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Trust Board Papers

Isle of Wight NHS Trust

Board Meeting in Public

to be held on

Thursday 12 March 2020

at

1.30pm - Conference Room

Level B Main Hospital

(opposite Full Circle Restaurant)

St. Mary’s Hospital, Parkhurst Road,

NEWPORT, Isle of Wight, PO30 5TG

Trust Board in Public

12 March 2020, 13:30 to 15:15Conference Room ‐ Level B, St Mary's Hospital, Newport, IW PO30 5TG

Agenda

PROCEDURAL1. Chair's Welcome and Apologies 3 minutes

Receive

Chair

2. Confirma on that mee ng is quorate 1 minutes

No business shall be transacted at a meeting of the Board of Directors unless one third of the whole number is present including the Chair, one Executive Director and two Non‐Executive Directors

Receive

Chair

3. Declara ons of Interest 2 minutesReceive

Chair

4. Minutes of previous mee ng 5 minutes

13 February 2020 ‐ Enc A

Minor amendments to be notified in advance. By exception

Receive

Chair

Enc A ‐ 2020‐02‐13 ‐ Minutes of the Meeting inPublic ‐ V2 Chair approved.pdf

(11 pages)

5. Ma ers Arising and Schedule of Ac ons 5 minutes

Enc B

By exception

Receive

Chair

Enc B ‐ Schedule of Actions ‐ Board in Public as at030220.pdf

(1 pages)

STRATEGY6. Chair's Update 10 minutes

Enc C Receive

Chair

Enc C ‐ Chairs Update ‐ Mar 20 Board Meeting.pdf (2 pages)

7. Chief Execu ve's Update 5 minutes

Enc D Receive

Maggie Oldham

Enc D ‐ Chief Executive Report_KMW.pdf (3 pages)

8. Acute, Ambulance & MH&LD Transforma on Report 5 minutes

Enc E Receive

Nikki Turner & Lesley Stevens

Enc E ‐ Transformation Report Trust Board forMarch 2020 v1.2.pdf

(5 pages)

PERFORMANCE9. Commi ee Report ‐ Quality Commi ee 15 minutes

To provide assurance on issues discussed at the meeting held on 12 February 2020

Enc F1 ‐ Quality Performance Report ‐ Lead: Suzanne Rostron

Verbal Assurance

Tim Peachey

Enc F1 ‐ Trust Board in Public Quality Reportv.01.pdf

(14 pages)

10. Commi ee Report ‐ Performance Commi ee 15 minutes


Enc G1 ‐ Financial Performance Report ‐ Lead: Darren CattellEnc G2 ‐ Hospital Performance Report ‐ Lead: Joe SmythEnc G3 ‐ Ambulance Performance Report ‐ Lead: Joe SmythEnc G4 ‐ Community Performance Report ‐ Lead: Alice WebsterEnc G5 ‐ Mental Health & Learning Disabilities Performance Report ‐ Lead: Lesley Stevens

Verbal Assurance

Caroline Spicer

Enc G1 ‐ Financial Performance Report M10(Board) v1.1.pdf

(11 pages)

Enc G2 ‐ Hospital Performance Report.pdf (34 pages)

Enc G3 ‐ Ambulance Final Performance report toTB March 2020 Exec Approved.pdf

(12 pages)

Enc G4 ‐ Community Performance Report.pdf (8 pages)

Enc G5 ‐ Trust Board MHLD March 2020.pdf (11 pages)

11. Commi ee Report ‐ HR & OD Commi ee 15 minutes


Enc H1 ‐ Workforce Performance Report ‐ Lead Julie PennycookEnc H2 ‐ Director of Nursing Report ‐ Lead Alice WebsterEnc H3 ‐ Medical Directors Report ‐ Lead Alistair Flowerdew

Verbal Assurance

Anne Stoneham

Enc H1 ‐ Workforce Performance Report.pdf (11 pages)

Enc H2 ‐ Director of Nursing Report January 2020v1.pdf

(13 pages)

Enc H3 ‐ Medical Directors Report ‐ v2.pdf (8 pages)

12. Freedom to Speak Up Guardian Report 5 minutes

Enc I Assurance

Maggie Oldham

Enc I ‐ Freedom to Speak Up Guardian Report.pdf (10 pages)

Governance13. Board Assurance Framework Quarter 3 Report 10 minutes

Enc J Assurance

Suzanne Rostron

Enc J1 ‐ BAF ‐Quarter 3 Report.pdf (9 pages)

Enc J2 ‐ Appendix 2 ‐ BAF Template.pdf (12 pages)

CLOSING MATTERS14. Confiden al issues to be covered in private 2 minutes

The meeting may need to move into private session to discuss issues which are considered to be ‘commercial in confidence’ or business relating to issues concerning individual people (staff or patients). On this occasion the Chairman will ask the Board to resolve: 'That representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest', Section 1(2), Public Bodies (Admission to Meetings) Act l960.

Information

Chair

15. Ques ons from the public on issues raised and covered on thisagenda

2 minutes

Staff and members of the public are asked to send their questions in advance by 5pm on the Monday preceding the Board meeting to [email protected] to ensure that as comprehensive a reply as possible can be given. Please can you ensure you clearly identify within the email subject as 'Question for the Trust Board'.

Any member of the public who has a question following their observation of the Board meeting will be given the opportunity to ask this at the end of the meeting, if time allows. All questions posed verbally must relate to the meeting and not introduce new issues. If time is insufficient to receive questions, members of the public may leave these in writing to be responded to outside of the Board meeting.

Receive

Chair

16. Any other business 5 minutesReceive

Chair

17. The next mee ng in Public of the IW NHS Trust Board will beDate: Thursday 9 April 2020

Venue: Conference Room ‐ Level B,

St Mary's Hospital, Newport, IW PO30 5TG

Information

Chair

18. Notes

18.1. Code of Conduct and Rules Protocol for people attending Isle of Wight NHSTrust Board, meetings and events. This meeting will be held in accordance with the Code of Conduct and Rules Protocol for people attending Isle of Wight NHS Trust Board, meetings and events.

Staff and members of the public are welcome to attend the meeting but must adhere to the rules and standards of behaviour outlined in the protocol.

The Chair reserves the right to exercise his conduct of the meeting in line with the Trust’s Code of Conduct protocol.

18.2. Recording of MeetingThis meeting will be recorded for the purposes of assisting in transcribing the minutes and actions from the meeting.

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IOW NHS Trust Board Meeting in Public 13 February 2020 1

And

Minutes of the meeting of the Isle of Wight NHS Trust Board held in public on Thursday 13 February 2020 in the Conference Room,

St Mary’s Hospital, Newport, IW PO30 5TG PRESENT: Non-Executive Vaughan Thomas Chair Kemi Adenubi Non-Executive Director Phil Berrington Associate Non-Executive Director (Non-

voting) Dr Paul Evans Non-Executive Director Dr Tim Peachey Non-Executive Director Caroline Spicer Non-Executive Director Anne Stoneham Non-Executive Director Sara Weech Associate Non-Executive Director (Non-

voting) Executive Directors Maggie Oldham Chief Executive Darren Cattell Director of Finance, Estates and IM&T &

Deputy CEO (DFEI) Alistair Flowerdew Medical Director Julie Pennycook Director of Human Resources &

Organisational Development (DHROD) (Non-voting)

Suzanne Rostron Director of Quality Governance (DQG) Joe Smyth Joe Smyth, Chief Operating Officer – Acute

& Ambulance Dr Lesley Stevens Director of Mental Health & Learning

Disabilities (DMHLD) (Non-voting) Dr Nikki Turner Director of Acute Transformation Alice Webster Director of Nursing, Midwifery, AHPs &

Community Service (DNMAC) Attendees Sarah Anderson Associate Director of Corporate Affairs Kirk Millis-Ward Associate Director of Communications Isobel Wroe Director of Strategy & Service Development,

South Central Ambulance Service Observers Jay Chappell Staff Side Representative Pam Fenna Chair of Patient Council Mick Tutt Solent NHS Trust Minuted by Lynn Cave Board Governance Officer (BGO) Members of Staff and Public in attendance:

There were members of the public and a media representative present

The meeting commenced at 1.30pm and closed at 2.50pm Minute No. PROCEDURAL 20/T/001 APOLOGIES FOR ABSENCE, CONFIRMATION THAT THE MEETING IS

QUORATE AND CHAIR’S OPENING REMARKS The Chair welcomed everyone to the meeting.

Apologies for absence were received from:

Enc A

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• Julia Ross, Associate Non-Executive Director (Non-voting) • Dudley Delannoy, Healthwatch Representative

The Chair confirmed that the meeting was quorate.

20/T/002 DECLARATIONS OF INTEREST Declarations of interest were received from:

• Phil Berrington as an employee of IBM • Darren Cattell, Director of Wightlife Partnership • Dr Paul Evans, Medical Director of the Faculty of Medical Leadership and

Management (FMLM) • Dr Tim Peachey, Non-Executive Director at University Hospital

Southampton NHS Foundation Trust • Sara Weech, Chair of Mountbatten

20/T/003 MINUTES OF PREVIOUS MEETING The minutes of the meeting of the Isle of Wight NHS Trust Board held on 12

December 2020 were reviewed and the following amendment was requested:

a) Caroline Spicer advised that she had not attended the meeting via conference call. It was noted that she would be marked as having provided her apologies for the meeting.

Resolution The Chair requested that the minutes of the meeting held on 12 December 2019 be Approved subject to the above amendments. The motion was carried unanimously.

20/T/004 MATTERS ARISING AND SCHEDULE OF ACTIONS a) Matters Arising: There were no matters arising.

b) Schedule of Actions:

i. TB/388 – Action Closed

Resolution The Isle of Wight NHS Trust Board received the Matters Arising and Schedule of Actions Update.

STRATEGY 20/T/005 CHAIRS UPDATE The Chair presented his report which was taken as read and advised that whilst

there had been no Board meeting in January, there continued to be work undertaken throughout December and January with our partner organisations both on the island and regionally which are aimed at providing a higher quality of care for island residents. He advised that Baroness Dido Harding, Chair of NHS Improvement had visited the Trust and had undertaken a very positive visit which has enabled her to have a clearer understanding of Trust and enabled staff to demonstrate their enthusiasm and energy for their areas. He formally thanked her for taking the time to visit the island. Resolution The Isle of Wight NHS Trust Board received the Chair’s Update.

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20/T/006 CHIEF EXECUTIVE’S UPDATE The Chief Executive presented the report and highlighted the following areas:

a) Care Quality Commission (CQC) Inspection: She advised that

following an unannounced inspection to assess progress against the warning notices which were placed on mental health and acute in May 2019. She confirmed that the visits had been very positive and the CQC were able to witness examples of the improvements which have been made within the acute areas visited. She advised that whilst the formal outcome was yet to be received that indicators had been positive and that the warning notice in Mental Health could be lifted. She advised that the outcome of the visits would not affect the Trust ratings and that the report would be published by the CQC in due course. There is a formal visit from the CQC expected during 2020. She thanked staff for all their work and confirmed that the Executive team are working to ensure that the lessons learnt are shared across the organisation.

b) Baroness Dido Harding visit: The Chief Executive advised that the Trust had been lucky to have a visit from the Chair of NHS Improvement as she is much in demand across the country. During her visit a number of departments had stands within the conference room showcasing their areas. She reported that the initial number of stands anticipated had been considerably increased due to the enthusiasm of staff which was very encouraging and had been well received.

c) Serious Incident (SI) Reporting: She advised that the Health Service Journal (HSJ) had included an article regarding the Trust in their recent publication which had including comments about SI reporting. It questioned why the Trust felt that it was good news that there was in increase. She advised that it was good news because it showed that staff felt able to report incidents which may lead to a SI being raised. However, she stressed that NHSE/I do not consider the Trust to be an outlier in this area and that the SI reporting is comparable with the rest of the NHS. The Chief Executive confirmed that she was pleased with the progress which has been achieved over the past two years and which has resulted in an improved CQC rating which commended the SI reporting. She advised that it was misleading when statistics are taken in isolation and provided the example of the Standardised Hospital Mortality Ratio (HSMR) which as at 31 December 1.01 and the Standardised Hospital Mortality Index (SHMI) which is 74.2 which is an improvement on the last reported data which was from Quarter 2 and which is included later in the agenda within the Learning from Deaths & Mortality Quarter 2 Report. It was however, noted that there was an incorrect figure shown for the SHMI within the report which would be corrected from 0.01 to 1.01.

d) Integrated Care Partnership (ICP) and our NHS region: The Chief Executive confirmed that work is continuing as a system towards the ICP which would go into its shadow phase in February in preparation to go live later in the year. She also confirmed that work is progressing with local partners which is good news for the Trust.

e) Winter Plan: She reported that as part of the winter plan the dedicated Community Unit has been opened which is providing care for patients who have been discharged from acute care but who need nursing support and a period of rest and convalescence before they can return home. It was advised that the current average length of stay was 6 days

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and that Dido Harding had visited the unit during her trip to the island. She gave thanks to staff for all their work to get this unit working well and also to the Living Well Volunteers who were providing additional support.

f) Food Hygiene Rating: The Chief Executive confirmed that following the

recent downgrading of the rating to 1 star a period of rapid improvements had been implemented. She was pleased to confirm that following a further inspection that this rating had been returned to Four Star Food Hygiene rating, but apologised that this should have happened in the first place.

g) Employee of the Month: Following the reintroduction of the scheme a

large number of nominations had been received for January, and she was pleased to announce that the award for January is to go to Dan Nugent who works in the Community Adult Mental Health Service team.

h) New Colleagues: The Chief Executive advised that at the February

Corporate Induction 62 new members of staff had been welcomed, and confirmed that recruitment continues to bring new staff to the island.

Action The CEO report to be amended to correct the SHMI figure from 0.01 to 1.01 together with the date this information was taken – 31 December 2019

Action by: ADC Resolution The Isle of Wight NHS Trust Board received the Chief Executive’s Update.

20/T/007 ACUTE, AMBULANCE & MENTAL HEALTH AND LEARNING DISABILITIES TRANSFORMATION REPORT

The Director of Acute Transformation presented the report which was taken as read and confirmed that since the last Board meeting there had been a number of developments with our partner organisations. She confirmed that the Memorandum of Understanding between the Isle of Wight NHS Trust and Portsmouth Hospitals NHS Trust for Acute Services is now in place and work is progressing to develop the clinical strategy, to scope ways to support fragile island services and to develop joint clinical roles to support long term essential services. She also confirmed that the Memorandum of Understanding between South Central Ambulance NHS Foundation Trust and the Isle of Wight Trust for Ambulance Services is in place with work progressing to develop work plan priorities and confirm key deliverables for the coming year. Sara Weech noted the governance structures shown within the report and queried if there was sufficient capacity to undertake the work. The Director of Acute Transformation advised that a report covering this aspect would be provided to the Executive team in March where the best use of resources would be considered. The Director of Finance, Estates and IM&T/Deputy CEO confirmed that this is included within the Trust Strategy planning and further information would be provided in March. Caroline Spicer confirmed that the Performance Committee had discussed the report and had highlighted the need for a single integrated view plan to be available. The Chief Executive confirmed that this was being undertaken. The Director of Mental Health & Learning Disabilities advised that Memorandum of Understanding between the IW NHS Trust and Solent NHS Trust is now in its

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third month and work is progressing through a diagnostic process which covers culture and leadership, governance, workforce and finance which will report at the end of March. Work is continuing within Community Mental Health Services to design and create implementation plans for the next two years. She stressed that these are in the early stages but work is progressing well. Kemi Adenubi stated that is was encouraging to hear that progress is being made but suggested that a clear presentation of what changes will mean for the public should be available. The Chief Executive confirmed that once the Trust Strategy is in plan it will enable discussions and reporting to reflect these aspects. Resolution The Isle of Wight NHS Trust Board received the Acute, Ambulance & Mental Health and Learning Disabilities Transformation Report

PERFORMANCE 20/T/008 COMMITTEE REPORT FROM QUALITY COMMITTEE Tim Peachey, Chair of the Quality Committee reported that following the meeting

held on 12 March 2020, that in addition to issues discussed elsewhere in the meeting, the following areas were to be brought to the Board’s attention:

a) Patient Safety Sub Committee: He advised that this reports monthly with a more detailed report on a quarterly basis. The report included details of:

• National Central Alert System (CAS) and that all historic alerts were now closed and new ones being monitored within timescale.

• Duty of Candour monitoring was progressing well • Serious Incidents were now in line with national levels. • Patient Safety Incident Response Framework has been

introduced with the IW NHS Trust being an early adopter site area for the region with work commencing in April 2020.

Reasonable Assurance b) Safe Staffing: The report covered two months and a good level of

assurance was provided for both periods. Reasonable Assurance

c) Quality Impact Assessments: Work is progressing and a year-end review will be undertaken to ensure all QIA’s were complete and fit for purpose going into 2020/21. There remain concerns due to operational pressures and a review is needed ahead of the year end in line with Cost Improvement Plan (CIP) reviews and approval of the next year’s schemes.

No Assurance d) Deep Dive – Deteriorating Patient & Sepsis Update: The Committee

noted that huge progress has been made but that there was still work to do to fully embed processes.

Reasonable Assurance e) Mental Health Act (MHA) & Section 136 Quarter 3 Report: The

Committee received the report which provided assurance that the application of the MHA was appropriate and compliant with legislation.

Substantial Assurance f) Deep Dive – Physical Health in Mental Health Services: The

Committee received an excellent report which it recommended was

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shared to a wider audience. An implementation plan with particular focus on escalating attention to all healthcare settings.

Substantial Assurance g) Quality Improvement Board (QIB): The Committee were advised that

reporting arrangements would be changing with routine quality reporting moving to the Quality Committee from March. The QIB would focus on identifying and course correcting major programmes which are not on track.

Substantial Assurance h) Board Assurance Framework (BAF) Quarter 3 Report: The

Committee agreed that there would be no change to risks in quarter 3. Reasonable Assurance

i) CQC Regulatory Compliance Update: The Director of Quality Governance confirmed that the CQC had been discussed at the meeting where it was noted that the initial verbal findings had supported the self-assessment undertaken by the teams. She confirmed that a number of ‘should do’ actions had been raised for the Community Mental Health Services but that no ‘must do’ actions which was the first time this had occurred which was very encouraging. She also advised that the inspectors had noted the improvement in Stroke Services and had witnessed staffs ability to demonstrate good understanding of the process and time constraints for identifying stroke patients.

Reasonable Assurance Caroline Spicer queried if there was a backlog of QIA reviews which should be considered against CIP by the Performance Committee. Tim Peachey advised there was no backlog but that a formal review at the end of the programme was part of the process and that some of these programmes were not due to end until after the end of the year and would therefore carry forward into 2020/21. The following report was taken as read and was confirmed to have been discussed at the committee meeting:

• Quality Performance Report

No issues were raised at the meeting concerning this report. Resolution The Isle of Wight NHS Trust Board received the Quality Committee’s report.

20/T/009 LEARNING FROM DEATHS & MORTALITY QUARTER 2 REPORT The Medical Director presented the report which he confirmed had been

discussed at the Quality Committee on 11 December 2019. He advised that for quarter 2 the Trust was performing well against the Standardised Hospital Mortality Ratio (HSMR) is 72.5(CI: 65.7-79.8) and the Standardised Hospital Mortality Index (SHMI) 1.02 (CI 0.88-1.18) remain well within acceptable ranges. The Trust is rated top in its peer group for HSMR and is 4th nationally which is good news. He confirmed that the teams are now achieving consistent reporting which with the Medical Examiner now being fully established, has enabled less cases to be referred to the coroner and less inquests. Phil Berrington queried the difference in the SHMI and HSMR data reported in this report and in the CEO report earlier. It was confirmed that the data here is for quarter 2 – July – September and the data given in the CEO report was taken as at the end of Quarter 3 – October – December. The quarter 3 data would be

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included in the next Learning From Deaths & Mortality report which will go to the Quality Committee. Resolution The Isle of Wight NHS Trust Board received the Learning from Deaths & Mortality Quarter 2 Report

20/T/010 COMMITTEE REPORT FROM PERFORMANCE COMMITTEE Caroline Spicer, Chair of the Performance Committee reported that following the

meeting held on 12 February 2020, that in addition to issues discussed elsewhere in the meeting, the following areas were to be brought to the Board’s attention:

a) Winter Resilience Plan Update: This item was discussed jointly with the Quality Committee where it was noted that the increase in activity had been supported by addition clinical lists and the use of community beds.

Reasonable Assurance b) Deep Dive – Data Quality: This item was discussed jointly with the

Quality Committee where it was acknowledged that more work needs to be done in this area and that an Information Strategy and action plan were being prepared to address issues.

Limited Assurance c) Acute, Ambulance and MH&LD Transformation Report: The

Committee were pleased with the work undertaken to date. It reviewed the work being undertaken in the acute areas and acknowledged that it was in the early stages of development of pathways and that further diagnostic work was to be undertaken.

Substantial Assurance d) Operating Plan 2019/20 Update: The Committee noted the progress

and that all indicators have Executive ownership. Limited Assurance

e) Mental Health & Learning Disabilities Performance Report: The Committee discussed the transformation programmes taking place within the division and the progress being made against the CQC Warning Notices and issues relating to workforce, staff engagement and estate.

Reasonable Assurance f) Hospital Performance Report: The Committee noted the key issues

and the challenges being faces regarding bed capacity. It also noted the progress against length of stay.

Limited Assurance g) Ambulance Performance Report: It noted the ongoing issues with

achieving the performance indicators and that the team were working with SCAS1 and the CCG to assess options for support.

Limited Assurance h) Community Performance Report: It noted the high level of flu

compliance within the division although it noted that there were staff that had formally declined the vaccine. It also noted the progress being achieved within the various programmes.

Substantial Assurance

1 South Central Ambulance Service

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i) Financial Performance Report: Caroline Spicer advised that an extraordinary meeting of the Trust Board in Private had met on 21 January to agree the forecast. The Committee noted that the quarter 3 plan position had been achieved with a £1.5m potential risk. It was confirmed that the year-end forecast had been revised and that if the Trust is not able to mitigate the costs incurred to deliver RTT2, then the year end position is expected to be £29.1m (£7.6m off plan). The Committee noted the impact agency spend had against CIP and the impact of delivery of care over plan. The Regulators had been informed and were aware of the recovery plan.

Limited Assurance

Caroline Spicer confirmed that there were two items which were not discussed at the meeting due to time constraints and which would be discussed at a separate meeting in the coming weeks. These were the Board Assurance Framework Quarter 3 Report and the Deep Dive – Cost Improvement Plan – Temporary Staffing and Vacancies.

The following reports were taken as read and were confirmed to have been discussed at the committee meeting:

• Finance Performance Report • Hospital Report including Hospital Improvement Programme • Ambulance Services Report • Community Services Report • Mental Health & Learning Disabilities Report

No issues were raised at the meeting concerning these reports. Resolution The Isle of Wight NHS Trust Board received the Performance Committee report.

20/T/011 COMMITTEE REPORT FROM HR & OD COMMITTEE Anne Stoneham, Chair of the HR&OD Committee reported that following the

meeting held on 12 February 2020 that in addition to issues discussed elsewhere in the meeting the following areas were to be brought to the Board’s attention. .

a) Workforce Performance Report: It was confirmed that this report is discussed at both the Performance Committee and HR&OD Committee. Key issues discussed were around recruitment and retention where it was noted that improvements have been made although there are still gaps in some areas. There are some gaps within medical workforce in areas which are difficult to recruit to but this is a national issue. Transformation work is taking place across the organisation which will be included within the workforce plan.

Limited Assurance b) Culture Change Programme: The Associate Director of Organisational

Development updated the Committee on the plans to develop the programme. It noted that he is new in post and work will be undertaken to develop staff experiences from induction through to appraisals. He

2 Referral to Treatment Time

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also highlighted that improvements to services offered to staff for health and wellbeing were being developed which can be used to build the Change Strategy and the architecture for staff engagement.

Reasonable Assurance c) Health & Wellbeing Programme: The Associate Director of

Organisational Development updated the Committee on plans to develop the level of services which can be offered to staff. This included a range of measures which would be developed to build resilience for staff.

Reasonable Assurance d) Strategic Priorities - Recruitment & Retention: The Committee noted

that there are processes in place to address all areas although there are areas and specialist posts which are difficult to recruit to. The master vendor agreement will provide support in reducing agency and locum usage.

Reasonable Assurance e) Strategic Priorities - Equality & Diversity: The Committee noted that

the Trust was compliant and that as part of the cultural programme more work will be done to promote equality and diversity across the organisations.

Reasonable Assurance f) Medical Directors Report: The Committee received the report which

covered a number of areas: • Recruitment - A number of consultant position have been

appointed and a programme for recruitment to mid-level posts to support the junior doctors is in place.

• Job planning is scheduled to be completed by April. • GMC review has been undertaken which has allowed all core

trainees to be retained, and an assessment on supervision and working rotas is being undertaken. It was confirmed that there would be another visit from the GMC to assess progress. Appraisals should be completed by the end of March

• Health Education England (HEE) – an assessment process in place and is being undertaken.

Reasonable Assurance g) Director of Nursing Report: The Committee noted that recruitment and

on boarding of new staff was going well which was supported by a number of success stories.

Substantial Assurance h) Healthcare Worker Flu Vaccination Self-Assessment: This return has

now been completed and is recommended to the Board. i) Board Assurance Framework Quarter 3 Report: The Committee

considered the BAF and in relation to SR04 that the recommendations to change the level of risk was agreed.

Reasonable Assurance The following reports were taken as read and were confirmed to have been discussed at the committee meeting:

• Workforce Performance Report • Director of Nursing Report • Medical Director Report

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No issues were raised at the meeting concerning these reports. Resolution The Isle of Wight NHS Trust Board received the HR&OD Committee report.

20/T/012 HEALTHCARE WORKER FLU SELF-ASSESSMENT REPORT The Director of Nursing, Midwifery, AHPs & Community Services advised that

NHSE/I required all Trusts to submit the self-assessment and to upload this by 31 January 2020. She confirmed that this has now been submitted and reported that although the uptake was good there remained a percentage of staff who continue to decline the vaccine for a number of reasons. In preparation for the 2020 season a reflection on the uptake for 2019/20 would be undertaken to understand where the barriers for accepting the vaccine are so that information to staff can be provided. She stressed that as healthcare workers staff have a responsibility to patients and their families to protect themselves against the virus. A national drive to promote the flu vaccine will be taking place and will be supported by infection prevention and control teams. The team would also be looking at a range of strategies which can be used to increase the number of staff who have the vaccine. The Chair advised that the Board were required to ratify the submission. Resolution The Chair requested that the Board ratify Approval of the Healthcare Worker Flu self-assessment submission. The motion was carried unanimously.

20/T/013 JUNIOR GUARDIAN OF SAFE WORKING QUARTER 2 REPORT The Medical Director presented the report which he confirmed had been

discussed at the HR & OD Committee on 11 December 2019. He advised that the report was being realigned to enable a more contemporary report to be provided to future meetings. He confirmed that reporting in the period had improved and that key issues are being taken forward by Medical HR and the Operational teams to ensure that rotas are included on the e-rostering system to ensure that the junior doctors rotas are appropriate. Sara Weech advised that the Committee had reviewed the paper and did not recognise or agree with the final sentence of section 6.3. Resolution The Chair requested that the Board Approve the Junior Guardian of Safe Working Quarter 2 Report noting the comment made by the HR&OD Committee. The Motion was carried unanimously.

CLOSING MATTERS 20/T/014 CHAIRS CLOSING COMMENTS AND ISSUES TO BE COVERED IN PRIVATE The Chair advised that the following items had been covered in a private

meeting of the Board: • Patient Safety matters • Commercial matters

20/T/015 QUESTIONS FROM THE PUBLIC The Chair advised that a question had been received which he confirmed would

be responded to directly. This would be sent to the member of the public following the meeting.

20/T/016 ISSUES RAISE BY OBSERVERS

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a) Staff Side: No Issues raised b) Patient Council: No Issues raised

20/T/017 ANY OTHER BUSINESS a) Committee Reporting to Board: The Chair commented that over the

past 2½ years the level of assurance reporting from the Board Committees has greatly increased and are rarely giving limited assurance. He was pleased that this demonstrates how different the organisation is now.

b) Healthwatch: The Chair advised that the Chair of Healthwatch had

informed him that Dudley Delannoy who is the Healthwatch Representative to the Board is standing down. He gave thanks to Mr Delannoy for his support.

c) Ambulance Call Out Trends: Cllr Nicholson commented that the island

has a small number of ambulances and it would be interesting to know how many calls are made at one category only to be in fact a lower category on arrival, and whether there were any trends. Isobel Wroe, SCAS Representative to the Board, advised that this information is available within the standard analysis tool used nationally. The Chief Executive advised that this would be looked into and an update could be provided to the IW Health Policy & Scrutiny Committee

d) Good News: A member of the public attending the meeting advised on the exceptional care they and their family had received recently in the Trust.

20/T/018 DATE OF NEXT MEETING The Chair confirmed that the next meeting of the Isle of Wight NHS Trust Board

to be held in public is on Thursday 12 March 2020 The venue for this meeting will be the Conference Room – Level B Main Hospital – opposite Full Circle Restaurant, St Mary’s Hospital, Newport, IW PO30 5TG

Signed: Vaughan Thomas, Chair Date: 12 March 2020

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Board & Board Committee KEY TO RAG STATUS

ROLLING SCHEDULE OF ACTIONS TAKEN FROM THE MINUTES Action overdue

Action not yet dueAction extendedAction completePropose Action to be closed

Name of Meeting Date of Meeting

Minute No. Action No.

Item Action Exec Lead Delegated to for actioning on behalf of the Exec

Lead

Update & Evidence of Completion Initial Due Date

Extended/Forecast Date

Progress RAG Date Closed

Board in Public 13-Feb-20 20/T/006 TB/390 Amendment to CEO report

The CEO report to be amended to correct the SHMI figure from 0.01 to 1.01 together with the date this information was taken – 31 December 2019

Kirk Millis-Ward Lynn Cave 18/02/20 - Report has been amended accordingly and the revised version has been loaded to the Website. Propose action is closed

18-Feb-20 18-Feb-20 Propose Action to be closed

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Agenda Item No 6 Meeting Trust Board in Public Meeting Date 12 March 2020 Title Chair Report Sponsoring Executive Director

Vaughan Thomas, Chair

Author(s) Vaughan Thomas, Chair Report previously considered by inc date

N/A

Purpose of the report Reason for submission to Trust Board in Private only (please indicate below

Link to CQC Domains Link to Trust Strategic Objectives

Information only Commercial Confidentiality Effective X SO 01: Provide safe, effective, caring and responsive services – ‘Good’ by 2020

X

Review & discuss X Patient Confidentiality Caring X SO 02: Ensure efficient use of resources X

Assurance Staff Confidentiality Safe X SO 03: Achieve patient standards X

Committee Agreement

Other Exception Circumstances Responsive X SO 04: Achieve excellence in employment X

Trust Board Approval

Well-Led X SO 05: Implement the Isle of Wight Health & Care Sustainability Plan

X

Key Recommendations to be considered: The Board is recommended to receive the report.

Enc C

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Page | 2

Executive Summary During the month I have conducted and participated in meetings with, advisors, stakeholders, staff, and partners of the Trust. These have included:

o Meetings with partner organisations including: Chairs and Chief Executives – IOW and PHS – Conference Call Jane Cole, Martyn Davies – NED discussion East Cowes Town Council – Agenda item – IOW Health and Care Plan Update Extraordinary HIOW Committee in Common (CEO and Chair Meeting)

o Meetings with Individuals including Trust Executives

Wessex Academic Health Science Network, Bill Gillespie, Chief Executive Officer Integrated Care Partnership – Conference Call Leisa Gardiner, Freedom of Speech representative Integrated Care Partnership Board Agenda Discussion Primary Care Network meeting with Cllr. Dave Stewart

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Agenda Item No 7 Meeting Trust Board in Public Meeting Date 12 March 2020 Title Chief Executive’s Report Sponsoring Executive Director

Maggie Oldham, Chief Executive

Author(s) Kirk Millis-Ward, Associate Director of Communications and Engagement Report previously considered by inc date

n/a



Information only X Commercial Confidentiality Effective X SO 01: Provide safe, effective, caring and responsive services – ‘Good’ by 2020

X

Review & discuss Patient Confidentiality Caring X SO 02: Ensure efficient use of resources X

Assurance Staff Confidentiality Safe X SO 03: Achieve patient standards X

Committee Agreement




X

Key Recommendations to be considered: The Board is asked to receive this report.

Enc D

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Page | 2

Executive Summary Novel coronavirus and COVID-19 The NHS in Hampshire and the Isle of Wight and Public Health England (PHE) are well prepared for outbreaks of new infectious diseases. We have put in place measures to ensure the safety of all patients and NHS staff while also ensuring services are available to the public as normal. You can find all of the latest advice and guidance online at: www.nhs.uk/conditions/coronavirus-covid-19 If people are concerned about coronavirus they should use the NHS 111 online tool https://111.nhs.uk/covid-19 or call NHS 111. Keeping patients and our staff safe is our absolute priority. Members of the public can help stop the spread of the virus by washing their hands regularly What to do if you think you may have coronavirus:

• Do not go to a GP surgery, pharmacy or hospital • Stay indoors and avoid close contact with other people, especially older or vulnerable people • Call NHS 111 or use the online service https://111.nhs.uk/covid-19 - you will be asked questions and given advice

We have set up dedicated website and intranet pages to keep people up-to-date with the latest information. All staff now receive a weekly COVID-19 Bulletin to help them stay informed, as well as communication through the normal channels. I am grateful for the hard work of everyone involved in helping us rise to this challenge. Partnerships The Isle of Wight Health and Care Plan, published in October 2019, set out the priorities for our local health and care system. The three pillars of that plan are improving our productivity, finding new models of care and working in partnership. The Trust strategy that is being developed will also have partnerships as a key theme – they make us stronger and will help us continue to improve our services for local people. In the last month there has been positive progress with Solent NHS Trust supporting us to continue to transform mental health services.

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http://www.nhs.uk/conditions/coronavirus-covid-19

https://111.nhs.uk/covid-19%20or%20call%20NHS%20111

https://111.nhs.uk/covid-19

Page | 3

We also held a small launch event for our work with Portsmouth Hospitals NHS Trust to start our work on the Acute Partnership. You will hear more information about these important pieces of work over the coming months. Welcoming new staff I was lucky enough to welcome 50 new staff members to the organisation as our excellent corporate induction. I really value this time with our new team members, it is great to see their enthusiasm and energy and it was clear just how keen they are to make a difference to our community. I am also pleased by the progress being made to recruit doctors to strengthen our medical rota, especially out of hours. International recruitment continues to bring in new colleagues – I am so grateful to them for choosing our Trust. I know all of our staff will make them welcome. Celebrating success Our efforts to recognise and celebrate the successes of staff all over the organisation are gathering pace. The new Employee of the Month programme has proven very popular with over 200 nominations so far. Our Greatix programme, which sees staff nominate each other for good practice or demonstrating our values, has seen more than 30 awards in recent months. The Communications and Engagement Team has started planning for a Trust-wide annual staff awards programme which we will be launching soon. This will include new Long Service Awards, recognising the contribution of staff who have worked for 10, 20, 30, 40 or 50 years in the NHS. I think that this work is so very important to our people and to show our community that we really do value the people who work in our Trust. I’d like to add a personal note of thanks to everyone that has taken the time to nominate a colleague for recognition, it means a huge amount to people.

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Enc E Agenda Item No 8 Meeting Trust Board in Public Meeting Date 12 March 2020

Title Transformation Report for March 2020

Sponsoring Executive Director Nikki Turner, Director of Acute Transformation and Lesley Stevens Director of MH/LD

Author(s) Nikki Turner, Director of Acute Transformation and Lesley Stevens Director of MH/LD

Report previously considered by inc date

Key Recommendation Trust Board is asked to: Receive the report on the progress of Acute, Ambulance and Mental Health partnerships.


Link to CQC Domains

Link to Trust Strategic Objectives

Information only Commercial Confidentiality

Effective X SO 01: Provide safe, effective, caring and responsive services – ‘Good’ by 2020

X


Assurance X Staff Confidentiality Safe X SO 03: Achieve patient standards X

Committee Agreement

Other Exception Circumstances

Responsive X SO 04: Achieve excellence in employment X



X

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Joint clinical strategy Joint service and digital strategies

Acute Social Care

Primary Care

PCNs

LA/ICP

IWT Organisational Strategy

Isle of Wight Health & Care Plan

Parallel Steps • Designing Governance Structures • Development of Delivery Plan • Development of Resource Plan

PHT

Ambulance

SCAS

Mental Health

Solent

Community

Clinical Strategy Strategic Partner

Operational Partner

Delivery Resource & Plan





Overarching view of the partnerships

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3

We are working together to address immediate operational priorities

Acute Services Partnership Update

We have agreed 6 priority areas with greatest risks on the island: Urology, General Surgery, Stroke, Gastroenterology, ED and Acute Medicine

Joint teams across the two Trusts working together to develop an action plan in each of these areas

Action will address immediate highest risk issues and impact on performance in key constitutional target areas: 52 week waits, UEC flow, cancer performance

Pace dependent on availability of resources

We are also developing a joint strategy for acute care across the two Trusts Developing a strategy for acute services for

the 800,000 population we serve together Launch event with clinical and managerial

leaders on 27 February 20, high level clinical strategy by April 20

Getting into the detail: developing joint clinical and workforce plans for the core hospital services (Emergency Surgery, Acute & Emergency Medicine, Paediatrics) to deliver long term sustainable model

Communication and engagement with internal and external stakeholders

MoU approved by both Boards Partnership Board established and leading

the work together Joint message to key stakeholders

February 20 and shared with media Internal resources allocated to support the

programme – additional resource requirement being scoped Feb 20

Determining the priorities for deployment of £48m capital allocation Alignment of joint Acute Clinical Strategy

with PHT by 31-3-20 Engagement with key stakeholders Submission of outline bid refreshed for

acute and PHT bid submitted Plans to urgently address acute capacity

across the acute partnership being developed

❶

❷

❸

❹

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4

Overview

Ambulance Partnership Update

Successful first year, with refreshed MOU for second year

Agreed priorities for 2020, and identified digital enablers

Writing up overarching strategy for ambulance sector

IWAS to become 8th node of SCAS from technical perspective

Pace dependent on availability of resources

Achieved so far

Rolled out 999 iCAD in Qtr3

Modelled for perfect week

Procured and loaned fleet SCAS Director providing specialist

expertise/advice SLA to support compliance with NHSE

core standards

Ongoing

› SCAS Director provides ‘ambulance voice’ at IWT Board

› EPPR response and specialist advice › Business intelligence support and

performance analysis

Priorities for 2020 › Emergency responses – joint action plan to meet

all 999 response time stds

› Patient transport – moving onto same system and redesign future service

› Developing a clinically sustainable model to safely transfer patients on and off island

› Move towards a shared Clinical Coordination Centre

› Digital enablers – moving IWAS onto SCAS platform

❶

❷

❸

❹

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5

Overview

Mental Health Partnership Update

Successful team engagement

Agreed priorities for 2020

Resourcing of diagnostic and design phase of programme put in place

Draft MOU approved by both Boards

Great joint learning is happening – it is a 2 way partnership

Achieved so far

Agreed resourcing for diagnostic phase with NHSE

Two New Product Design workshops completed, and third planned for March

Delivery of MADE event on 10/1/20 Agreed workstreams working at pace and

on time in 3 month diagnostic phase

Ongoing

› Robust governance in place with representatives from NHSE/I, CCG, Solent and IOW Trust and IOW Council at monthly meetings, with extended membership quarterly to include Southern Health, Primary Care Networks and Trust NEDs

› Workshop planned for 27th April to share outcome of diagnostic and design work with staff, service users and stakeholders

› Implementation and resource plan to be in place by end May 2020

Priorities for 2020

› Develop and deliver transformation programme based on the outputs of the New Product Design work, and supported by programmes arising from diagnostic work, to include:

› Leadership and culture › Workforce › Governance › Estates and IT

❶

❷

❸

❹

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Agenda Item No 9 Meeting Trust Board in Public Meeting Date 12 March 2020 Title Quality Report Sponsoring Executive Director

Suzanne Rostron, Director of Quality Governance

Author(s) Vanessa Flower, Head of Quality Governance Jo Case, Head of Service Improvement


The information within this report has been discussed at the Quality Committee and/or its subcommittees.




X

Review & discuss X Patient Confidentiality Caring SO 02: Ensure efficient use of resources X


Committee Agreement

X Other Exception Circumstances Responsive X SO 04: Achieve excellence in employment



Key Recommendations to be considered:

The Trust Board is asked to consider the following recommendations:

- To receive the report

Enc F

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Executive Summary This report provides a summary of quality improvements, inquests, learning from feedback and compliance across the Trust. Serious Incidents 10 serious incidents were declared to the Isle of Wight Clinical Commissioning Group (CCG) during January 2020 and 41 cases are in open management at the time of reporting. Claims & Inquests The Trust has received 3 Clinical Negligence Claims in January 2020 and have had 30 new referrals from HM Senior Coroner. Details are encompassed within the Private Trust Board Report. Patient Experience The Trust received a total of 38 complaints in January 2020, compared to 30 January 2019. The highest number of 14 was received for SWCH. The Trust has seen a decrease in concerns but have attributed this to staffing shortages within the Patient Advice & Liaison Service. The Trust received eight returning complaints in January 2020, and this continues to be an increasing picture, and is due to the Trust not fully answering the complaint in the initial response. Work is ongoing to improve the quality and timeliness of responses. Health & Safety 1 RIDDOR has been declared and details are captured within the report. CQC The Trust awaits the publication of the Acute Warning Notice Report but other assurance mechanisms are in place to provide support to Divisions. Check and Challenge Sessions shall be established within Acute and Mental Health and a Mock Inspection is being coordinated to take place in April.

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Trust Board Report Quality Governance

Date: 17 February 2020

1. Purpose of the Paper

To inform the Board of any quality improvements, concerns or risks and advise of actions being taken.

2. Background The ‘Quality Report’ summarises key information that has been presented to the Quality Committee that the Board needs to be sighted on. The Quality Committee Sub-Committees receive more detailed information and interrogate thematic and trend analysis. The Quality Committee receives escalation and assurance reports and will investigate issues to seek assurance on behalf of the Trust Board. This report provides an overview of key issues or achievements and seeks approval when necessary

3. Patient Safety 3.1 Serious Incidents 10 serious incidents were declared to the Isle of Wight Clinical Commissioning Group (CCG) during January 2020; a detailed summary of these is included in the private board papers. In February 2020, up to 20.02.20, 6 serious incidents have been declared so far. 3.1.1 Ongoing Serious Incident Management The current SI status, as of 20.02.20 is as follows: 41 SI cases are currently being managed broken down as follows: 13 cases are overdue for completion and this includes 4 cases that were returned by the CCG for further assurance (of those overdue 7 are Coroner’s cases) 28 cases are ongoing and currently within timescale

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(17 cases currently with CCG awaiting closure following investigation/clock stopped) 3.2 Key Performance Indicators The KPI below is set against the SI process, and in line with national requirements.

3.3 Overview of SI cases submitted to CCG

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20New SIs reported in month 6 10 14 12 19 15 4 9 10 10SI reported in 2 working days (of awareness) 6 10 14 12 18 15 4 9 10 9% in 2 working days 100% 100% 100% 100% 95% 100% 100% 100% 100% 90%

8 cases were due for submission in

January 2020 (agreed timescale)

5 were submitted

in-time

Ongoing: 1 case is still being investigated but is

now overdue

2 were submitted out of time

There were a total of 10

sent for closure in January (not just those due in Jan); 3 of these

were returned by CCG as non-closures; 3 were

closed first time; 4 are still pending closure

(as of 20.02.20)

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3.4 Learning Lessons from Events 9 cases were closed in January 2020, all of which have lessons learned documented. A detailed summary of lessons learnt for each closed case is given in the private Trust Board Quality report.

4. Legal Services 4.1 Claims The Trust received three clinical negligence claims in January 2020. Details are contained within the Trust Board in Private Report. 4.2 Inquests The Trust received 30 new referrals from the HM Senior Coroner in January 2020. Details of these are included in the private Trust Board Quality report. Outcomes from those inquests held in January are also captured.

5. Patient Experience 5.1 Complaints, Compliments, Comments & Concerns The Trust received a total of 38 complaints in January 2020, compared to 30 January 2019. Surgery, Women’s and Children’s Health (SWCH) received the highest number of complaints in January receiving 14, closely followed by Integrated Urgent and Emergency Care (IUEC) who received 13, 11 of which related to the Emergency Department. The SPC charts below show the trends for both complaints and concerns, during January an increase in complaints has been seen, and a slight decrease in concerns. The decrease in concerns may be due to the delay in logging these on datix due to the reduced capacity in the Patient Experience Team, which will be retrospectively updated. Up until January 2020 the Trust had started to see a reduction in numbers however, the numbers of complaints are subject to natural variation, and should not be a cause for concern. It is important to ensure that complaints are responded to in a timely way, and lessons are learnt from this valuable source of feedback.

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This special cause variation is due to an increase in formal complaints due to new staff in PALS incorrectly managing. Further Training occurred to improve position.

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The top 5 departments receiving the highest number of complaints in January were

• Emergency Department (11) • Orthopaedics (include fracture) (4) • Medical Assessment Unit (3) • Gynaecology Clinic / Team (3) • Ambulance Emergency Services (3)

Whilst the Trust saw an increase of complaints during January 2020, there was a decrease in concerns with 66 received. It should be noted that due to reduced capacity in the Patient Experience Team there is a backlog of information to be captured on the Datix System in relation to concerns, and

Looking at this special cause variation – the PALS office had new staff and a higher number of issues were referred to be managed as formal complaints.

This is likely reduced due to reduced capacity in the team meaning that not all concerns have been logged on the Datix system at the time of reporting.

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this number may be subject to change. Any update in numbers will be reflected in the next report. The chart below shows the number of new formal complaints received by Division since April 2019 (please note this includes all new complaints received including those that were subsequently withdrawn). As can be seen below both SWCH and IUEC both saw an increase in complaints compared to previous months.

0

2

4

6

8

10

12

14

16

18

20

Acute Division -CSCD

Acute Division -MED

Acute Division -SWCH

Acute Division -IUEC

CommunityDivision

Mental Health& LearningDisabilities

Division

Finance, Estatesand IM&TDivision

QualityGovernance

Division

OperationsDivision

Other Provider(Patient

ExperienceOnly)

Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Jan 2020

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In relation to concerns Surgery, Women’s and Children’s Health saw the largest number of concerns during January with 29 received. The top three areas of these being General Surgery (6), Orthopaedics (6) and Urology (4). The top subjects for these were Communication (28%), and appointments (145) and staff attitude, waiting times and clinical care (10%). During January 100 Compliments were recorded as being received on Datix, which is a significant decrease in previous months, and may be due to a delay in Divisions adding the data to the system. Of the 100 received 26 related to SWCH, 24 to Clinical Support, Cancer and Diagnostic Services (CSCD), 1 for Medicine, 19 IUEC, 20 Community, 9 Mental Health and Learning Disabilities, and 1 for Finance, Estates and IM&T. 5.2 Returning Complaints: The Trust received eight returning complaints in January 2020, and this continues to be an increasing picture, and is due to the Trust not fully answering the complaint in the initial response. The Chart below shows the new and returning complaints received by the Trust since April 2019; this data includes all new complaints, including any complaints subsequently withdrawn.

As can be seen from above the number of formal complaints received fluctuates monthly and ranges from 16 -51 per month. The Trust had initially seen a reduction in returning complaints; however, this has started to steadily increase since November 2019, despite us implementing Executive

0

10

20

30

40

50

60

Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Jan 2020New Complaints returning complaints

Increase due to new staff in PALS failing to resolve issues at an earlier stage – training put in place which has seen led to a significant

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Director sign off of complaints. The main reason for complainants returning is due to not adequately addressing the concerns raised. For January the returning complaints related to IUEC (6) and SWCH (2). The Head of Quality Governance is currently reviewing all drafts before submission to the Chief Executive to ensure that all questions posed are answered, and will be working with the Care Groups to ensure all action has been taken. 5.3 Ongoing Complaint Management

The table below shows the current compliance, at the time of reporting for January 2020 for complaints received and managed in month compliance as at the time of reporting. It should be remembered that is subject to change as the month progresses, some complaints received in December would still be within timescale at the time of the report. The delay in signing off complaints in December and showing the Trust in a worsening position, was impacted on due to the Christmas / New Year period and key staff managing complaints process being away from the Trust.

Division

Closed In time (January ) =34% 13/38*)

December Percentage Compliance

Percentage compliance Closed in time (December) = 44%(7/16*)

Clinical Support, Cancer and Diagnostic Services

1/1 = 100% 50% 1/2 = 50%

Medicine 1/1 = 100% 50% 2/2 = 100% Surgery, Women’s and Children’s Health

2/14 = 14% 50% 1/2 = 50%

Integrated Urgent and Emergency Care

5/13 = 38% 0% 3/7 = 50%

Community 2/3 = 66% 0% 1/1 = 100% Mental Health and Learning Disabilities

1/4 = 25% 0% 1/2 = 80%

Operations Divisions No complaints - No complaints Finance 1/2 = 50% - No complaints Other Provider (Dermatology) No complaints - No complaints

(*total number of new complaints received in month) At the time of reporting the Trust has seen a slight deterioration in complaints closed within timescale in December only 44% were closed within timescale, and 9 of these are still requiring a response. At the time of reporting only 34% of complaints received in January have been closed within

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timescale, however, some of the responses for the complaints received in January are not due at the time of reporting, and this will be updated in the report for February data. This is well below the Trusts 75% target; however Medicine and CSCD have both achieved 100% this month. In some cases due to the complexity of the issues raised, the complaints may require more time to investigate these, especially if the complaints are supported by SeAp and a meeting is required. Following a discussion at the Patient Experience Sub-Committee in February 2020, it has been decided to ensure that the Trust puts in place a clear process for when an extension to the investigation times is legitimate, and reporting updated to reflect this going forward. 5.4 Parliamentary Health Service Ombudsmen One request for initial information was received from the PHSO in January 2019. At the time of reporting the Trust is working with the PHSO on the following cases: Case Ref

Date request received

Service Current status

14085 07/03/2018 Rheumatology Under investigation – still awaiting contact from PHSO 14639 27/11/2018 Surgery Awaiting further contact from PHSO 14580 08/03/2019 Colwell Ward Under investigation. Awaiting contact from PHSO 13827 02/05/2019 Medicine PHSO have partly upheld this complaint (9/1/2020). The Trust has to write to the

complainant within 6 weeks to apologise for the management failings, and provide assurance that action will be taking to ensure similar incidents do not occur. Awaiting Divisional response to recommendations.

16698 30/07/2019 Surgery Final report received (3/2/2020) Complaint not upheld. 5.5 Learning from Feedback The following actions are a sample of those taken from complaints partially upheld or upheld in January 2020. Main themes of complaints and action taken by division: Integrated, Urgent and Emergency Care: Patient removed conflicting information about diagnosis:

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• Clinicians to ensure full review of previous notes prior to decision making. Poor interaction with reception staff:

• Action taken with individual member of staff Noise at night in the Emergency Department:

• Ensure that relatives are asked to reduce noise levels at night.

Poor attitude of staff on MAU: • Addressed with individual member of staff

Lack of hot meals for patient on MAU:

• Staff reminded how to access additional hot meals for patients, and catering asked to ensure hot soup is available for all meals. Poor Care on MAU:

• Apology given for poor care received; the ward now employees seven deputy sisters to ensure there is a senior nurse who co-ordinates every shift to avoid this happening in future.

Clinical Support, Cancer and Diagnostic services: Unprofessional behaviour of clerical staff:

• Addressed with individual member of staff. Surgery, Women’s and Children’s Health: Patients surgery cancelled due to lack of ultrasound machine:

• New machines have been purchased and training completed for staff in new equipment. Failure to return patient calls:

• Review of current admission and booking process underway with the aim to centralise the process and maximise efficiencies and provide a more comprehensive service.

Attitude of Nursing staff:

• Addressed with individual member of staff

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6. Health, Safety & Security 6.1 RIDDOR The following RIDDOR case was reported in the Trust during February 2020. Incident Date

RIDDOR Reportable

RIDDOR Completed

Date of RIDDOR

RIDDOR NUMBER

Reason WHO Closed/ Open?

Lessons Learned.

11/2/2020 YES YES 07/02/2020 C4A17011F Whilst carrying a patient down stairs at the last step, injured persons missed their footing and as they were putting the carry chair down it twisted catching their side/ribs with the handle causing discomfort.

Member of Staff

CLOSED Isolated incident. Staff member is up to date with Manual Handling training. Monitor for future similar incidents.

7. Compliance

7.1 CQC The Acute warning notice expired on the 31 December 2019. The Trust submitted a report, at the request of the CQC, on the 17 January 2020 detailing progress against the warning notice. The CQC undertook an unannounced inspection on the 3 and 4 February 2020. Further information requests have been submitted to inform their report and we await its publication. If any verbal feedback is received, this shall be shared with the Board.

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The Trust continues to support monthly assurance visits and planning has begun to establish a Mock CQC Inspection in April 2020. Check and Challenge Sessions shall also be established through the Trust Quality Committee to support the Acute and Mental Health Divisions.

8. Quality Improvement QSIR (Quality, Service Improvement & Redesign) The first Quality, Service Improvement Redesign (QSIR) Practitioner 5 day Training commenced in January 2020. The feedback from the 22 staff on the cohort has been great. The staff have been able to apply the tools they are learning to their quality improvements within their own services. Two fundamental days have been run so far totalling to 20 staff members. Monthly one day fundamental training sessions are running throughout the year. The second 5 day practitioner course will commence in April with 26 staff booked (max booking is 30).

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Ambulance, Community, Corporate, Hospital, Learning Disability & Mental Health Services - www.iow.nhs.uk 1

Enc G1

Agenda Item No 10 Meeting Trust Board in Public Meeting Date 12 March 2020

Title Financial Performance – Month 10 2019/20

Sponsoring Executive Director

Darren Cattell – Director of Finance, Estates , IM&T and Deputy Chief Executive

Author(s) Gary Edgson – Deputy Director of Finance


Trust Leadership Committee - 26 February 2020 Performance Committee - 11 March 2020

Key Recommendations to be considered:

To receive the Month 10 Trust performance against the 2019-20 financial plan.

The Board is asked to note the limited assurance on the Trusts overall financial performance to date and note we are on track to deliver the revised year end forecast of £29.1m deficit, and ongoing recovery actions.


Link to CQC Domains


Information only Commercial Confidentiality Effective SO 01: Provide safe, effective, caring and responsive services – ‘Good’ by 2020

X

Review & discuss Patient Confidentiality Caring SO 02: Ensure efficient use of resources X

Assurance X Staff Confidentiality Safe SO 03: Achieve patient standards

Committee Agreement


Responsive SO 04: Achieve excellence in employment



1/11 37/175

http://www.iow.nhs.uk/


Executive Summary

Q3 financial position Q3 plan position achieved, which secures £5.2m of Q3 external support funding.

M10 position Deficit in month of £3.8m Off plan by £2.7m (excluding support funding) – this is consistent with the trajectory towards the Board approved forecast outturn of £29.1m deficit

M11 & M12 control totals Trust forecast deficit is £29.1m (including £0.5m to deliver RTT recovery). To deliver this position, each Division and Directorate has a ‘control total’ to achieve

Action being taken • Commitment given from Divisions and Directorates to achieve these control totals, to ensure delivery of the overall Trust position –

assurances have been received at Divisional Boards and Finance Recovery Board

2020/21 Financial Planning • Projection and reconciliation of the underlying financial position from this year’s £29.1m – work on-going with Divisions • Financial planning meetings scheduled throughout March

Progress to date against CIP delivery • £7.1m planned delivery to date from a total plan of £10.5m • £5.4m actual delivery to date, £1.7m adverse to plan but on track to deliver the forecast • Delivery includes £2m of non-recurrent savings

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Executive Summary

CIP Forecast • A risk based assessment of the forecast values of individual CIP schemes has been undertaken by the finance programme

management office. This indicates a likely shortfall of circa £2.5m (i.e. delivery will total £7.9m of the £10.5m baseline plan, £1.35m of which was the NHSE/I stretch target)

• The Finance Recovery Board (FRB) continues to drive performance delivery, to identify recovery actions, CIP mitigations and consider required investment decisions which will support improved quality/financial sustainability

• Delivering the in-year CIP forecast, and planning for 2020/21 is now the focus of the FRB Capital Investment Update • The revised capital programme for 2019/20 totals £8.6m • The increased programme reflects the impact of additional allocations for NHS Digital programme and emergency care performance • As at Month 10, year to date capital investment is £4.6m. There is reasonable assurance within the Capital Investment Group that the

full £8.6m programme will be delivered • Planning for the £48m capital allocation is progressing and is being developed by internal and external stakeholders, alongside the

overall Trust strategy. A Programme Business Case will be developed by 31 March 2020.

Cash update • At the end of January the Trust’s cash balance was £2.2m, a decrease on the previous month’s balance by £0.5m. Reduction in

working capital of £2m due to increase in creditors was offset by operating deficit and increase in capital spend • March cash balances are expected to be as per approved cash flow plans

Use of Resources rating • The Trust’s Use of Resources Rating (UoR) has remained at a score 4 (1 being best and 4 being worst) • As the Trust is under Financial Special Measures the UoR rating will default to 4

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Area Key issues Current month (ytd)

Previous month (ytd)

Overall Plan The Trust is reporting a deficit of £21.9m (excluding support funding) as at the end of January, which £2.7m off plan. A risk of £7.6m, including £0.5m for RTT, to the planned year end position has been highlighted following the Q3 forecasting refresh (see Appendix F). Control totals have been issued to each division to meet the forecast deficit of £29.1m (including £0.5m to deliver RTT recovery).

£2.7m off plan

On plan

FOT £7.1m risk to plan (£7.6m with

RTT)

Income At month 10 income is £5.8m favourable to plan (after in-year adjustments to the income plan). This is mainly as a result of other income in excess of planned levels and an additional £0.4m for non elective activity above the SLA level.

£5.8m fav to plan

£6.1m fav to plan

Expenditure Expenditure is £8.6m adverse to plan at the end of January. This is mainly the result of additional staffing costs in the Emergency Department, cost of additional non elective activity and a shortfall in CIP. This has been partially offset by the use of central funding.

£8.6m adv to plan

£6.1m adv to plan

CIP As at the end of the January the Trust has delivered £5.4m of CIP against a plan to deliver £7.1m (£3.4m of this is recurrent, £2m is non-recurrent). A scheme by scheme risk adjusted forecast indicates that £7.9m of the £10.5m CIP will be achieved.

£1.7m adv to plan

£0.8m adv to plan

Capital Capital expenditure is £0.2m ahead of the YTD original plan due to the expenditure incurred to relocate the Outpatients Department. However the year end forecast is that capital expenditure will be in-line with the revised plan of £8.6m in total.

£0.1m adv to plan

£0.4m adv to plan

Cash At the end of January the Trust’s cash balance was £2.2m, a decrease on the previous month’s balance by £0.5m. Reduction in working capital of £2m due to increase in creditors was offset by operating deficit and increase in capital spend.

£2.2m Cash

Balance

£2.7m Cash

Balance

Financial risk rating (UoR)

At the end of January the Trust’s Financial use of resources rating was ‘4’ as per the plan (as the Trust is in Financial Special Measures the risk rating will default to a ‘4’).

Overall score 4

Overall score 4

Month 10 Executive Summary

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Month 10 - Overall Financial Performance

Summary Escalating service pressures continue to exert financial pressures, most significantly in ED & MAU. Additional non-elective activity (above the block contract value), an under delivery of CIP and projects relating to delivering financial recovery and transformation have also impacted planned levels of expenditure. A deficit of £3.8m in M10 is off plan by £2.7m, excluding any external support funding. Control totals have been issued to each Division to achieve a collective £29.1m deficit forecast.

Expenditure exceeded income by £2.7m in M10 which is consistent with the trajectory towards the Board approved forecast outturn. No further PSF/FRF support funding is assumed to be received in 2019/20.

NB – Variances may not sum exactly due to roundings

Year (£m)

Plan Actual Variance Plan Actual Variance PlanIncome 14.6 14.3 -0.3 147.2 153.0 5.8 176.5Pay -10.7 -12.3 -1.5 -116.3 -119.7 -3.4 -137.7Non Pay -4.2 -5.2 -1.0 -42.3 -47.9 -5.6 -50.8

EBITDA -0.4 -3.2 -2.8 -11.4 -14.6 -3.2 -12.0Post EBITDA -0.8 -0.7 0.0 -7.9 -7.5 0.4 -9.5

Pre PSF/FRF -1.2 -3.8 -2.8 -19.3 -22.0 -2.7 -21.5PSF/FRF 2.0 0.0 -2.0 13.4 11.4 -2.0 17.5

Surplus/(Deficit) 0.9 -3.8 -4.7 -5.8 -10.5 -4.7 -4.0

In Month (£m) Year to Date (£m)Operating Plan

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Month 10 Financial Performance (by division)

Pressures at divisional level are reflected in the table below, the key adverse variances are as follows: • Integrated Urgent & Emergency Care – agency staffing costs in the Emergency Department/MAU, CIP under

delivery and additional work to support patient flow • Acute Services – costs relating to additional activity and CIP under delivery

NB – Variances may not sum exactly due to roundings

The overspends in Integrated Urgent & Emergency Care, Acute Services overseas recruitment of nurses have been only partially mitigated by small underspends in Community Services and some Corporate areas and the use of centrally held funding. The latter has adversely impacted on the amount that the Trust has available for investment priorities.

Year (£m)Plan Actual Var Plan Actual Var Plan

Acute Services -6.8 -8.2 -1.4 -73.4 -77.0 -3.6 -85.4Community Services -1.4 -1.5 -0.1 -14.3 -14.2 0.1 -16.9Mental Health and Learning Disabilities -1.5 -1.7 -0.2 -15.5 -16.1 -0.7 -18.4Integrated Urgent & Emergency Care -1.6 -2.6 -1.0 -16.5 -20.0 -3.5 -19.5Finance, Information & Estates -1.5 -1.8 -0.2 -14.5 -14.4 0.2 -16.9Trust Administration -0.5 -1.1 -0.6 -5.0 -5.5 -0.5 -6.0Human Resources and Organisational Development -0.2 -0.2 0.0 -2.3 -3.1 -0.8 -2.7Nursing, Midwifery, AHP -0.1 -0.1 0.0 -1.4 -1.5 0.0 -1.7Medical Director 0.0 0.0 0.0 -0.4 -0.2 0.2 -0.4Quality Governance -0.2 -0.2 0.0 -1.8 -1.5 0.3 -2.1

Total (Divisions) -13.8 -17.4 -3.6 -145.0 -153.5 -8.6 -170.1

Non devolved income/expenditure/finance costs Plan Actual Var Plan Actual Var PlanIncome (not devolved) 15.4 13.4 -2.1 148.8 149.5 0.7 179.5Capital Charges -0.4 -0.4 0.0 -5.8 -5.8 0.0 -7.2Finance Costs (inc donated asset income/depreciation) -0.2 -0.2 0.0 -1.8 -1.6 0.2 -2.2Centrally Held Funding* -0.2 0.8 0.9 -2.0 0.9 3.0 -4.0

Total 14.7 13.6 -1.1 139.1 143.0 3.9 166.1

Trust Total 0.9 -3.8 -4.7 -5.8 -10.5 -4.7 -4.0

DivisionIn Month (£m) Year to Date (£m)

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Month 10 CIP

CIP YTD DELIVERY & FORECAST

CIP Forecast The latest divisional level CIP forecast is that £7.9m of CIP will be delivered by the end of the financial year. This is against a target to deliver £10.5m (forecast is £2.5m below target). The table (bottom left) analyses forecast delivery by division and by risk rating. 43% of the £10.5m CIP target is now either rated ‘Blue’ (delivered) or ‘Green’ (will deliver). Actions are ongoing to improve this.

CIP YTD Delivery As at month 10 £5.4m of savings (£3.4m recurrent and £2m non recurrent) have been delivered

Current In Year Financial Forecast £m 0.0 0.0 0.4 1.6 6.0 7.9

Previous In Year Financial Forecast £m 0.0 1.1 0.9 0.8 5.1 7.9

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Month 10 Balance Sheet

Summary The key year to date balance sheets movements are as follows: • Reduction to Fixed Assets – Depreciation is

currently lower than the rate of capital additions • Increase in Debtors - mainly due to accrued in

year non-tariff drugs and Acute activity over performance which is included as additional income above plan in the I&E position and PSF/FRF

• Increase in Creditors - mainly invoiced creditors due to revised deficit position

• Increase in Borrowings > 1 year – loans in advance of PSF/FRF support funding are required, but are repaid once PSF/FRF is received from DHSC

• Retained Earnings - reduction reflects the deficit I&E position

Balance SheetM12

18/19Month

9Month

10In Month

MovementFixed Assets 111.5 110.7 111.1 0.4

Stock 2.3 2.1 2.2 0.1Debtors 10.8 20.0 20.6 0.6Cash 4.5 2.7 2.2 -0.5

Creditors -16.9 -21.9 -24.1 -2.3Capital creditors -2.2 -1.2 -1.2 0.0PDC dividend creditor 0.0 -0.8 -0.7 0.1Interest payable creditor -0.2 -0.1 -0.1 0.0Other Liabilities -1.9 -2.1 -2.6 -0.4Provisions < 1 year -0.2 -0.1 -0.1 0.0Borrowings < 1 year -0.1 0.0 -0.7 -0.6

Net current assets/(liabilities) -4.1 -1.4 -4.5 -3.1

Provisions > 1 year -0.2 -0.2 -0.2 0.0Borrowings > 1 year -68.2 -76.9 -78.0 -1.2Long term liabilities -68.4 -77.0 -78.2 -1.2

Net assets 39.0 32.2 28.4 -3.8

Taxpayer's equityPublic dividend capital 7.9 7.9 7.9 0.0Retained earnings -2.4 -9.2 -13.0 -3.8Revaluation reserve 33.6 33.6 33.6 0.0Other reserves 0.0 0.0 0.0 0.0Total tax payer's equity 39.0 32.2 28.4 -3.8

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Summary The cash balance held at the end of January is £2.2m, a £0.5m decrease on the previous month. The Month 10 cumulative I&E deficit of £10.6m is adjusted for depreciation (£5.1m) as it does not impact on cash. The charges for Interest Payable/Receivable (£1.7m) and PDC Dividend (£0.7m) are also added back as the amounts actually paid for these expenses are shown lower down for presentational purposes. This generates a YTD cash ‘Operating Surplus’ of £3.1m. The Trust accessed loan funding of £1.7m in January in advance of receipt of Q3 FRF/PSF which is expected to be received in February. The net impact of changes in working capital, payments for capital expenditure and an decrease in working capital loans combine to create the £0.5m overall decrease in the cash position since the previous month.

Month 10 Cash

Cash Analysis - Movement in Month

Actual M9

Actual M10

In Month

Cash Balance (19/20 Opening) 4.5 4.5

Income & Expenditure Surplus/(Deficit) -6.8 -10.6 -3.8Depreciation 4.6 5.1 0.5Interest Payable/Receivable 1.5 1.7 0.2PDC Dividend 0.8 0.7 -0.1Operating Surplus/(Deficit) 0.1 -3.1 -3.3Change in Stock 0.2 0.0 -0.1Change in Debtors -9.6 -10.2 -0.6Change in Creditors & Other Liabilities 5.8 8.5 2.7Changes in Provisions -0.1 -0.1 0.0Net Change in Working Capital -3.7 -1.8 2.0Capital Spend -4.8 -5.7 -0.9Interest Paid/Received -1.1 -1.2 -0.1PDC Dividend Paid -0.2 -0.2 0.0Other 0.0 0.0 0.0Investing Activities -6.2 -7.1 -1.0Working Capital Loans 8.0 9.8 1.7Loan/Finance Lease Repayments -0.1 -0.1 0.0Cash Balance 2.7 2.2 -0.5

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Summary As at month 10 capital expenditure is £0.1m ahead of the year to date plan. Although the 19/20 capital programme is only 54% complete, this reflects the phasing of the remaining expenditure in Q4.

There is positive assurance that the full capital investment of £8.6m in 2019/20 will be completed. Planning for the £48m capital allocation is progressing and is being developed by internal and external stakeholders, alongside the overall Trust strategy.

Month 10 Capital 2019/20 Capital Programme

Source of FundsOriginal Plan'£k

Revised Plan '£k

CRL based on depreciation 6,337 6,337Depreciation Re-Lifing (327)Emergency Care Performance 450NHS Digital 1,399Property Sale 400Imaging Equipment Funding 318Donated Assets 50 50

Total Source of funds 6,387 8,627

Application of Funds £k £kIM&T RRP & New Schemes 500 829Equipment RRP 500 919Backlog Maintenance 651 778Shackleton interim 200 345Shackleton reprovision 800DSU 1,040ED Paediatrics 200 300Backup Generators 916 1,157Relocation CMHS 1,300Fire Compartment Remediation 230 232Urgent Care 180OPD Relocation 1,070Staff Capitalisation 200Emergency Care Performance 450NHS Digital 1,399Imaging Equipment Funding 318Unallocated re Property Sale 400Donated Assets 50 50

Total Application of Funds 6,387 8,627

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The Trust’s Use of Resources Rating is a ‘4’. This is against a score of 1 being best and 4 being worst.

As the Trust is under Financial Special Measures the overall UoR rating will default to ‘4’.

Finance & Use of Resources Risk Rating

Use of resources risk rating summaryPlan

RatingActual Rating Var

Capital Service Capacity 4 4 0Liquidity (days) 4 3 -1I&E Margin 4 4 0Distance from financial plan 1 4 3Agency spend 4 4 0

Overall Risk Rating 3.4 3.8

Risk rating after overrides 4.0 4.0

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Enc G2 Agenda Item No 10 Meeting Trust Board in Public Meeting Date 12 March 2020 Title Integrated Hospital Performance Report for Month 9 December 2019

Sponsoring Executive Director Joe Smyth, Chief Operating Officer for Acute and Ambulance Services Author(s) Jo Ferguson, Business Support Acute Services


Acute Performance Committee 18th February 2020

Key Recommendation

The Hospital Integrated Report is set out in the attached presentation and provides an overview of quality, activity, and performance within the Hospital for month 9, December 2019. Also included is the current status of the Performance Improvement Recovery Programme, the aim of which is to significantly improve patient flow across the organisation and meet national performance standards and to work more efficiently to optimise available capacity. This monthly Summary Report is produced from a number of data sources, which are all reported through the Hospital Division’s Quality, Performance and Board meetings. The Committee, will continue to receive a separate report for Ambulance information. The Board is asked to receive the monthly Hospital performance summary for Month 9 for assurance.


Link to CQC Domains



Effective X SO 01: Provide safe, effective, caring and responsive services – ‘Good’ by 2020

X

Review & discuss

Patient Confidentiality

Caring X SO 02: Ensure efficient use of resources X


Committee Agreement


Responsive X SO 04: Achieve excellence in employment X



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Integrated Hospital Report Board Meeting March 2020 Data presented is for month 9 (December 2019)

Executive Presenter: Joe Smyth Chief Operating Officer 1 2/34 49/175

EXECUTIVE SUMMARY – MONTH 9 December Safe

1. SI’s – There were 3 new SI’s reported in month all sit within the SWCH Care Group, the division is tracking serious incidents as set out in the report within the safe domain, additional information is also available in appendix A slide 2.

2. Complaints – There are 30 active complaints open for the Division of which 11 are over due. The majority of these delays are within the Emergency Department and are due to either the complexity of investigation or allocation of resource to undertake the investigation. The Care Group Director and ADO have been asked to address this and report back on progress

3. There were 2 new risks to report in month one in Medicine regarding workload for Junior Doctors out of hours – an action plan to manage and monitor this has been put in place. The second risk relates to fragility of the Urology service. The division is tracking 11 (high risks) rated 15 or above on a monthly basis.

4. These slides are under development and going forward will provide more of a trend analysis and a more detailed narrative explaining the current position.

Responsive 1. Summary • The Emergency care Standard 4 hour performance has continued to increase month on month in Q3 and for December increased

by 2.2% from November’s performance. Performance against trajectory is below target and can be attributed to staff shortages and capacity constraints from winter pressures. Further details are provided in Slide 9.

• RTT performance at Month 9 decreased to 72.2%, however an improving trajectory over the last quarter for incomplete performance continues. The in-month performance RTT drop is due to the impact of the ASI transfers which have been added on to the profile of the waiting list. List size increased by 435 patients due to transfer of ASI patients. Forecasting remains in line with trajectory. There has been a significant reduction in the number of patients over 40 weeks.

• In December the Trust achieved all measurable Cancer Waiting Times standards with the exception of the 62 day standard. 71% was achieved against the trajectory of 79% and the 85% standard. A low number of treatments only 44 were recorded in month with a higher number of breaches (13): 8 of which were due to Urology and Colorectal.

• Diagnostics. 98.2% was achieved against a performance of 99%. Sonographer vacancy due to leaver reduced service capacity with increased delays. Ongoing issues with Endoscopy capacity have been clearly articulated and requires increase in resource to open additional theatre

2

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Use of Resources In Month 10 the division are overspent by £3.6m which is an increase of £1.7m over plan. The overspend can be attributed to additional registrars over night, agency spend, approved costs pressures (e.g. MRI, Medinet and non-funded business cases attributing to the variance).

• The financial recovery board have agreed a new revised budget for the division of £90.4m plus 0.5m for RTT recovery. This equates to a £91m total revised budget and an increase of £14m against plan

• The forecast for Q4 run rate is lower than it has been the rest of the year.

• £1.8 million of opportunities have been identified.

• Senior finance meeting with the division taking place 3 March to establish demand plans and activity.

• CIP planning for 2020/21 is in progress in line with the Trust’s planning for the next financial year.

Well Led • Sickness absence within Acute is over target at 5.07% (December 19). Whilst sickness remains above target – December’s absence rate is

the lowest since June 2019. For IUEC the sickness rate is 4.66% which is the 4th consecutive month that sickness has reduced.

• Appraisal compliance for December for the Division was 82%. A further breakdown can be found on slide 17.

• Mandatory training compliance is above target for Acute with compliance at 89% (December). IUEC compliance is currently below target at 79% but has improved significantly on Q2.

• International Registered Nurse Deployment. Deployment continues throughout 2020 until August. Cohort 5 Overseas Nurses Commenced OSCE Bootcamp and Cohort 4 Overseas Nurses supported in Transition Programme – continue with 100% Pass rate.

• Recruitment continues to be challenging for some specialties. Joint appointments are currently being explored within Stroke and Gastro.

• Medical Workforce - Job planning overall compliance is at 76.4%. Compliance for General Medicine and SWCH continues to be a challenge and an action plan on how to achieve this will be discussed between the COO and CGD for CSCD.

Key Risks/Areas of escalation for Board awareness 1. 62 Day Pathway – Urology/Colorectal 2. Capacity – Beds / Demand / Length of Stay. Emergency admissions increased by 2% in December 2019. There was a 0.1% reduction on

length of stay however this was not sufficient to offset emergency admissions. The discharge standard before 12pm is currently not being met and a focus will be placed for the next reporting period. We are exceeding our extended LOS 21> (target 39 patients to date we are averaging 48). Bed occupancy for the month of December averaged at 102.2%

3. Vacancies – Clinical Lead in Emergency Department – job advert has been finalised and uploaded to NHS jobs awaiting Royal College approval to go live before end of February 2020.

4. System Affordability to commission appropriate levels of activity to avoid future long waits and 52 week breaches in the elective pathway.

EXECUTIVE SUMMARY – MONTH 9 December

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Item Slides

Quality Serious Incidents Complaints Risks

6-8 6 7 8

Performance Summary A&E (Emergency Care Standard) RTT Cancer Diagnostics

9 10 11-13 14-16 17

Finance 18-19

Workforce 20

Performance Improvement Recovery Plan (PIRP)

21-25

Contents

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Safe 1. Serious Incidents

New SIs reported this month – 3 as at 31/12/19

2019/27747 SWCH Delay in treatment Patient's planned operation delayed by 5 months. Subsequent operation more complicated due to delay and has adversely affected patient's long term prognosis.

2019/27740 SWCH Sub-optimal care of deteriorating patient

Patient found collapsed having mobilised out to toilet (noted telemetry leads on chest; patient was being cared for in corridor in Emergency Department)

2019/27950 SWCH Failure of procedures Following identification of a patient on a 90-week wait, additional un-appointed referrals found.

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2. Complaints Safe

0

2

4

6

8

10

12

14

16

CSCD MED SWCH IUEC

2 2

6 7

1

4

12

10

1

4 5

7 6

1

11

15

0

3

7 6

1 1

6

12

0

4

12

7

2 2

4

8

2 2 3

5

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

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Safe

No new risks rated 12 and above added for December for CSCD or IUEC

Medicine

• 1635 Workload for Junior Doctors out of hours – ST trainees in medicine Current rating = 12

• No risks closed in December 2019

SWCH

• 1666- Urology Fragile Service

Risk Categories Number of open risks

Risks rated > 15 (High) 11

Risks rated between 8 - 12 (Moderate) 72

Risks rated between 4 – 7 (Low) 17

Risks rated < 4 (Very low) 0

Total number of risk currently being managed by Division

100

3. Hospital Risk Management position - December

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Constitutional targets

Target %

April 19 %

May 19 %

June 19 %

July 19 %

Aug 19 %

Sept 19 %

Oct 19 %

Nov 19 %

Dec 19 %

Month Previous Quarter

Emergency Care Standard

95% Trajectory

91.7% 76.7 79.1 77.9 77.6 67.72 71.9 70.9 72.6 74.8

RTT 92% Trajectory

77.3% 75.7 73.3 71.4 71.7 70.4 70.4 71.7 73.5 72.2

Cancer 85% Trajectory

74% 62.9 67.8 77.9 75.6 75.0 76.7 77 76 63.38*

Diagnostics 99% Trajectory

99% 95.4 94.9 96.8 97.9 98.4 98.8 99.4 98.8 98.2

Performance Summary against constitutional standards

* = Potentially achieved but still needs to be fully validated once tertiary upload has been finalised

1. Operational Performance Summary Month 9 Responsive

Summary:

• The Emergency care Standard 4 hour performance has continued to increase month on month in Q3 and for December increased by 2.2% from November’s performance. Performance against trajectory is below target and can be attributed to staff shortages and capacity constraints from winter pressures. Further details are provided in Slide 9.

• RTT performance at Month 9 decreased to 72.2% , however an improving trajectory over the last quarter for incomplete performance continues. The in-month performance RTT drop is due to the impact of the ASI transfers which have been added on to the profile of the waiting list. List size increased by 435 patients due to transfer of ASI patients. Forecasting remains in line with trajectory.

• Cancer in In December the Trust achieved all measurable Cancer Waiting Times standards with the exception of the 62 day standard. 71% was achieved against the trajectory of 79% and the 85% standard. A low number of treatments only 44 were recorded in month with a higher number of breaches x 13: 8 of which were due to Urology and Colorectal.

• Diagnostics. 98.2% was achieved against a performance of 99%. Sonographer vacancy due to leaver reduced service capacity with increased delays. Ongoing issues with Endoscopy capacity have been clearly articulated and requires increase in resource to open additional theatre

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2. Emergency Care 4 hour Standard – Dec 19 Responsive

Commentary; The 4 hour Emergency Care performance has continued to increase month on month in Q3 and for December increased by 2.2% from November’s performance. Performance against trajectory is below target and can be attributed to staff shortages and capacity constraints from winter pressures as outlined below; 1. Emergency admissions increased by 2% in December 2019 2. There was a 0.1% reduction on length of stay however this was not sufficient to offset emergency admissions 3. The discharge standard before 12pm is currently not being met and a focus will be placed for the next reporting period 4. We are exceeding our extended LOS 21> Target (target 39 patients to date we are averaging 48) 5. Bed occupancy for the month of December averaged at 102.2%

Summary Analysis of Performance Discharge Lounge and SDEC operating as inpatient facilities , creating exit block from ED causing congestion in the department which lead to significant numbers of breaches. Insufficient bed capacity to meet demand, admitted ED performance was significantly impacted achieving 16.6% in month. Adherence to agreed systems and processes in ED causing unnecessary delays and negatively impacting the four hour standard Allocating of beds from ED to the ward cumbersome delaying patients, creating congestion and impacting performance

Actions: ECIST to work with the hospital for 6 – 12 months and focus in improving flow to maximise bed availability Additional Community beds to be commissioned to free up SDEC , Discharge Lounge and to ease congestion on the wards (additional patient) Continued focus on education and training of all staff on process and procedures – continued detailed breach analysis to inform future training Improve bed allocation system to release capacity within the ED Department Adjust the IT tracking system within the department to help reduce unnecessary delays for patients

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The Trust is no longer performance managed on the 92% standard however it is required to report on list size, 52 week breaches and patients waiting over 40 weeks. Information on the total list size is available on the next slide Commentary: The admitted long waiting patient plan continues to deliver and the total number of patients awaiting admitted treatment is now close to the year end trajectory. We continue to closely manage patients near 52 weeks on their pathway to avoid further breaches in order to hit the year end zero breach commitment. There are now 75 patients over 40 weeks on the non admitted PTL and although this is similar to the numbers at the start of September 19, a large peak in numbers across December/January as a result of the ASI issue has been successfully managed and we are now reducing down the over 40 weeks numbers as we move towards year end.

3. RTT Performance

Service Sep-19 24 Feb 2020 Forecast agreed recovery plan

>=40 inpatient >=40 daycase >=40 inpatient >=40 daycase >=40 inpatient >=40 daycase General Surgery 5 6 1 Urology 30 44 8 6 5 4 Colorectal Surgery 1 3 1 Trauma & Orthopaedics 76 35 20 27 25 Ophthalmology 27 5 28 Gynaecology 3 1 2 2 2 8 Residual 2 4 Total 115 118 31 45 32 40

Admitted incomplete waiting list profile

Month Dec Actual

Jan F/cast*

Feb F/cast

Mar F/cast

April F/cast

Incomplete 30 12 (13) 5 0 0 Non admitted 10 14 (4) 1 0 0 Admitted 5 9 (16) 5 3 0

52 week breach recovery trajectory

* Figures in brackets in January are a non validated final position against forecast

10

Responsive

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3. RTT Performance List Size at end 23 Feb 20

General Surgery 668 (6) 692 24 - 705 37 Urology 906 (8) 826 (80) - 858 (48) Breast Surgery 120 - 93 (27) - 128 8 Colorectal Surgery 463 (4) 249 (214) - 248 (215) Trauma & Orthopaedics 1,450 (3) 1,400 (50) - 1,444 (6) ENT 993 (6) 866 (127) 3 879 (114) Ophthalmology 1,633 (74) 1,832 199 - 1,846 213 Maxilo Facial and Oral Surgery 369 (4) 568 199 - 550 181

Pain Management 197 (1) 233 36 - 251 54 Gastroenterology 191 (4) 420 229 6 389 198 Endocrinology 55 - 30 (25) - 30 (25) Clinical Haematology 206 (5) 101 (105) 11 97 (109) Clinical Immunology And Allergy 206 (6) 201 (5) - 197 (9)

Cardiology 458 (73) 717 259 2 747 289 Dermatology 478 (11) 438 (40) - 520 42 Respiratory Medicine 137 (1) 273 136 - 261 124 Rheumatology 178 (17) 218 40 2 228 50 Paediatrics 239 (1) 131 (108) - 151 (88) Geriatric Medicine 75 (4) 44 (31) - 47 (28) Gynaecology 905 (8) 943 38 26 933 28 Residual 345 (5) 434 89 5 415 70

List Size @ Validation List Size @ Variance to Slot Issues @ Forecast List Size @ Variance to

Mar-19 Impact 23-Feb-20 Mar-19 16-Feb-20 Mar-20 Mar-19

Total Incomplete 10,272 (241) 10,709 437 55 10,923 651

Non-Admitted 7,573 (203) 7,941 368 55 8,178 605

Admitted 2,699 (38) 2,768 69 - 2,745 46

Inpatient 707 - 642 (65) - 636 (71)

Day Case 1,992 - 2,126 134 - 2,109 117

Responsive

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12

3. RTT Admitted Long Waits Trend Responsive

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4. Cancer Targets – December 19 Responsive

* Last month is provisional data

Commentary In December the Trust achieved all measurable Cancer Waiting Times standards with the exception of the 62 day standard. 71% was achieved against the trajectory of 79% and the 85% standard. A low number of treatments only 44 were recorded in month with a higher number of breaches x 13: 8 of which were due to Urology and Colorectal. •Number of patients beyond 62 days has been greatly reduced from 104 to 39 as of February 2020 and is due to the treatment of prostate

long waiters. •Provisional figures for January are showing a significant high number of local breaches x18: 12 of which are urology. Prostate breaches

have been caused by the treatment of long waiters and reduction in >62 day and inadequate OPA capacity which has now been resolved. Additional Actions taken :- Colorectal – • Straight to Test Colorectal pathway commenced 4 February 2020 to eliminate the 1st OPD appointment and gain 2 -3 weeks on the patient

pathway. Impact on performance will be seen in March / April 2020 with a reduction in colorectal breaches. • 62 day patient pathways numbers and waiting times -Lead Cancer Clinician to implement clear ‘no cancer’ annotation for endoscopy

reports to facilitate early removal from the pathway. Validation of Endoscopy referrals to enable prioritisation of 2ww patients completed. Discharge back to Consultant for patients who fail to engage

Urology – Reduction in Urology prostate patients pathway 1st OPD appointment post MRI. Friday morning Prostate clinics reserved for 2ww patients.; Additional post MDT follow up clinics also reserved and booking informed by MDT Co-ordinator Barriers :- Urology -Lack of routine Local anaesthetic provision for Trans perioneal biopsies (LATP). General Anaesthetic TP available for patients previously sent to Portsmouth. This is resulting in local internal delays and increase in backlog of patients which will impact on 62 day performance. 13

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4. Cancer 62 day performance Urology The change in Cancer performance from previous months is due to a high number of breaches recorded in month (18 local breaches) specifically due to Urology (12 breaches). The normal breach rate for Urology is 3 to 4 per month. The high number of urology breaches in month are specifically due to :-

• Treatment of urology long waiters through increased capacity as part of the 52 week initiative. • Delays in commencement of a new pathway for local Trans Perineal biopsies. The revised pathway will

improve flow as patients will no longer need to go to Portsmouth for template biopsies. • There have been delays to implementing this pathway due to on going training requirements 62 Day Plus Patients The number of patients beyond 62 days has reduced from 104 in February 2019 to currently 49 - a slight increase from 39 in February 2020. The number of patients beyond 62 days are broken down into

• 25 Urology: delays to local OPA and investigation; patient choice; awaiting tertiary centre input • 16 Colorectal: delays to endoscopy and Consultant review; patient choice • 3 Lung: oncology delays awaiting oncology OPA and chemotherapy treatment • 1 Head and Neck: awaiting tertiary centre histology • 2 UGI: awaiting tertiary centre treatment/MDT discussion • 1 Sarcoma: awaiting tertiary centre treatment

Responsive

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Cancer 62 day performance recovery

15

Actions Status New pathway for Prostate Cancer – Straight to Test, reduction to current pathway of over 20-30 days. Complete

New colorectal pathway straight to test– reduction to current pathway of 10 – 15 days Complete

Patients who have either cancelled or Did Not Attend more than twice to be removed from 62 day pathway and referred back to their GP

Complete

Improved Cancer MDT tracking through team right sizing Complete

Increase weekly cancer Outpatient clinics Complete

Reduce number of tertiary centre delays Complete

Ensure tacking of patients at weekly site specific meetings to expedite patients close to reaching 62 days.

Complete

Endoscopy business case approve to provide additional capacity Complete

Increased urology capacity is maintained for Outpatient clinics

On going

Local Anaesthetic Trans perineal biopsies to undertaken routinely April 20

Third theatre to open

April 20

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5. Diagnostic Waiting Times Responsive

Commentary 98.2% was achieved against a performance of 99% Sonographer vacancy due to leaver reduced service capacity with increased delays. Ongoing issues with Endoscopy capacity have been clearly articulated and requires increase in resource to open additional theatre

Actions taken Sonographer posts are difficult to recruit to as such Trainee sonographer recruited into vacant post to provide long term service resilience – Health Education funding for trainee post supporting Bank sonographer in service to meet capacity shortfall during training period. Outsourcing Company contracted to undertake additional demand in Endoscopy unable to be met by current capacity within the service

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1. Hospital Division – Month 10

HEADLINES: • The Division are overspent in month by £1.3m

and year to date by £3.6m as YTD position includes undelivered CIP

• Care Groups - £1.5m of undelivered CIP’s • IUEC - £0.7m of undelivered CIP’s • Approved Business Cases – MRI,

apprenticeships, overseas supernumerary costs • In year pressures on agency

Budget Actual Variance Budget Actual Variance£'000's £'000's £'000's £'000's £'000's £'000's

Income (603) (641) (38) (6,026) (6,351) (326) Non-Pay 2,239 2,803 564 23,308 25,313 2,005 Pay 5,191 6,041 850 56,117 58,066 1,950

Total 6,827 8,204 1,376 73,398 77,028 3,629

Year to DateIn Month

Next Steps: • Focus on delivery on year-end forecasts including

costs reductions

• Budget Setting and Business planning for 2020/21

• Pipeline Cash releasing schemes for 2020/21

CIP Overview; • COO and CSCD - Over achieved CIP target by £15k

and £28k respectively • CSCD are forecasting an additional £50k from

medicines optimisation and £42k non recurrent pay • Medicine risks; £1.154m forecast, with the majority

being £431k return to Home and £639k agency reduction

• SWCHS risks - £214k forecasted relating to income • Both Medicine and SWCH have not delivered CIP

forecast in month 10

Use of Resources

Please note these figures do not currently include IUEC but is being developed to include for future so IUEC data is present at slide 17

17 18/34 65/175

HEADLINES: • The Division is overspent against

plan, mainly due to unachieved CIP of £430k, high level of agency spend, consultancy fees and junior doctor fees

• Decrease in agency/bank spend

Next Steps: • Weekly check & challenge meetings to

challenge, motivate & support delivery of CIP.

• Exploration of coding to ensure that ED episodes are correctly coded and that funding is being received

• Review of current ED and MAU workforce

2. IUEC Month 9 Use of Resources

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1. Workforce Summary Data based on M9 data

Sickness absence;

Care Group % as at Dec

CSCD 89.65

Gen Med 86.89

SWCH 89.86

IUEC 61.86

IUEC

Acute KPI Budget In-post Variance

In post v Budgeted FTE

1426.46 1313.80

-112.66

In month YTD Trust In Month Trust YTD

Turnover 0.59% 10.96% 0.55% 10.45%

In month YTD KPI Target RAG

Sickness * 5.07% 5.37% (As at Nov 19)

3.5%

Appraisal** 91.72% 91.72% 85%

Mandatory Training ***

89% 89% 85%

Care Group

Dec 2019

Nov 2019

Oct 2019

Sept 2019

Hot spots

CSCD 4.88% 5.11% 5.39% 3.89% OPARU, Breast Screening, ITU, Pathology General

GM 5.72% 7.19% 5.80% 5.29% Appley, Colwell, Stroke Community Team, GM Mgt team

SWCH 4.84% 4.74% 3.69% 3.02% Alverstone, DSU, Day Surgery Ward, Theatres, Ophthalmic Dept, PAAU, ST Helens

IUEC 4.66% 5.87% 6.29% 6.96% ED Non-Clinical Staff, ED

KPI Budget In-post Variance

In post v Budgeted FTE

189.39 151.04 -38.35

In month YTD Trust In Month

Trust YTD

Turnover 0.00% 6.98% 0.55% 10.45%

In month YTD KPI Target RAG

Sickness* 4.66% 4.92% (As at Nov 19)

3.5%

Appraisal** 61.86% 61.86% 85%

Mandatory*** Training

79% 79% 85%

Appraisal compliance as at 23 December;

Well Led

19 20/34 67/175

Performance Improvement Recovery

Programme Update Jan- Feb

20 21/34 68/175

Emergency Department Project Status Completed Actions (January 2020) Impact

• Monitor the new processes that have been put in place and assess the impact against performance (reduction in 12 hour trolley breaches)

• Reviewed bed management processes, to ensure quicker transfer of patients from the department to reduce improve care and reduce breaches (ED performance improvement)

• Refining UTC processes to ensure patients are streamed to the correct service (avoidance of ED where possible)

• Initial Assessment and Treatment (IAT) standard operating procedures agreed. All ambulance arrivals seen and triaged appropriately

• Internal Professional Standards re- circulated and discussed at Care Group Directors meeting

• Improved tracking of patients and understanding of performance by implementing the ‘Knowing how we are doing’ boards

• ECIST programme agreed to support SAFER on wards • Weekend Operations Manager

• Increase in number of patients being referred from UTC to SDEC instead of ED.

• Performance sustained from December to January (75%)

• Improved care for patients waiting for beds • UTC consistently achieving 98 – 100% • Improved ambulance triage and handover processes,

zero 30 minute delay in January • IAT functionality working well • Reduction in number of 12 hour breaches (2 month to

date Feb) • Improved staff engagement and ownership of

performance • Improved weekend performance • Improved DTOC • Greater use of community beds • Discharge lounge re-established

Next Steps (February 2020)

• JD for Clinical Director • Revision of symphony to support better bed management function • Commence implementation of the ECIST SAFER programme • Stream patients from IAT to UTC and SDEC – avoiding ED. • Develop a mechanism for monitoring compliance with the internal professional standards • SDEC and MAU pull strategies to be implemented (delayed due to capacity constraints) • Integrated discharge process mapping workshop – multi agency in March / April.

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In October the ED performance averaged 68%; to date the Trust is now performing 78%; demonstrating a 10% overall improvement. This can be attributed to: • The successful implementation of the band 7 development training programme • Emergency physician of the day on 24/7 now in place • Weekend Director in place improving discharges • Medical engagement remains a challenge but we have agreed a new approach to medical leadership in the department and will go out to advert

for a new ED Clinical Director as well as advertise the vacant consultant posts; giving the new CD an opportunity to recruit his/her own team • A reduction in medical fit patients has been realised from mid 60’s to the low 40’s • Implemented our ward dashboards and are focusing in on our discharges before 12 / safer / red to green work.

Emergency Department

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UTC Implementation

Ambulance Streaming

RPIW Outcomes

Band 7 Nurses

SDEC Expansion

SDEC Pull Model

71% 73% 78% 80% 82% 84% 86%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20

Actual 73%

Baseline

ED Performance Trajectory

ED Performance Trajectory

Actual 75%

Actual 71%

Actual 74%

Actual (to date)

77%

Performance has not yet met trajectory, however a steady improvement has been realised month on month

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Risks / Issues Risk Mitigation RAG

Emergency admissions increasing due to winter pressures ; creating project slippage due to operational demands

• Continue delivery of the actions within each of the plans to support patient flow and improve patient experience (SAFER)

• A robust reporting and governance structure has been put in place to flag slippage areas. The fortnightly Programme Board will hold people to account but will also be a forum to escalate risks

The size and interdependencies of the programme makes it difficult to assess the impact

• Specific KPIs against each workstream are being agreed to monitor the effectiveness of the programme. (outside of the national targets)

Operational and clinical staff not having sufficient capacity to deliver against the actions required for the programme to be a success

• A programme manager has ben appointed to oversea delivery, track progress and mitigate risks. The support of 2 w.t.e from PMO has been negotiated to work on the Trust Processes and SDEC & Acute Medicine workstream actions.

The actions completed within the plan not having a positive impact on performance

• A fortnightly review will be completed; assessing delivery against organisational performance

Lack of engagement from clinical and operational staff to deliver the work

• External support has been commissioned to facilitate clinical engagement. Programme manager will support ADO’s to mitigate encountered risks and issues

RTT available capacity • Additional three beds identified and flex-opened for long waiting patients

• Ring-fenced unit for screened elective orthopaedic patients in place throughout the year.

Cancer Recovery • Inability to attract locum urologist may affect the additional

Friday clinic capacity • Nurse practitioner role yet to be advertised.

• Raise at the next ADO meeting to discuss mitigating actions

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Appendix A Supporting information to

Hospital Performance Report for Month 9

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Safe Serious Incidents New SIs reported this month – 3 @ 31/12/19

In month, the highest areas for incidents were patient breaches at 65 for December which are currently undergoing the Trust’s RCA process and review. 52 patient slip, trip and fall incidents were reported in December. Of these there were a total of 3 controlled falls, 32 x patient falls, 17 x patient slips. Of the 52 slips/trips/falls, 5 patients had more than 1 fall broken down as 1 patient ITU (2 falls) 1 patient CCU (2 falls) 3 patients Colwell (1 patient had 2 falls, another 2 falls & 3 falls) 27/34 74/175

Safe Complaints

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COMPLAINTS Open/Overdue and Oldest Safe

Division Total Number of Complaints open (incl. re-opened)

Total of complaints overdue:

Complaints responses due (27 Dec – 03 Jan 2020) :

Oldest complaint and number of days overdue :

CSCD 3 (3) (0) 20320 Due 27/12/19

Medicine 2 (2) (0)

Surgery, Women’s and Children’s Health

5 (7) 2 (1) 20287 Due 27/12/19 19826 - 28 days overdue 20270 - 4 days overdue

MAU 2 (2) 1 (1) 20127 – 14 days overdue

ED 18 (15) 8 (6) 18968 – 77 days overdue 19273 – 59 days overdue 19300 - 57 days overdue 19828 – 25 days overdue 19801 – 22 days overdue 20180 – 9 days overdue 20268 – 4 days overdue 20569 – 3 days overdue – Returned to division, further information needed

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Compliments/Concerns Compliments Received (As added to Datix as at 31.12.19)

Concerns Received up to 31.12.19

0

20

40

60

80

100

120

140

160

180

200

CSCD MED SWCH IUEC

18

0 15

5 21

1 9 6 9 3

12 5

22 28 41

17 17 22 14

3

34

183

24 21 33

4

37

6

33

8

32

74

55 33

50

4

Apr-19

May-19

Jun-19

Jul-19

Aug-19

Sep-19

Oct-19

Nov-19

Dec-19

0

5

10

15

20

25

30

35

40

45

CSCD MED SWCH IUEC

0 4

12

4 4 8

16

7

2 0

4 2

18

11

27

11

5 4

13

5

10 9

31

10

23

17

42

15 11

13

37

12

5 10

26

10

Apr-19

May-19

Jun-19

Jul-19

Aug-19

Sep-19

Oct-19

Nov-19

Dec-19

Safe

30/34 77/175

Commentary: Position at Month 9 decreased to 72.2% , however an improving trajectory over the last quarter for incomplete performance continues. The in-month performance RTT drop is due to the impact of the ASI transfers which have been added on to the profile of the waiting list List size increased by 435 patients due to transfer of ASI patients. Forecasting remains in line with trajectory.

Actions taken have they worked any barriers? • Planned Care Board continues to ensure resources are provided to deliver quick wins and that high impact schemes are given focus to support

continued performance levels. • Orthopaedic bed capacity remains ring fenced and further elective surgery capacity has now been created for long waiting patients. • Dynamic allocation of lists continues so as to avoid breaches • MDT validation of breach pathways • All admitted pathways >30 weeks non clinically validated • Development of full suite of SOPs and training programme with NoE CSU

Further actions and trajectory for improvement • Continue to deliver activity against plan • Urology workforce mitigations • Complete demand and capacity modelling for 20/21 • Meet with the CCG to agree commissioning intentions for 20/21

Responsive RTT Incomplete Performance December 2019

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Cancer

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19Breast 9 7 9 6 10 7 2 9 9

Lung 4.5 2.5 4 2 3 4 3 2.5 1.5Skin 6 12 11 8 16 10 8 8 2Urological (Excluding Testicular) 7.5 14.5 18 11.5 16 21 13 11.5 10.5Colorectal 8.5 4 4 2 3 5 2 2 4.5Gynaecology 2.5 2 2.5 1 4 5.5 2 3 1.5UGI 0 0 2.5 2 2 4.5 1 1.5 1Haematology - 1 1.5 1 2 - 3 1 2

Total Seen

Performance % Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Breast 67% 100% 67% 83% 90% 86% 100% 89% 78%Lung 33% 40% 100% 75% 83% 100% 82% 100% 67%Skin 100% 100% 100% 100% 100% 100% 100% 100% 100%Urological (Excluding Testicular) 53% 41% 75% 61% 69% 76% 58% 57% 67%Colorectal 35% 13% 25% 0% 0% 40% 0% - -Gynaecology 100% 0% 60% 0% 38% 55% 50% 67% 33%UGI - 0% 100% 100% 100.0% 56% 33% 100% -Haematology 0% 0% - 100% 50% - 100% - 100%

Further actions and trajectory for improvement Endoscopy Business case was approved at February Acute Board to ensure capacity available to meet demand in 20/21 without relying on outsourcing.

Responsive

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Key Performance Indicator Data toTarget 19/20

Actual YTD

Actual Month 4 Month Trend

Exception Report

Required

Patients that develop a grade 4 pressure ulcer Dec-19 3 1 1 NO

Patients that develop an ungraded pressure ulcer Dec-19 0 16 1 YES

VTE (Assessment for risk of) Dec-19 >95% 98.1% 97.8% NO

MRSA (confirmed MRSA bacteraemia) Dec-19 0 0 0 NO

C.Diff (confirmed Clostridium Difficile infection - stretched target) Dec-19 7 14 1 NO

Clinical Incidents (Major) resulting in harm(all reported, actual & potential, includes falls & PU G4)

Dec-19 10 31 4 NO

Clinical Incidents (Catastrophic) resulting in harm(actual only - as confirmed by investigation)

Dec-19 - 23 1 NO

Falls - resulting in significant injury Dec-19 5 1 0 NO

Symptomatic Breast Referrals Seen <2 weeks*** Dec-19 93.0% 94.9% 100.0% YES

Cancer patients seen <14 days after urgent GP referral***

Dec-19 93.0% 94.5% 95.9% NO

Cancer Patients receiving subsequent Chemo/Drug <31 days***

Dec-19 98.0% 100.0% 100.0% NO

Cancer Patients receiving subsequent surgery <31 days***

Dec-19 94.0% 97.9% 100.0% YES

Cancer diagnosis to treatment <31 days*** Dec-19 96.0% 97.4% 96.1% NO

Cancer Patients treated after screening referral <62 days***

Dec-19 90.0% 90.7% 95.5% NO

Cancer Patients treated after consultant upgrade <62 days*** Dec-19

No measured operational

standard81.8% 100.0% NO

Cancer urgent referral to treatment <62 days*** (target) Dec-19 85.0% 73.2% 63.4% YES

Cancer urgent referral to treatment <62 days*** (trajectory)

Dec-19 79.3% 73.2% 63.4% YES

Never events Dec-19 0 0 0 NO

Stroke patients (90% of stay on Stroke Unit) Dec-19 80.0% 79.8% 80.0% NO

High risk TIA fully investigated & treated within 24 hours (National 60%)

Dec-19 60.0% 100.0% 100.0% YES

Total Workforce (inc flexible working) (FTE's) Dec-19 2,998.1 3,081.0

Total workforce SIP (FTEs) Dec-19 2,792.5 2,856.0

Variable Hours (FTE) Dec-19 205.6 1,750 225

Delayed Transfer of Care (lost bed days) - (Acute) Dec-19 115 1905 212 NO

LOS 7+ Patients Dec-19 127 1079 136 NO

LOS 21+ Patients Dec-19 46 442 52 YES

Bed Occupancy - Acute Dec-19 0 - 99.8 NO

* Rolling year

***Cancer figures for December are provisional.

** Appraisal Monitoring has changed from rolling 12 months to single quarter

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Key Performance Indicator Data to Target 19/20Actual YTD

Actual Month

4 Month Trend

Exception Report

Required

Emergency Care 4 hour Standards Dec-19 95% 75% 75% YES

Emergency Care 4 hour StandardsDec-19 Trajectory

88.0%75% 75% YES

Number of patients who have waited over 12 hours in A&E from decision to admit to admission

Dec-19 0 158 65 NO

All Cancelled Operations on/after day of admission Dec-19 - 530 78 NO

Cancelled operations on/after day of admission (not rebooked within 28 days) - including those not rebooked at the time of reporting

Dec-19 0 21 5 NO

Patient Satisfaction (Friends & Family test - Total response rate)

Dec-19 30.0% 3.5% 5.2% NO

Patient Satisfaction (Friends & Family test - A&E response rate)

Dec-19 95.0% 1.5% 0.2% NO

Mixed Sex Accommodation Breaches Dec-19 0 124 9 YES

Formal Complaints Dec-19 - 256 16 NO

RTT % of incomplete pathways within 18 weeks - IoW CCG

Dec-19 92.0% - 71.5% YES

RTT % of incomplete pathways within 18 weeks - NHS England

Dec-19 92.0% - 85.9% YES

Zero tolerance RTT waits over 52 weeks (Incomplete Return)

Dec-19 0 136 29 NO

RTT Incomplete Trust Combined Dec-19 92.0% - 72.2% YES

RTT Incomplete Trust Combined Dec-19 Trajectory84.5% - 72.2% YES

RTT waits over 52 weeks (Incomplete Return) - Total Dec-19 0 136 29 YES

No. Patients waiting > 6 weeks for diagnostics Dec-19 17 354 28 YES

% Patients waiting > 6 weeks for diagnostics Dec-19 99% 97.5% 98.2% YES

Theatre Utilisation - Audit Commission (NEW) Dec-19 - 73.9% 73.5% NO

Variable Hours (£000) (Trust Wide) Dec-19 236 13,429 1,945 YES

Staff absences - Acute Dec-19 3% - 5.07% YES

Staff absences - CSCD Dec-19 3% - 4.88% NO

Staff absences - GEN MED Dec-19 3% - 5.27% NO

Staff absences - SWCH Dec-19 3% - 4.84% NO

Appraisal Monitoring - Acute** Dec-19 100% - 90.0% YES

Appraisal Monitoring - CSCD** Dec-19 100% - 89.7% YES

Appraisal Monitoring - GEN MED** Dec-19 100% - 86.9% YES

Appraisal Monitoring - SWCH** Dec-19 100% - 88.7% YES

Mandatory Training* Dec-19 85% 86% 86% NO

Staff Turnover Dec-19 5% 10.49% 0.55% NO

Employee Relations Cases Dec-19 0 139 21 NO34/34 81/175

Page | 1

Agenda Item No 10 Meeting Trust Board in Public Meeting Date 12 March 2020 Title Ambulance Performance Report – Month 10 January data Sponsoring Executive Director

Joe Smyth, Chief Operating Officer, Ambulance and Acute Division

Author(s) Victoria White, Head of Ambulance Service Report previously considered by inc date

Ambulance Divisional Board, 23/01/2019



Information only x Commercial Confidentiality Effective x SO 01: Provide safe, effective, caring and responsive services – ‘Good’ by 2020

x

Review & discuss Patient Confidentiality Caring x SO 02: Ensure efficient use of resources

Assurance Staff Confidentiality Safe x SO 03: Achieve patient standards x

Committee Agreement

Other Exception Circumstances Responsive x SO 04: Achieve excellence in employment


Well-Led x SO 05: Implement the Isle of Wight Health & Care Sustainability Plan

Key Recommendations to be considered: The Trust Board is asked to consider the following recommendations:

• To receive this report for assurance on Ambulance performance and understanding of the key messages and risks for the service

Enc G3

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Page | 2

Executive Summary Context

• The ambulance service comprises the Urgent and Emergency Service (U+E), Emergency Operations Centre (EOC), NHS 111 service, Patient Transport Service (PTS) and Non patient Transport service, Commercial training and Community Responders, and Emergency Preparedness, Response and Resilience (EPRR).

Key Messages

• The U+E service is not meeting constitutional targets for ambulance responses across C1, 2 ,3 and 4 • A briefing paper has been submitted to the Executive team outlining plans to improve performance. These plans would require a significant investment

and the Executive and CCG are considering the merits of a full business case. • SCAS have been approached to see what support they can provide to support the Island’s ambulance service.. SCAS have confirmed that they do not

have sufficient resource to transfer patients to the mainland from the island. • A meeting was held on 14/2 with SCAS to agree the 2020/21 key work streams for the partnership working and a workshop with both organisations has

been arranged for March to share across teams • The trust is not compliant with the EPRR core standard relating to provision of strategic commander – the Service Level Agreement with SCAS has been

agreed, however funding still needs to be finalised • The NHS 111 service continues to perform well in comparison to other providers across the country. However the impact of the coronavirus outbreak is

having an effect on both 111 performance and finance

Key Risks • 999/111 performance • Sickness Levels across the front line staff and subsequent impact on resilience, performance and staff welfare • CQC outstanding actions relating to cleanliness of ambulances

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Page | 3

Ambulance Trust Board Report The division’s Quality, Performance and Divisional Board Meetings took place by 26th February 2019. The purpose of this report is to provide an overview of the key current opportunities, issues, challenges or risks affecting the division. Key Items of Information for Trust Board: • Quality and Safety: CQC Inspection Report:

o The service has completed 79% of the CQC action plan o Underlying work to put in robust processes to assure cleanliness of ambulances have been comepleted allowing the service to fully

understand cpaaicty gaps and training requirements for staff Emergency Preparedness and Resilience

o The service remains non complaint with the EPRR core standard for strategic commander. The Service evel Agreement to address this shortfall has been agreed in principle with South Central Ambulance which will provide this service. A meeting set up to agree this additional funding in February was cancelled by NHSE. The briefing paper has however been submitted electronically with a follow up call planned in month

o Robust plans are in place in the 999 and 111 service relating to coronovirus although performance is being impacted by additional call volumes in the 111 service.

Staff Welfare o 6.16% sickness, which is a slight improvement. Frontline operations remains a concern (8.24%) o A 10 week improvement plan is now underway with support from HR service to reduce sickness and improve staff welfare

Appraisals o Current performance has increased from 77.27% to 83%, further progress has taken place in completing apprasials in month, especially

within the U+E service. The service plans to be compliant at 95% by end of March. o Service areas are putting in plans for next years roll out commencing in April when the appraisal will be zero based

Operational Performance: U+E service

o Performance standards for 999 not being met consistently across the service. o Whilst marginal efficiency improvements can be made the overall average performance relative to the required standards will largely remain

unchanged o The service commissioned an independent report to model capacity required to meet ARO o 2 additional double crewed ambulances and 2 additional Rapid response vehicles are required in order for the service to meet all national

standards from Category 1-4

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Page | 4

o This would require an estimated investment of £1.5m o A briefing paper has been submitted to the executive management team outling the issues and options for consideration o The opitions set out to cost implications against impact on performance and will require careful consideration by the CCG and the Trust. o The executive require further information on demand profiling and numbers of calls to progress this case. o SCAS do not have any spare capacity to support the IOW with additional crews to undertake mainland transfers, but will support the service

procure private ambulances through their framework at a far more competitive rate

111 Service o The NHS111 performance standards are also attached in the dashboard below and demonstrate 90.38% achievement against the standard

of 95%. o This is a 0.28% improvement on last month o Recruitment into vacancies and pathways training has been successfully completed and new call handlers are now in post. o There continues to have been an increase in out of area calls being transferred into the service which is affecting performance. o These are calls which will be transferred through a national divert if another NHS 111 system is down, or may be where services are not

answering calls within the allocated timeframe o Additional call volumes relating to coronavirus queries have had an impact on the NHS 111 service performance this month o A business case to increase clinicians in the control room has been written and shared with commissioners – this will now be progressed

internally within the trust o The service is meeting the standards for calls abandoned, 111 clinician input and IUC(CAS) clinician – calls triaged

PTS service

o PTS activity has increased by approx. 10% in year o Hospital discharges booked same day has increased over the last 2 months o The increase in activity is impacting timeliness of arrival to scheduled appointment time, and increased waits for patients to be collected from

their appointment o Please note – caveats apply to PTS data as there is no computer aided dispatch, and so the service is providing a manual workaround to

capture data currently o Capital funding was agreed in 2019/20 to support the implementation of a PTS Computer Aided Dispatch system. o The service has agreed in principle with SCAS to be an eighth node off their system and will now need to identify the costs in order that

revised business case can be presented o The service in the meantime continues to receive minimal complaints for stakeholders in primary care and within the trust in regards to

disruption to the service due to their current working arrangements.

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Page | 5

• Programme items: Partnership working with SCAS

o A meeting was held 14/2 to agree the strategy and priorities for the ambulance partnership between organisations o Focus for 2020/21 to include:

Developing a shared digital platform to integrate, improve and sustain care for our population Sustaining ambulance services on the island Workshop arranged 20/3 to formulate detailed plan

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Page | 6

Performance Summary

Initial Performance report January 2020

999Performance

999 Call Volumes (A0) 2,614 2,789 2,753 3,118 3,012 2,814 2,667 2,561 2,906 2,735

111 Call Volumes (5.3) 6,697 7,165 7,471 7,619 7,840 6,841 7,112 7,036 7,853 7,102

2,037

TrendAug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20

2,029 2,003 2,169

Apr-19 May-19 Jun-19

1,961 2,022 2,012 2,078 2,003 1,978Total Ambulance Responses (A7)

Jul-19

111 / IUCPerformance

Call Answered 95% < 60 seconds 90.38%Calls Abandoned <5% after 30 seconds 4.84%111 Clinician Input >20% 37.55%

Standard Performance

IUC (CAS) Clinician – Calls Triaged >50% 56.87%

999 ResponsePerformance Target TargetCall Answer 8.22(s) 2(s) Category 1 7 mins 00:11:55 15 Mins 00:20:47 Category 2 18 Mins 00:27:32 40 Mins 01:01:00 Category 3 01:26:29 120 Mins 03:43:03 Category 4 01:20:12 180 Mins 03:18:10

Mean 90th PercentileActualActual

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Page | 7

PTS Performance

KPI Description Threshold Target May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20

1Patients travelling less than 10 miles With an Island based destination should not spend more than 60 minutes on any one journey

90% 95% 96.4% 96.8% 96.2% 96.1% 98.1% 95.3% 96.8% 95.5% 95.5%

2Patients travelling between 10 and 35 miles should not spend more than 90 minutes on any one journey plus 90mins for the Ferry 180 mins (30 mins terminal waiting 60mins crossing)

85% 90% 98.7% 94.0% 96.2% 94.2% 97.5% 96.0% 96.7% 99.0% 98.3%

3Patients travelling between 35 and 50 miles should not spend more than 120 minutes on any one journey plus 90mins for the Ferry 210 mins (30 mins terminal waiting 60mins crossing)

80% 85% 100.0% 80.0% 75.0% 88.9% 90.0% 100.0% 50.0% 100.0% 100.0%

4Arrival within 60 minutes before or within 15 minutes after scheduled appointment timeIsland based appointments

90% 95% 95.3% 91.4% 93.0% 91.9% 92.0% 83.4% 64.8% 70.6% 67.3%

6 Patients not waiting more than 60 minutes for their journey pick up (before appointment)

80% 85% 82.7% 85.4% 90.5% 93.5% 81.5% 79.2% 66.4% 70.4% 67.5%

7 Patients not waiting more than 60 minutes for their journey collection (after appointment)

80% 85% 81.9% 86.3% 83.7% 79.5% 80.0% 81.3% 85.0% 87.4% 81.4%

8 4 hour pick up on the same day < 24hrs (i.e. same day discharge/ requires job being accepted according to capacity)

80% 85% 93.5% 91.7% 95.2% 78.2% 82.1% 87.6% 82.0% 90.4% 92.4%

PTS KPI's PTS KPI's

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Page | 8

WORKFORCE SCORECARD – Ambulance Division Summary

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Page | 9

Subjective

Class Budget Actual Variance Budget Actual Variance

PAY 628,836 668,395 39,559 6,429,082 6,536,929 107,847

NON-PAY 201,944 212,189 10,245 1,938,830 1,916,411 (22,419)

INCOME (26,973) (31,946) (4,973) (269,730) (304,009) (34,279)

Grand Total 803,807 848,637 44,830 8,098,182 8,149,331 51,149

In month (£000s) YTD (£000s)

DivisionCIP Plan

£'000BLACK (Gap)

RED AMBER GREENTOTAL

Recurrent planForecast Rec. Achievement

Plan to date

Delivered to date

Ambulance 345 32 0 0 313 313 336 206 242

CQC action plan

CIP Progress 2019/20

Overall Financial Position – M10 2019/20

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Page | 10

79%of action plan completed as

of 21/02/2020

Detail Improvement Programmme Lead

Operational Lead

01234

Status - 0 = not started1 = started

2 = in progress

3 = nearly complete

4 = complete

Completion Date Notes

Ambulance Should Do 20 24

The Service SHOULD check medicines supplied and administered against the directions of a prescriber or via local documents arecompliant with the medicine’s legislation and best practice

Tholi Wood 4 ● 30/09/2019 Action plan completed, assurance to demonstrate now BAU, reported through CQUEG

The Service SHOULD develop a procedure for maintaining the cleanliness of vehicles and the equipment carried in them

Darren Claydon PSO 3 ◕ 30/09/2019 21.02.2020 Procedure developed, currently within ratification process.

The Service SHOULD continue to improve the appraisal rates and mandatory training rates for all staff

Darren Claydon PSO/CSO 3 ◕ 31/12/2019 all appraisals planned and booked - to maintain focus on delivery

The Service SHOULD develop an asset register for all equipment together with a procedure to monitor equipment service periods

Darren Claydon PSO 4 ● 31/12/2019 equ rptment register created,Jan 2020 equipment register with rrpmdates created

The Service SHOULD continue to monitor and analyse the safeguarding referral process to determine if efficiencies can be achieved to release frontline crews.

Tholi Wood PSO/CSO 2 ◑ 31/12/2019 BAU - monthly reporting. forward plan to reduce/streamline efficiencies

The Service SHOULD maintain the security of keys to ambulance service vehicles Darren Claydon PSO 4 ● 30/10/2019 Jan 2020 audit demonstrating vehicle and key security

EOC - Should Do 15 20

The Service SHOULD consider updating their telephony system within the hub. Victoria White Lee Haward 3 ◕ 31/03/2019 Businss case Drafted; Discussions underway with partner organisation, currently added to the Divisional Risk Register February 2020.

The Service SHOULD review staffing levels for there to be the required number for clinical support staff on the night time shift

Lee Haward 3 ◕ 13/12/2019 SBAR written and approved; to discuss with CCG

The Service SHOULD consider and plan how there will tackle increased demand Lee Haward 2 ◑ 31/12/2019 REAP escalation plan to be revised for 111, staff communications regarding expections

The Service SHOULD work to embed the changes made in their governance processes

Victoria White Lee Haward 3 ◕ 31/12/2019 demonstrating improvements, embedding lessons learned etc move to BAU

The Service SHOULD continue to develop the use of the data available to them and the use of the data to drive improvements.

Victoria White Lee Haward 4 ● 30.10.2019 Perfect week planned, daily monitoring of data, data to be included in BC's

Quality Strategy Action Plan

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Assurance Areas of risk

Aim: Provide best possible treatment and outcomes, delivered in line with the trust CARE values

Objectives: Improving the safety of patients Increasing the effectiveness of the service Improving the experience of service users

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• 85% compliance against plan. • Continue with 100% compliance against DoC • No ‘Never Events’ • Mortality review process embedded and

matches new national standards.

• Dementia, collaborative working • Ambulance service dementia lead • Access to Datix for frontline staff to improve reporting,

tablets yet to be handed over by IT. • Claims data not available • Achievement of full strategy.

Actions Taken Next Steps

• 10 tablets ordered for crews to take on the road, improving access to Datix, mandatory training, emails etc.

• Discussion re how to record verbal DoC when case notes unavailable, update to Trust processes will include this

• Closure paper for current strategy including rational for closure

• Develop next year’s strategy and review AACE future national ambulance clinical priorities.

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Agenda Item No 10 Meeting Trust Board in Public Meeting Date 12 March 2020 Title Community Division Performance Report Sponsoring Executive Director

Alice Webster, Director of Nursing, Midwifery, AHP’s & Community Services

Author(s) Nicola Longson, Deputy Director of Out of Hospital Services Report previously considered by inc date

Community Divisional Board (18.02.20) Community Quality and Performance Meeting (18.02.20) Performance Committee 11 March 2020




X



Committee Agreement




X

Key Recommendations to be considered: The Trust Board is asked to:

• Note the update provided

• Receive assurance on performance in relation to CQC key lines of enquiry

Enc G4

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Executive Summary SAFE

• Mandatory training compliance rates are reported at 89%. The Division continues to perform above the target of 85%, acknowledging that this target will increase to 95% from April 2020 changes and communication is underway to enable this.

• Duty of Candour continues to see excellent performance with 100% compliance since September 2019.

• Further development of Community Rapid Response (CRR) is underway which incorporates the Crisis Response team, the OHPiT service, Community ACP’s, OCI funded Domiciliary Care provision, ACP’s at front door and Community Hospital @ Home service.

RESPONSIVE • The Adult Speech and Language Therapy Service has achieved good performance with its ‘responsiveness to referrals within 2 working days’

reported at 98% for January. • The Division recently approved new Patient Group Directions which will enable a pilot of 3 x Senior Community Nurses to carry and administer

antibiotics to patients in their home. Anticipated benefits include: o More rapid access to antibiotics for patients, thereby reducing the likelihood of deterioration. o Increase non admission by more rapid treatment o Improvement in staff morale and efficiency by utilizing staff skill sets more effectively o Better patient experience as less logistics in accessing medications

CARING • The Division continues to report low MES response rates. The original mitigation was to utilise volunteers for data inputting, however this has not

been as successful as hoped and the Division will now assign the backlog to administrative staff to ensure the response rates are reflective of actual patient feedback made.

• The Community Nursing team received the following letter in January: I would like to take this opportunity to thank all the staff who cared for my mum at home. All the nurses were extremely kind, professional, they took time to listen to mum and myself as to our concerns, fears and worries. Her pain was kept under control, the nurses were never late in renewing mum’s syringe driver and kept me up to date as to her medication requirements.

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The services my mum received was first class. Although I sadly lost mum in December 201, it does give me comfort to know she was so well looked after at home by your superb team. I would like you to forward this letter onto your CQC Inspector as I am full of praise for this service and would like your CQC Inspector to know what a fantastic job the team is doing.

EFFECTIVE

• The Orthotics & Prosthetics Service are a ‘showcase team’ for the NHSI Community Service Productives - 52% of orthoses are delivered on the same day compared with 9% in other QI Collaborative participants. A further example of good performance was highlighted to Divisional Board with a patient who was previously unable to wear a prosthesis and had been recommended for further amputation, patient is now reporting 0/10 for pain with new design socket supplied by team.

• The Division is continuing to apply the ‘SWARM’ process to respond to complaints, resulting in an excellent turnaround time of responses to the 2 complaints received this period from over 21,000 contacts within the month.

WELL-LED

• The Division has recognised that some of the excellent work and transformational activities underway are not being celebrated via award nomination or publication of research. The leadership team will undertake work to address this going forward.

• Estate moves underway for the integrated teams currently located at Sandown Medical Centre; staff will be co-located at The Barracks, Sandown from March as per integrated care plan.

• Over 87% of Community staff have followed flu plan guidelines, with 65% of staff having received jabs. Rigorous monitoring and reporting in place, an analysis of ‘declines’ is underway to support planning for 20/21.

• Continuing with positive risk management performance in month with 100% of risks reviewed within timeframe and 19% of open risk actions overdue. Graphical representation of performance is set out in Appendix 2. Monitoring embedded as business as usual and all overdue actions are followed up with line management as part of a zero tolerance approach.

• The Paediatric Speech & Language Therapy (SLT) Service reported that the recent OFSTED/CQC report stated that SLT is a good service; overall positive report for the children and young people with Special Educational Needs on the Island.

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WORKFORCE & INNOVATION

• Appraisal compliance rates remain above target at 98.30%. Work with the corporate team to understand and address data anomalies is ongoing.

• A workshop, supported by HR, is planned to help address sickness policy compliance across the Division with a focus on the upskilling of staff on effective sickness management and use of Bradford scoring, all to improve assurance in this area.

• The staff turnover rate is currently 8.2%, performing well against the Trust turnover rate of 10.83%.

FINANCES

• The Division is working to deliver the revised control total of £232k; supporting processes in place to ensure all budget managers are regularly checking spend to forecast.

• Cost Improvement Plan delivery is to plan.

• In recent months the Division has reported limited financial support and this has led to increased risk to effective financial management. This month the Division is pleased to report these risks are now mitigated with additional support allocated to the Division and further recruitment of finance staff underway.

COMMUNITY TRANSFORMATION Onwards Care & Independence Programme (OCI) The Onwards Care and Independence programme continues to drive the delivery of the community elements of the Health and Care Plan for the IOW Integrated Care Partnership. A breakdown of impact in areas of Technology Enabled Care and Regaining Independence is included in Appendix 2. Winter Plan The Community Division continue to deliver the winter schemes and good progress continues to be made.

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Appendix 1

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Appendix 2

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Appendix 3

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Appendix 4

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Enc G5

Agenda Item No 10 Meeting Trust Board in Public Meeting Date 12 March 2020

Title Performance Report - Mental Health & Learning Disabilities Services

Sponsoring Executive Director Dr. Lesley Stevens, Director of Mental Health and Learning Disabilities

Author(s) Sue Nelson, Business Manager Mental Health and Learning Disabilities Report previously considered by inc date

Based on data and reports considered in the Mental Health and Learning Disabilities Board February 2020

Key Recommendation The Trust Board is asked to take assurance from the current performance position of the Mental Health & Learning Disabilities Service.


Link to CQC Domains



Effective x SO 01: Provide safe, effective, caring and responsive services – ‘Good’ by 2020 x

Review & discuss Patient Confidentiality Caring x SO 02: Ensure efficient use of resources x Assurance x Staff Confidentiality Safe x SO 03: Achieve patient standards x Committee Agreement


Responsive X SO 04: Achieve excellence in employment x Trust Board Approval

Well-Led x SO 05: Implement the Isle of Wight Health & Care Sustainability Plan x

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Executive Summary • Claire Murdoch, the National Director of Mental Health visited IOW mental health services on 28th

February 2020, visiting the CMHT, Safe Haven, Wellbeing Service and also met with primary care staff involved in developing the primary care mental health service. She provided positive feedback about the improvements since her last visit almost 2 years ago.

• IAPT Performance against the access target remains below required level - it has been agreed that a

Task & Finish group is set up to carry out a deep dive, support the team to retrieve the performance and ensure the service is safe.

• The Division is developing a new medical workforce model to address risks associated with vacancies.

• ��Recruitment of staff for the new Dementia outreach service is underway for implementation of Phase 1 of

service transformation. The emerging service will initially provide urgent referral response (admission avoidance) and a limited pilot of Care Home Liaison

• Recruitment is in progress to primary care mental health practitioner roles linked to the CMHT and to the

Wellbeing service.

• Two Transformation Design Workshops have taken place at Gurnard Pines. These were attended by senior staff from across the Division, CCG, Primary Care, Social Care, 3rd Sector, people with lived experience and carers. In the first workshop five Design Teams were mobilised and have met to progress work using the New Product Design Methodology which has been successfully used by Solent NHS Trust in a number of transformation projects. Prototype service designs were presented at the second workshop. The Design Teams are now working on the detail of their proposed models and these will be put forward at the final workshop to be held on 19th March. The designs will be scored against Acceptance Criteria agreed at the first meeting.

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Performance Summary – Effective

• Pressures on beds and acute services continues. Afton Bed Occupancy figures continue to be lower than expected. It is

believed this is as a result of a recording issue with regards to recording of Adult outliers on the system. Validation of data continues to ensure accurate data recording/reporting. Performance against CPA 7-day follow-up is being sustained at 100%. Year to date position expected to be achieved if current performance maintained.

• Small number of S136 admissions continues to impact on performance against the Crisis Resolution target. One breach in January has resulted in performance below required 95%,

• IAPT recovery performance continues to improve as new Psychological Wellbeing Practitioners build caseloads.

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Performance Summary - Safe

• Caseload reduction trajectory has been revised to reflect slower rate of discharges. However, Team Leader absence and Consultant Psychiatrist vacancy continue to impact on capacity to facilitate discharges.

• Risk Assessment compliance has remained static in month. Work to be undertaken to identify issues preventing completion of risk assessments.

• Weekly monitoring meetings with CMHT Leadership Team to be reinstated to monitor and agree actions.

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Performance Summary - Caring

• The Division continues to explore options for collecting feedback and the most appropriate tools implemented for

each service, through engagement with the Service User and Carer forum, The HONQ and Service User Engagement Co-ordinator are linked in with Solent NHS Trust to learn from their experiences. .

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Performance Summary – Well-Led

• Appraisal performance has improved slightly in January . The Division is sighted on the higher target next year and a trajectory is being developed and will be monitored through Divisional Performance and Divisional Board with a clear expectation that all appraisals will be completed in Quarter 1

• Sickness absence has increased in January. The highest reason for sickness absence by far continues to be

Stress/Anxiety/Depression but this has decreased slightly in month to 38% of all sickness. Split between short-term and long-term sickness is almost even.

• The Division is concerned that performance against the Management Supervision target has decreased in January. Plans to address this will be taken forward with Service Leads and Team Leaders.

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Performance Summary – Responsive

• The CAMHS Eating Disorder does not become a mandated target until 1st April 2020. Provisional Q3 Figures show

performance below requirement but small numbers have significant impact on performance. Work is underway to review capacity of the workforce in relation to the demand.

• As expected performance against the IAPT Access Rate improved during January but performance is still well below

required 22%. The Team Lead has written an SBAR detailing plans for recovery. a It has been agreed that a Task & Finish group will be set up to carry out a deep dive, support the team to retrieve the performance and ensure the service is safe.

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Performance Summary – Responsive

• One long wait for a patient on an RTT pathway in July for Adult MH continues to impacted on YTD performance. Currently

there are no Adult MH patients on RTT pathways.

• RTT performance for OPMH remains a significant challenge. Plans are have been agreed for the longest waits to be seen and appointments are in place. An Agency Consultant has been secured and joined the service on 6th March. Focus for this new Consultant will be on the out-patient waiting list. In additional plans are in place for Nurse Prescribers to support the triage and assessment of new patients.

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Workforce and Finance (Month 10) Summaries

January 2020 data 9

Workforce FTE Budget

Establishment: 402 In-post : 357 (361 M9)

Variance: -44 (-42 M9)

Sickness Absence:

7.62% (6.57% M9) Trust 5.66% 4.5% Target Turnover:

11.07% (Rolling 12

months) Trust Turnover

10.63%

Appraisal Complianc

e: 86% 95% Target

Mandatory Training:

86% 85% Target

Vacancy Factor: 11.03%

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Risks

As of the 19-2-20 there were 7 MH&LD risks rated as high as per below.

10

• It is anticipated that the Transformation work currently underway will support in addressing many of the above risks.

• In terms of ownership of budgets the Finance managers assigned to support the Division is in the process of delivering training and will write a SOP outlining budget holders responsibilities. Once in place the division can start to hold budget holders to account.

• The risk of highest concern at this time is the Medical Workforce (see slide 12)

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Strategic Developments and Service Transformation • Recruitment of staff for the new Dementia outreach service is underway for implementation of Phase 1 of

service transformation. The emerging service will initially provide urgent referral response (admission avoidance) and a limited pilot of Care Home Liaison

• Community Mental Health and Wellbeing Service Transformation - there has been a reduction in the rate of

discharge from CMHT and in risk assessment compliance, due to medical staffing gaps and absence of transformation resource. This will be resolved in March 2020. An organisational development programme for the team is in development and will be delivered in Q1. Full procurement of the Wellbeing Service (WBS) will take place over the course of 2020/21, and will support delivery of the New Product Design outputs. In the interim we are reviewing the contractual arrangements with the WBS. Currently the Trust sub-contracts the WBS, and the CCG also has a contract with the WBS. The MH&LD Board agreed to move to one contract between the CCG and Wellbeing Service in the interim period before procurement. We expect this to be in place by the end of April 2020.

• Recruitment is in progress to primary care mental health practitioner roles linked to the CMHT and to the Wellbeing service.

• Two Transformation Design Workshops have taken place at Gurnard Pines. These were attended by senior staff from across the Division, CCG, Primary Care, Social Care, 3rd Sector, people with lived experience and carers. In the first workshop five Design Teams were mobilised and have met to progress work using the New Product Design Methodology which has been successfully used by Solent NHS Trust in a number of transformation projects. Prototype service designs were presented at the second workshop. The Design Teams are now working on the detail of their proposed models and these will be put forward at the final workshop to be held on 19th March. The designs will be scored against Acceptance Criteria agreed at the first meeting.

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Agenda Item No 11 Meeting Trust Board in Public Meeting Date 12 March 2020 Title Workforce Performance report Sponsoring Executive Director

Julie Pennycook, Director of HR & OD

Author(s) Rowena Welsford, Deputy Director of HR Report previously considered by inc date

HR & OD Committee 11 March 2020 Performance Committee 11 March 2020




X


Assurance x Staff Confidentiality Safe X SO 03: Achieve patient standards

Committee Agreement




X

Key Recommendations to be considered: The Trust Board is asked to receive and note the contents of the report

Enc H1

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Page | 2

Executive Summary

• Workforce: the Trust employs 3336 (headcount) substantive full and part time staff, 400 bank workers with additional support provided by 300 volunteers.

• Overseas RN recruitment: 125 FTE appointments to date, (52 deployed to Wards, 5 due in 19/20, 68 currently in process due for deployment in 20/21).

• Medical Staffing: offers made to: Consultant MAU, Consultant Obs and Gynae, Specialty Doctor Orthopaedics, Specialty Doctor Respiratory, Specialty Doctor Obs and Gynae, x3 LAS FY2, x14 ST3+ General Medicine

• Advertising for LAS CT2 in General Surgery to fill vacancy from February. • Recruitment to a significant number of trainee gaps (13 total) across General Medicine.

• Turnover increased to 10.63% remains lower than regional average of 14%. • Vacancy Factor: reduced to 8.14% • Staffing Capacity: overall staff capacity increased in month by 16 wte • Temporary staffing: both Agency and Bank utilisation increased in month with reduction in substantive. 68.75% of temporary staff

utilisation (bank & agency) is within the Nursing staff group • Sickness absence 5.66% (5.36% M9). Stress Anxiety & Depression remains the highest cause of absence, with 31% of total Trust

sickness (30% M9). HRBP’s continue to work with managers on deep dive’s in specific areas. Stress, anxiety and depression remains the main reasons for absence. The Mental Health (MH) Practitioner will be delivering train the trainer sessions to develop MH champions located at ward level to deliver first line coaching and support.

• Mandatory training currently at 85%, Areas under target have action plans

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Workforce Performance Report Board

March 2020 (January 2020 Data)

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Workforce FTE Budget Establishment: 3113

In-post : 2843 (2856 M9)

Bank Usage: 188 (164 M9)

Agency Usage: 74(69 M9)

TOTAL: 3105 (3089 M9)

Variance: -8 (-41 M9)

Sickness Absence:

5.66% (5.36% M9) 5.37% YTD 4% Target

Turnover: 10.63%

(Rolling 12 months) This

includes junior doctor rotation

Appraisal Compliance:

80% 95% Target

Mandatory Training:

85% 85% Target

Vacancy Factor: 8.14%

(9.6% M9)

Jan 2020 data (Finance data includes CIP within establishment)

• The Trust employs 3336 (headcount)

substantive full and part time staff, 400 bank workers with additional support provided by 300 volunteers.

• Sickness absence rate: 5.66%. 5015 FTE Days Lost. (5.36% M9). Stress Anxiety & Depression remains the highest cause of absence, with 31% of total Trust sickness (30% M9) This has caused an increase in the use of temporary staff.

• Mandatory training currently at 85% • 68.75% of temporary staff utilisation (bank

& agency) is within the Nursing staff group • Overseas RN recruitment: 125 FTE

appointments to date. (52 deployed to Wards, 5 due in 19/20, 68 currently in process due 20/21).

• Turnover increased to 10.63% remains lower than regional average of 14%.

• Vacancy Factor: 8.14% M10 this is a reduction in month (9.6% M9)

Workforce Trust level Metrics: M10


Note - Substantive staffing is reported as being lower this month due to a change of reporting methodology. Work is underway to establish the reason for the difference between the ledger and ESR FTE.

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Well-Led: Culture & Leadership Programme

Corporate Induction • Corporate Induction delivered to over 60 delegates in January 2020 and approximately 550 attendees since January 2019; • A review of Corporate Induction is underway to further enable staff to connect with the Trust Vision and Values and will be

delivered from April 2020.

On-Boarding Experience • A pilot is being undertaken to identify the on-boarding experience of staff attending Organisational Induction from January

2020. A mixture of Quantitative and Qualitative experience data will be published in a Quarterly Report and be used to identify improvement actions to enable ‘the best start’ for staff at IOW NHS Trust.

Quality and Inclusive Leadership Conference 2020 • The Quality and Inclusive Leadership Conference will take place on the 19th March at Northwood House with invitations

issued to staff. Leadership Development Programmes • Cohort 3 of the Team leader’s and Supervisors programme has been delivered with positive feedback received, cohort 4 to

start in February. • All programmes and Leadership Development offer to the Organisation currently under review. An Organisational

Development service offer paper will be presented to Trust Board in March 2020 utilising feedback from the NHS Staff Survey 2019.

Staff Engagement Survey • Results of the NHS Staff Survey have been received and published • Q4 Staff Friends and Family Test will open during March 2020.

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Staff Engagement: Staff Survey

NHS Staff Survey 2019 - at a glance • The final response rate as an overall organisation was 42.1% • Survey Results at a glance: with Staff Engagement Score /10 1. Mental Health 6.7/10 2. Community : 6.6/10 3. Acute 6.6/10 4. Ambulance: 6.3/10

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Training & Development: Appraisal

Trust compliance at 31.01.20 (excl. medical/dental)

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Workforce Metrics – M1 Plan

• Majority of temporary staffing usage is across Medical, RN and AHP staff groups due to the level of vacancies across the Trust.

• Temporary staffing usage adverse to plan ytd by 69 wte. 66 bank & agency 3 wte.

• Peak usage at month 3 - 293 wte v 262 wte

at month 10 (-31 wte)

• Substantive staff in post across Medical, RN and AHP staff groups has increased by 49 wte since month 1 leaving a gap of 175 wte

• International recruitment remains a success

• Retention of RNs is adverse to plan and a deep dive is being undertaken to understand the reasons.

Workforce Metrics: M10

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Summary

Month 10 sickness rate 5.66%. Slight increase on M9 (5.36%) and remains above target.

Underlying issues

Our top 3 reasons for sickness absence are; Stress, anxiety & depression; Coughs, Cold & Flu and Musculoskeletal problems

Actions and interventions

• 2.75% of all absence is attributed to long term (28 days or more) absence which is a marginal increase on the previous month (2.66%).

• Main focus; targeted care group support continues including deep dives at cost centre level.

• A new Health and Wellbeing programme ‘Thrive’ will focus on the mental, physical, social, and Financial wellbeing of our people.

Workforce Metrics – Sickness Workforce Metrics - Sickness

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RN recruitment and retention Performance against 2019/20 plan

• Overseas Recruitment total is currently 125 FTE; 52 deployed, a further 5 in 19/20 and 68 in process due 20/21.

• RN retention in the month is slightly below plan. However RN recruitment in month is above plan and this is supporting our YTD net position.

• The use of temporary staffing is being used to mitigate vacancy gap. Regular deployment of overseas RNs will enable this use to be decreased further.

Successes Process Improvement Planned activity

• Overseas Nurses: Total 125 nurses appointed (52 already deployed to Wards , 5 due before the end of 19/20 financial year. 68 due in 20/21)

• 4.23 FTE RN new UK starters in M10. • Offers made to: Consultant MAU, Consultant

Obs and Gynae, Specialty Doctor Orthopaedics, Specialty Doctor Respiratory, Specialty Doctor Obs and Gynae, x3 LAS FY2, x14 ST3+ General Medicine

• Resourcing Officers to schedule workshops for recruiting managers to support their understanding of the NHS Jobs dashboards and to provide regular support/general system development updates – 2 workshops to be scheduled in March 20 (dates to be confirmed) and monthly moving forward.

• Temporary Staffing Officers to be assigned to Divisions to align with Divisional Recruitment Officers from 1 Mar 20. This is to support the alignment of temporary and permanent recruitment within the divisions.

• Bi-monthly Overseas nurse skype interviews planned to support continued RN recruitment .

• Project group to develop social media presence – working with our Communications team

• Link with South Coast Universities to attend careers events to support future recruitment.

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• There is now a project plan in place for medical recruitment.

• Offers made to: 2 Consultants, 3 speciality doctors 3 LAS FY’s. 10 offers have been made to 14 ST3 for General Medicine

• Advertising for LAS CT2 in General Surgery to fill vacancy from February.

• New starters anticipated for February and March is above the projected plan.

Medic recruitment and retention Performance against 2019/20 plan

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Enc H2

Agenda Item No 11 Meeting Trust Board in Public Meeting Date 12 March 2020 Title Director of Nursing, Midwifery, AHPs and

Community Services report to Trust Board Sponsoring Executive Director Alice Webster

Author(s) Judy Dyos Deputy Director of Nursing, Mandy Blackler Business and Operations Manager


HR & OD Committee 11 March 2020

Key Recommendation The Board is asked to consider the following recommendations:

Receive this report and consider its contents


Link to CQC Domains



Effective x SO 01: Provide safe, effective, caring and responsive services – ‘Good’ by 2020

x

Review & discuss x Patient Confidentiality Caring x SO 02: Ensure efficient use of resources x

Assurance x Staff Confidentiality Safe x SO 03: Achieve patient standards x

Committee Agreement


Responsive x SO 04: Achieve excellence in employment x



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Executive Summary The purpose of this paper is to inform the Board of activities within the Corporate Nursing Directorate over the month of January 2020oss the organisation. Corporate Nursing has overarching responsibility for the nursing workforce of the organisation. It is a small but diverse area of the organisation that embraces several services alongside its corporate responsibilities; including Medical Electronics, Adult and Children’s Safeguarding, Children in Care Team, Infection Prevention and Control, Dementia and End of Life Care. It has corporate responsibility for the nursing workforce across the organisation

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Workforce stabilisation –

• Nursing vacancy for acute areas continues to

reduce with the on-going arrival of the overseas nurses, this is leading to a month on month reduction in agency spend for nursing cover

• As we reach a more stable position we plan to open up a transfer window system to allow staff to try working in different areas, this approach has positively impacted on retention in other NHS trusts and may allow us to close some the vacancy in mental health and community services

• The Mental Health Optimal Staffing tool is now rolled out across mental services and we hope to see the first reports in the coming months

• A consultation paper to ensure we are compliant with the working time directive is being launched

Funded RN

(WTE)

Contracted RN

(WTE)

Overseas Vacancy

ALVERSTONE 11.39 10.4 1.0 0.35

LUCCOMBE 16.51 11.16 1.0 4.35

MOTTISTONE 11.39 9.29 1.0 1.1

ST HELENS 13.66 13.1 - 0.56

WHIPPINGHAM 21.63 14.8 1.0 5.83

PAEDIATRIC WARD 23.59 20.02 - 3.57

MATERNITY 34.81 34.81 - 0

SPECIAL CARE UNIT 14.34 10.45 - 3.89

STROKE 21.72 17.33 1.0 3.39

COLWELL 16.51 11.47 1.0 4.04

APPLEY 17.79 12.2 - 5.59

INTENSIVE CARE UNIT 41.29 40.07 - 1.22

CORONARY CARE UNIT 29.46 23.24 1.0 5.22

EMERGENCY DEPARTMENT 30.61 21.13 1.0 8.48

MEDICAL ASSESSMENT UNIT 26.79 22.84 - 3.95

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Safety thermometer National Benchmarking

• In December 2019 the Trust recorded

92.4% harm free care which was above the national line for the first time since 2017

• In December 2019 we reported recorded 4.4.% pressure ulcers which made us under the national average, whereas in January 2020 6.2 pressure ulcers were recorded showing a small rise

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Model hospital • Of significant note, last April we

were an outlier for harm free care and were right at the far end of the scale.

• Work with ward teams to correct errors in reporting has resulted with us now showing almost mid-table

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Model hospital

• We are demonstrating a positive position for VTE, Clostridium Difficile and MRSA

• Emergency C-section rate is slightly above national average which has deteriorated since the last reporting period. The maternity team are reviewing interventions and as part of a national programme we are moving to a new anti natal CTG monitoring system that will improve recognition of abnormal CTGs and increased levels of Ultrasound scanning

• Never events are below national average

• No CAS alerts has over due

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AHP Update

Orthotics and Prosthetics received great feedback following a visit from NHSI. The first STP wide AHP Mid-career Leadership event is taking place on the 18th March. This will include national speakers and bring AHPs across the STP together to look at the interim people plan, the Digital Framework for AHPs, initiatives to attract more people into AHP professions, advanced practice, and what can we do differently with our workforce. The HIOW AHP council had a successful meeting with Allocate to understand the functionality of e-job planning for AHPs, in line with the national mandate for April 2021. The AHP Professional Leads had a positive discussion regarding the draft AHP Strategy and will continue to engage staff over the next month to refine this further with a view to publishing it in early April

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Maternity Update There is a comprehensive report on Maternity services being submitted to Board this month, therefore this section is being omitted for January’s report

Mental Health Update

• Roll out of the Mental Health Optimal Staffing Tool (MHOST) within inpatient services has begun. Data Collection is currently in progress.

• Quality Governance review with Solent partners continues in the diagnostic phase. • Zero Suicide Strategy is completed in draft and with stakeholders for comment • Product Design Workshop with staff and stakeholders was held on the 14th February to begin the

next phase of transformation • Benchmarking data has shown some really positive practice within inpatient wards regarding the

use of restraint. We are the best performing Trust in our region and one of the best performances nationally. This is a really important measure of the quality of acute services, and reflects the positive and proactive approach taken by our staff

• Results of the MH National Inpatient Survey showed In comparison to the 2018 results the Trust has seen improvement in 27 domains and deterioration in 15 domains however the change in percentages are overall small and the response rate was poor . The Division is currently developing and action plan for the audit findings and a plan for improving levels and type of service user feedback

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15 Steps

Five areas were assessed as part of the 15 steps programme in January: MAU – partial accreditation with conditions but close to a full accreditation (no protected mealtimes) Whippingham – refer (concerns included clutter, out of date information, poor documentation, pods not locked away and dirty omnicell) Luccombe – partial accreditation with conditions (no evidence of protected mealtimes) St Helens – partial accreditation with conditions (patient pain score not recoded on NEWS 2) Alverstone – partial accreditation with conditions (no evidence of protected mealtimes)

Awards and Thanks Clinical accreditation We now have three areas that have achieved full clinical accreditation: • Intensive Care Unit • St Helens Ward • Mottistone Suite Sincere congratulations to all three areas for all their hard work in achieving this

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Dido Harding visit • Baroness Dido Harding, Chair of NHS

Improvement, and Duncan Burton Regional Chief Nurse visited the Community Unit and spoke about the positive environment that is being created.

• They also met staff who showcased the improvement work they are doing and witnessed a real sense of pride. These included the developments in End of Life Care, listening to our Education team talk about the 100 plus students we have in the Trust and the overseas nurses who have achieved a 100% first time pass rate for their entry to the Nursing and Midwifery Council register.

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CQC visit The CQC inspection team were positive, letting us know that things had ‘moved in a good way’ and that we are heading in the right direction. More importantly they said that they could see that there was a lot of effort going into the changes we needed to make. It is also always good to hear that the Inspectors saw the changes in our Medical Assessment Unit (MAU). They told us that there was a ‘very nice working atmosphere’ on display, with smiling and friendly staff showing good team work, with doctors, nurses, AHPs and the rest of the team. There was also praise for the work being done on St Helens and our Coronary Care Unit (CCU) – specifically how well they have improved their documentation. Our Stroke care was also highlighted by the inspection team as another example of positive improvement. Not to be left out Our Emergency Department (ED) was also singled out for praise. Inspectors told us that staff were positive about recent changes and that they were pleased with the department’s leadership. However all that said two wards were identified as needing more improvement. We will work with those teams, offering additional support and sharing the learning from other areas of the Trust to make the positive changes that we need to see.

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Documentation update • A full review has taken place of risk

assessment documentation, fluid balance charts and falls protocol

• Rollout of the new paperwork has taken place in a three month trial. Revisions are currently being made and the latest audits are showing an improvement

• A new Mediaudit programme has been procured to improve the quality of data gathering . All ward sisters and matrons are now trained and we have commenced our first run of audits

IPC update • TIAA have audited our compliance in

relation to Infection prevention and Control under the Health and Social Care Act and have given “Reasonable Assurance”.

• The recommendation to move to “Good Assurance have already been completed

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Dementia update

• 14 new Dementia Champions have just undertaken the new Dr Gemma Jones training. Two days have been completed with a further two days in March. Staff who attended reported that the training was very insightful.

• The simulation suite in the Education Centre has been used for some filming which can be incorporated in the bespoke Tier 1 dementia training that will be rolled out shortly. Some of the champions that are attending the training above will also undertake further education in April to enable them to deliver the Tier 1 and Tier 2 training.

Awards and Thanks Employee of the month Congratulations also to Dan Nugent, from the Community CAMHS team, who won the Trust-wide Employee of the Month Award in January in recognition of the great work he is doing with young people.

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11 Meeting Trust Board in Public Meeting Date 12 March 2020 Title Medical Director’s Report Sponsoring Executive Director

Mr Alistair Flowerdew, Medical Director

Author(s) Mr Alistair Flowerdew, Medical Director


n/a




X

Review & discuss X Patient Confidentiality Caring SO 02: Ensure efficient use of resources X


Committee Agreement

Other Exception Circumstances Responsive SO 04: Achieve excellence in employment X



X


To receive the update from previous months Medical Directors report with regard to the GMC/HEE inspection, recruitment, job planning and partnership working with partner trusts

Enc H3

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Executive Report 1. Introduction

The report highlights the activities undertaken by the Medical Director and his team.

Significant focus has been on improving training experience of the doctors in training and also ensuring that safe care is provided at all times including out of hours. The Medical Director has also been leading the clinical partnerships with Portsmouth and other external stakeholders.

2. Medical Recruitment Acute Division

Update on recruitment:

• There is now a project plan in place for medical recruitment. • Advertising for LAS CT2 in General Surgery to fill vacancy from February. • Specialty Doctor Anaesthetics interview held on 27th February, one doctor appointed awaiting acceptance. • New starters anticipated for February and March is above the projected plan.

Miss Anusuya Dhanpal, Consultant in Obstetrics and Gynaecology – start date April 2020

Middle Grade and Junior posts: There has been excellent progress in recruitment of middle grade position through international recruitment. In order to address the requirements set out by GMC/HEE to strengthen the overnight and weekend cover an additional establishment from 10 to 16 physicians at the level of specialty training ST3 or above have been recruited. As there were 6 vacant posts in the current establishment active recruitment for 10 doctors has taken place. As at 28th February, 8 of the 10 posts have been filled, but important to be cautious as four of these are Deanery posts which may be filled in August rotation. Early confirmation from Deanery of at least one AIM (x3 posts total) being filled and some of the new appointments wish to go onto AIM lines through MTI scheme.

Specialty doctor appointments in Gynaecology has also been made following visas and immigration issue with earlier appointed candidate.

Additional junior doctors are currently been recruited to fill vacant F2 positions and fill the gaps in the rota which have arisen due the new working time directive for junior doctors. These doctors are all due to start 23rd March. There is also considerable effort in Medicine for rotas to provide enhanced continuity of care and working experience of the trainee doctors.

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3. Job Planning Lesley Simpson has now replaced Jonathan Shoebridge as interim Medical Workforce Lead and following a handover with Jonathan is now leading on the process to take forward 2020 job planning for all consultant and SAS doctors. She is working with the PMO who have developed the job planning plan with timelines and are now working towards finishing this year’s round by the end of March 2020.

Job plans will subsequently be reopened to enable prospective job planning to be undertaken in April 2020 and continue on annual basis thereafter. This information was shared by Lesley Simpson at the LNC (27/02/20) and the process to take forward 2020 job planning for all consultant and SAS doctors will be communicated to the medical staff w/c 2nd March 2020 (Please find attached communication).

Job planning is nearing completion in Paediatrics and Obstetrics and Gynaecology. In General Surgery, job plans of consultants are being changed to reflect the new way of working within the department. This will enhance patient safety and better continuity of care for patients and training for trainee doctors.

As a consequence from the beginning of April more timely job planning will follow and be recorded accurately for reporting purposes.

4. GMC/HEE Review The Trust has engaged proactively with the Deanery to address concerns about the out-of-hours service and the experience of our trainee doctors. We have reported our progress with recruitment and the other work to support the required improvements. The pace of our response was welcomed but we agree that there is still a lot of work to do. A review by the Post Graduate Dean will be taking place prior to 24th April 2020. In addition, the report provided to the Post Graduate Dean in January 2020 has been included in Appendix 1.

5. Appraisals Update

Of appraisals due in the last 3 months, percentage completed (as at 29 February 2020)

90.7%

Appraisals completed year to date (as at 29 February 2020)

65%

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Appraisal Development A Business case has been submitted to provide external quality assurance and develop an enhanced appraisal process for 2020/2021.

Alistair Flowerdew Medical Director March 2020

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Appendix 1

Report for Wessex deanery education and workforce IOW January 2020

1. Background:

I have been working with the IOW NHS trust as Associate Dean for 3 months (2 days per weeks) supporting workforce review and educational infrastructure.

2. Overview I have been engaged with 4 main areas of work and these form the work streams to be addressed in future development work: 2.1 Filling current medical vacancies with substantive staff and reducing locum medical staff 2.2. Developing a modern workforce strategy and the actions to deliver it, 2.3. Developing a consistent education and training culture in the organization 2.4. Quality assurance of the learning environment for trainees. 2.5. The trust has been engaged in working with me and has been open to feedback, discussion and advise 2.6. The trust has shown activity at pace in some key areas. It has instigated a monthly senior workforce meeting and progressed some

recruitment actions agreeing funding, instigated advertisement, selection and recruitment of new middle grade medical staff to support safety of its out of hours medical rota.

2.7. The trust has shown commitment to addressing issues of bullying and undermining reported in some consultant staff/ managers. Appropriate conversations have occurred with individuals and groups of senior leaders. The trust is working on defining and establishing a more positive IOW culture to support and nurture trainees

2.8. The trust has shown it is committed to maintaining trainees on the island and understands that a fundamental requirement to sustaining this is a well led educational service, an adequate training environment and an appropriate workload for trainees.

3. Service issues

3.1. It is clear that the issues around educational experience for trainees are highly influenced by the well identified service and performance challenges for the trust.

3.2. Factors from how the clinical service is configured and the current internal trust processes additionally strongly affect educational experience. These do not primarily sit within my current role and remit but would wish to highlight. 3.3 The Issue of how the Emergency Department relates to the rest if the trust especially when bed flow is poor; of how patients are transferred

between services and how this affects the clinical work environment, patient care and work related stress in staff. Progress has been made with re-clarification of processes and the clinical ownership/accountability of patients at any point within this pathway. However, the trust needs to be consistent in how communication is delivered to staff and embed and monitor the practices.

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3.4 The high levels of DTOCs and the increased workload for staff maintaining overview of these patients; how it puts the ‘wrong patients in wrong beds’. Staff reflect a lack of knowledge of what the trust/system strategy is to significantly change the current situation. This is a big issue for morale

3.5 The issue of how workload is divided between teams and of cross cover and clinical supervision is delivered to more junior staff. There is a model in place that appears to be of teams in silo working: there is a disparity of workload between teams and a rigid system that does not flex to demand and manage the workload between teams. Access of how to escalate to a senior in not always clear. New clinical leadership in medicine is addressing some of these issues

3.6 The nature of how all teams are supported out of hours and whether the current staffing model is optimal; a more integrated out of hours team might solve some issues especially with the work to deliver a second senior decision maker at night that the trust has already delivered.

4 Key workforce and educational themes, progress and recommendations

4.1 Medical vacancy levels 4.1.1. The trust has significant unfilled medical staff roles at consultant and non consultant grades. 4.1.2. Many key clinical services have vacancies; in a small trust this has a significant effect on capacity and performance and puts

increased demands on existing staff 4.1.3. A reliance on variable quality/ high cost locums staff has a significant impact financially, operationally, on the education of trainees and

on staff morale. 4.1.4. The geographical issue of being an island and commuting times from the mainland are significant barriers to recruitment 4.1.5. As an island economy the incentives of efficient relocation, offer of accommodation and relocation expenses important factors in

recruitment. Clarity on the IOW offer and best use of resource including the contract it holds with a private accommodation provider will support recruitment.

4.1.6. The recruitment process for medical staff is reported at times to be slower than the best NHS trusts: this can results in the loss of candidates at interview due to delay. The trust needs to ensure a lean process and monitor performance of its recruitment process.

4.1.7. There is a reliance on virtual candidate interview (A Skype type system-Zoom)This requires both investment in hardware and physical environment to improve resilience in the system

4.1.8. The trust has recruited unsuccessfully against unchanged job descriptions for some roles and needs to review its strategy for recruitment and review long term vacancies. There needs to be exploration of joint appointments with partners or rotational roles, a clinical review of vacant posts and whether they can be reconfigured. a clear timescale for this work needs to be in place

4.1.9. There needs to be a refresh of alternative or bespoke recruitment strategies for hard to fill posts. A review of best practice elsewhere and options appraisal may be beneficial

4.1.10. The IOW has instigated a workforce meeting that has the correct membership representing, finance, HR, medical leadership and a wider professional groups to which I am a member. This forum needs to be the mechanism to drive forward recruitment and to enable this I have suggested identification of key metrics and a focus on immediate service and workforce priorities with actions captured through an active action plan.

4.1.11. The meeting also needs to focus on future workforce redesign and to reenergise the recruitment process.

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4.1.12. The trust has acknowledged a priority to recruit middle grade staff in medicine to increase capacity in medicine at night; support junior medical staff including those covering surgical specialities and reduce work related stress. It has responded with an agreement for funding, a review of job descriptions and recruitment of substantive staff and through agencies. 15 formal job offers have been made: 6 have formally accepted 5 are awaiting response from the applicants. They have worked at pace to respond the primary concerns around educational experience. The recruitment, induction and development of these staff must remain a priority for the trust to have an enhanced rota in place in 4 months’ time

4.2 Workforce design;

4.2.1 The IOW trust has a relatively traditional workforce model to deliver service and there are opportunities to look at transfer of work from traditional medical roles to other staff groups to increase service capacity and manage future demand. This may be mirrored in other professional staff groups

4.2.2 There are examples of good practice on the island and recent recruitment of night practitioners and physician associates shows recognition and commitment of the trust to new roles and service redesign. 4 night practitioners have been recruited and will all start work by the end of February 2020. These new posts need supervision to get best value out of the roles, to develop the post holders and ultimately provide a career pathway for them.

4.2.3 The island status of the trust would suggest a ‘grow your own’ model for new roles from the trust population may be the most successful in terms of recruitment and retention to new roles. The trust needs a clear view what roles are priorities for trust clinical services; how many new staff are required and where funding is to be diverted to support this work.

4.2.4 This should lead to a view what support this may require of the local healthcare system: a review of best practice from other services, partnership arrangements and replication/buy in of existing training programmes

4.3 Educational infrastructure

4.3.1 The feedback from trainees for the IOW is well documented across a number of quality measures and reviews. 4.3.2 The trust has an engaged postgraduate staff and medical education leadership and provides good formal teaching programmes and

pastoral support. 4.3.3 Clinical and educational supervision is variable: individual clinicians are recognised as good supervisors and provide an excellent

experience to ‘their’ trainees. 4.3.4 The offer to all trainees must be more consistent and could be supported with some focussed development of consultant

body. 4.3.5 An opportunity exists to include trust expectations of placement supervision into the induction for senior longer term locums; the trust

needs to be consistent in their message that education is core business and with defined expectations of supervisors. 4.3.6 The trust has a junior doctor’s forum and collects feedback on issues in reaction to when issues arise. A more formal approach of

‘you said; we did’ feedback may improve trainee engagement. 4.3.7 The pressures on SPR training experience may be helped with a dedicated teaching programme to improve their experience 4.3.8 The trust has employed Iain Bailey (senior surgeon UHS) to review and redesign surgical services; there is a proposal to work

different to improve patient care and junior doctor experience. Work is necessary to communicate the proposals, action and embed the changes

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4.4 Culture 4.4.1 Trainee feedback has reported issues of bullying and undermining within the organization. The trust takes these issues seriously and

has addressed concerns with individual departments and staff members. However, it is my opinion that the trust needs to be very clear in communicating about what behaviours it wants and does not want in its senior medical staff in both locum and substantive roles. If there are issues reported these need rapid review and a clear and uniform action taken if substantiated.

4.5 Leadership

4.5.1 It is clear there are good leaders in the trust and they are committed to patient care and educational experience of trainees. A number of new appointments are already making a difference to the trust and its services; there is an opportunity to develop them and support them in their roles.

4.5.2 To an outsider to the trust it is not always clear how decisions are made and communication is relatively informal- this may be a manifestation of a small trust. Issues around medical education and change in service that affect junior medical staff may benefit from a focus on how communication occurs. A review of how aware and engaged senior staff are of trust issues might help form a communication strategy.

4.5.3 Some meetings and activities may benefit from a formalised use of action plans where actions are more specific, accountable to an individuals and time limited. The action plans need to the mechanisms for change not the record of it.

4.5.4 A clear vision for education and training and the definition of trust standards of behaviour and good practice may be enablers for the future.

5. Overall recommendations for HEE Wessex

5.1 The trust has engaged well with me and has some work streams that address deanery concerns and workforce issues. 5.2 The trust has responded at pace to the serious concerns over the out of hours service and trainee experience. 4 Nurse practitioners will be in

place by the end of the month There will be an interim period where recruitment takes place and doctors are available to start posts to augment the out of hours rota. However, the identification and job offers to 14 suitable candidates represent significant work and progress

5.3 Further removal of posts at the trust would compromise remaining training posts, impact on the reputation to the trust, future recruitment and undermine progress so far.

I would recommend an extension to the sanction to remove posts and a regular reporting mechanism to update progress and ensure embedding of changes delivered so far.

James Adams Associate Dean January 2020

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Agenda Item No 12 Meeting Trust Board in Public Meeting Date 12 March 2020 Title Freedom to Speak Up Guardian Report Quarter 2 (July-September) and Quarter 3 (October-December) 2019/2020 Sponsoring Executive Director

Maggie Oldham, Chief Executive

Author(s) Leisa Gardiner, Trust Freedom To Speak Up Guardian Report previously considered by inc date

HR & OD Committee 11 March 2020




X

Review & discuss Patient Confidentiality Caring X SO 02: Ensure efficient use of resources

Assurance X Staff Confidentiality Safe X SO 03: Achieve patient standards

Committee Agreement





To receive and have assurance given by the report that there is a robust policy and structure which allows our staff to safely raise concerns, to be supported in doing so and to ensure they are treated according to the principles outlined by Sir Robert Francis.

Enc I

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Executive Summary

The Freedom to Speak Up independent review into creating an open and honest culture in the NHS (2015) recommended the widespread introduction of the Freedom to Speak Up Guardian (FTSU) role in each NHS organisation. The Trust has appointed Leisa Gardiner as the Freedom To Speak Up Guardian. The FTSU Guardian/Team received 28 concerns for Quarter 2 (July-September 2019) and 62 concerns for Quarter 3 (October – December). Of the 28 concerns raised during Quarter 2, 2 related to related to patient safety and quality and 25 related to behaviours including bullying and harassment. Of the 62 concerns raised during Quarter 3, 1 related to patient safety and quality and 39 related to behaviours including bullying and harassment The biggest staff group to raise concerns in Quarter 2 were Nurses and in Quarter 3 were Administrative staff. When a concern is raised the Freedom To Speak Up Guardian, a Freedom To Speak Up Advocate or Anti Bullying Advisor meets with the member of staff to hear the concern, provide support and escalate when appropriate including having direct access to the Chair and CEO. The intension of this FTSU report is that it will be submitted quarterly to be in the public domain.

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FREEDOM TO SPEAK UP REPORT

1 Purpose

1.1 This report outlines activity and progress to date of the Freedom To Speak Up Guardian (FTSU) role and provides a summary of concerns raised for Quarter 2 & Quarter 3 (July –September and October – December 2019).

2 Background

2.1 The Freedom to Speak Up independent review into creating an open and honest culture in the NHS (2015) recommended the widespread introduction of the Freedom to Speak Up Guardian (FTSU) role in each NHS organisation.

2.2 The standard NHS contract requires all trusts and foundation trusts to nominate a Freedom to Speak Up Guardian by October 2016.

2.3 Leisa Gardiner, took up this Guardian role in October 2016. Prior to this as part of her role as Lead for LiA (Listening into Action) staff approached her to raise their concerns and she encouraged staff to speak up and well as providing support.

2.4 This report outlines activity and progress to date and provides a summary of concerns raised for Quarter 2 & Quarter 3.

3 Structure of the Freedom to Speak Up Model

The Trust has a nominated Freedom To Speak Up Guardian who is supported by a team of Freedom To Speak Up Advocates and Anti-Bullying Advisors. The team will provide support for the workforce to raise and respond to concerns in relation to patient safety, bullying and harassment and any other concerns by ensuring an environment of trust, openness and respect. The Freedom to Speak Up Guardian will help to raise the profile of raising concerns in the organisation. Provide confidential advice and support to staff in relation to concerns they have and/or the way their concern has been handled. Facilitate the raising concerns process where needed. Ensure the organisational policies are followed correctly.

3.1 When a staff member raises a concern either through the Freedom To Speak Up route or via an Anti Bullying Advisor, a meeting is arranged to meet with the staff member. At the meeting the concern is heard, the member of staff is supported and options how their concern can be dealt with are discussed. Where appropriate, concerns are escalated and direct access is available to the Chair and CEO. Ongoing contact and support is available to the staff member until they feel their concern has been addressed or resolved. A feedback form is sent to the staff member who has raised the concern to ask whether they felt supported and would raise a concern again.

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4 Communication plan

The Freedom To Speak Up Guardian attends staff induction (including Student Nurse and Junior Doctor inductions) and attends the Junior Doctors Forum and staff team meetings to provide updates on Freedom To Speak Up. Speaking up forms part of a wider programme of work in helping to create an open and transparent culture. It is important that we provide different mediums of communication for all staffing groups. The FTSU Guardian is invited to attend staff meetings to ensure that staff from all areas get an opportunity to hear about speaking up.

5 Freedom to Speak Up Activity in the Trust

5.1 Concerns raised in Quarter 2 and Quarter 3

There have been a total of 28 concerns raised during Quarter 2 (July – September 2019) and 62 concerns raised during Quarter 3 to the FTSU Guardian/Advocates and Anti Bullying Advisors.

5.2 Concerns were raised by the following staff groups

Quarter 2

Doctors Nurse Administrator AHP Corporate Healthcare Assistant

Pharmacy

3 11 6 3 3 1 1

Quarter 3

Doctors Nurse Administrator AHP Corporate Healthcare Assistant

Midwives Ancillary staff

Other

14 4 26 7 3 1 1 2 4

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Concerns were categorised as follows

Quarter 2

Patient Safety and Quality

Behavioural including Bullying and Harassments

Other

2 25 1

Quarter 3

Patient Safety and Quality

Behavioural including Bullying and Harassments

Other

1 39 22

In order to gain a better understanding of the concerns raised around behaviours and whether these are reported as bullying and harassment, the FTSUG (Freedom To Speak Up Guardian) has been in liaison with the regional network team and National Guardian Office. Guidance provided was that where the individual raising the case believes there is an element of bullying or harassment then the case should be recorded in this category. There are various definitions of bullying and harassment but the definition from ACAS is:

“Bullying and harassment means unwanted behaviour that makes someone feel intimidated, degraded, humiliated or offended. It is not necessarily always obvious or apparent to others, and may happen in the workplace without an employer’s awareness. “

“Bullying or harassment can be between two individuals or it may involve groups of people. It might be obvious or it might be insidious. It may be persistent or an isolated incident. It can also occur in written communications, by phone or through email, not just face-to-face”.

The National Guardian Office advises that the terms should be interpreted broadly and that the focus should be on the perceptions of the individual bringing the case.

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5.3 Data

Isle of Wight NHS Data on “Speaking Up”

It is a requirement for all FTSU Guardians to submit data to the National Guardian Office and the graft above shows the total number of concerns raised and the number by category. There was a significant increase in Quarter 3 (October-December 2018). The increase related to the Freedom To Speak Up Guardian’s hours being increased and October 2018 was the first National Speak Up month campaign where the picture nationally was one of a rise during this time period. Again in Quarter 3 (October-December 2019) there was a significant increase in the number of concerns which is believed to be related to the Speak Up campaign in October 2019.

0

10

20

30

40

50

60

70

80

90

100

Qu 118/19

Qu 218/19

Qu 318/19

Qu 418/19

Qu 119/20

Qu 219/20

Qu 319/20

Total No. of patient concerns

Patient safety related concerns

Behavioural/Bullying/Harrassment

Other

National Speak Up October month 2019 (Quarter 3 19/20)

National Speak Up October month 2018 and increase in FTSU Guardian hours (Quarter 3 18/19)

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6 Themes of concerns raised

The majority of cases related to poor behaviours and or bullying/harassment. There remains a low number of cases raised relating to patient safety concerns. It is felt that staff are confident in raising patient safety concerns and know the process to raise these concerns i.e. through their line managers and this is often supported with the completion of a Datix. This is also evidenced in the staff survey in that it is reported they know how to report an unsafe clinical practice.

In relation to the cases of behaviours, future Board reports will include a breakdown of cases and whether they were reported as bullying/harassment or poor behaviours. The National Data base will continue to report as bullying/harassment or other in respect of behaviours. The National Guardian, Dr Henrietta Hughes will be reviewing the categories for reporting cases moving forward.

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7 Monthly Staff Pulse Surveys

Number of staff (%) who responded positively to Question 8 of the pulse survey that states have not personally experienced harassment, bullying or abuse in the last month.

No data available for October/November due to the Annual staff survey. The Staff Pulse Surveys will be moving to quarterly from the 1st April 2020. Next data due for Quarter 4 will be presented in the Annual FTSU report in May 2020.

8 Lessons learnt

8.1 The number of concerns being raised by staff increased significantly in Quarter 3 compared to Quarter 1 and Quarter 2, with the majority of concerns relating to behaviours. This pattern is the same as it was in the same quarter last year when there was also the “Speak Up October” Campaign. There needs to be a continued focus on the Behaviours Framework with all staffing groups.

8.2 The staff pulse survey data is encouraging in that the September data shows us that there was a 10% increase in the number of staff reporting they had not personally experienced harassment, bullying or abuse . This will need to monitored going forward.

8.3 We need to monitor this against the number of concerns raised in relation to poor behaviours and encourage more staff to complete the survey to get an improved overall picture.

60

65

70

75

80

85

90

Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19

% of staff who responded positively

% of staff who respondedpositively

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9 Activity and progress to date

9.1 FTSU Guardian is supporting the delivery of Human Factors training to staff throughout the year.

9.2 Visit from South Central Ambulance Service’s FTSUG and invite to join the Freedom To Speak Up Guardian National Ambulance Network.

9.3 Supporting the Junior Doctors at their Junior Doctor Forums.

9.4 Delivery of “Speak Up October” campaign for the Trust including; Staff awareness sessions outside the canteen, main entrance and by children’s ward. Distribution of green ribbons to highlight the importance of staff speaking up. Attendance at care group and team meetings. Communication via the intranet, staff news letters and CEO conversation.

9.5 Regular 1:1 sessions with the CEO.

9.6 Attendance at Trust Leadership Committee.

9.7 Invite from the National Guardian Office for attendance at a FTSU celebratory event on the 8th October 2019 in London on behalf of the Ambulance Service’s achievement with the Freedom To Speak Up Index.

9.8 Monthly supervision sessions with the FTSU Advocates and Anti-Bullying Advisors.

9.7 Attendance at staff induction and the monthly staff wellbeing MDT meetings.

9.8 Attendance and networking at Regional and national meetings.

10 National and Regional Developments and updates

10.1 Q2 headlines from trusts; 3,486 cases were raised to Freedom to Speak Up Guardians/ambassadors/champions (846 included an element of patient safety/quality of care and 1,246 included elements of bullying and harassment) Q3 headlines from trusts; 4,120 cases were raised to Freedom to Speak Up Guardians/ambassadors/champions (915 included an element of patient safety/quality of care and 1,496 included elements of bullying and harassment).

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10.2 Regional Integration and Development Events being hosted during March 2020 to promote an integrated approach to speaking up right across the health sector and enable networking across the Freedom To Speak Up community.

10.3 National Guardian’s Office report 18/19 dated January 2020. The report states that there has been a 73% rise in the number of cases reported to Guardians compared to the previous year.

11 Next Steps and future priorities

11.1 Continue to support the delivery of Human Factors training to staff throughout the year.

11.2 Review the role of the anti - bullying advisors and FTSU advocates.

11.3 FTSU Guardian to undertake Exit interviews to support staff

11.4 Continue to engage with staff to make Freedom to speak up more visible and encourage staff to raise concerns. Work in partnership with the Culture and Leadership work for the Trust.

11.5 Following review of the Annual staff survey work with teams around increasing staff confidence around speaking up about unsafe practice.

11.6 Review the National guidelines on Freedom To Speak Up training in the health sector in England and create an action plan to support delivery in line with the National Guardian’s Office recommendations and training pack when received.

11.7 Work alongside staff to understand and experience their concerns first hand.

11.8 Attendance at regional and National meetings including the National Ambulance Network for Freedom To Speak Up.

12.10 Continue to submit data to the National Office.

12.11 Continue to provide quarterly reports and an annual report for the Trust Board.

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Agenda Item No 13 Meeting Trust Board in Public Meeting Date 12 March 2020 Title Board Assurance Framework Sponsoring Executive Director

Suzanne Rostron, Director of Quality Governance

Author(s) Sarah Anderson, Associate Director of Corporate Affairs Report previously considered by inc date

Quality Committee (12 February 2020); Performance Committee (12 February 2020) HR & OD Committee (12 February 2020)




X



Committee Agreement




X


• Confirm that the strategic risks are being managed appropriately and that sufficient assurance has been provided on the progress being made in relation to these risks

• Approve the proposed change in current risk score for SR04-1 and SR04-2 • Support the current and target risk ratings • Receive and approve the Board Assurance Framework for Quarter 3 of 2019/20

Enc J

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Executive Summary This report provides the Board with details of the Board Assurance Framework (BAF) for 2019/20 and the current position as at the end of Quarter 3. It builds upon the reports taken to each of the Assurance Committees in the quarter and seeks to provide details of the work in hand to continue to develop risk maturity within the organisation. Only two of the twelve risks within the BAF have been proposed for a revised current risk score at this stage; while work is in hand to progress a number of actions and seek assurance from a range of sources it is considered that the risk levels have not moved sufficiently in any other areas at this stage. The target risks are set for the end of the financial year, with movement in current risk ratings expected during Q4.

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Board Assurance Framework for Strategic Risks 1. INTRODUCTION The Board Assurance Framework (BAF) sets out the principal strategic risks, controls and lines of assurance against the strategic objectives. It provides assurance that the Trust is appropriately sighted on and has a structure to support effective management of risk within the organisation.

The BAF is a structured means of identifying the main sources of risk, assurance and controls in a coordinated way to enable discussion and challenge to take place at Board level. It identifies which of the Trust’s strategic objectives are at risk of not being delivered. At the same time, it provides positive assurance where risks are being managed effectively and objectives are being delivered. This allows the Board to determine where to make most efficient use of their resources and address the issues identified in order to improve the quality and safety of care.

The process for gaining assurance is fundamentally about taking all of the relevant evidence together and arriving at informed conclusions. The most objective assurances are derived from independent reviewers; these are supplemented by internal sources such as clinical audit, internal management representations, performance management and self-assessment reports.

2. BACKGROUND Board Seminar workshops in May and June 2019 were held to develop the Board Assurance Framework (BAF) for 2019/20. This considers the strategic objectives for 2019/20 and the strategic risks for each of those strategic objectives. It also gives consideration to the risk appetite and inherent, current and target risk scores for each of these strategic risks.

The Governance Advisor worked with each of the Executive Directors to build upon the outputs of the workshops, with the development of the Board Assurance Framework for 2019/20 and a position for the end of Quarter 1. This built on the Board Assurance Framework for 2018/19 and was approved by the Trust Board at its meeting on 4 July 2019, following discussion and input through the assurance committees.

The December Audit Committee did not recommend any additional sources of assurance but did request that Board Committees review the target risk scores, as it felt these to be over ambitious. This was reflected in the Executive review of the BAF in Quarter 3 and included in recommendations to committees. Quarter 3 updates of the BAF were shared with each of the Performance Committee, Quality Committee and HR & OD Committee at the February meetings.

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The BAF risks are allocated to Committees as set out below:

Assurance Committee Strategic Risk Quality Committee SR01-1: Inability to achieve and maintain regulatory compliance

SR01-2: Non-delivery of the outcomes of the Quality Strategy

SR01-3: Failure to deliver safe care

Performance Committee SR02-1: Expenditure incurred exceeds income by greater than agreed control total

SR02-2: Inability to achive productivity improvements as required across all areas

SR03-1: Failure to deliver patient standards of care to constitutional and contractual levels as agreed with commissioners

SR05-1: Pace of implementation of IoW Health and Care Sustainability Plan for achieving clinical and financial sustainability is not delivered

SR05-2: Strategic partner to support delivery of phase two of the Acute Services Redesign (superceded by Health and Care Plan) may withdraw from agreement

SR05-3: Underpinning and supporting Trust plans aligned to Sustainability Plan not implemented

HR & OD Committee SR04-1: Unable to recruit sufficient numbers of people with the right skills and values

SR04-2: Unable to retain the right people

SR04-3: Unable to achieve necessary cultural change

Each Committee has noted the progress of work underway, against agreed timeframes, and has not sought further changes or assurance at this stage in the year.

Appendix 1 provides a summary of the strategic risks for the organisation, their inherent, current and target ratings and current position.

A summary of the current position in relation to the risks at the end of Quarter 3 is set out below, with an overview of the BAF risks detailed at Appendix 2.

The Corporate Risk Register is provided to the Board in the Part 2 papers.

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3. PROGRESS The BAF brings together in one place all of the relevant information on the risks to the Board’s strategic objectives. Having robust and proportionate assurance arrangements in place is critical for the Board to receive assurance that resource can be directed at the most significant areas for managing and mitigating strategic risks.

At the end of Quarter 3 only two of the twelve strategic risks has shown an improvement in the risk score since the BAF was established at the end of Quarter 1. This is to be expected at this stage of the financial year, with all target risks in place for achievement at the end of Quarter 4. Many actions have taken place to lay the foundations for improving and mitigating the risk position for the Trust across all strategic risks during Quarter 3 with no concerns raised by the Board Committees in terms of progress against plans.

The current risk score for SR04-1: Unable to recruit sufficient numbers of people with the right skills and values has seen an improved position with the recruitment of cohorts of overseas staff. Therefore it is proposed that the current risk rating of 15 at Quarter 2 be reduced to a risk rating of 12, which the HR&OD Committee recommends to the Board.

The current risk score for SR04-2: Unable to retain the right people has seen an improved position with staff retention improving although the benchmarked position with other trusts identifies the Trust as an outlier. Therefore it is proposed that the current risk rating of 16 at Quarter 2 be reduced to a risk rating of 12, which the HR&OD Committee recommends to the Board.

In addition to receiving the Quarter 3 Board Assurance Framework reports and progress updates, the Board Committees also received the associated Corporate Risks that are linked to the principal risks. It should be recognised that the reports received in relation to the Corporate Risk Register are at a point in time only as these are taken from a live system, which has continuous updates. The full Corporate Risk Register is presented to the Operational Risk Sub-Committee and the Trust Leadership Committee.

Appendix 1 shows the summary of the inherent, current and target risk scores for each strategic risk.

Appendix 2 details the BAF.

The Corporate Risk Register in full can be found in the Private Board papers.

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The risk scoring model for likelihood and impact are set out below with the full breakdown of scoring detailed in the Trust Risk Management Strategy:

Impact Score 1 2 3 4 5

Like

lihoo

d Sc

ore 1 1 2 3 4 5

2 2 4 6 8 10 3 3 6 9 12 15 4 4 8 12 16 20 5 5 10 15 20 25

Risk Score 1 – 3 Low 4 – 6 Moderate 8 – 12 High 15 – 25 Extreme

A breakdown of the actions undertaken, sources of assurance, and future actions has been shared with the relevant committees but more work needs to be undertaken in Quarter 4 to mitigate the risks to enable to target risk ratings to be achieved.

4. RISK APPETITE The Trust recognises it is impossible to deliver its services and achieve positive outcomes for its stakeholders without taking risks. Indeed, only by taking risks can the Trust realise its aims. It must, however, take risks in a controlled manner, thus reducing its exposure to a level deemed acceptable from time to time by the Board and, by extension, external inspectors/regulators and relevant legislation.

Risk appetite can be defined as the amount of risk, on a broad level, that an organisation is willing to take on in pursuit of value or the total impact of risk an organisation is prepared to accept in the pursuit of its strategic objectives.

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Risk appetite therefore goes to the heart of how an organisation does business and how it wishes to be perceived by key stakeholders including employees, regulators, rating agencies and the public.

The amount of risk an organisation is willing to accept can vary from one organisation to another depending upon circumstances unique to each. Factors such as the external environment, people, business systems and policies will all influence an organisation’s risk appetite.

The risk appetite for the strategic risks captured within the Board Assurance Framework has not changed from Quarter 1 and remains as indicated in Appendix 2.

5. RECOMMENDATIONS The Board is recommended to:

• Confirm that the strategic risks are being managed appropriately and that sufficient assurance has been provided on the progress being made in relation to these risks

• Approve the proposed change in current risk score for SR04-1 and SR04-2

• Support the current and target risk ratings

• Receive and approve the Board Assurance Framework for Quarter 3 of 2019/20

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Appendix 1 – Draft Quarter 3 ratings – Subject to Approval

RISK APPETITE

STRATEGIC OBJECTIVES AND STRATEGIC RISKS

INHERENT RISK SCORE

CURRENT RISK SCORE AT Q3 TARGET RISK SCORE LEAD

COMMITTEE EXECUTIVE LEAD POSITION

L I Score L I Score L I Score STRATEGIC OBJECTIVE 01: PROVIDE SAFE, EFFECTIVE, CARING AND RESPONSIVE SERVICES – GOOD BY 2020 Minimal

Inability to achieve and maintain regulatory compliance

4 5 20 4 3 12 3 3 9 Quality Director of Quality Governance

Cautious

Non-delivery of the outcomes of the Quality Strategy

4 4 16 3 4 12 2 3 6 Quality Medical Director / Director of Nursing / Director of Quality Governance

Avoid

Failure to deliver safe care 4 5 20 3 4 12 2 4 8 Quality

Medical Director / Director of Nursing / Director of Quality Governance

STRATEGIC OBJECTIVE 02: ENSURE EFFICIENT USE OF RESOURCES Open

Expenditure incurred exceeds income by greater than agreed control total

5 5 25 4 5 20 3 5 15 Performance Director of FEIMT & Deputy CEO / Divisional Directors

Open

Inability to achieve productivity improvements as required across all areas

5 4 20 3 4 12 3 4 12 Performance Director of FEIMT & Deputy CEO / Divisional Directors

STRATEGIC OBJECTIVE 03: PATIENT STANDARDS Cautious

Failure to deliver patient standards of care to constitutional and contractual levels as agreed with commissioners

4 5 20 4 4 16 3 4 12 Performance Divisional Directors

STRATEGIC OBJECTIVE 04: ACHIEVE EXCELLENCE IN EMPLOYMENT Open

Unable to recruit sufficient numbers of people with the right skills

4 5 20 3 4 12 (proposed from

3 4 12 Human Resources & Organisational

Director of Human Resources & OD

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L = Likelihood

I = Impact

Scoring matrix as detailed in the Trust Risk Management Policy

and values

3x5=15)) Development

Open Unable to retain the right

people

4 5 20 3 4

12 (proposed from 4x4=16)

3 4 12

Human Resources & Organisational Development


Open

Unable to achieve necessary cultural change

4 4 16 3 4 12 3 4 12

Human Resources & Organisational Development


STRATEGIC OBJECTIVE 05: IMPLEMENT THE ISLE OF WIGHT HEALTH AND CARE SUSTAINABILITY PLAN Open Pace of implementation

of the IOW Health and Care Sustainability Plan for achieving clinical and financial sustainability is not delivered

5 4 20 3 4 12 2 4 8 Performance Chief Executive

Seek Strategic partner to support delivery of phase two of the Acute Services Redesign may withdraw from agreement


Open Underpinning and supporting Trust plans aligned to Sustainability Plan not implemented


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SO1: Objective: PROVIDE SAFE, EFFECTIVE, CARING AND RESPONSIVE SERVICES – GOOD BY 2020 Assurance Committee: ASSURANCE RISK AND COMPLIANCE COMMITTEE Executive Lead: DIRECTOR OF QUALITY GOVERNANCE CQC Domain: ALL Enabling Strategy: QUALITY STRATEGY/ RISK MANAGEMENT STRATEGY

Risks to objective Controls Gaps in controls Sources of Assurance

Assurance outcomes / gaps

Action plan Progress / Timescales

Strategic risk: SR01-1 Condition: Inability to achieve and maintain regulatory compliance Cause: Lack of robust processes and management systems to provide evidence and assurance to regulatory agencies, poor understanding of minimum standards, ineffective governance, poor leadership. Consequence: Enforcement action, special measures, prosecution, financial penalties, reputational damage, loss of commissioner and patient confidence in provision of services

1. Governance

structures 2. Clinical standards

programme & professional standards

3. Board walk arounds 4. Quality Impact

Assessments for all service changes and CIPs

5. Trust policies and procedures

6. Quality Strategy and Risk Management Strategy

7. Improved effectiveness of Board governance

8. Clinical audits/outcomes

9. Strengthened Divisional governance processes

10. Performance Framework in place for reviewing divisional areas of strengths and areas of development

11. Registers for external agency visits and accreditations with mechanisms to identify and deliver regulatory requirements

12. Mandatory training targets achieved in 18/19 and monitoring in place for maintenance

13. Effective risk management in place with improving maturity levels

1. Embedding of

lessons learnt 2. Inconsistent

challenge/accountability for maintaining professional standards.

3. Maturing of

divisional governance structures building on work in 1819 and consistency of monitoring of standards

4. IG Toolkit mandatory training not achieved

5. Ongoing capturing

of PIR levels of information capture

6. Acute monitoring

and escalation of completion of regulatory actions

Management assurance:

1. Quality Committee 2. Performance

Committee 3. Divisional

Committees and Boards

4. Information Governance Sub-Committee

5. Operational Risk Sub-Committee

6. Quality Improvement Board

7. Well led reviews 8. Assurance visits

and mock inspection reports

9. Action tracker for regulatory actions

Gaps: 1. IMT visibility of

challenges and progress through sub-committee to Assurance Committees

1. Implementation of action plan following inspection feedback

2. Actions to address ED warning notice

3. To continue a programme of

assurance visits/ mock inspections and reviews across the Trust

4. Maintain Provider information

return with a quarterly review of data to identify any risks.

5. Implement a process for

formal recording of Board walk rounds and any subsequent actions. (schedule agreed with Chair)

6. Implementation of action plan

to achieve improved performance within IG training and compliance

7. Interim IMT update report to

set out timeline for future developments

(briefing to Board Seminar 4 July) 8. Development of IMT strategy

with stakeholder engagement

9. Actions as detailed within the Quality Strategy at a Trustwide and Divisional basis

10. Reporting against

performance frameworks

11. Horizon scanning & learning from thematic reviews/ insight reports

12. Actions to address MH

warning notice

1. Q1 / Q2 – Report published Sept 19. Improvement plans submitted end of Q2. Reviewed Q3 – progress made

2. Q1 - Met

3. Q1 – Met. New

dates agreed for BAU.

4. On track - BAU 5. Q1 – agreed –

BAU commenced Oct 19

6. Q2 – BAU to keep compliance under review

7. Q1 – BAU

8. Q3 / Q4 - progressing

9. Q1 - BAU

10. Q2 - BAU

11. Q2 – BAU included in divisional reviews

12. Q3 - on track

Risks from Risk Register: 1394 Inability to achieve & maintain regulatory compliance 1566 - Risk to achievement of 2019/20 Financial Plan 1649 – Inability to meet regulatory infection control standards in respect to ambulance vehicles and inconsistent vehicle readiness. 1668 – Lack of standardised processes working independently with no oversight of booking systems 1680 – Risk that future 0-19 service provision will not maintain 2019 CQC requirements

Metrics 1. Internal peer

review/mock inspection ratings

2. Improved regulatory standing

3. SI/Never Events

Outcomes: 1. S29A warning

notice for ED (Jan ‘19) lifted

2. Section 31 removed & addressing requirements of warning notice/ removal before end of 19/20

3. Improved regulatory position across the Trust

4. Progress on “Getting to Good”

5. Accreditations of key services in place (Pathology & JAC)

Independent / semi-independent:

1. CQC 2. QIPOG & Oversight 3. CCG, Healthwatch 4. NHSI regional visits 5. NHSI national visits 6. Improvement

Director report 7. Internal Audit

reports

Inherent risk Risk as at 31/12/2019 Target risk position by 31/3/2020

Likelihood Impact Score Likelihood Impact Score Likelihood Impact Score 4 5 20 4 3 12 3 3 9

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SO1: Objective: PROVIDE SAFE, EFFECTIVE, CARING AND RESPONSIVE SERVICES – GOOD BY 2020 Assurance Committee: QUALITY COMMITTEE Executive Lead: MEDICAL DIRECTOR/ DIRECTOR OF NURSING/ DIRECTOR OF QUALITY CQC Domain: ALL Enabling Strategy: QUALITY STRATEGY




Strategic risk: SR01-2 Condition: Non-delivery of the outcomes of the Quality Strategy Cause: Implementation of year two of strategy collating quality matters from across the Trust for consistent application and roll out Consequence: Failure to provide safe, effective, caring and responsive services.

1. Divisional level

Quality strategies and plans in place

2. Quality Strategy delivery reviewed at Divisional Quality Committees and Divisional Boards on a monthly basis

3. Quality Improvement

Board receives updates from areas on compliance with regulatory actions

4. Islandwide Quality

Committee review of actions and implementation linked with partners for system approach to delivery of agendas

5. Research and

development annual plan and reporting in place

6. High levels of

engagement in audit

7. Mortality reporting and improving results comparable with national average

8. GIRFT programme

covering range of specialties to reduce variation and apply best practice

1. Further development

of the implementation plan for the eight strands detailed in the Quality Strategy (Effective Domain and Dementia)

2. Divisional

implementation of Quality Strategy at pace

3. Lack of visibility of engagement events and approach

4. Effective visibility of data relating to delivery of the strategy and its outcomes

5. Work with Acute Service Redesign partner to be confirmed; model to be consulted, progressed and implemented which will support qualitative improvements

Management assurance: 1. Quality Committee 2. Divisional Quality

Committees 3. Patient Safety Sub-

Committee 4. Patient Experience

Sub-Committee 5. Clinical

Effectiveness Sub-Committee

6. Divisional Boards 7. Quality

Improvement Board 8. Board

Gaps: 1. Further

strengthening of Divisional Boards and supporting committees

2. Visibility of data to support effective reporting and analysis of progress

1. Quality Strategy work

plan for year 2 of delivery (report to QC on 3 July)

2. Improved visibility of quality strategy outcomes and quality dashboard

3. Divisional level Quality Strategies & implementation plans (ref within report to QC, 3/7)

4. Overarching Trust level communications & engagement approach to be developed

5. Divisional

Communications & engagement approach to be developed

6. GIRFT programme

extension to 17 areas (extension agreed)

7. Reporting on

improvement plans arising from GIRFT programme by service through governance routes

1. Q1 - complete

2. Q2 - complete

3. Q1 - complete

4. Q2 – delayed but improved processes in place

5. Q2 – complete in Ambulance & Mental Health

6. Q1 - BAU

7. Q2 - BAU

Risks from Risk Register:

1479 Insufficient resources allocated to Adult ADHD / ASD resulting in excessive waiting times and limited post diagnostic support 1475 Insufficient capacity within Paed ADHD 1410 – Risk that ED and Medical Assessment Unit Monitoring Equipment is not effectively maintained impacting patient safety

Metrics 1. As detailed in

Quality Strategy; including bed occupancy 90%, decreased stranded patients, improved PLACE results

2. Complaints & compliments data

3. National Inpatient Survey

4. Pulse survey improvements

5. HSMR/SHMI

Outcomes: 1. Progress on

“Getting to Good”

2. Improved patient experience

3. Improved clinical

outcomes (national audits, benchmarking)

Independent / semi-independent: 1. QIPOG 2. NHSI Oversight

Meetings 3. CCG 4. Healthwatch 5. Islandwide Quality

Committee 6. Internal Audit

reports 7. GIRFT



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SO1: Objective: PROVIDE SAFE, EFFECTIVE, CARING AND RESPONSIVE SERVICES – GOOD BY 2020 Assurance Committee: QUALITY COMMITTEE Executive Lead: MEDICAL DIRECTOR/ DIRECTOR OF NURSING/ DIRECTOR OF QUALITY CQC Domain: SAFE / WELL LED Enabling Strategy: QUALITY STRATEGY

Risks to objective Controls Gaps in controls Sources of Assurance Assurance outcomes / gaps


Strategic risk: SR01-3 Condition: Failure to deliver safe care Cause: multiple grounds of causality for failure to deliver safe care as identified in the 2018 CQC report/ 2019 ED CQC notice indicating the Trust is inadequate on the safe domain across Community, Acute, Mental Health and Learning Disability services and requires improvement within Ambulance services. Consequence: Increased complication rate, poor clinical outcomes for patients, loss of commissioner and patient confidence in provision of services, reputational damage, continued regulatory intervention (special measures)

1. Clinical standards clearly stated across the Trust’s services

2. Governance structures

3. Improved medical leadership in place

4. Training programme (mandatory and non-mandatory) including leadership development, human factors, QI methodology, and professional standards

5. Supervision and

education of clinical staff across all professions.

6. Clinical revalidation

7. Clinical Audit Programme including participation in relevant National Audit Programmes and reviews.

8. Mortality & SJR process

9. Internal Audit programme to review Coronial process and other key areas

10. Application of clinical pathways and guidelines.

11. Research & development programme

12. SI and Inquest

processes and learning

13. Quality Strategy

1. Patient risk

assessment and escalation

2. Staffing levels and development of new support roles/ ways of working

3. Systems and

connectivity

4. Safeguarding

5. Mandatory training

6. Standard of record keeping

7. Learning from incidents

8. Medical

Examiner role

Management assurance: 1. Quality Committee 2. Quality Improvement

Board 3. Operational Risk Sub-

Committee 4. Patient Safety Sub-

Committee 5. Patient Experience Sub-

Committee 6. Clinical Effectiveness

Sub-Committee 7. Divisional Boards

Gaps: 1.

1. Implementation of

action plan following inspection feedback

2. Research and development programme and expansion of audit approach

3. Increased analysis of SJR as part of learning from deaths process

4. Application of 10

week programmes across additional areas including stroke, PARIS, pharmacy monitored through PSSC

5. Actions to address

ED warning notice 6. Finalisation of

Islandwide plan programme & resource

7. Support consultation,

progression and subsequent implementation of the ASR.

8. Appointment Medical

Examiner 9. Audit of seven day

working programme 10. Continued delivery of

training and development programme

11. Progress on clinical

standards roll out and application

1. Q1 / Q2 - Report

published Sept 19. Improvement plans submitted end of Q2 – on track to deliver

2. Q2 - BAU ongoing

3. Q2 - BAU ongoing

4. Q1 – complete BAU

5. Q1 – complete 6. Q1 – Health &

Care plan published. 7. Q1 – partnership

arrangements established

8. Q1/Q2 - complete

9. Q2 - BAU

10. Q4

11. Q1 - BAU

Risks from Risk Register: 1410 Risk that ED and Medical Assessment Unit Monitoring Equipment is not effectively maintained impacting patient safety 1431 - Gastroenterology capacity impacting service delivery 1470 - Aseptic & oncology services staffing pressures which could lead to a lack of availability of chemotherapy and hence patient harm

Metrics 1. National Audits 2. Complication Rates 3. Outlier alerts 4. HSMR/SHMI 5. NICE compliance 6. Internal peer review/

mock inspection

Outcomes: 1. Progress on

“Getting to Good” 2. Improved

patient outcomes 3. S29A warning

notice for ED(Jan ‘19) lifted

4. Section 31 removed & addressing requirements of warning notice/ removal before end of 19/20

5. Improved regulatory position across the Trust

6. Improved clinical outcomes

Independent / semi-independent: 1. NHSI: QIPOG/Oversight 2. CCG 3. CQC 4. Healthwatch 5. NHSI regional visits 6. NHSI national visits 7. Improvement Director

report 8. Islandwide Quality

Committee 9. Internal Audit reports 10. GIRFT



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SO2: Objective: ENSURE EFFICIENT USE OF RESOURCES Assurance Committee: PERFORMANCE COMMITTEE Executive Lead: DIRECTOR OF FINANCE / DIVISIONAL DIRECTORS CQC Domain: WELL LED Enabling Strategy: FINANCIAL RECOVERY PLAN Risks to objective Controls Gaps in controls Sources of

Assurance Assurance outcomes / gaps


Strategic risk: SR02-1 Condition: Expenditure incurred exceeds income by greater than agreed control total Cause: Divisions and Corporate Departments do not deliver services within agreed budgets and do not achieve CIPs Capped and block contract arrangements limit scope for payment Additional activity delivered may not result in increased income; due to levels of activity or coding issues Consequence: Impact on investment in quality Inability to meet regulatory requirements Reputational damage Impact upon recruitment Continuation of financial special measures

1. Devolved and delegated budgets based on 2018/19 outturn in place with amendments for recurrent/non recurrent schemes

2. Matured contractual

arrangements with PbR models in place for acute based activity subject to risk share elements/caps

3. Financial Special

Measures regime 4. Strengthened CIP

process building on learning from 1819

5. Establishment of

contingency element under development

6. Financial Performance Review meetings in place with Divisions

7. Continuation of

process for expenditure reduction throughout the Trust

8. Mechanisms for joint working with other partners established and operating effectively with CCG and local authority through Islandwide Plan

9. Revised committee

models to support focus on key areas

10. Realistic and

achievable plan in place developed with staff input and sustainability funds identified

1. Ongoing development of accountability of Divisions – further improvements required

2. Block contractual

arrangements remain in place for certain areas

3. Cost reduction and

expenditure controls in place but with lack of consistent application within Divisions and corporate functions

4. Gap in identified

CIP schemes and required level

5. Failure to include

sufficient buffer on deliverability of CIP schemes

6. Limited measures

in place for capacity restrictions

7. Limited planned

demand control measures in place across system

8. Development of

Islandwide Plan into operational delivery

9. Development of

system governance model to support implementation of Islandwide Plan and management of system pressures on control total

Management assurance: 1. Divisional

Performance Committee and Boards

2. Finance Performance Reviews

3. Financial Recovery Board

4. Performance Committee

5. Trust Board

Gaps: 1. Divisional

awareness of spend within new structures as budget centres have shifted

2. Clarity of ownership of schemes

3. Pace of delivery

1. Monthly monitoring and assessment of risk share arrangements within contractual models against delivery of activity

2. Monthly review at

system level of demand management

3. CIP to be green rated

within Q1 4. CIP weekly check and

challenge meetings in place schemes and FSMID to explore robustness of plans and provide assurance on delivery to report through strengthened governance processes

5. Continued

development of CIP pipeline with quarterly updates to provide ongoing opportunities

6. Monthly control totals

issued to divisions and care groups

7. Monthly reporting to

FSM regime 8. Finalisation of Island-

wide plan programme Q1 9. Confirmation of

governance of Islandwide plan

10. Plan finalised to

ensure effective grip and control & providing assurance to national team

1. Q1 - BAU

2. Q1 - BAU

3. Q1 – BAU (Q3 emerging cost pressures on CIP)

4. Q1 / BAU

5. Q1 - BAU

6. Q1 - BAU

7. Q1 - BAU

8. Q1 - achieved 9. Q2 - BAU 10. Q1 - ongoing to

monitor and address emerging risks

Risks from Risk Register: 1566 Risk to achievement of 2019/20 Financial Plan 1563 Potential deterioration of cash position if financial position goes off plan 1421 - Inability to deliver financial plan due to need to use agency / locum staff and lack of devolved ownership of individual budgets

Metrics 1. Run rate 2. I&E position 3. CIPs position 4. Activity

performance against plan

5. Cash flow

Outcomes: 1. Reduced NHSI

regulation 2. Achieve Board

approved financial plan

3. Achieve financial control total at Trust and system level

Independent / semi-independent: 1. NHSI: FSM &

Oversight 2. CQC 3. Internal Audit 4. External Audit 5. Local Counter

Fraud Specialist



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SO2: Objective: ENSURE EFFICIENT USE OF RESOURCES Assurance Committee: PERFORMANCE COMMITTEE Executive Lead: DIRECTOR OF FINANCE / DIVISIONAL DIRECTORS CQC Domain: WELL LED Enabling Strategy: ISLANDWIDE SUSTAINABILITY PLAN Risks to objective Controls Gaps in controls Sources of



Strategic risk: SR02-2 Condition: Inability to achieve productivity improvements as required across all areas Cause: Divisions and Corporate Departments do not deliver productivity improvements in accordance with plans and as included within CIP and operating plan assumptions Consequence: Do not deliver results that are comparable to the Trust’s peers in clinical, clinical support and corporate functions Impact on investment in quality Inability to meet regulatory requirements Reputational damage

1. Islandwide Plan

2. Mechanisms for joint

working with other partners established and operating effectively with CCG and local authority

3. Review of operational activity on a monthly basis through internal governance processes


GIRFT programme to identify and address areas of inefficiency and minimise negative variance

5. Improved financial

controls and governance in place

6. CIP process in place

and establishment of contingency element under development

7.

1. Project resource to

support delivery of improvement programmes

2. Level of capability

within existing staff teams to drive service changes and productivity improvements alongside BAU

3. Service Line

reporting implementation to be developed and extended

4. Robust application

of model hospital and NHS benchmarking comparators to be progressed

5. Lack of IMT

strategy 6. Lack of clinical

strategy to provide consistent direction over and above that contained within the Islandwide Plan

Management assurance: 1. Divisional

Performance Committee and Boards

2. Clinical Effectiveness Sub-Committee

3. Trust Leadership Committee

4. Finance Performance Reviews

5. Financial Recovery Board


7. Trust Board

Gaps: None

1. Finalisation of Islandwide plan programme & resource

2. GIRFT programme

delivery throughout the financial year with quarterly updates through clinical effectiveness reporting Total of 17 specialities reviewed by end Q1

3. Investments in IMT

to support development of productivity across the Trust supported by STP wave 4 funding for digitalisation and through capital funds for streamlining of service delivery

4. Interim IMT update report to set out timeline for future developments

5. Development of IMT

strategy with stakeholder engagement

6. Investment in DSU to

increase capacity and support flow through capital programme

7. Improved theatre

utilisation – c. 10% improvement in Q1

8. Patient flow working

with system partners in the delivery of the Islandwide plan

9. Outpatient

throughput development

1. Q1 - completed

2. Q1 - BAU ongoing

3. Q2 - BAU ongoing

4. Q1 - complete

5. Q3 / Q4 - progressing

6. Q2 – delayed Q3/Q4 and to be considered as part of £48m investment as not on capital programme

7. Q1 - BAU

ongoing

8. Q1 - BAU

9. Q1 - BAU

Risks from Risk Register: 1405 Risk that the Trust fails to plan effectively for future financial sustainability impacting future viability of the Trust 1564 Risk that CIP are not achieved affecting achievement of the 2019/20 Financial Plan 1627 - There is a risk that Division may not deliver CIP due to limited financial support

Metrics 1. Benchmarking 2. Delivery of

financial plan 3. Activity

performance

Outcomes: 4. Achieve Board

approved financial plan

5. Achieve financial control total

Independent / semi-independent: 1. NHS

Benchmarking 2. GIRFT 3. NHSI & Oversight

meetings 4. CQC 5. Internal Audit 6. External Audit



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SO3: Objective: PATIENT STANDARDS Assurance Committee: PERFORMANCE COMMITTEE Executive Lead: DIVISIONAL DIRECTORS CQC Domain: RESPONSIVE Enabling Strategy: OPERATIONAL STRATEGY




Strategic risk: SR03-1 Conditions: Failure to deliver patient standards of care to constitutional and contractual levels as agreed with commissioners Causes: Flow, demand and capacity across Acute, MHLD Ambulance, Community, and wider issues of system-wide challenges including social care, 111, primary care etc. Lack of appropriately trained medical, nursing and allied healthcare staffing Instances of inappropriate use of system resources Service restrictions due to funding challenges Consequence: Medically fit for discharge patients not progressing through the health & social care system ED breaching 4-hour targets Failure to achieve cancer standards and RTT timeline

1. Islandwide plan agreed between partners to support service development with increased focus on community models and self-care

2. Effective relationships with IW Council and CCG and primary care

3. Annual Operating Plan developed with increased staff input

4. Integrated Trust

provides the opportunity for collaborative working without organisational boundaries

5. Plans in place to finalise selection of system partner to support delivery of Acute Services Redesign and progress at pace

6. Collaborative approach to care planning with service users across mental health

7. Winter Plan

including system winter plan

8. Workforce strategies in place

1. Governance developments to support delivery of Islandwide plan between partners

2. Capitalise on opportunities to maximise benefits of unified Trust

3. Plan with Acute Service

Redesign partner to be confirmed; model to be consulted, progressed and implemented

4. Inconsistent approach to promoting and educating users on self-management and collaboration

5. Limited planned system

demand control measures

6. Urgent Care Centres model development

7. Quarterly planning cycle

to address seasonal pressures required

8. Inconsistency in standards re utilisation of locum and agency staff

9. Plan for achievement of

Cancer targets & ECS require further development

10. RTT Total Incomplete

performance will be 75.7% in March 2020 and52 week breaches expected in 19/20

11. Current plans indicate

that we will be non-compliant against the Ambulance performance standards

Management assurance:

1. Divisional

Committees and Board

2. Trust Leadership Committee


4. Trust Board

Gaps: 1. Improved visibility

on reporting on pace of delivery

2. Review of IMT reporting and data responsiveness

1. Finalisation of

Islandwide plan programme & resource

2. Confirmation of governance of Islandwide plan

3. Support consultation, progression and subsequent implementation of the ASR.

4. Developing parallel path model linked with mainland Trusts

5. Improved visibility and reporting on KPIs within ED/IUEC

6. ED environmental

developments and Urgent Treatment Centre

7. Quarterly seasonal

planning to address challenges and implement operating plan

8. Minimise use of locum

and agency staff in order to support the improvement in consistency in standards

9. Further development of

plans for Cancer & ECS target delivery

10. Develop, cost and seek

approval of a plan for achievement of RTT targets & to address 52-week breaches

1. Q1 - complete 2. Q2 - BAU 3. Q4 - BAU

aligned to new partnership working

4. Q4 – BAU

aligned to partners 5. Q1 - BAU 6. Q2 – delayed to

Q3 – complete ad BAU

7. Q1 – BAU

ongoing 8. Q1 - BAU 9. Q2 – action plan

in place and some progress being made

10. Q2 – Plan in

place and progressing

Risks from Risk Register: 661 – Oncology service contract 1667 - Waiting time in Older People's Mental Health Services 1637 - Inadequate estate for Mental Health and Learning Disability Services 1630 - Risk to the effective delivery of cradle to grave integrated care following loss of 0-19 contract 1559 - Risk of loss of Integrated Sexual Health Service contract impacting on future of Sexual Health Service provision

Metrics: 1. Ambulance Cat

1-4 2. A&E 4 hour

target 3. Cancer 62 day 4. RTT incomplete 5. DTOC system

performance

Outcomes: 1. Right place right

time for care 2. Timely access to

services with consistent flow through the health and social care system

3. Achievement of

constitutional and contractual levels of service provision

Independent / semi-independent: NHSI- Oversight & QIPOG CQC Internal Audit External agency visits



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SO4: Objective: ACHIEVE EXCELLENCE IN EMPLOYMENT

Committee: HUMAN RESOURCES AND ORGANISATIONAL DEVELOPMENT COMMITTEE

Executive Lead: DIRECTOR OF HUMAN RESOURCES & ORGANISATIONAL DEVELOPMENT

CQC Domain: WELL LED Enabling Strategy: RECRUITMENT & RETENTION STRATEGY / LEADERSHIP STRATEGY Risks to objective Controls Gaps in controls Sources of


Action plan Progress / Time scales

Strategic risk: SR04-1 Condition: Unable to recruit sufficient numbers of people with the right skills and values Cause: 1. Shortage of

appropriately trained and skilled clinical staff throughout the NHS in certain specialties

2. The Trust’s geographical location

Consequence: 1. Inability to deliver

high quality clinical services

2. High use of agency and locum staff leading to increased costs

1. Improved effective and efficient recruitment processes, including automation in place 2. Appraisal Policy and paperwork in place for all staff 3. Leadership Strategy and programme in place 4. Mandatory Training programme in place 5. Induction process for all new employees 6. Staff Recognition Programme in place 7. Visions & values in places and promoted 8. Recruitment and Retention Strategy approved 9. Recruitment campaigns in place including overseas 10. Recruitment brand ‘Great place to live, great place to work’ in place 11. Careers Facebook page live with high level of followers 12. Collaboration with CCG and council with some joint appointments

1. Implementation required of the Workforce and OD Plan, aligned to Sustainability Plan

2. Staff development programme not fully in place

3. Not all new starters attending induction

4. Operational demands restricting release of staff for training

5. Limited talent spotting in place

6. Limited succession

planning in place

Management assurance 1. HR&OD

Committee

2. Quality Committee


4. Audit Committee

5. Trust Leadership

Committee

6. Integrated Performance Reviews

7. Divisional Boards

8. Operational Risk

Sub-Committee

Gaps: 1. Trajectory

and forecast reporting against the recruitment plan

1. Implement the Workforce & OD Plan, aligned to the Trust Workforce Strategy (which is aligned to the IOW Health and Care Plan)

2. Staff development

programme to be fully rolled out

3. Mandate for all staff to

attend induction on first day of employment

4. Further recruitment

initiatives to be explored and introduced jointly with external STP partners

5. Further incentives to

be agreed and introduced to attract health professionals

6. Deliver further cohorts

to appoint additional nurse apprentices and trainee nursing associate apprentices

7. Develop new initiatives

to enhance talent management and succession planning

8. Improve reporting on

trajectories and forecasting against the recruitment plan

1. Q4 – complete. BAU to refresh for 2020-23

2. Q4 – complete. BAU to

refresh for future years 3. Q2 – BAU – address

compliance in Bank Staff 4. Q2 - BAU 5. Q2 - BAU 6. Q3 - BAU 7. Q2 - BAU 8. Q2 - BAU

Risks from Risk Register: 1499 - Risk that the Trust fails to attract and recruit the right staff 1482 - Stroke Services impacted by workforce issues and unable to deliver sustainable service

Metrics 1. Time to fill posts 2. Sickness rates 3. Vacancy rates 4. Usage of agency

and locum staff

Outcomes: 1. Delivery of

Operating Plan 2. Improved

Staff Survey results

3. Improved CQC rating Independent / semi-

independent 1. NHSI 2. CQC 3. CCG 4. Internal Auditors 5. National award

(Recruitment Team was a finalist by nursing Times for ‘Best Recruitment Experience’


Likelihood Impact Score Likelihood Impact Score Likelihood Impact Score 4 5 20 3 4 (proposed) 12 (from 3x5=15) 3 4 12

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SO4: Objective: ACHIEVE EXCELLENCE IN EMPLOYMENT Committee: HUMAN RESOURCES AND OD COMMITTEE





Strategic risk: SR04-2 Condition: Unable to retain the right people Causes: 1. Poor staff morale 2. Lack of clarity re

objectives 3. Lack of ability to

influence 4. Insufficient numbers

of staff with appropriate skill mix

5. Inconsistent quality of appraisals

6. Poor communication

Consequence: 1. Inability to deliver


2. High use of agency and locum staff leading to increased costs

1. Appraisal paperwork in place for most staff

2. Leadership Programme 3. Mandatory Training

programme in place 4. Induction process for all

new employees 5. Whistleblowing Policy 6. Anti-Bullying Advisors 7. Freedom to speak up

guardian process 8. Staff Engagement

Group in place 9. Staff Recognition

Programme in place 10. Clinical Supervision

Policy 11. Updated Visions &

Values 12. Recruitment and

Retention Strategy in place 13. Process for all new staff

to receive a comprehensive induction and receive additional support in their first few months

14. Consulting staff on new workforce policies and practices that create a positive and supportive working environment

15. Professional Development Frameworks for Clinical bands 2-8

16. Advanced Practice Framework implemented

17. Faculty of Medical Leadership and Management programme in place

1. Implementation of the Workforce and OD Plan, aligned to Sustainability Plan

2. Poor quality of

appraisals 3. Clinical supervision not

consistently in place 4. Low compliance of

mandatory training 5. Inability to release staff

for training 6. Lack of formal internal

Communications Strategy and process

7. Lack of consistent exit

interview / questionnaire process

8.


Committee



4. Audit Committee

5. Trust Leadership

Committee



8. Operational Risk

Sub-Committee

Gaps: 1. Trajectory and

forecast reporting against the retention plan

1. Implement the Workforce

& OD Plan, Trust Workforce Strategy aligned to the Interim People Plan

2. Development programme to include Kings Fund culture programme and published organisational standards

3. Leadership development

programme for all managers to be fully delivered

4. New policies to be agreed

reflecting the needs of staff development

5. Improve reporting on

trajectories and forecasting against the retention plan

6. Revise and implement

robust exit interview / questionnaire process

1. Q4 – on-going 2. Q2 - BAU 3. Q4 – BAU – Phase

2 for 2020-21 to be developed

4. Q2 - complete 5. Q2 - BAU 6. Q3 – Complete –

BAU to determine how to improve uptake and use the data

Risks from Risk Register: 1427 - Risk to the delivery of safe and effective services due to inability to recruit and retain sufficient staff 1482 Stroke Services impacted by workforce issues and unable to deliver sustainable service 1666 - Urology Fragile Service 1655 - Ability to provide ADHD assessment, prescribing and reviews

Metrics 1. Sickness rates 2. Vacancy rates 3. Usage of agency

and locum staff 4. Mandatory

training compliance 5. Appraisal rates

Outcomes: 1. Delivery of

Operating Plan 2. Improved Staff

Survey results

3. Improved CQC rating

Independent / semi-independent 1. NHSI 2. CQC 3. CCG 4. Internal Auditors


Likelihood Impact Score Likelihood Impact Score Likelihood Impact Score 4 5 20 3 (proposed) 4 12 (from 4x4=16) 3 4 12

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SO4: Objective: ACHIEVE EXCELLENCE IN EMPLOYMENT Committee: HUMAN RESOURCES AND OD COMMITTEE





Strategic risk: SR04-3 Condition: Unable to achieve necessary cultural change Cause: 1. Inappropriate staff behaviours 2. Leaders in roles without support or development 3. Equality and Diversity not fully recognised 4. Lack of clarity of direction for staff roles 5. Ineffective team working and communication 7. Lack of staff engagement and ownership by services of results from staff surveys Consequence: 1. Inability to deliver


2. High levels of staff sickness, low morale and motivation

1. Vision and values

developed and rolled-out

2. Leadership programmes throughout the organisation

3. Visible leadership

4. Equality & Diversity programme

5. Board Development

Programme agreed with NHSLA

6. Freedom to speak up

and Anti-bullying campaigns

7. Consult staff on strategy, planning and policies

8. Partnership approach

with Council to driving improvements in communicating with staff through joint appointment

9. The 10 core behaviours

mapped to the values

1. Implementation of the

Workforce and OD Plan, aligned to Sustainability Plan

2. Culture and Leadership programme not yet fully completed

3. Not all Leadership

Development Programmes have yet had the desired impact

4. Equality impact

assessments not yet developed in divisions

5. Staff have not yet

completed the refreshed Equality and Diversity mandatory training

6. Benefits not yet

embedded of Occupational Health nurse recently commenced in post

7. Review of results of

staff survey and agreed actions not yet implemented


Committee



4. Audit Committee

5. Trust Leadership

Committee



8. Operational Risk

Sub-Committee

Gaps: 1. Development of

culture dashboard not implemented through all divisions

1. Implement the

Workforce & OD Plan, Trust Workforce Strategy aligned to the Interim People Plan

2. Fully implement the Culture and Leadership Programme

3. Fully deliver the Leadership Development Programme

4. Develop equality impact assessments in divisions

5. Equality and diversity mandatory training to be consistently completed

6. Deliver the objectives of the Occupational Health nurse appointment

7. Agree action plan following staff survey and implement it

8. Implement culture dashboard across divisions

1. Q4 - progressing

after the development of the Health and Care Plan and Interim People Plan

2. Q4 - progressing 3. Q4 – BAU to

develop Phase 2 for 2020-21

4. Q2 - complete 5. Q2 - BAU 6. Q2 - complete 7. Q4 - staff survey

completed Nov 19 and to report in Q4

8. Q2 - complete

Risks from Risk Register: 1470 Aseptic & oncology services staffing pressures which could lead to a lack of availability of chemotherapy and hence patient harm

Metrics 1. Recruitment &

retention 2. Sickness data 3. Staff Survey

results

Outcomes: 1. Behaviours

framework in place and embedded

2. Reduction in the number of reported incidents to F2SU and surveys

3. Development of action learning sets

4. Evidence of co-production

5. Evaluation and change in practice

Independent / semi-independent 1. NHSI 2. CQC 3. CCG 4. Internal Auditors 5. Professional

bodies

Inherent risk Risk as at 31/12/2019 Target risk position by 31/3/2020 Likelihood Impact Score Likelihood Impact Score Likelihood Impact Score

4 4 16 3 4 12 3 3 9

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SO5: Objective: IMPLEMENT THE ISLE OF WIGHT HEALTH AND CARE SUSTAINABILITY PLAN Committee: PERFORMANCE COMMITTEE Executive Lead: CHIEF EXECUTIVE CQC Domain: WELL LED Enabling Strategy: SUSTAINABILITY PLAN




Strategic risk: SR05-1 Condition: Pace of implementation of the IoW Health and Care Sustainability Plan for achieving clinical and financial sustainability is not delivered Cause: Insufficient capacity and capability resource to deliver the plan Consequence: Failure to deliver the vision of effective, efficient, affordable high-quality health and care services for the population of the Isle of Wight, with increased regulatory scrutiny

1. Implementation plan for

the Sustainability Plan agreed by Trust, Council and Partnership of CCGs

2. Trust Operating Plan for 2019/2020 including activity, quality, workforce and finance plans – year one of sustainability plan

3. System-wide Senior Responsible Officer (SRO) and Programme Management Office (PMO)

4. Weekly SRO meeting 5. Weekly CEOs meeting 6. Fortnightly Project

Board meeting / Leadership Forum

7. Acute Services Redesign Programme

8. Community Services Redesign Programme

9. Mental Health and Learning Disabilities blue print

10. Solent Acute Alliance review of the coordination of a range of services

11. Sustainability Plan 3 domains in place with Senior Responsible Officers: Care models, Productivity, and Networks

12. Assessment of capacity and capability of Island resources to complete each domain undertaken

13. Detailed evidenced based approach completed to understand the challenges and population needs to inform planning and decision making

1. Assessment of capacity

and capability resource requirements to deliver the Sustainability Plan not finalised and approved

2. Mapping of

implementation plan milestones to actual delivery outputs not finalised and approved

Assurance: 1. Local Care Board

and supporting system-wide governance

2. Trust Board 3. Performance

Committee 4. Financial

Recovery Board 5. Quality

Committee 6. Quality

Improvement Board 7. Human

Resources and Organisational Development Committee

8. Internal Trust confirm and challenge meetings

Gaps: 1. Contemporaneous

reporting not yet fully developed to include metrics, KPIs and outcomes

2. Changes to system-

wide governance arrangements in discussion to support improved accountability, reporting and assurance mechanisms

1. Finalise and approve

assessment of capacity and capability resource plan to deliver the Health and Care Plan

2. Appoint as necessary

3. Finalise and approve mapping of implementation plan milestones to actual delivery outputs

4. Fully develop

contemporaneous reporting metrics, KPIs and outcomes

5. Contribute to the

discussions and agreement for changes to system-wide governance arrangements to ensure accountability, reporting and assurance mechanisms

1. Q2 - complete 2. Q3 - complete 3. Q1 - complete 4. Q1 - complete 5. Q1 - complete

Risks from Risk Register: 1482 - Stroke Services impacted by workforce issues and unable to deliver sustainable service 1559 - Risk of loss of Integrated Sexual Health Service contract impacting on future of Sexual Health Service provision

Metrics 1. Clinically,

operationally and financially sustainable

Outcomes: 1. Implementation of

Sustainability Plan

2. Fully resourced Sustainability Plan developed and agreed taking account of all capacity and capability requirements Independent / semi-

independent 1. STP 2. Local Care Board 3. System-wide

CEOs meeting 4. NHSI 5. CQC 6. Internal Auditors 7. External advisors



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SO5: Objective: IMPLEMENT THE ISLE OF WIGHT HEALTH AND CARE SUSTAINABILITY PLAN Committee: PERFORMANCE COMMITTEE Executive Lead: CHIEF EXECUTIVE CQC Domain: WELL LED Enabling Strategy: SUSTAINABILITY PLAN




Strategic risk: SR05-2 Condition: Strategic partner to support delivery of phase two of the Acute Services Redesign may withdraw from agreement Cause: Full due diligence and diagnostics not yet undertaken by strategic partner Consequence: Failure to deliver the vision of effective, efficient, affordable high-quality health and care services for the population of the Isle of Wight, with increased regulatory scrutiny

1. Implementation plan

for the Sustainability Plan agreed by Trust, Council and Partnership of CCGs

2. Acute Services Redesign stocktake, including scope, approach, leadership, governance, project management, engagement, regulatory support and immediate next steps

3. Potential partners

identified, approached and formalised positive intent received from one partner

4. Outline plans in place

and agreed for establishing service baseline and defining requirements to deliver phase 2: develop the new acute services model and assess all options

1. Full due diligence and

diagnostics in progress by strategic partner

2. Capacity and

capability requirements of strategic partner not yet fully scoped

3. Optimal configuration

of services not fully identified

4. Parameters of the

partnership model not yet agreed

5. No full-time SRO in

place to manage the 7-month initial process

Assurance: 1. STP

2. Local Care Board

and supporting system-wide governance

3. Trust Board

Gaps: 1. Formal

governance for initial 7-month process not yet agreed with strategic partner

1. Support strategic

partner as required in undertaking full due diligence and diagnostics

2. Support strategic partner in scoping capacity and capability requirements

3. In conjunction with

strategic partner, identify optimal configuration of services

4. Agree the parameters

of the partnership model

5. Jointly validate the appointment of an SRO as nominated by the strategic partner

1. Q3 – progressing

MOU for SCAS, Solent and PHT in place. MH due diligence in progress.

2. Q2 – progressing

through Q3

3. Q3 - progressing

4. Q2 - complete

5. Q2 - complete Risks from Risk Register: Operational risks that may impact upon this strategic objective to be considered by each Division at Operational Risk Sub-Committee in March 2020.

Metrics 1. Clinically,

operationally and financially sustainable

Outcomes: 1. Implementation of

Sustainability Plan

2. Delivery of 7-month process

3. New acute

services model developed and all options assessed

Independent / semi-independent 1. STP 2. Local Care Board 3. System-wide




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SO5: Objective: IMPLEMENT THE ISLE OF WIGHT HEALTH AND CARE SUSTAINABILITY PLAN Committee: PERFORMANCE COMMITTEE Executive Lead: CHIEF EXECUTIVE CQC Domain: WELL LED Enabling Strategy: SUSTAINABILITY PLAN Risks to objective Controls Gaps in controls Sources of



Strategic risk: SR05-3 Condition: Underpinning and supporting Trust plans aligned to Sustainability Plan not implemented Cause: Plans recently developed for clinical, workforce, estates & facilities and ICT Consequence: Failure to deliver the vision of effective, efficient, affordable high-quality health and care services for the population of the Isle of Wight, with increased regulatory scrutiny

1. Acute Services

Redesign Programme

2. Community Services Redesign Programme

3. Mental Health and Learning Disabilities blue print

4. Solent Acute Alliance review of the coordination of a range of services

5. Recruitment &

Retention Strategy

6. Leadership Strategy

7. Trust-wide plans in place to address gaps in workforce, estates, facilities, ICT and information provision

8. Estates, facilities, ICT and information forums and groups in place including regional groups

9. Agreement in place for

7-month process for development of clinical plans


workforce plan aligned to Sustainability Plan in progress

2. Development of

estates & facilities plan aligned to Sustainability Plan in progress

3. Implementation of ICT plan aligned to Sustainability Plan in progress

Assurance: 1. Trust Board

2. Performance

Committee


4. Human

Resources and Organisational Development Committee

5. Financial

Recovery Board

6. Quality Improvement Board

7. Integrated

performance Reviews


Gaps: 1. HR & OD

Committee recently approved not yet fully established

1. Implement workforce

plan aligned to Health and Care Plan and Interim People Plan

2. Estates and facilities

plan to be developed (in conjunction with Council and CCG) and implemented aligned to Health and Care Plan

3. Implement ICT plan

(in conjunction with Council and CCG) aligned to Health and Care Plan

4. HR & OD Committee to become fully functional

1. Q4 – complete.

Plans developed and aligned

2. Q4 - progressing 3. Q4 - progressing 4. Q1 – complete

BAU

Risks from Risk Register: 1630 Risk to the effective delivery of cradle to grave integrated care following loss of 0-19 contract 1667 Waiting time in Older People's Mental Health Services

Metrics 1. Vision: “people

will live healthy and independent lives”

2. Clinically, operationally and financially sustainable

Outcomes: 1. All underpinning

strategies supported by funded plans, aligned to Sustainability Plan and approved by Trust Board

Independent / semi-independent 1. STP 2. Local Care Board 3. System-wide




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trust board papers · • darren cattell, director of wightlife partnership • dr paul evans,...

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