4 July 2019Title of Report: Cyber-Security Report 7Status of report:(Approval, position statement, information, discussion)

Information

Report Approval Route:Lead Executive Director: Howard Oddy, Director of Finance and InformationAuthor: David Warden, Associate Director of IM&TAppendices:

1. Purpose of the reportThis report provides members of the Board with an update on the Trust’s cyber-security preparedness and highlights those areas where future action may be required.

2. RecommendationsThis report is intended for information and assurance.

3. Executive Director OpinionThis report provides the Board with an update on the arrangements made by the Trust in respect of cyber-security. It can be seen that the Trust is investing significant capital in order to address the combined issues of both hardware and software obsolescence and this will reduce the security risk associated with these issues. The major issue for the Board to be aware of is regarding the current advice on passwords, which the Trust has initially chosen not to follow – this issue will be monitored over forthcoming months.












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Scope of Report

This report covers the following topics.

1. Cyber Essentials Plus – the standard against which the Trust’s cyber security readiness is audited

2. Hardware and software obsolescence

3. New national password guidance

4. NHS Digital’s Unified Cyber Risk Framework (UCRF)

Cyber Essentials Plus

The requirements for this standard were covered in the previous report dated January 2019. The January report followed the NHS Digital on-site inspection which was conducted by Dionach in November 2018. In February, Dionach undertook a review of progress against the remediation plan developed following the inspection. Two critical findings had been addressed by Hoople and were closed. Outstanding critical findings which, unless addressed, will prevent the Trust achieving Cyber Essentials Plus compliance are:

Old and unsupported versions of client software

Weak user passwords

The Trust’s approach to these recommendations is covered in the items below.

Hardware and Software Obsolescence

The Trust is in the process of investing in the replacement of obsolete hardware and software as part of its three year IM&T investment programme. The Data Centre project began last year to replace the server hardware platform. This original scope is nearing completion with 104 out of 115 servers now transferred to the new platform. This year capital money has been allocated, and a business case is nearing completion, for subsequent phases of the project, to address the upgrade of SQL 2008 and Windows Server 2008 which go out of support in July 2019 and January 2020 respectively.

The Trust’s client computing estate is receiving similar attention through the project begun in April 2019 to replace client hardware more than five years old and to upgrade to Windows 10. Windows 7, which is in use on the majority of the Trust’s PCs, goes out of support in January 2020 although, by virtue of adopting the national licence agreement for Windows 10, the Trust expects to receive extended support for Windows 7 for a limited period. This will enable the project to span two financial years, as planned, without incurring additional cost or risk.

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New National Password Guidance

On 19 November 2018, the UK National Cyber Security Centre (NCSC) published new guidance to organisations on how to update their approach to passwords. Modern computer technology enables a motivated hacker to compromise any complex, eight character password in about six hours.

The new guidance included the recommendation to increase the minimum length of user passwords, reduce complexity requirements and increase the length of time between password changes. It also included recommendations for technology to help users with “password overload”. The immediate impact of this guidance on the NHS is that systems such as NHSmail will soon start to require users to set longer passwords when their current passwords expire.

TMB considered the new guidance on 3rd May 2019 upon the recommendation of the Trust’s Information Governance Committee. To avoid adverse operational impact, the decision was taken not to implement longer passwords with an extended expiry date in the Trust at this time but to keep the situation under review. There was interest in the smart-card based single sign-on pilot being undertaken at George Eliot Hospital and it was agreed to consider adopting this at a later stage of the hardware replacement project to improve the clinical user experience.

The Board should note that the Trust will not achieve Cyber Essentials Plus compliance while easily-compromised passwords are allowed on its systems.

Unified Cyber Risk Framework

In March 2019, the Trust became an early adopter of the NHS Digital UCRF. This is a new framework for managing cyber-security risk. Two full day workshops were conducted by Dionach, the output from which was a locally customised list of cyber risks that have been identified nationally because of their potential to affect Trusts. Work is now taking place to assimilate these risks with the Hoople and Trust risk registers and implement joint quarterly reviews. Informal feedback from the early adopter process indicated that the Trust’s approach to managing cyber risk was already above average in the NHS.

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Report to: Board of Directors Date of Meeting: 4th July 2019Title of Report: Board Update on Progress against Undertaking agreed with NHSIStatus of report:(Approval, position statement, information, discussion)Report Approval Route: Agreed through Performance Review Meeting with NHSILead Executive Director: Jane Ives Managing DirectorAuthor: Jane IvesAppendices: Undertakings Enforcement Notice Annex 1, Progress Review

Outcome Annex 21. Purpose of the report

To Inform the Board of progress against the Undertakings enforcement notice received in January from NHSI.

2. RecommendationsThe Board is asked to note the progress report.

3. Executive Director OpinionThere has been good progress against the undertakings and a number of areas have been completed. A trajectory for RTT improvement has not yet been agreed by NHSI or the CCG. The attached report on progress has been signed off by NHSI as an accurate record on progress.

4. Please state (using ‘x’) which element of the Trust’s Objectives the report relates to:1. Quality Improvement: Continuously

improve quality of care by delivering on our quality priorities, focussing on our patients and the time they spend in our care.


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Executive Summary

In December 2018 enforcement undertakings were received by the Trust from NHSI. These were discussed and accepted by the Board in January 2019.

The response to NHSI highlighted that the Board were a little concerned that, by its tone, the order appeared not to recognise the significant improvements that the Trust had made of the past year. In particular, that our primary focus had been to address serious quality concerns including those previously raised by the CQC and those emanating from our historical mortality levels. Both had which had significantly improved over the previous year.

We also pointed out to NHSI the marked improvement in our staff survey and year on year improvements in recruitment and retention and in addressing long waits for elective surgery. All of this had been achieved alongside two consecutive years where the Trust had achieved greater efficiency savings proportionately than any other provider in the region.

However, the Board recognised that by its nature the undertakings letter concentrated on the remaining areas for improvement and confirmed its commitment to the improvements that were highlighted. We also noted the need to set realistic trajectories, which have been set in most areas, but remain outstanding for RTT improvement with the CCG wishing to restrict improvement to 2018/18 outturn and the Trust recognising that the reliable elimination of 52 weeks waiting patients requires a trajectory of 82.6%.

Annex 1 is a copy of the undertakings letter and at annex 2 is the position agreed with NHSI at the end of May. The RAG rating colour coding is blue where the element is complete, green where progress remains on plan and amber where there is some risk to delivery. There are currently no red rated areas.

The template will be completed quarterly with NHSI and reported to the Board.

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ANNEX 1ENFORCEMENT UNDERTAKINGS

NHS TRUST:Wye Valley NHS Trust (‘the Trust’)Hereford County HospitalStonebow RoadHerefordHR1 2BN

DECISION:

On the basis of the grounds set out below and pursuant to the powers exercisable by NHS Improvement under or by virtue of the National Health Service Act 2006 and the TDA Directions, NHS Improvement has decided to accept undertakings from the Trust.

DEFINITIONS:

In this document:

“the conditions of the Licence” means the conditions of the licence issued by Monitor under Chapter 3 of Part 3 of the Health and Social Care Act 2012 in respect of which NHS Improvement has deemed it appropriate for NHS Trusts to comply with equivalent conditions, pursuant to paragraph 6(c) of the TDA Directions;

“NHS Improvement” means the National Health Service Trust Development Authority;

“TDA Directions” means the National Health Service Trust Development Authority Directions and Revocations and the Revocation of the Imperial College Healthcare National Health Service Trust Directions 2016.

GROUNDS:

1. The Trust

The Trust is an NHS Trust all or most of whose hospitals, facilities and establishment are situated in England.

2. Issues and need for action

2.1. NHS Improvement has reasonable grounds to suspect that the Trust has provided and is providing health services for the purposes of the health service in England while failing to comply with the following conditions of the Licence: FT4(5)(a) to (e), and FT4(6)(a) to (f).

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2.2. In particular:

Quality

2.2.1. The Trust was inspected by the Care Quality Commission (CQC) in June 2018 which resulted in an Overall rating of ‘Requires Improvement’. The Trust received ‘Good’ for Caring and ‘Requires Improvement’ for Safe, Effective, Well-led and Responsive. The Responsive domain improved from Inadequate to Requires Improvement, however remained Inadequate for Surgery. Further evidence is set out in the CQC’s report. The inspection resulted in 13 must-do and 37 should-do actions with three requirement notices. The Trust was also issued a section 29A notice in August 2018 as a result of ongoing concerns in Referral to Treatment (RTT) and waiting times across all specialities.

2.2.2. The Trust has been a statistical outlier for both SHMI and HSMR over an extensive period of time. SHMI has reduced to 1.12 for the period of April 2017 to March 2018 resulting in the Trust no longer being a published outlier. A further reduction has been observed since although the latest data is awaiting publication. In terms of HSMR, this indicator has reduced to 116.4 for the period of January 2017 to December 2017 and remains an outlier. The Trust continues to deliver and embed its mortality strategy and associated improvement actions.

2.2.3. The Trust reports a high vacancy rate for consultants and nursing workforce and subsequent excessive agency spend.

Operational Performance

2.2.4. The Trust has failed to achieve the A&E 4 hour waiting time since 2014 and did not deliver its recovery trajectory in 2017/18. The Trust has failed to achieve the RTT standard prior to 2014 with its best performance position reported as 80.2% in November 2017. The Trust has reported 52-week Referral to Treatment breaches, with the latest position of 81 breaches in November 2018. The Trust has not achieved the 2 week-wait cancer standard for breast patients during 2018/19 and is not delivering its recovery trajectory.

Financial Position

2.2.5. For 2017/18, the Trust agreed a revised control total of £31.3 million deficit and reported a year end deficit of £31.272 million (excluding STF) which represented a £5.9 million improvement on 2016/17. The deficit represents 16.6% of the Trust’s (£188.498m). However, in June 2018 the Trust had a ‘Use of Resources’ inspection and was rated Inadequate based on historic performance of the Trust in 2015/16 and 2016/17. The Trust’s cash flow position has been challenging with the Trust being dependent on revenue and capital loans. The total outstanding loans at 2017/18 year end was £103.58 million, excluding PFI liabilities of £48.5 million. In 2018/19, the Trust agreed a control total of £27.2 million deficit, before Provider Sustainability Funding (PSF). It formally revised its forecast outturn (at month 6) to a deficit of £31.1m, before PSF but the run rate has continued to deteriorate.

2.2.6. The Trust has significantly failed to deliver its agency ceiling for the last two years. The Trust’s agency ceiling was £9.76m and its outturn in 2016/17 was £16.84m and in 2017/18 was £15.21m. The Trust’s plan for 2018/19 was £8.9m but is forecasting £13.7m (as at October).

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2.3. These failings by the Trust demonstrate a failure of governance arrangements including, in particular, failure to establish and effectively implement systems and/or processes:

to ensure compliance with health care standards binding on the Trust; for financial decision making, management and control (including but not restricted to

appropriate systems and/or process to ensure the Trust’s ability to continue as a going concern;

to ensure compliance with the Trust’s duty to operate efficiently, economically and effectively.

2.4. Need for action:

NHS Improvement believes that the action which the Trust has undertaken to take pursuant to these undertakings, is action required to secure that the failures to comply with the relevant requirements of the conditions of Licence do not continue or recur.

UNDERTAKINGS

NHS Improvement has agreed to accept and the Trust has agreed to give the following undertakings:

1. Quality Improvement Plan

1.1. The Trust will take all reasonable steps to address the concerns identified in, but not limited to the CQC report, including carrying out the actions and warning notices set out in the CQC report in accordance with timescales as determined by the CQC such that, upon re-inspection by the CQC (such as any date CQC may determine), the Trust will no longer be found to be ‘Inadequate’ in any CQC domain (surgery).

1.2. The Trust will develop a comprehensive Quality Improvement Plan (QIP) submitted to NHS Improvement at a date to be determined and ensure its Board receives monthly updates on its progress. In addition, the Trust will share progress against QIP with NHS Improvement on a monthly basis to include progress against actions and mitigations.

1.3. The Trust will fully test out the effectiveness of its quality governance arrangements to ensure they are robust and effective.

1.4. The Trust will continue to deliver and embed its Mortality Strategy and associated improvement actions, and these must be linked to clear outcome measures. The Trust will ensure that its Board receives monthly progress updates pertaining to its Mortality Strategy and associated improvement actions and outcome measures. The Trust will be expected to continue to work closely with NHS Improvement, to provide assurance on progress and to ensure potential support needs are identified and will be required to continue to work collaboratively with Herefordshire CCG in support of mortality quality improvements.

1.5. The Trust will be required to continue to engage with NHS Improvement on workforce improvement strategies, including workforce and agency oversight meetings and associated collaboratives. NHS Improvement will undertake a focussed workforce/agency review and observe the Workforce Committee as part of this review.

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2. Urgent and Emergency Care

2.1. The Trust will take all reasonable steps in order to meet its projected operational performance and achieve sustainable compliance with the 4 hour A&E standard, in line with the Trust trajectory delivery of 90% by December 2018 and 95% by March 2019.

2.2. The Trust will submit to NHS Improvement an (updated) improvement plan to achieve compliance with the standard on a sustainable basis. The plan will be delivered in a timeframe to be decided by NHS Improvement.

3. Cancer

3.1. The Trust will take all reasonable steps to recover and sustainably maintain cancer performance in Cancer 62day, Cancer 2ww and Cancer 2ww breast by January 2019 in line with the agreed trajectories.

3.2. The Trust will produce and submit to NHS Improvement an action plan to achieve compliance with the 2ww and 62 day standard on a sustainable basis. The plan will be delivered in a timeframe to be decided by NHS Improvement

4. Elective Care

4.1. The Trust will take all reasonable steps to recover operational performance to meet its trajectory and clear all 52 week breaches by March 2019.

4.2. The Trust will work with commissioners to model and agree what a sustainable compliance with the RTT standards would require in terms of Trust capacity and commissioner affordability and then develop a delivery plan to achieve this. The plan will be delivered in a timeframe to be decided by NHS Improvement.

5. Financial Performance

5.1. The Trust will take all reasonable steps to deliver its 2018/19 financial plan as submitted to NHS Improvement on 20th June 2018. In particular, the Trust will ensure that robust arrangements are in place to maintain and strengthen financial control, reduce run rate, preserve cash and minimise the deficit.

5.2. The Trust will, by a date to be agreed by NHS Improvement, develop and submit a strategic financial plan with key milestones to monitor progress against the strategic direction.

5.3. The plan should include an understanding of the underlying causes of the Trust’s financial position, including identification of any loss-making services to be addressed to ensure financial sustainability, any current issues (such as the requirement to deliver seven-day services) that impact on the Trust’s ability to deliver financial sustainability, fragile services (either current or medium to long term) that require strategic planning and any system-wide changes that are planned under the Strategic Transformation Partnership (STP) that will impact the long term financial sustainability of the Trust.

5.4. The Trust will comply with any terms and conditions which attached to the interim support financing, provided by the

Secretary of State for Health to the Trust under Schedule 5 to the National Health Service Act 2006

terms and conditions attached to the Provider Sustainability Fund payments.

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spending approvals processes that are deemed necessary by NHS Improvement.

6. Agency Ceiling

6.1. The Trust will, by a date to be agreed by NHS Improvement, develop and submit an agency plan (AP). This plan should include detailed actions with clear timescales by when the Trust will achieve the agency ceiling.

6.2. The content of the AP will be agreed with NHS Improvement and is to include actions to address the key issues identified, including high level milestones for delivery of the Trust’s key schemes, a phased monthly financial trajectory, governance processes, programme management arrangements to support delivery of the plan and a credible trajectory to achieve ceiling.

7. Programme management

7.1. The Trust will implement sufficient programme management and governance arrangements to enable delivery of these undertakings.

7.2. Such programme management and governance arrangements must enable the board to:

obtain clear oversight over the process in delivering these undertakings; obtain an understanding of the risks to the successful achievement of the undertakings and

ensure appropriate mitigation; and hold individuals to account for the delivery of the undertakings.

8. Access

8.1. The Trust will provide to NHS Improvement direct access to its advisors, programme leads and the Trust’s board members as needed in relation to the matters covered by these undertakings.

9. Meetings and reports

9.1. In addition to the action in paragraph 5.2 (reporting in relation to Financial Performance) the Trust will:

attend meetings or, if NHS Improvement stipulates, conference calls, at such times and places, and with such attendees, as may be required by NHS Improvement; and

provide such reports in relation to the matters covered by these undertakings as NHS Improvement may require.

10. Partner organisation

10.1. The Trust will continue to co-operate and work with South Warwickshire NHS Foundation Trust and will:

accept support and expertise provided to the Trust; and

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accept assistance provided to the Trust regarding the delivery of its Quality Improvement Plan and/or the improvement of its finances and the quality of care the Trust provides.

Any failure to comply with the above undertakings may result in the NHS Improvement taking further formal action. This could include giving directions to the Trust under section 8 of the National Health Service Act 2006 and paragraph 6 of the TDA Directions.

THE TRUSTSigned (Chair or Chief Executive of Trust)

Dated

NHS IMPROVEMENTSigned (Chair of the Regional Support Group – Midlands and East)

Dated

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Annex 2

Quality Improvement Update 20/05/19 May RAG

The Trust will take all reasonable steps to address the concerns identified in, but not limited to the CQC report, including carrying out the actions and warning notices set out in the CQC report in accordance with timescales as determined by the CQC such that, upon reinspection by the CQC (such as any date CQC may determine), the Trust will no longer be found to be ‘Inadequate’ in any CQC domain (surgery).

Zero 52 week waits April and on plan for May. Contract not yet agreed but proposal is for an improvement to 82.6%. CQC advice sought for the implication of this on inadequate rating for surgery.

All CQC 'must do' action now completed with ongoing work on VTE compliance and Updating guidelines.

The Trust will develop a comprehensive Quality Improvement Plan (QIP) submitted to NHS Improvement at a date to be determined and ensure its Board receives monthly updates on its progress. In addition, the Trust will share progress against QIP with NHS Improvement on a monthly basis to include progress against actions and mitigations

Oversight is included in CQC action plan, quality priorities for the year agreed through board and published

The Trust will fully test out the effectiveness of its quality governance arrangements to ensure they are robust and effective

Review of governance has been undertaken across the foundation group (report shared with NMSM)

CQC have observed Quality Committee and verbal feedback was positive with no recommendations for actions.

The Trust will continue to deliver and embed its Mortality Strategy and associated improvement actions, and these must be linked to clear outcome measures. The Trust will ensure that its Board receives monthly progress updates pertaining to its Mortality Strategy and associated improvement actions and outcome measures. The Trust will be expected to continue to work closely with NHS Improvement, to provide assurance on progress and to ensure potential support needs are identified and will be required to continue to work collaboratively with Herefordshire CCG in support of mortality quality improvements

SHMI 99.43 - Complete

The Trust will be required to continue to engage with NHS Improvement on workforce improvement strategies, including workforce and agency oversight meetings and associated collaboratives. NHS Improvement will undertake a focussed workforce/agency review and observe the Workforce Committee as part of this review

Nurse agency/medical agency boards in place. Workforce deep dive undertaken, observation of committee undertaken.

Trust are relaunching bank to standardise bank rates on July 1stUEC

The Trust will take all reasonable steps in order to meet its projected operational performance and achieve sustainable compliance with the 4 hour A&E standard, in line with the Trust trajectory delivery of 90% by December 2018 and 95% by March 2019.

UEC system programme of work in place for Herefordshire, already demonstrating improvement in performance - 86% to date in May ahead of trajectory. PM lead appointed

The Trust will submit to NHS Improvement an (updated) improvement plan to achieve compliance with the standard on a sustainable basis. The plan will be delivered in a timeframe to be decided by NHS Improvement. Improved trajectory submitted as part of 19/20 planning submissionCancer

The Trust will take all reasonable steps to recover and sustainably maintain cancer performance in Cancer 62day, Cancer 2ww and Cancer 2ww breast by January 2019 in line with the agreed trajectories.

Good level of specialty review, senior oversight and improved management structure

The Trust will produce and submit to NHS Improvement an action plan to achieve compliance with the 2ww and 62 day standard on a sustainable basis. The plan will be delivered in a timeframe to be decided by NHS Improvement Trajectories submitted as part of 19/20 planning submissionRTT

The Trust will take all reasonable steps to recover operational performance to meet its trajectory and clear all 52 week breaches by March 2019. Zero 52 week waits and of April and on target for end of MayThe Trust will work with commissioners to model and agree what a sustainable compliance with the RTT standards would require in terms of Trust capacity and commissioner affordability and then develop a delivery plan to achieve this. The plan will be delivered in a timeframe to be decided by NHS Improvement

Ongoing contractual discussions - Trust view that assurance on 52 week wait patients will require an overall performance improvement to 82.6%

Financial Performance

The Trust will take all reasonable steps to deliver its 2018/19 financial plan as submitted to NHS Improvement on 20th June 2018. In particular, the Trust will ensure that robust arrangements are in place to maintain and strengthen financial control, reduce run rate, preserve cash and minimise the deficit.

Agreed to CT for 19/20Worse case 18/19 position submitted but may change according to contractual factors

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The Trust will, by a date to be agreed by NHS Improvement, develop and submit a strategic financial plan with key milestones to monitor progress against the strategic direction.

NHSM expectation that a system service design, operational and financial strategy is agreed and submitted by Q2

IBP and LTFM to be agreed by Board in July 2019Agency Ceiling

The Trust will, by a date to be agreed by NHS Improvement, develop and submit an agency plan (AP). This plan should include detailed actions with clear timescales by when the Trust will achieve the agency ceiling.

Trajectory set to reduce spend over cap from 62% (£13,575) to 29% (£10,862)

WVT agency plan included in CPIP plans for the year

The content of the AP will be agreed with NHS Improvement and is to include actions to address the key issues identified, including high level milestones for delivery of the Trust’s key schemes, a phased monthly financial trajectory, governance processes, programme management arrangements to support delivery of the plan and a credible trajectory to achieve ceiling.

NHSI audit in December led to Agency improvement action plan including trajectory and governance that is monitored monthly at Board

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Quality Improvement

The Trust will take all reasonable steps to address the concerns identified in, but not limited to the CQC report,including carrying out the actions and warning notices set out in the CQC report in accordance with timescalesas determined by the CQC such that, upon re-inspection by the CQC (such as any date CQC may determine),the Trust will no longer be found to be ‘Inadequate’ in any CQC domain (surgery).

The Trust will develop a comprehensive Quality Improvement Plan (QIP) submitted to NHS Improvement at adate to be determined and ensure its Board receives monthly updates on its progress. In addition, the Trust willshare progress against QIP with NHS Improvement on a monthly basis to include progress against actions andmitigations

The Trust will fully test out the effectiveness of its quality governance arrangements to ensure they are robustand effectiveThe Trust will continue to deliver and embed its Mortality Strategy and associated improvement actions, andthese must be linked to clear outcome measures. The Trust will ensure that its Board receives monthlyprogress updates pertaining to its Mortality Strategy and associated improvement actions and outcomemeasures. The Trust will be expected to continue to work closely with NHS Improvement, to provide assuranceon progress and to ensure potential support needs are identified and will be required to continue to workcollaboratively with Herefordshire CCG in support of mortality quality improvements

The Trust will be required to continue to engage with NHS Improvement on workforce improvement strategies,including workforce and agency oversight meetings and associated collaboratives. NHS Improvement willundertake a focussed workforce/agency review and observe the Workforce Committee as part of this reviewUECThe Trust will take all reasonable steps in order to meet its projected operational performance and achievesustainable compliance with the 4 hour A&E standard, in line with the Trust trajectory delivery of 90% byDecember 2018 and 95% by March 2019.The Trust will submit to NHS Improvement an (updated) improvement plan to achieve compliancewith the standard on a sustainable basis. The plan will be delivered in a timeframe to be decided byNHS Improvement.CancerThe Trust will take all reasonable steps to recover and sustainably maintain cancer performance inCancer 62day, Cancer 2ww and Cancer 2ww breast by January 2019 in line with the agreedtrajectories. The Trust will produce and submit to NHS Improvement an action plan to achieve compliance withthe 2ww and 62 day standard on a sustainable basis. The plan will be delivered in a timeframe to bedecided by NHS ImprovementRTTThe Trust will take all reasonable steps to recover operational performance to meet its trajectory andclear all 52 week breaches by March 2019.The Trust will work with commissioners to model and agree what a sustainable compliance with theRTT standards would require in terms of Trust capacity and commissioner affordability and thendevelop a delivery plan to achieve this. The plan will be delivered in a timeframe to be decided byNHS ImprovementFinancial PerformanceThe Trust will take all reasonable steps to deliver its 2018/19 financial plan as submitted to NHSImprovement on 20th June 2018. In particular, the Trust will ensure that robust arrangements are inplace to maintain and strengthen financial control, reduce run rate, preserve cash and minimise thedeficit.

The Trust will, by a date to be agreed by NHS Improvement, develop and submit a strategicfinancial plan with key milestones to monitor progress against the strategic direction.

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Agency Ceiling

The Trust will, by a date to be agreed by NHS Improvement, develop and submit an agency plan(AP). This plan should include detailed actions with clear timescales by when the Trust will achievethe agency ceiling.

The content of the AP will be agreed with NHS Improvement and is to include actions to address thekey issues identified, including high level milestones for delivery of the Trust’s key schemes, aphased monthly financial trajectory, governance processes, programme management arrangementsto support delivery of the plan and a credible trajectory to achieve ceiling.

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Update 20/05/19 May RAG

Zero 52 week waits April and on plan for May. Contract not yet agreedbut proposal is for an improvememt to 82.6%. CQC advice sought forthe implication of this on inadequate rating for surgery.

All CQC 'must do' action now completed with ongoing work on VTEcomplinace and Updating guidelines.

Oversight is included in CQC action plan, quality priorities for the yearagreed through board and publishedReview of governance has been undertaken across the foundationgroup (report shared with NMSM)

CQC have observed Quality Committee and verbal feedback waspositive with no recommendations for actions.SHMI 99.43 - Complete

Nurse agency/medical agency boards in place. Workforce deep diveundertaken, observation of committee undertaken.

Trust are relaunching bank to standardise bank rates on July 1st

UEC system programme of work in place for Herefordshire, alreadydemonstrating improvement in performance - 86% to date in Mayahead of trajectory. PM lead appointed

Improved trajectory submitted as part of 19/20 planning submission

Good level of specialty review, senior oversight and improvedmanagement structure

Trajectories submitted as part of 19/20 planning submission

Zero 52 week waits and of April and on target for end of MayOngoing contractual discussions - Trust view that assurance on 52week wait patients will require an overall performaance improvementto 82.6%

Agreed to CT for 19/20Worse case 18/19 position submitted but may change according tocontractual factors

NHSM expectation that a system service design, operational andfinancial strategy is agreed and submitted by Q2

IBP and LTFM to be agreed by Board in July 2019

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Trajectory set to reduce spend over cap from 62% (£13,575) to 29%(£10,862)

WVT agency plan included in CPIP plans for the year

NHSI audit in December led to Agency improvement action planincluding trajectory and governance that is monitored monthly at Board

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Report to: Board of DirectorsDate of Meeting: 4th July 2019Title of Report: Clinical Quality Committee Summary Report of 30th May 2019

meetingStatus of report:(Approval, position statement, information, discussion)

For information

Report Approval Route: N/ALead Executive Director: Lucy Flanagan, Director of NursingAuthor: Christobel Hargraves, NED. Chair of Quality CommitteeAppendices: None

1. Purpose of the reportThe Board of Directors are invited to receive and note the report.

2. RecommendationsTo note the contents of the report in particular:

- The inability to complete the review of all guidelines before the next CQC visit- The information about staffing of inpatient areas as this was an item specifically delegated

by the Board of Directors to the Quality Committee.- To consider the suggestion that the work on Mortality should now be business as usual.

3. Executive Director OpinionN/A





x 7. Integration: Care for more people closer to home by integrating our community services with our One Herefordshire Partners.





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Summary of Key Issues for Discussion

Divisional reports:

Surgery: Continued improvement within reporting period of patients waiting over 52 weeks for a surgical procedure with no patients breaching in April 2019. Significant improvement in numbers of patients awaiting endoscopy procedures both for diagnostics and surveillance with JAG accreditation gained in May 2019. Improvement in reporting period for compliance in the delivery of the 14 day target for first outpatient appointments for Breast and Breast Symptomatic referrals. Paediatric respiratory nurse specialist has been awarded second place in the British Journal of Nursing respiratory nurse of the year award.

Improvement is still needed to improve compliance with VTE assessments in most surgical areas. There is a Trust wide project to address this. Friends and Family response and recommendation rates are not hitting our targets in some areas despite a continued focus and complaints have shown an increase within the Division and the majority related to the attitude of staff and poor care. Focus was needed on the CQC action plan as progress was slow in some areas.

Clinical Support: Work has been undertaken to embed a process of reviewing moderate and low harm incidents and identified appropriate actions to avoid reoccurrence. This was seen as good practice by the Committee. The Division’s clinical audit plan had been agreed and reflected prioritised quality improvement within the Division and a process had been agreed for gaining assurance regarding the implementation of relevant external reports/guidance e.g. NICE, NPSA etc.

Improvement is needed to improve compliance with IV medicines administration training, to improve cleanliness scores and compliance across the Division and to encourage reporting of more clinical incidents with no increase in harm. A concern was also brought to the Committee’s attention in relation to the mismatch of identification details between systems within the Radiology Department.

Maternity & Women’s Health: Achievement of Baby Friendly Initiative Level 3. Launch of the Perinatal Mental Health Service for Herefordshire.

There was concern with regard to a number of senior leadership vacancies and midwife vacancies due to maternity leave. As there was only a small number of agency staff available this was causing concern. Compounding the staff issues there had also been an increase in serious incidents. The staffing issues were on the risk register and the Committee was advised that there were clear action plans agreed at Divisional Governance meetings.

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Confidential Items:

The Committee was informed of the one Never Event and the six serious incidents that had been reported in April. The Never Event was a repeat of two that happened last year. Enhanced spot checking was taking place to mitigate the risk of this happening again.

Insulin Cluster Review: A review of recent insulin incidents was presented to the Committee. A trust-wide action plan had been developed to address the learning identified. There was some discussion as to whether the frequency of training should be increased to yearly from the current three yearly offering.

Update Never Event – Misplaced Nasogastric Tube: A final report on the investigation and subsequent actions from this Never Event was accepted by the Committee. A significant amount of nursing staff had now been assessed to ensure they could both pass a tube and feed a patient.

Patient Experience Committee Terms of Reference: The Committee approved these terms of reference and agreed that the minutes would be received by them. It was noted that patients were represented on each of the sub-groups of this committee. The terms of reference would be reviewed annually.

Mortality Report: The HSMR continued to reduce and was now the second lowest in the region. The first One Herefordshire Mortality Group had taken place in May looking at a system wide approach to the issue. Fracture Neck of Femur was still an outlier although reductions were now being seen in the rolling 12 month HSMR. Work was now underway to develop a Community Hospital Mortality Improvement Plan.

It was noted that Mortality remained a Quality Priority for 19/20. In the light of the significant improvements in this area the Quality Committee agreed to recommend to the Board that this should now be seen as business as usual and this meant that a detailed report was no longer required at Board meetings. A summary would continue to be provided via this report and the KPI reports to Board.

Must and Should CQC Action Plan: It was noted that the plan still did not contain enough details of evidence once an item had been completed. It was agreed that a deep dive would be conducted in those areas where there had been a lack of progress.

The main area of concern was the ability to review all guidelines in the Trust and to determine a process going forward that would achieve this. The Committee heard that this will not be completed before the CQC visit again and agreed that the Board of Directors should be alerted to this fact.

Monthly Report Quality: A revised report was presented to the Committee showing the quality indicators that have been agreed as priorities alongside other key data items. The Committee felt this was a much clearer way of presenting pertinent information with narrative where things were not on target.

FTSU Report: Quarter 4 position presented to the Committee detailing concerns raised, learning received and key activities of the FTSU Guardian.

Quarter 4 Infection Prevention Update: Of the 24 C diff cases reported (17 target), 14 were lapses in care mainly relating to poor hand hygiene and not being bare below the elbow. Work is also needed to reduce the number of

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e-coli cases particularly over the summer period when poor hydration led to a higher number of bacteraemias. Several “clinical practice weeks” had been held which had been well received by staff on the wards leading to good clinical engagement during refresher training.

VTE Progress Report: The Committee was not yet assured that the Trust had a grip on this matter but there had been good progress with the development of a robust action plan. This is one of our Quality Priorities for 19/30.

Staffing Paper- in patient areas: The report presented met the mandatory requirements as set out by NHS England but further work was needed to triangulate the staffing data with quality outcomes and workforce information. Specific concern was raised that there was a rise in the number of incidents reported relating to patient case mix complexity and staffing skill mix with newly qualified and agency nurses leaving the burden of complexity on the experienced substantive nursing staff. This would be monitored going forward.

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Report to: Board Of DirectorsDate of Meeting: 4 July 2019Title of Report: Audit Committee Summary Report of 20 June 2019 meetingStatus of report:(Approval, position statement, information, discussion)

For information

Report Approval Route: N/ALead Executive Director: Howard Oddy, Director of Finance & InformationAuthor: Andrew Cottom, Chair of Audit CommitteeAppendices:

1. Purpose of the reportThe Board of Directors are invited to receive and note the report.

2. RecommendationsTo note the contents of the report and consider any items highlighted for its attention.













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Wye Valley NHS TrustTrust Board Meeting – 4th July 2019

Summary of Audit Committee (AC) meeting held on 20th June 2019

Medical DevicesThe AC received a paper that briefly reviewed the potential benefits and policy direction of asset tracking for over 6000 medical devices the Trust has in use. Currently there is no “live tracking” of these devices within the Trust and the AC has for some time felt that its introduction would resolve a number of safety and cost concerns repeatedly raised through Internal Audit. Furthermore, there is no awareness of the cost and implications of not knowing where devices are and whether they are fully operational. The paper received by AC essentially concluded that, taking account of risks, the capital investment required and changing technologies, the time was not right to pursue Asset Tracking as a priority. Whilst the AC was reluctantly prepared to accept this conclusion, it was on the basis that the feasibility of producing a more holistic strategy on the management of Medical Devices be produced for consideration at its meeting in September.

Quality Improvement PrioritiesThe AC had set aside time in the Internal Audit Plan to review governance arrangements for the Quality Improvement Priorities (QIP) of the Trust. With the Chair of the Quality Committee present, the AC received a presentation from the Nursing Director and Medical Director to that effect. The presentation covered the mandated requirements for QIP’s, the journey of their development within the Trust including how the priorities are set and, how their achievement is measured and managed. Recognising the trajectory of improvement in governance arrangements, the AC were pleased that it had sufficient assurance to enable it to agree to remove the proposed review by Internal Audit from the plan.

Other Matters & ReportsReport Discussion & recommendation

Governance AC reviewed its Terms of Reference and forward work plan. With some minor changes to the former, they were agreed for consideration by the Board.

Declaration of Interests, Gifts and Hospitality Register

This is the first declaration prepared under the new Managing of Conflicts Policy. The AC reviewed the declaration with its main concern being about how the information is used. It was noted that in line with guidance, the information will be public facing once a page on our web-site is established.

Internal Audit (IA) – Plan for 2019/20

The decision relating to Quality Improvement Priorities (see above) means that there is some space in the plan. Two proposals are being considered:- IA input to the AC’s annual assessment of Financial

Reporting arrangements Review of the claims process for clinical negligence

IA report – Agency Staffing

As a follow-up to a previous report, compliance to authorisation protocols was tested. A good level of assurance was gained

IA report – Data Quality for reporting RTT

This follow-up report showed a noticeable improvement in data quality since the last review but did note ongoing challenges within the Maxims area that can impact on data quality if not validated robustly.

Counter Fraud workplan – 2019/20

This was approved.

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Report Discussion & recommendationCounter Fraud – Invoices Payable

Using Interactive Data Extraction and Analysis (IDEA), a review of the Trust’s accounts payable has recently been undertaken. A number of instances of duplicate bank details were found but in all instances, satisfactory reasons and protections were provided.

Waivers to SFI’s These were reviewed. Waivers for the use of private healthcare facilities had been

agreed in 2018 and the time limits on these would need to be established.

A waiver to procure additional Medical Records storage flagged raised concerns about capacity within that service.

External Audit – Annual Audit Letter

AC expressed concern about the conclusion in the draft letter regarding the Trust’s arrangements for securing value for money. It is recognised that External Audit need to take account a number of key measures including the Trust’s underlying deficit. However, the Trust have been able to establish the system wide nature of its issues. Also the significant progress in ensuring the Trust is well managed was not sufficiently recognised in the executive summary.

Prepared by:-Andrew Cottom, Chair of Audit Committee

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Report to: Board of DirectorsDate of Meeting: 4 July 2019Title of Report: Foundation Group Strategy Sub Committee Summary Report – 28

May 2019Status of report:(Approval, position statement, information, discussion)

For information.

Report Approval Route:Lead Executive Director:Author: Richard Humphries, NED Representative for the Foundation GroupAppendices:

1. Purpose of the reportFor information.

2. RecommendationsTo note the report.













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Report to Foundation Group Strategy Sub-Committee – 28 May 2019

Foundation Group Strategy Sub-Committee Annual Report 2018/19

1. Introduction

In 2017 the Foundation Group was formed when South Warwickshire NHS Foundation Trust (SWFT) formalised its collaboration with Wye Valley NHS Trust (WVT). In June 2018, George Eliot Hospital NHS Trust (GEH) joined the Foundation Group. The Foundation Group Strategy Sub-Committee (FGSSC) is established under Board delegation of each Trust of the Foundation Group with approved Terms of Reference which are reviewed annually and any requests for amendment are made to the Board of Directors of each Trust. The Sub-Committee consists of the Chairman and Chief Executive of the Trusts, a Non-Executive Director (NED) from each Trust, Managing Director from each Trust, Medical Director from each Trust, Group Strategy Advisor (who is the Managing Director at SWFT) and Group Strategic Financial Advisor. Other officers from each Trust may be invited to attend for appropriate agenda items. The inaugural meeting was held on 23 January 2018 and the Sub-Committee has met on 7 occasions to the end of March 2019. The meetings are scheduled on a bi-monthly basis, although extra meetings may be called if the need arises. A schedule of attendance at meetings from January 2018 to March 2019 is attached (Appendix A).

The NED from each Trust reports in writing to their respective Board of Directors on key issues considered by the Sub-Committee following every meeting. In addition to this, the approved Minutes of the meetings are also submitted to the Board of each Trust. As part of the annual review of the Terms of Reference, amendments were approved by each Board In April 2019 which included the Sub-Committee’s agendas and meeting papers being made available to all Board members of each Trust. 2. Principal Areas of Review

The Terms of Reference set out Strategic Financial and Operational Plan as the key duty for the Sub-Committee which includes the following responsibilities:

• developing strategy and investment plans, including finance, IT, estates, and

commercial development; • overseeing processes which benchmark clinical outcomes and productivity

across the Foundation Group supporting the implementation of best practice solutions;

• developing new working models for corporate functions; • developing new business models to progress the development of accountable

care; • developing and executing a communications strategy; • developing and maintaining business development capacity and capability

across the Foundation Group;

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2

• determining the framework that supports each provider’s organisational objectives and targets;

• developing and supporting achievement of operating, business, efficiency and delivery plans;

• identifying, reviewing and mitigating strategic risks, and • proposing and implementing joint working with partner organisations where

collaborative approaches will yield tangible improvements and/or efficiencies overseeing service transformation and pathway redesign.

3. FGSSC – Review of Effectiveness

The FGSSC has been active during the year in carrying out its duty in providing the Board of each Trust with assurance relating to the Foundation Group’s strategic financial and operational planning. The Sub-Committee also advises the Boards of each Trust on all matters relevant to identifying and sharing best practice at pace. The Sub-Committee has undertaken a formal review of its effectiveness during 2018/19 and a separate report has been submitted to the Committee on the responses received. It can be confirmed that the Committee met on 7 occasions between January 2018 to March 2019 and achieved an attendance rate of 91%. It should be noted that 80% is considered to be a good rate of attendance. The Committee achieved its aim by delivering the duties set out in its Terms of Reference and referred to in section 2 of this report.

4. Areas of Particular Note

During the year the Committee has had the opportunity to consider strategic financial and operational planning opportunities as part of collaborative working across the Foundation Group. Examples of these are detailed below but it should be noted that the list is not exhaustive:-

• development of a Group Strategy and joint planning process; • Five Year Plans; • collaborative working across back office functions such as communications,

procurement, quality and service improvement, and IT; • work plan for the Committee; • Digital and IT Strategy; • updates on SWFT Clinical Services Ltd, which is a subsidiary company of

SWFT; • Clinical Leadership development which included the appointment of Group

Associate Medical Director roles; • development of the Foundation Group to include GEH; • financial plans for each Trust; • update on the partnership arrangement between SWFT and Sensyne. WVT

and GEH Boards subsequently considered a partnership arrangement with Sensyne which was approved;

• update on Model Hospital and Reference Cost Index; • NHS Long Term Plan overview, and • overview of the NEDs discussion on best practice clinical governance.

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3

Looking forward into 2019/20, the Committee continues to focus on development opportunities for strategic financial and operational planning. Also identifying and sharing best practice at pace across the Foundation Group. 5. Conclusion The Sub-Committee is of the opinion that this Annual Report demonstrates compliance with the requirements of its Terms of Reference and that there are no matters the Sub-Committee is aware of at this time which have not been disclosed properly. 6. Recommendation The FGSSC is asked to consider its Annual Report for 2018/19, prior to submission to the Board of Directors of each Trust. Russell Hardy Foundation Group Chairman

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Foundation Group Strategy Sub-Committee Attendance 2018/19

23

January 2018

19 March 2018

22 May 2018

23 July 2018

19 November 2018

22 January 2019

18 March 2019

Members Russell Hardy (Chair) Charles Ashton (Group Medical Director) Jayne Blacklay (Group Strategy Advisor) Glen Burley (Group Chief Executive) David Eltringham (Managing Director at GEH) Catherine Free (Medical Director at GEH) Richard Humphries (NED at WVT) Jane Ives (Managing Director at WVT) Helen Lancaster (Director of Operations at SWFT) Chris Lewington (NED at SWFT) David Moon (Group Strategic Financial Advisor) David Mowbray (Medical Director at WVT) Simon Page (NED at SWFT) Prem Singh (NED representative at GEH) Julie Houlder (NED representative at GEH)

Committee Attendance Rate 90% 90% 80% 100% 100% 100% 76.9%

The meeting scheduled on 18 September 2018 was cancelled.

Appendix A

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South Warwickshire NHS Foundation Trust, Wye Valley NHS Trust and George Eliot Hospital NHS Trust FOUNDATION GROUP STRATEGY SUB-COMMITTEE

EFFECTIVENESS SELF-ASSESSMENT TOOL 2019

Page 1 of 6

Please tick to indicate your level of agreement with the following statements. Please add any comments or actions required in the relevant column. If you have rated any of the statements as a 1 or a 2 (strongly disagree or disagree), please provide your reasons in the relevant section below.

Statement Strongly Agree (4)

Agree (3)

Disagree (2)

Strongly Disagree (1)

Unable to Answer

Comments / Action

Theme 1 – Committee Focus The Committee is clear on its core purpose and objectives. Developing all the time.

The Committee’s business covers matters of importance relevant to its Terms of Reference.

The Committee reviews its activities against those delegated to it in the Terms of Reference

The Committee has made a conscious decision about how it wants to operate in terms of the level of information it would like to receive for each of the items on its cycle of business.

Still developing its approach to this. Not sure we have a cycle of business. The Committee has just finished its first year of operation so to a degree there is an element of “still learning”.

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Page 2 of 6


Agree (3)

Disagree (2)


Unable to Answer

Comments / Action

There is appropriate detailed discussion focused on decisions required and decision making is clear and transparent.

Sometimes feels like decisions being made rather than recommendations to Boards. It would be easy for GSC to stray into making decisions for all 3 organisations – but is careful to remain advisory.

The frequency of meetings is appropriate and enables the Committee to effectively carry out all of its duties.

If you have rated any of the above aspects as a 1 or a 2, please give your reasons below: The Committee needs to review its way of working since the 3rd member joined. A forward programme of agenda items for the next year would be helpful.

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Page 3 of 6


Agree (3)

Disagree (2)


Unable to Answer

Comments / Action

Theme 2 – Committee Team Working The Committee has the right balance of experience, knowledge and skills.

The membership and attendance of the Committee as set out in the Terms of Reference is appropriate.

The Committee ensures that the relevant director /manager attends meetings to enable it to secure the required level of understanding of the reports and information it receives.

Members are properly prepared for the meetings. The order of discussions between the FGSSC and individual Boards has been raised as an issue on a couple of occasions and sequencing agenda items/sharing papers well ahead of FGSSC meetings would help to smooth business processes. Need to be better at producing papers for complex matters or where decisions are required rather than items being verbal or a presentation.

All members of the Committee behave with courtesy and respect, and views of others are respected and heard non-judgementally.

If you have rated any of the above aspects as a 1 or a 2, please give your reasons below: It would be helpful to review membership and decide whether a smaller, tighter focused Committee with Group leads might be more helpful to ensure the Committee remains focused and strategic.

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Page 4 of 6


Agree (3)

Disagree (2)


Unable to Answer

Comments / Action

Theme 3 – Committee Effectiveness Papers are received in sufficient time to allow proper consideration and understanding.

We need to be clear which papers need to be circulated prior to the meeting as certain agenda items are best if presented on the day. Although often items are presentations and these are not circulated in advance. See note above re sequencing. Need to be better at producing papers for complex matters or where decisions are required rather than items being verbal or a presentation.

The quality of Committee papers received allows me to perform my role effectively.

Sufficient time is given to the proper debate and understanding of business items.

Members provide real and genuine challenge – they do not just seek clarification and/or reassurance.

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Page 5 of 6


Agree (3)

Disagree (2)


Unable to Answer

Comments / Action

The business is appropriately prioritised and debate is allowed to flow and conclusions reached without being cut short or stifled due to time constraints etc.

Each agenda item is ‘closed off’ appropriately so that I am clear the conclusion; who is doing what, when and how and how it is being monitored.

The Committee has a tracker system to ensure others are acting on and completing actions allocated to them and I feel confident that it will be implemented as agreed and in line with the timescale set down.

Assess the impact of the Foundation Group Strategy Sub-Committee and overall performance of the three Trusts.

We need to do this moving forward. Clearly in the first year of operation (and with GEH not joining until Summer ’18) this is something that has to develop.

If you have rated any of the above aspects as a 1 or a 2, please give your reasons below:

We have been slow to get going on some projects and so it is too early to assess impact.

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Page 6 of 6

Please return completed forms, either hard copy or electronically, to Sarah Collett (Foundation Group PA) by 22 April 2019.


Agree (3)

Disagree (2)


Unable to Answer

Comments / Action

Theme 4 – Committee Leadership and Administration

The Committee Chair has a positive impact on the performance of the Committee.

Committee meetings are chaired effectively and with clarity of purpose and outcome (e.g. keeping agenda on time, checking for consensus between members before decisions are made)

The Committee has adequate administrative support.

Minutes clearly identify debate, actions and who is responsible for them.

If you have rated any of the above aspects as a 1 or a 2, please give your reasons below:

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WYE VALLEY NHS TRUST Minutes of the Clinical Quality Committee

Held on 25 April at 1.30 pm Boardroom, Trust Headquarters, Hereford County Hospital

Present:

Christobel Hargraves CH Committee Chair and Non-Executive Director (NED)

Jon Barnes JB Chief Operating Officer

Cath Davies CD Deputy Director of Quality Governance

Lucy Flanagan LF Director Of Nursing

Richard Humphries RH Non-Executive Director (NED)

David Mowbray DM Medical Director

Neeraj Prasad NP Associate Medical Director, Governance – Left partway through 8c

Mark Waller MW Non-Executive Director (NED)

In attendance:

Mehmood Akhtar MA Consultant Urologist – For Items 8a and 8b

Chris Beaumont CB Mortality Project Manager – For Items 12 and 13

Claire Griffin CG General Manager, Surgical Division – For Items 8a and 8b

Maxine Chong MC Head of Midwifery

Robbie Dedi RD Associate Medical Director, Medical Division

Amanda Edwards AE Divisional Lead Nurse, Integrated Care

David Farnsworth DF Associate Director, Integrated Care – Left after Item 13

Nicky Goodwin NG Patient Safety and Risk Manager – For Item 7

Susan Hamman SHa Deputy Chief Nurse, Herefordshire Clinical Commissioning Group - Observing

Sarah Holliehead SH Divisional Nurse Director, Medical Division

Jane Ives JI Managing Director

Val Jones VJ Executive Assistant (for the minutes)

Tony McConkey TM Professional Lead, Clinical Support Division/Clinical Director, Pharmacy & Medicines Optimisation

Sue Moody SM Divisional Professional Lead, Integrated Care Division

CLINICAL PERFORMANCE

MINUTE ACTION

Revd Hargraves (Chair and NED) welcomed Susan Hamman, Deputy Chief

Nurse (DCN), Herefordshire Clinical Commissioning Group (HCCG) he

meeting.

CQ001/04.19 APOLOGIES FOR ABSENCE

Apologies were received from Christopher Brammer, Associate Medical Director, Clinical Support Division, Claire Carlsen, Divisional Operational Director, Clinical Support Division, Simon Fisher, Associate Medical Director, Surgical Division and Emma Smith, Divisional Nurse Director, Surgical Division.

CQ002/04.19 QUORUM

The meeting was quorate.

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CQ003/04.19 DECLARATIONS OF INTEREST

There were no new declarations of interest.

CQ004/04.19 The Director of Nursing (DON) played a patient safety DVD produced by another trust to set the scene for the meeting. This included significant safety incidents.

The Associate Medical Director (AMD), Governance noted that four out of five of the incidents were medication related incidents. This fact needed to be recognised and a focus on this area to improve medication safety. The Professional Lead, Clinical Support Division/Clinical Director, Pharmacy & Medicines Optimisation (PL) advised that lessons were being learnt from medication errors locally and nationally.

The Medical Director advised that the Serious Incident Panel saw patterns of incidents that were not necessarily obvious to staff, suggesting that the number of incidents around themes should be fed back to all staff to highlight these issues.

Revd Hargraves (Chair and NED) questioned how learning was shared with staff that was quickly and easily digested, suggesting using social media to highlight issues. The Medical Director advised that a piece of software being reviewed for use at the Trust could include this area. The DON noted that learning from incidents for staff needed to become more “real”.

CQ005/04.19 MINUTES OF THE MEETING HELD 28 MARCH 2019

Resolved – that the minutes of the meeting held on 28 March 2019 be confirmed as an accurate record of the meeting and signed by the Committee Chair.

CQ006/04.19 MATTERS ARISING AND ACTION LOG

(a) CQC006/01.19 – Divisional Report – Surgical Division – (C) – The update on the progress on the review of the surveillance waiting lists was on the agenda.

(b) CQ004/02.19 – Matters Arising and Action Log – (D) – The Medical Director advised that Regional Best Practice had been reviewed and would be adopted. A further update on progress would be provided to the June meeting.

(c) CQ010/02.19 – Duty of Candour/Serious Incidents Policy – (C) – The Patient Safety and Risk Manager had sent out the Flow Chart to the Committee. This action could therefore be closed.

(d) CQ004/03.19 – Matters Arising and Action Log – (D) – The Professional Lead, Clinical Support Division advised that the results of the Medication and Controlled Drugs Audit had been circulated to the Division. This action could therefore be closed.

DM

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(e) CQ005/03.19 – Divisional Report – Surgical Division – (B) - This action was closed.

(f) CQ009/03.19 – Mortality Report – (B) – The Medical Director confirmed that a breakdown of deaths reviewed would be included from the May report onwards. This action could therefore be closed.

(g) CQ009/03.19 – Mortality Report – (C) – The information around mortality on the Trust website was reviewed. This action could therefore be closed.

(h) CQ014/03.19 – CQC Action Plan Update – (D) – The Deputy Director of Quality Governance (DDQG) had contacted the AMD, Clinical Support Division regarding a meeting. A date was still to be set.

CB/CD

Resolved – that

(A) The action log be received and noted.

(B) The Medical Director would provide a further update on the

progress on adopting the Regional Best Practice regarding

safeguarding responsibilities for locums and medical agency

staff.

(C) The Associate Medical Director, Clinical support Division would meet with the Deputy Director of Quality Governance to discuss the CQC Action plan as their versions did not coincide.

DM CB/CD

CQ007/04.19 DIVISIONAL REPORT – MEDICAL DIVISION

The Divisional Nurse Director (DND), Medical Division presented the Medical Divisional Report and the following key points were made:

An additional section had been added to the Nurse Sensitive Indicators table regarding fill rates. Assurance was provided around actions being taken where there were gaps.

The Emergency Department achieved 85% of patients being seen within 4 hours in March. This was good not only for patient experience but flow throughout the hospital.

The “Test of Change” week commenced on 8 April with the highlights included with the report. The Emergency Care Intensive Support Team (ECIST) visited the Trust on 5 March and made recommendations regarding patient flow. ECIST also supported a two day workshop on 25 and 26 March. There was real engagement from the teams attending around the proposed changes.

The AMU team have been nominated as team of the month for the Going The Extra Mile Award for valuing patients time during the pressures in December.

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Improved communications were occurring between Ward Co-ordinators and the nurse in charge using dedicated mobile phones to speed up the transfer of our patients.

The Lead Sepsis Nurse was undertaking weekly sepsis quality improvement meetings, with positive engagement from staff, with standards being monitored.

The Diabetic Specialist Nurse team have been liaising with the Care Commissioning Group, GP Lead for Diabetes and Practice Nurse Lead regarding the future Diabetes Community Services which enabled upskilling and shared care within teams which would also prevent admissions. The Medical Director asked if this concept could be used for other areas, eg Heart Failure. The AMD, Medical Division advised that this would be difficult due to capacity. The AMD, Governance advised that that was no Community Team for this area but a lot of Community engagement with Nurse Specialists required.

Lugg Ward had championed the EPR system and were being very proactive regarding patient flow as part of the ECIST work. Lugg Ward were also 100% compliant with naso-gastric insertion and administering of food and medication compliance and training engagement.

Weekly ward governance meetings had been implemented on all medical wards to discuss incidents. Survey Monkey was being used for staff and patients, with staff being asked key questions relating to the Staff Survey results.

Plans for Clinical Practice weeks and Culture Reviews were progressing which would include reflection around Lugg Ward. Two key areas per month would be focused on as well as key issues.

Areas for improvement included a review of air and oxygen flow meter management following the Never Event on Frome Ward, and infection prevention across the Division, with engagement with the Infection Prevention Team around this issue. Dementia screening on admission to hospital was another area to highlight with a review of adding this process to the paperwork completed when a patient was admitted.

Falls remained high on Arrow Ward with a bid put in for alterations to the ward following the change in speciality. A review was being undertaken to find out whether the higher rates of falls were within the expected range for a geriatric ward. It was acknowledged that mobilising patient is the right thing to do even if this increases their risk of falls.

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Medication incidents are high on Frome Ward although there were no issues around training compliance. A weekly meeting was held with Pharmacy to discuss. The DND, Medical Division advised that learning was fed back at Divisional and Directorate meetings and between the matrons. The DCN, HCCG questioned how the issues around temporary staffing and interruptions were being dealt with, suggesting that a Registered Nurse was not always required to administer medications. The DON agreed this was a possible solution but required further discussion.

Mr Humphries (NED) highlighted that the issues of falls and frailty would only continue to increase with an aging population. The DON advised that the reported increase of falls on Arrow Ward had been discussed at the Falls Panel and questioned if within a normal variation. The DND, Medical Division advised that the number of falls on Frome Ward had decreased following the change of speciality.

Mr Waller (NED) noted that a lot of data/numbers were driven by the size and nature of the ward and therefore certain wards may be expected to have higher numbers and queried whether a rating system could be used. The AMD, Medical Division suggested using a six month average as a marker.

Revd Hargraves (Chair and NED) noted the “No formal supervision process” action from the Care Quality Commission report, and questioned how this was being progressed. The AMD, Medical Division advised that this would be discussed at the Finance & Performance Meeting in May as the Supervision Policy was out of date which required review to ensure details of how supervision was tracked and by whom. The DON advised that the Supervision Policy was under review by the Education Team, confirming that where supervision was in place, eg for Safeguarding, this was being tracked.

The DON questioned how the Must and Should Do Action Plan was progressing as the report did not include evidence of progression. The AMD, Medical Division confirmed that progress was being made but the Division were reviewing how to map this information differently in future reports, as some were “business as usual” and presented to different forums.

The Managing Director suggesting having an overall Trustwide review of the Action Plan. The DON advised this was being monitored and felt that Divisions should monitor the additional actions, noting that the Must and Should Do Action Plan would be updated for the next meeting to enable it to be an easier document to read.

Resolved – that the Divisional Report – Medical Division be received

and noted.

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CQ008/04.19 DIVISIONAL REPORT – INTEGRATED CARE DIVISION

The Divisional Lead Nurse (DLN), Integrated Care Division presented the Integrated Care Divisional Report and the following key points were made:

There had been a reduction in the number and severity of pressure ulcers reported, a reduction in the number of falls and continued reduction in delayed transfers of care and agency spend and recruitment.

There had been no medication related incidents in the Responsive Directorate since July 2018 which was a huge achievement.

Areas requiring improvement included reducing sickness levels across the Division which continued to be a challenge, achieving mandatory training and appraisal compliance and improve response rates and scores for Friends and Family Test. A reduction waiting times for Paediatric SALT and OT were needed and timely management of open actions and incidents on Datix. Improvement with bare below the elbows compliance was also required.

Key Priorities for the Division included development of a Health & Wellbeing Strategy for the Division, development of a dedicated Lead Pharmacist role and enhanced divisional governance process/support for medicines management in the localities and understand and develop shared governance requirements to support integrated locality working.

The Associate Director, Integrated Care advised that mortality figures were not included within the report due to timing of the papers. The figures were being worked on and would be included in future reports.

The DCN, HCCG noted that governance across localities was an issue and questioned how learning occurred across boundaries. The DON advised that a review of how to integrate systems was being undertaken, as currently there were four Datix platforms with the plan to move to one integrated system.

There had been a significant number of falls on Peregrine Ward at Ross Community Hospital with a review being undertaken to ensure that there were no common themes. The DON did not feel that the deep dive had been as in-depth as required, and questioned whether this was due to the limited information presented within the report. The DLN advised that a detailed deep dive had been undertaken but more work was still required.

Mr Humphries (NED) questioned around future governance in regards development of the Health & Wellbeing Strategy whether this was a Trustwide strategy or for each Division. The DON advised that there would be a Trustwide strategy, with the Associate Director, Integrated Care advising that each Division had a different set of challenges to work on.

AE

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Revd Hargraves (Chair and NED) questioned whether staffing figures could be included in future reports. The Associate Director, Integrated Care advised that there were challenges in understanding figures but these would be included within future reports.

The DON highlighted that there were no updates regarding the Care Quality Commission Action Plan. The Associate Director, Integrated Care advised that there had been some developments with two workshops being held on how to design an end of life pathway across teams (Specialist Palliative Care teams, Wye Valley Trust and St Michaels Hospice). The DON proposed that a combined Corporate and Divisional Care Quality Commission Action Plan was presented to the July meeting.

The Managing Director noted that high level issues had not been included within the report for areas had been discussed in the meeting.

CD

Resolved – that:

(A) The Divisional Report – Integrated Care Division be received and

noted.

(B) Staffing figures could be included in future Integrated Care

Division reports.

(C) A combined Corporate and Divisional Care Quality Commission

Action Plan would be presented to the July meeting.

AE

CD

ASSURANCE REPORTS

CONFIDENTIAL SECTION

CQ009/04.19 SERIOUS INCIDENT REPORT

BUSINESS SECTION

CQ010/04.19 CLINICAL QUALITY COMMITTEE TERMS OF REFERENCE AND WORKPLAN

The DON presented the Clinical Quality Committee Terms of Reference (TOR) and Workplan and the following key points were noted: TERMS OF REFERENCE

The updated TOR reflected what the Committee does rather than the previous generic TOR, with the performance and assurance sections and where the Board of Directors had delegated responsibility to the Committee more explicit.

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The following comments were noted: Revd Hargraves (Chair and NED) noted that this was the first time

that it had been explicitly recognised that the Committee provided both an assurance and an accountability function as a subcommittee of the Board of Directors.

Mr Humphries (NED) felt that the wording “provide assurance to the Board of Directors” should be changed to “provide assurance about how well the Trust is...” as this was more accurate.

Mr Waller (NED) agreed with this suggestion, noting that the Committee did not hold Divisions to account.

Revd Hargraves (Chair and NED) advised that she was trying to be efficient with the available resources to prevent setting up another meeting, noting that there may be restricted discussion having NEDs and the CCG present.

The PL agreed that it could be difficult sometimes to highlight issues and provide the necessary assurance required.

The AMD, Governance felt that the Committee worked well with a good overall balance and did not have any issues with the NEDs present.

The Managing Director highlighted that no one should ever feel concerned about raising issues regardless of who is present. She felt that perhaps it was too detailed separating the sections out in the meeting noting that the performance areas were partly how the Committee provided assurance to the Board of Directors.

The DDQG felt that detailed areas did not always get aired in the meeting, which may be more appropriate for sub-committees to discuss if processes were in place. This was also a high level Committee for staff to present, who were often new in post and still learning and therefore were not aware of how to present/write a report.

Revd Hargraves (Chair and NED) queried if the Divisional structure was sufficiently developed, discussions could be held prior to coming to the Committee and therefore enable more open discussions.

Mr Humphries (NED) felt that the Committee was a group of people who promote quality and are champions of this.

Mr Waller (NED) felt that the most important part of the Terms of Reference was to capture the purpose, duties and then accountability and governance, but these were always at the end of the document. Revd Hargraves (Chair and NED) would discuss the proposed TOR with the DON, Medical Director and Managing Director before presentation to the Board of Directors.

Duties of the Committee Quality Impact Assessment had been included again. 10.1 – Quality Priorities – It was suggested that a summary report

was presented to the Committee from the DON and Medical Director on the Quality Priorities received. The Managing Director felt reporting should be by exception.

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DM/JI

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Serious Incidents The Managing Director felt appropriate time should be spent to

review Serious Incidents in detail and to ensure that they had been appropriately investigated, actions taken and the mechanism in place to follow through. She felt that some of the queries from the CCG were not high level but the Committee needed to sign off the final Serious Incident Reports.

The AMD, Medical Division noted that the Serious Incident report signed off by the Committee may have a different timeframe to the CCG and may need to be resent if changes were made.

The DON advised that for significant events requiring a full Root Cause Analysis that a thorough investigation was more important than achieving the 60 day timeframe and may well take longer.

The Medical Director suggested a virtual review before coming to the Committee; Revd Hargraves (Chair and NED) agreed with this proposal.

Mr Waller (NED) noted that mortality and safeguarding were not specifically referred to. The DON advised that all the subcommittees reporting to the Committee had not been detailed and were covered by an overarching reference. The Workforce safeguards had been included specifically as this has been delegated by the Board.

The DON and Medical Director were reviewing the structure of the subcommittees and this would be attached to the TOR when completed.

WORKPLAN

The DON welcomed feedback on what the Committee required in terms of subcommittees reporting.

The Triangulated report had been well received but the conclusion was that it was not meaningful to have a combined report and a quarterly Incidents and Complaints Report would be produced. A staffing report would also be produced as this was a national requirement.

The DON/Medical Director and DDQG would discuss the process of subcommittees reporting to the Committee.

The DON would send out the updated TOR and Workplan to the Committee prior to being presented to the Board of Directors on 23 May.

LF/DM LF/DM/ CD LF

Resolved – that:

(A) The Clinical Quality Committee Terms of Reference and Workplan was received and noted.

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(B) Revd Hargraves (Chair and NED) would discuss the Terms of

Reference template with the Director of Nursing, Medical

Director and Managing Director before presentation to the

Board of Directors.

(C) A monthly report would be provided to the Clinical Quality Committee on the Quality Priorities signed off.

(D) The revised structure of the subcommittees would be attached

to the Terms of Reference for the Clinical Quality Committee.

(E) The Director of Nursing, Medical Director and Deputy Director

of Quality Governance would discuss the process of

subcommittees reporting to the Committee.

(F) The Director of Nursing would send out the updated Terms of Reference and Workplan to the Clinical Quality Committee prior to them being presented to the Board of Directors on 23 May.

CH/LF/

DM/JI

LF/DM

LF/DM

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CD

LF

CQ011/04.19 DRAFT QUALITY REPORT

The DON presented the Draft Quality Report and the following key points were noted:

The report is designed to include the agreed measures for monitoring performance against the quality priorities for the organisation, which would be presented monthly to the Committee. The Committee would continue to receive the agreed deep dive reports.

The Board quality reporting requirements – It would be discussed at the Executive Directors meeting whether the Board of Directors received the same report. Revd Hargraves (Chair and NED) suggested adding an update from the Committee discussions to the Board report. The AMD, Governance suggested capturing the comments within the Committee meeting and adding these to the Board paper.

The Committee were in agreement to receive the monthly staffing report, noting that this was a mandatory requirement.

It was acknowledged that some indicators have not been fully developed and that some are subject to changes moving from month 12 to month 1.

The Committee would receive a report in May which includes all indicators performance and associated narrative.

LF

LF

Resolved – that:

(A) The Draft Quality Report was received and noted.

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(B) It would be discussed at the Executive Directors meeting whether the Board of Directors received the same Quality Report as the Clinical Quality Committee.

(C) The Clinical Quality Committee would receive a Quality Indicators Report in May which includes all indicators performance and associated narrative.

LF

LF

CQ012/04.19 CORPORATE CQC ACTION PLAN

The DON presented the Corporate CQC Action Plan and the following key points were noted:

The DON had revisited the CQC report and lifted any comments that were not included in the “Must” and “Should” do list.

The Associate Director of Corporate Governance was reviewing the governance structure to ensure that there was a “golden thread” to all Committees and Sub-Committees, this would address most well led outstanding actions.

Resolved – that the Corporate CQC Action Plan be received and noted.

CQ013/04.19 MORTALITY REPORT

The Mortality Project Manager (MPM) presented the Mortality Report and Action Plan and the following key points were noted:

Wye Valley Trust were the most improved Trust regarding mortality in the last two years.

SHMI has reduced to 104.81, the lowest ever recorded. HSMR has also fallen to 103.2.

It was also the 7th consecutive reduction in deaths attributed to CCF to 92.27. This is the lowest reported HSMR for CCF deaths. Sepsis deaths have also fallen to the lowest ever reported for the 14th consecutive month to 94.83. A reduction of 5.36 in the HSMR for deaths attributed to fracture neck of femur to 169.40.

Community Hospital audits of all deaths in the last 12 months have been completed for all sites with the draft reports out for review with both Primary and Secondary Care key stakeholders. Due to the small numbers involved, spikes will occur.

Benchmarking against the National Guidance for Learning from Deaths highlights the progress made by the Trust with areas of excellent implementation.

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The AMD, Medical Division questioned how the HSMR figures would be managed for the Community Hospitals, eg what they would be benchmarked against. The Medical Director advised that the figure produced was an aggregate of individual codes amalgamated. The difficulty would be around the low numbers which may require an individual audit of each death.

The Associate Director, Integrated Care advised that GPs reviewing the own patients may not be as critical, with a suggestion that a GP not known to the patient would review the death.

Mr Waller (NED) questioned how this positive information on mortality figures would be shared internally and externally. The Medical Director advised this would be shared through Trust Talk, Mortality Newsletters and Intranet pages along with Healthwatch and the Annual General Meeting for the public.

Resolved – that the Mortality Report be received and noted.

CQ014/04.19 LEARNING FROM DEATHS

The MPM presented the Learning From Deaths Report and the following key points were noted:

The Learning from Deaths guidance and the outline steps were included within the report. Robust review systems are in place and learning to drive quality improvement across outlier groups.

Learning disabilities was an area to focus on. Plans were in place but a more robust process was needed.

The gap in bereavement services was recognised regarding the need for more resource in terms of dealing with families and providing information and including them as part of the review. The plan was to use an existing resource to fund a bereavement post. The DON noted the challenge around finding an appropriate environment for the office base. Revd Hargraves (Chair and NED) suggested using charitable funds for improving the office environment for items such as lighting.

Mr Humphries (NED) noted the positive achievement of having four Medical Examiners in the Trust, which was not a role held in many Trusts.

Resolved – that the Learning From Deaths Report be received and noted.

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CQ015/04.19 SAFEGUARDING QUARTERLY REPORT

The DON presented the Safeguarding Quarterly Report and the following key points were noted:

Training compliance continues to improve. Prevent Level 3 compliance has improved but we are still not at the national requirement of 83%, additional training sessions have been provided.

The delay in health assessments has been fully resolved. The capacity issues with the Looked After Children Team continues to be an issue. Additional monies have been put into the contract for this year.

The Community Paediatrician post has been approved for advert.

Mental Health Act – Work is being carried out around the process for the Trust to legally detain patients where appropriate. This would be presented to a Board Workshop once the review had been concluded.

New strategic guidance around Child Safeguarding required specific cohorts of staff to achieve a higher level of training. The AMD, Medical Division advised that there were not always enough training sessions available for staff. The DON would discuss this issue with the Training Department.

Revd Hargraves (Chair and NED) noted the downward trend on attendance at Child Protection Conferences. The DON would review this issue.

Revd Hargraves (Chair and NED) noted that the supervision levels for all teams was reducing, an issue that had been raised previously. The Head of Midwifery advised that this was a reflection in sickness and staffing gaps for midwifery rather than supervisors not being present. The DON confirmed that the same issues applied for the School Nurses and Health Visitors.

Mr Humphries (NED) noted his concern over the low levels of Initial Health Assessments being carried out by the Trust due to the Consultant Paediatric shortage. The Medical Director advised that Worcester colleagues were supporting the Trust and numbers were now back on track.

Revd Hargraves (Chair and NED) questioned the implications of not meeting the Prevent training target. The DON advised that a monthly and regional return was sent, with the Commissioners holding us to account as this was one of the ten statutory requirements. This was also regularly discussed at the CQRF meeting. The DON advised that work was being carried out to improve figures, noting that Herefordshire was a low risk area.

DM

LF

LF

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Resolved – that:

(A) The Safeguarding Quarterly Report was received and noted.

(B) The process for the Trust to legally detain patients where appropriate would be presented to a future Board Workshop.

(C) The Director of Nursing would discuss the issue around

additional Child Safeguarding sessions with the Training

Department.

(D) The Director of Nursing would review the downward trend on attendance at Child Protection Conferences.

DM

LF

LF

CQ016/04.19 MEDICINES OPTIMISATION REPORT

The PL presented the Medicines Optimisation Report and the following key points were noted:

Completion/Compliance rates audits – Overall general medicines audit compliance was 85% - eleven wards achieved 100% compliance with those achieving below 79% listed in the report with work ongoing regarding these areas. The common areas of non-compliance were also included. Controlled drug audit compliance was 83% - Wye and Monnow Wards had achieved compliance. The areas below compliance were also included within the report.

The DDQG questioned if there was opportunities for the Wards obtaining 100% compliance to share their learning and good practice. The PL advised that the Medical Division had started including information within their Divisional Report. The AMD, Governance noted that areas with the highest levels of turnover and complicated patients were likely to have lower compliance rates.

Medicines Related Training Compliance – IV therapy was the main concern. Numbers were increasing but compliance was still low. Revd Hargraves (Chair and NED) queried if a member of staff was not compliant should they be giving IVs. The PL advised that he would suggest that they did not, but noted that these staff were all trained but had not completed their refresher training.

There had been a 28% movement from Red to Green/Amber on the dashboard from April 2018 to March 2019.

Medicines Safety Committee – The key highlights were included within the report. Attendance from nursing representation from Surgical and Medical Divisions was required.

The DON questioned whether the Patient Safety Alert around injectable medicines was being monitored as it was not included in the Divisional Report. The PL advised that these were highlighted through the CAS alerts and any outstanding specific actions for the Divisions would be presented through the Exception Report along with the Compliance Report sent through to Divisions.

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Mr Waller (NED) questioned what the “just below acceptable compliance levels” meant. The PL advised that levels were around 75% with the threshold at 90%. The wording related to being just below the 80% figure which would put us in the amber rating rather than green. Mr Waller (NED) what else could be done to improve compliance, noting that E-prescribing was not due until 2020/21. The PL advised that a number of different strategies had been tried and felt that E-prescribing would resolve a lot of these issues. The DON confirmed that other actions were being undertaken and a report had been written by the Consultant Microbiologist around antibiotic stewardship which would provide more information.

Resolved – that the Medicines Optimisation Report be received and noted.

CONFIDENTIAL SECTION

CQ017/04.19 SERIOUS INCIDENT REVIEW

BUSINESS SECTION

CQ018/04.19 WIDER CANCER SURVEILLANCE REVIEW

The COO gave a presentation on the Wider Cancer Surveillance Review

and the following key points were noted:

The DDQG confirmed that regarding Duty Of Candour, patients were

being contacted verbally and by letter, which included all the patients

awaiting appointments with the Plastics Department. Revd

Hargraves (Chair and NED) noted the importance of people being

open and honest around this incident.

The COO advised that following Stocktake 1 it was thought that all

specialities had been captured, but then the issues around Plastics

were found. The Information Team were reviewing lists to ensure no

other areas had been missed.

The Managing Director highlighted the human and financial costs for

patients having extended waiting times, which was not to be

underestimated.

Resolved - that the Wider Cancer Surveillance Review presentation

was received and noted.

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CQ019/04.19 RESEARCH AND DEVELOPMENT

The Medical Director presented the Research and Development report and

the following key points were noted:

There had been six serious adverse events. This title was misleading

as this related to the readmission of patients mainly with cancer or

sepsis, and not due to a complication of experimental treatment.

Assurance had been provided by the Consultant

Haematologist/Chair of the Research and Development Committee

that every patient was discussed and anything felt to be experimental

would be raised.

Resolved – that the Research and Development report was received

and noted.

CQ020/04.19 ANY OTHER BUSINESS

There was no further business to discuss.

CQ021/04.19 DATE OF NEXT MEETING

The next meeting was due to be held on 30 May 2019 at 1.30 pm in the

Boardroom, Trust Headquarters, Hereford County Hospital.

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Acronym

AAU Acute Admissions Unit ACS Accountable Care SystemsACE Active Care for EveryoneAEDB Accident & Emergency Delivery BoardAHP Allied Health Professional AKI Acute Kidney InjuryAMU Ambulatory Medical UnitA&E Accident & Emergency DepartmentBAF Board Assurance FrameworkBGAF Board Governance Assurance FrameworkCAMHS Child and Adolescent Mental Health ServicesCAS Central Alert SystemCAU Clinical Assessment UnitC. Diff Clostridium DifficileCCG Clinical Commissioning GroupCPIP Cost Productivity Improvement PlanCNST Clinical Negligence Scheme for TrustsCOPD Chronic Obstructive Pulmonary DiseaseCOSHH Control Of Substances Harmful to HealthCQC Care Quality CommissionCQUIN Commissioning for Quality & InnovationCTP Costing Transformation ProgrammeDOLS Deprivation of Liberty SafeguardsDCU Day Case UnitDNA Did Not AttendDNACPR Do Not Attempt Cardiopulmonary Resuscitation DTOC Delayed Transfer Of CareECIST Emergency Care Intensive Support TeamED Emergency DepartmentEDD Expected Date of DischargeEDS Electronic Discharge SummaryEPMA Electronic Prescribing & Medication AdministrationEPR Electronic Patient RecordESR Electronic Staff RecordFAU Frailty Assessment UnitFBC Full Business CaseFOI Freedom of InformationF&F Friends & Family FRP Financial Recovery Plan FTE Full Time EquivalentGE George Eliot Hospital GMC General Medical CouncilHCA Healthcare AssistantHSE Health & Safety ExecutiveHFMA Healthcare Financial Management AssociationHSMR Hospital Standardised Mortality RatioHV Health VisitorIG Information Governance

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IV IntravenousKPIs Key Performance IndicatorsLAC Looked After ChildrenLAT Looked After TeamLMS Local Maternity SystemMCA Mental Capacity ActMES Managed Equipment ServicesMIU Minor Injury UnitMLU Midwifery Led UnitMRSA Methicillin-Resistant Staphylococcus AureusMSSA Methicillin-Sensitive Staphylococcus AureusNEWS National Early Warning ScoresNHSCFA NHS Counter Fraud AuthorityNHSLA NHS Litigation AuthorityNICE National Institute for Health & Clinical ExcellenceNIV Non-invasive ventilationNSI Nurse Sensitive IndicatorsOOC Out Of CountyOOH Out Of HoursPALS Patient Advice & Liaison ServicePAS Patient Administration SystemPCIP Patient Care Improvement PlanPFI Private Finance InitiativePID Project Initiation DocumentPLACE Patient Led Assessment of the Care EnvironmentPHE Public Health EnglandPROMs Patient Reported Outcome MeasuresPTL Patient Tracking List QIA Quality Impact AssessmentQIP Quality Improvement ProgrammeRAG Red, Amber, Green ratingRRR Rapid Responsive ReviewRCA Root Cause AnalysisRGN Registered General NurseRTT Referral to TreatmentSCBU Special Care Baby UnitSOP Standard Operating ProceduresSOC Strategic Outline CaseSHMI Summary Hospital Level Mortality IndicatorSI Serious IncidentSIRI Serious Incident Requiring InvestigationSOP Standard Operating ProcedureSTF Sustainability and Transformation FundingSTP Sustainability and Transformation PlanSWFT South Warwickshire NHS Foundation TrustTMB Trust Management BoardTIA Transient Ischemic AttackTOR Terms of ReferenceTTO To Take OutTVN Tissue Viability NurseUTI Urinary Tract Infection

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WAHT Worcestershire Acute Hospitals NHS TrustWTE Whole Time EquivalentWHO World Health OrganisationWVT Wye Valley NHS Trust YTD Year To Date2g 2gether NHS Foundation Trust#NOF Fractured Neck of Femur

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